·--- NINCDS Monograph No.15 ;~,~ Th ~~,~ e , l\ Research !~ Status Slof Spinal ;~-~ M _anipU· Iat1ve · ~,)Therapy

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U.S. DEPARTMENT OF HEALTH, EDUCATION, AND · WELFARE Public Health Service National Institutes of Health NINCDS Monograph Series

The NlNCDS Monograph Series , edited and issued by the Office of Scientific and Health Reports, National Institute of Neurological and Communicative Disorders and Stro~e , presents ~ontributions to knowledge in the neurological and sensory disease fields, particularly material that is extensive , detailed, or specialized . The following publications in this series are available from the NlNCDS Office of Scientific and Health Reports :

NINOS Monograph No. I : Epilepsy-A Review of Basie and Clinical Research . 69 pp., 1965. NINOS Monograph No, 3: Minimal Brain Dysfunction in Children, Terminology and Identification , 18 pp., I 96.6. J:IJINDS Monograph No. 9: Central Proce ssing Dysfunc tions in Children : A Review of Rese arch Needs , 148 pp., 1969. NINOS Monograph No. 10: Human Communication and Its Disorders-An Overview, 176 pp. , 1970. NINOS Monograph No. 11: Reading Forum: A Collection of Reference Papers Concemed With Reading Disability. 256 pp. , 1972. NINOS Monograph No. 12: Studies on the Clinical Efficacy ,of Marketed Anl iepileptic Drugs. 36 pp., 1,971. , NINOS Monograph No. 14: 'iFhe Epidemiology of Epilepsy: A Workshop. 167 pp., 1972.

T NINCDS Monograph No. 15

THERESEARCH STATUS OF SPINALMANIPULATIVE THERAPY

A Workshop held at the National Institutes of Health, February 2-4, 1975.

Murray Goldstein, Editor

DHEW Publication No. (NIH) 76 - 998

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Institutes of Health National Institute of Neurological and Communicative Disorders and Stroke Bethesda , Maryland 20014

1975 WORKSHOP PLANNING COMMITTEE

Murray Goldstein, Chairman Philip E. Greenman Scott Haldeman Horace W. Magoun James H. McElhaney Donald B. Tower Henry G. West, Jr. Andrew B. Wymore

NIH LIAISON Philip S. Chen Howard P. Jenerick

For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 - Price $4.75 Stock Number 017-049-00060-7 Workshop Participants

Ballantine, H. Thomas, Jr., M.D.: Senior Neurosurgeon, Massachusetts General Hospital; Associate Clinical Professor of Surgery, Harvard Medical School, Boston, Massachusetts Bromley, William, D.C.: Audubon, New Jersey Burke, Robert E.,.M.D.: Laboratory of Neural Control, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland Chase, Thomas N., M.D.: Director of Intramural Research, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland Cleveland, Carl S., Jr., D.C.: President, Cleveland College of Chiropractic, Kansas City, Missouri Cornfield, Jerome: Professor of Statistics, George Washington University; Biostatistics Center, Bethesda, Maryland Cyriax, James, M.D., M.R.C.P.: St. Thomas's Hospital London, England Day, William S., D.C.: Spokane, Washington Denslow, J. S., D.O.: Vice President, Kirksville College of Osteopathic Medicine, Kirksville, Missouri DiChiro, Giovanni, M.D.: Head, Section on Neuroradiology, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland Drum, David C., D.C.: Department of Chiropractic Science, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada Dubbs, Gustave, D.C.: Hempstead, New York Frank, Karl, Ph. D.: Chief, Laboratory of Neural Control, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland French, Lyle A., M.D., Ph. D.: Vice President for Health Sciences Affairs, University of Minnesota, Minneapolis, Minnesota. Member, National Advisory Neurological Diseases and Stroke Council, National Institutes of Health Gitelman, Ronald, D.C., F.C.C.S.: Canadian Memorial Chiropractic College, Toronto, Ontario, Canada Goldstein, Murray, D.O., M.P.H.: Director, Extramural Activities Program: Associate Director, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland Greenman, Philip, D.O.: Professor and Chairman, Department of Biomechanics, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan Gurdjian, E. S., M.D., Ph. D.: Professor Emeritus, Neurological Surgery, Wayne State University, Detroit, Michigan Guth, Lloyd, M.D.: Head, Section on Neuronal Development and Regeneration, Laboratory of Neuro­ chemistry, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland Haldeman, Scott, D.C., Ph. D.: Vancouver, B.C., Canada Howe, Joseph W., D.C.: Professor and Chairman, Department of Roentgenology, The National College of Chiropractic, Lombard, Illinois Janse, Joseph, D.C.: President, The National College of Chiropractic, Lombard, Illinois Jenness, Martin, E., D.C., Ph.D.: Director of /_?..esearch,Palmer College of Chiropractic, Davenport, Iowa Johnston, William L., D.O.: Professor, Department of Biomechanics, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan · Kent, Christopher, B., D.C.: Investigator, Research Department; Instructor in X-Ray, Anatomy and Chiropractic Science, X-Ray Department, Palmer College of Chiropractic, Davenport, Iowa. Klatzo, Igor, M.D.: Chief. Laboratory of Neuropathology and Neuroanatomical Sciences, National Insti­ tute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland Kleynhans, Andries M., D.C.: Chairman, Committee on Research, The National College of Chiropractic, Lombard, Illinois iii Korr, Irvin M., Ph. D.: Professor. Department of Biomechanics. College of Osteopathic Medicine, Michi­ gan State University, East Lansing. Michigan Lomax, Elizabeth, M.D., Ph. D.: Encino, California Magoun, Horace W .. Ph. D.: Professor Emeritus, Department of Psychiatry, School of Medicine, Uni­ versity of California at Los Angeles, Los Angeles, California Maigne, Robert, M.D.: Head, Physical Medicine and Rehabilitation Center, Hotel Dieu Hospital, Paris, France Martin, Peter Allen, D.C.: Director, Department of Continuing Education, Palmer College of Chiropractic, Davenport, Iowa Mazzarelli, Jospeh P., D.C.: Pennsauken, New Jersey McDowell, Fletcher H., M.D.: Professor of Neurology, Cornell University College of Medicine, New York, New York McElhaney, James H., Ph. D.: Professor of Biomeclwnics and Director of Graduate Studies, Depart­ ment of Biomedical Engineering, Duke University School of Engineering, Durham, North Carolina MennelL John McM., M.D.: Chief. Rehabilitation Medicine Service, Veterans Administration Hospital, Martinez, California. Associate Clinical Professor, Department of Physical Medicine & Rehabili­ tation, Univ. of California, Davis Miller, William D., D.O.: Acting Dean, The Postgraduate Institute of Osteopathic Medicine and Surgery, New York, New York Nachemson, Alf, M.D., Ph.D.: Professor and Chairman, Department of Orthopaedic Surgery, University of Goteborg, Goteborg, Sweden Northup. George, D.O.: Director. Center for Rehabilitation Medicine, Mesa General Hospital, Mesa, Arizona Ochs, Sidney, Ph. D.: Professor, Department of Physiology, Indiana University School of Medicine, Indianapolis, Indiana Patton, Harry D., M.D., Ph. D.: Professor and Chairman, Department of Physiology and Biophysics, School of Medicine, University of Washington, Seattle, Washington Perl. Edward R., M.D.: Professor, Department of Physiology, University o.f North Carolina, Chapel Hill, North Carolina Pleasure, David E., M.D.: Associate Professor, Neurology, Pediatrics and Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Pullella, Santo F., Ph. D.: Associate Professor and Chairman, Department of Physiology and Chemistry, Palmer College of Chiropractic, Davenport, Iowa Remington, Richard, Ph. D.: Dean, School of Public H ea/th, University of Michigan, Ann Arbor, Michigan Sato, Akio, M.D.: Head, 2nd Department of Physiology, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan Schaumburg, Herbert H., M.D.: Associate Professor, Departments of Neurology and Neuropathology, Albert Einstein College of Medicine, Bronx, New York Shapiro, Robert, M.D.: Chairman, Department of Radiology, Hospital of St. Raphael, New Haven, Connecticut; Clinical Professor of Radiology, Yale University School of Medicine Sharpless, Seth, Ph. D.: Professor of Psychology, Department of Psychology, University of Colorado, Boulder, C o/orado Suh, Chung Ha, Ph. D.: Professor and Chairman, Department of Engineering Design and Economic Evaluation, University of Colorado, Boulder, Colorado Sunderland, Sir Sydney, M.D.: Professor. Department of Experimental Neurology, University of Mel­ bourne, Parkville, Australia Tilley, Peter, 0.0.: Professor, Department of Radiology, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania Tower, Donald B., M.D., Ph. D.: Director, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland Wardwell, Walter I., Ph. D.: Professor of Sociology, Department of Sociology, College of Liberal Arts and Sciences, University of Connecticut, Storrs. Connecticut iv Weis, Edmund 8., Jr., M.D.: Division of Orthopaedics, Ohio State University, Columbus, Ohio West, Henry G., Jr., D.C.: Pocatello, Idaho White, Augustus A., Ill., M.D.: Associate Professor, Department of Orthopaedic Surgery, Yale University School of Medicine, New Haven, Connecticut Wymore, Andrew 8., D.C.: Osawatomie, Kansas

V Contents

Page CHAPTER I. INTRODUCTION, SUMMARY, AND ANALYSIS Murray Goldstein... 3 CHAPTER II. EVOLUTION AND DEVELOPMENT OF THE CONCEPTS OF MANIP- ULATIVE THERAPY Donald B. Tower, Chairman Manipulative Therapy: A Historical Perspective from Ancient Times to the Modern Era Elizabeth Lomax...... I I History of the Development of Medical Manipulative Concepts: Medical Terminology John McM. Mennell...... 19 History of the Development of Chiropractic Concepts; Chiropractic Termi- nology Joseph Janse...... 25 History of the Development of Osteopathic Concepts: Osteopathic Termi- nology George W. Northup...... 43 Discussion: The Impact of Spinal Manipulative Therapy on the Health Care System Walter I. Wardwell...... 53 Chairman's Summary: Evolution and Development of the Concepts of Manipu- lative Therapy Donald B. Tower...... 59 CHAPTER III. WHAT DO THE BASIC SCIENCES TELL US ABOUT MANIPULATIVE THERAPY? (ANATOMICAL AND BIOMECHANICAL STUDIES) Philip Greenman, Chairman The Vertebral Motor Unit and Intervertebral Foramen David C. Drum...... 63 Spinal Geometry: Normal and Abnormal Edmund B. Weis, Jr...... 77 Spinal Kinematics Augustus A. White, Ill and Manohar M. Panjahi...... 93 Biomechanical Aspects of Subl_uxation C. H. Suh ...... 103 Discussion: Anatomical and Biomechanical Studies James H. McElhaney..... 121 Anatomical Perivertebral Influences on the Intervertebral Foramen Sydney Sunderland...... 129 Pathology of Spinal Root Compression H. H. Schaumburg and P. S. Spencer... 141 Chairman's Summary: Anatomical and Biomechanical Studies Philip Greenman ...... I 49 CHAPTER IV. WHAT DO THE BASIC SCIENCES TELL US ABOUT MANIPULATIVE THERAPY? (NEUROSCIENCE STUDIES) Horace W. Magoun, Chairman Susceptibility of Spinal Roots to Compression Block Seth K. Sharpless...... l 55 The Somatosympathetic Reflexes: Their Physiological and Clinical Signifi- cance Akio Sato...... 163 Pain: Spinal and Peripheral Nerve Factors Edward R. Perl...... l 73 Discussion: The Importance of Neurophysiological Research Into the Principles of Spinal Manipulation Scott Haldeman...... 183 A Brief Review of Material Transport in Nerve Fibers Sidney Ochs...... l 89 Nerve Root Compression: Effects on Neural Chemistry and Metabolism David Pleasure...... 197 Discussion: Papers of Sidney Ochs and David E. Pleasure Irvin M. Karr...... 203 Chairman's Summary: Neuroscience Studies Horace W. Magoun...... 209 Summary of General Discussion: What do the Basic Sciences Tell Us About Manipulative Therapy? Harry D. Patton...... 213

vii Page CHAPTER V. WHAT DO THE CLINICAL SCIENCES TELL US ABOUT MANIPU- LATIVE THERAPY? (SUBLUXATION: PATHOPHYSIOLOGY AND DIAGNOSIS) Henry G. West, Chairman The Pathophysiology of the Spinal Subluxation Scott H aide man ...... 217 Pathophysiologic Evidence for the Osteopathic Lesion. Data on What is Known, What is not Known, and What is Controversial J. S. Denslow...... 227 Discussion: Papers of J. S. Denslow and Scott Haldeman Lyle A. French...... 235 The Role of X-Ray Findings in Structural Diagnosis Joseph W. Howe ...... 239 The Role of Static and Motion Palpation in Structural Diagnosis William L. Johnston ...... 249 The Role of Thermography and Postural Measurement in Structural Diagnosis Martin E. Jenness...... 255 Discussion: Comments on Subluxation -Pathophysiology and Diagnosis Robert Shapiro...... 265 Chairman's Summary: What do the Clinical Sciences tell us about Manipulative Therapy? Henry G. West...... 267 CHAPTER VI. WHAT DO THE CLINICAL SCIENCES TELL US ABOUT MANIPU­ LATIVE THERAPY? (THERAPEUTIC STUDIES) Andrew B. Wymore, Chairman 27 I Treatment of Pain by Manipulation James Cyriax...... 277 The Treatment of Pain by Spinal Manipulation Ronald Gitelman ...... A Critical Look at the Treatment for Low Back Pain Alf Nachemson...... 287 Treatment of Visceral Disorders by Manipulative Therapy William D. Miller... 295 Design of Clinical Trials Jerome Cornfield...... 303 Chairman's Summary: Comments on Therapeutic Studies Andrew B. Wymore... 307 Clinical Research Areas Requiring Further Study Fletcher H. McDowell...... 309

viii Chapter I.

Introduction, Summary, and Analysis

Murray Goldstein, General Chairman Introduction, Summary, and Analysis

MURRAY GOLDSTEIN Director, Extramural Activities Program National Institute of N eurologica/ and Communicative Disorders and Stroke National Institutes of H ea/th

As part of ttie Senate Report on the Fiscal Year including 16 Doctors of Chiropractic (D.C.), 24 1974 Appropriation for the National Institute of Doctors of Medicine (M.D.), 7 Doctors of Osteo­ Neurological Diseases and Stroke (NINOS) of pathic Medicine (D.0.), and I I basic scientists the National Institutes of Health (NIH), the (usually Ph. D.): seven of the aforementioned clin­ Senate Appropriations Labor-HEW Subcommittee ical participants were holders of both the Ph. D. specified that . . . "this would be an opportune and a clinical degree. Participants came from the time for an 'independent, unbiased' study of the United States and eight foreign countries. The fundamentals of the chiropractic profession. Such Workshop was open to representatives of other studies should be high among the priorities of the Federal agencies and to the public, with approxi­ NINOS . ... " mately 200 persons monitoring the discussions. In order to provide the substantive scientific The history of manipulative therapy is an ancient base necessary for this evaluation, the NINOS one with evidence of its use dating from Hippoc­ convened a "Workshop on the Research Status of rates. Through the ages, both orthodox physicians Spinal Manipulative Therapy." The Workshop and folk practitioners in Europe and the Middle was held at the NIH on February 2-4, 1975 and East wrote about and debated the usefulness of focused specifically on the documentation and manipulation, particularly for the treatment of evaluation of research results and clinical investi­ actue back pain and for "spinal curvatures" (i.e., gative experience. Spinal manipulative therapy kyphosis and scoliosis). By the late I 9th century, was chosen as the theme of the Workshop since it most of the basic concepts and clinical principles is the primary therapeutic modality of chiropractic of modern day usage had been formulated and and would serve as a base for evaluating the documented. It seems probable that the genesis scientific data about the fundamentals of chiro­ of the modern theory and practice of manipulative practic including the anatomy and pathophysiology therapy as used by chiropractors, osteopathic of subluxation and methods of chiropractic diag­ physicians and medical physicians arose from nosis and therapy. The Workshop agenda included concepts generally acceptable to many eminent a detailed review of the history of manipulative 19th century medical practitioners and scientists therapy and discussion of the scientific issues of since it was during this period that the role of the spinal geometry and kinematics, the intervertebral spinal cord in health and disease was being vig­ foramen, spinal root compression, spinal root and orously explored and discussed. Since that time, peripheral nerve pain, the pathophysiology of back however, the three contemporary clinical profes­ pain, the concept of spinal vertebral subluxation, sions utilizing manipulative therapy (M.D., D.O., the clinical diagnosis of subluxation, and the evalua­ D.C.) have developed in relative isolation from one tion of the efficacy of spinal manipulative therapy. another. Each group evolved primarily in a clinical Workshop participants included 58 scientists setting with a self-generated terminology specific and clinicians of national and international stature, to the history of the clinical school. Individuals 3 from each clinical school of therapy have crossed by scientists and clinicians. However, more con­ professional lines as students and as instructors, troversial is the hypothesis that somatic disorders but this has usually been done in secrecy; if done reflexly influence visceral function through somato­ openly, it usually resulted in professional criticism. sympathetic reflexes. A relatively small but sound As a result of this isolation, a major problem of body of data is evolving that gives credence to the present is the difficulty of sharing clinical this hypothesis. However, data were not presented experiences and scientific results because of self­ which substantiate a direct relationship between developed terminology and continued inter-pro­ manipulative therapy and clinical improvement by fesional isolation. means of influencing segmental neuronal inter­ Review and discussion of spinal biomechanical actions. "Spinal man'' -the paraplegic and tetra­ and anatomical research demonstrate these to plegic - provides a useful model for examining the be ongoing areas of scientific interest and pro­ role of spinal viscero-somatic and somatico-vis­ ductivity. Many of the more recent biomechanical ceral reflex~s and pathways. studies have focused on the consequences to the Back pain continues to be a clinical problem human spine of the biped erect stance and the con­ affecting large numbers of people. Acute back pain sequences of trauma, particularly in association can result in complete immobilization; chronic with rapid acceleration or deceleration. These back pain at the least is a continuing irritant and problems have given emphasis to the need for at the worst leads to physical incapacitation and mathematical and mechanical studies to provide to emotional degeneration. Most tissues have no­ methods for three-dimensional, quantitative de­ ciceptors, the stimulation of which often is experi­ scriptions of the complexity of normal spinal enced as pain. The mechanisms underlying the most biomechanics. The anatomy of the intervertebral generally recognized causes of back pain are foramen is now quite well documented and the reasonably well understood and include visceral dynamic relationships of the para- and interver­ disease (e.g., renal pathology), intervertebral disc tebral structures are being elucidated. The roles herniation, dislocations and fractures; however, of paravertebral supportive, vascular, and inner­ ligamentous and capsular pathology and intra­ vate tissues are becoming clearer, demonstrating articular displacement are thought to be causes the dangers of traction and manipulation, particu­ of the more common type of back pain, but these larly to vascular and neural elements. However, hypotheses suffer from lack of substantive evi­ despite attempts to describe "subluxation" bio­ dence. Questions posed during the Workshop mechanically and anatomically, present data lack include: How do mechanical forces bring about the reliable quantitative precision and qualitative long-term discharge of nerve fibers? What is the reproducibility. origin of the neural discharge? Where are the A review of studies of the pathophysiology and receptors? This unclear situation is reinforced pathology of spinal root compression is character­ by the paucity of fundamental information about ized by the lack of available data. The spinal root the mechanism of pain per se. Recent research and its pathology have not been areas of widespread opportunities generated by the interest in and clini­ research interest. Available data are primarily cal use of dorsal column stimulation and acupunc­ focused on issues of gross injury secondary to ture may help to improve the conceptual framework major trauma or significant bony or cartilaginous necessary to approach the problem(s) of the impingement. The role of more subtle ··pressure" treatment of pain, but pain continues to be a poorly or entrapment of specific types of nerve fibers in understood phenomenon. The presently available the spinal root is just being explored, as are the evidence indicates that we do not yet understand effects of metabolic changes in the neuron on the cause or pathophysiology of many cases of peripheral and autonomic functions; this latter back pain. The several theories presented are area of research, the cellular metabolism of the conceptually viable, some are scientifically attrac­ neuron, includes some of the most exciting ex­ tive, but all remain unsubstantiated. plorations in modern neuroscience and is being A definition of the chiropractic subluxation was pursued vigorously in laboratories in this country offered as: "an alteration of the normal dynamic, and abroad. The phenomena of referred pain and anatomical or physiological relationships of con­ of reflex somatic and visceral dysfunction second­ tiguous articular structures." Etiologic (e.g., ary to visceral disorders are generally accepted traumatic, inflammatory, reflex, etc.) symptomatic 4 (e.g., fixed, hypermobile, painful, etc.) and patho­ ·•... l will prescribe regimen for the good physiologic (e.g., primary, secondary) character­ of my patients according to my ability istics of the "nidus" were presented. To avoid and my judgment and never do harm to semantic misunderstandings, the term "nidus," anyone .... " meaning focus of a morbid process, is used to incorporate the various clinical terms used by the The modem therapy for essential hypertension, several professions. The use of specific adjustive stroke, cancer, the common cold-and back pain - thrusts and the general techniques of spinal manip­ fall within these guidelines for the treatment of ulation were described as methods for the reduction disorders of unknown etiology. Several empiric of positional abnormalities (subluxations), increas­ therapies including spinal manipulative therapy ing movement at a "locked joint" and/or the are suggested for the relief of back pain within the "reduction" of disc lesions, with each therapeutic concepts of the Hippocratic Oath, an ethic funda­ maneuver requiring the attainment of motion mental to all schools of the healing arts. between vertebral segments to achieve its goal. The Workshop did not directly address the The evidence for the pathophysiologic consequen­ issue: Does spinal manipulative therapy do harm? ces of the proposed ''nidus" remains unclear. There are no experimental studies or controlled The etiology of disc disease is still not completely clinical trials of which the NINCDS is aware, understood and the chain of events resulting in documenting the evidence for injury. There are pain and incapacity is surmised rather than individual case reports in the literature document­ demonstrated. Because· of their rich sensory in­ ing specific instances of misdiagnosis~ poor clini­ nervation, the posterior spinal articular face(s and cal results and serious and occasional lethal their associated ligaments are suggested by some aftereffects of spinal manipulative therapy - as as a "nidus" for back pain and the locus of the there are for most modes of diagnosis and therapy subluxation phenomenon. Flexion and/or rotation offered by all clinical disciplines and all clinical subluxations are described in anatomical and bio­ professions. The clinical research issue which the mechanical terms, but their pathophysiologic subsequent sections of the Workshop did address effects on spinal roots, paravertebral tissues, is: Does spinal manipulative therapy do good? interarticular capsules or segmental neural trans­ The applicability of spinal manipulation hinges mission are presented as hypotheses rather than on the precision of the diagnosis of the underlying the results of experimental studies. The lack of a pathology described variously as a "subluxation" relevant and reproducible animal model may be by chiropractors, as an "osteopathic lesion" by one important obstacle to clarification of these osteopathic physicians and as an ·•intra-articular issues. The pathophysiologic role of subluxation displacement" by some medical physicians. The as a cause or concomitant of organic disease (e.g., clinical skill of palpation is offered by each as a diabetes mellitus) was not presented or discussed. major diagnostic tool. Palpation is used clinically Like the biomedical evidence for the cause of back to: localize the anatomical site of the "nidus"; pain in general, the evidence for the chiropractic describe its anatomic properties; identify its static subluxation is inferential rather than experimental, and dynamic biomechanical characteristics: evalu­ the scientific references being selected from a ate paraspinal tissue '"texture": and elicit pain or broad and dispersed literature: however, the evi­ discomfort. Like most techniques of physical dence at this time for disqualification of the diagnosis including the other classical diagnostic hypothesis also is inferential. Thus, subluxa­ techniques of inspection, percussion and ausculta­ tion remains a hypothesis yet to be evaluated tion, palpation often is described as a skill passed experimentally. from teacher to student, with the interpretation of At this point, a word of caution is needed about findings based on clinical experience. Other than interpretation of the preceding paragraphs. Many clinical and often anecdotal experience, no evi­ physical and emotional disorders of man are not dence was presented attesting to the specific relia­ understood etiologically or pathophysiologically; bility of palpatory findings in accurately describing despite this, society demands relief. Historically, the anatomical or biomechanical characteristics physicians have provided therapy based on of the "nidus," or its paraspinal or painful proper­ empiricism and accumulated experience guided by ties. Studies were reported and data reviewed about that portion of the Hippocratic Oath that pledges: both electrophysiologic and sudatory changes 5 associated with palpatory findings; However, dis­ studies or from controlled clinical trials were pre­ cussion suggested that these findings are more sented for or against therapeutic efficacy for low significant at this time as experimental tools than as back pain. The NINCDS is aware of a recent clinical techniques. The Workshop presentations population study in the United States demon­ and discussion indicated a lack of evidence about strating equal results in overall outcome when chiro­ the interexaminer reliability of palpatory findings. practic and conservative medical management of Also, there was a paucity of evidence correlating low back pain were compared; however, the study palpatory with other diagnostic or pathological suffers from the problems of a research design studies relevant to the "nidus.'' However, skilled based upon retrospective case history analyses. A clinicians claimed they could accurately differ­ prospective study of manipulative therapy is re­ entiate by palpation between the presence or ported to be in progress in Great Britain but no absence of a "nidus." The lack of data about the data were available. Preliminary data were offered adequacy of palpatory findings needs considera­ from a controlled clinical trial of manipulative tion in the context of the status of similar types of therapy in the treatment of chronic obstructive experimental information about most classical pulmonary disease now in progress. The data physical diagnostic techniques. suggest but do not establish improvement in pul­ The presentations on X-ray examination of the monary function; however, patients claim subjec­ patient with a suspected "nidus" polarized dis­ tive improvement in work capacity. cussion. Those utilizing X-ray examination for this During general discussion, there was a plea for purpose presented slides and quoted references precise definitions of terms (e.g., subluxation; attesting to the efficacy and safety of this diag­ clinical improvement) so that communication could nostic technique: others just as authoritatively be even more meaningful in the future. It was also presented slides and quoted references attesting suggested that precision of terminology would to the inaccuracy and dangers of using the tech­ provide a base for focused investigations, com­ nique for this purpose. No evidence utilizing con­ parisons of results and cooperative efforts among trolled retrospective or prospective trials was investigators. presented; no animal data were presented. The The NINOS Workshop on the Research As­ issues of efficacy and safety remain unresolved pects of Spinal Manipulative Therapy and staff after the presentations and discussions. If the review and analysis of available data clearly indi­ intensity of the discussion is an indication of the cate that specific conclusions cannot be derived priority of this subject for focused investigative from the scientific literature for or against either attention, it would receive a priority score of I on the efficacy of spinal manipulative therapy or the a decreasing scale of I to 5. Other "objective" pathophysiologic foundations from which it is diagnostic modalities were also presented but derived. The efficacy of spinal manipulative therapy stimulated minimal discussion; included were ther­ is based on a body of clinical experience in the mography, electromyography, the spinogram and "hands" of specialized clinicians. Chiropractors, techniques for evaluating posture. osteopathic physicians, medical manipulative The evidence for the efficacy of spinal manipu­ specialists and their patients all claim spinal lative therapy in the treatment of pain, particularly manipulation provides relief from pain, particularly low back pain and neck pain, was discussed in back pain, and sometimes cure; some medical great detail. Three types of evidence were pre­ physicians, particularly those not trained in manipu­ sented: case histories; clinical experience; infer­ lative techniques, claim it does not provide relief, ence. Established and prestigious medical and does not cure, and may be dangerous, particularly osteopathic physicians and chiropractors provided if used by nonphysicians. The available data do testimonial evidence in support of the efficacy and not clarify either view. However, most partici­ safety of manipulative therapy. This was held to be pants in the Workshop felt that manipulative true for properly diagnosed cases of both acute and therapy was of clinical value in the treatment of chronic pain. Orthopedic and neurological surgeons back pain, a difference of opinion focusing on the found the evidence unconvincing and by inference issues of indications, contraindications and the from other diseases of spinal structure, patho­ precise scientific basis for the results obtained. No physiologically unacceptable. Again, polarity of evidence was presented to substantiate the useful­ discussion occurred. No data derived from animal ness of manipulative therapy at this time in the

6 treatment of visceral disorders. reimbursements and professional perogatives were Biological and medical research focused on the turned aside at the Workshop as unacceptable bases issues of the biomechanics of the spine, kinesiology, for biomedical scientific exchange. spinal reflexes and pain are all areas just beginning Thus the Department of Health, Education, and to recapture the interests and attention of the Welfare needs to consider both chiropractic and scientific community. This is a reflection of the manipulative therapy from the viewpoints of strat­ development of a cadre of investigators technically egy and priority. The fundamentals of chiropractic prepared to design meaningful experiments in and of the other schools of manipulative therapy these areas, the availability of new technologies are founded on a century of clinical experience. and instrumentation providing methods for quanti­ There are little scientific data of significance from tative measurement, and the availability of re­ which to evaluate this clinical approach to health search grant funds through the competitive research and to the treatment of disease. An obvious strat­ grant programs of the NIH. Moreover, a body of egy would be the fostering of biological and clinical experience is now available for the development research so that answers to the questions of clinical and conduct of controlled clinical trials of diagnosis indications and therapeutic efficacy of manipula­ and therapy; these are expensive undertakings tive therapy can be approached more meaning­ requiring the investment of the coordinated efforts fully. The issue of priority is a more difficult one. of scientists, biostatisticians, clinicians, patients With limited national resources for research and and administrators over relatively long periods of research training, what relative priority should be time. Yet controlled studies provide the only placed upon this targeted area? Should funds and scientific means presently available for the solution personnel presently assigned to other research of the clinical research issues identified in this areas be reassigned? Should additional research analysis. funds be made available specifically for this area? Fi nail y, the Workshop represents the beginnings Should research on chiropractic and manipulative of an interprofessional dialogue among chiro­ therapy compete on scientific merit with other practors, physicians and biological scientists on the areas of research for funds already available for "neutral" and commonly-shared issues of science biomedical research? The answers to these issues and research. I nterprofessional rivalries charac­ of health policy will determine the scope and in­ terized by the issues of accreditation, licensure, fee tensity of the research effort.

7 Chapter 11.

Evolution and Development of the Concepts of Manipulative Therapy

Donald B. Tower, Chairman

597-036 0 - 76 - 2 Manipulative Therapy: A Historical Perspective from Ancient Times to the Modern Era

ELIZABETH LOMAX N euro-Psychiatric Institute The Center for the Health Sciences Los Angeles

This brief survey of manipulative therapy will Such extension would do no great harm, if serve as an introduction to the authoritative pres­ well arranged, unless one deliberately entations to follow. For the sake of conservation wanted to do harm. The physician, or an of time, and in light of an abundant history, I shall assistant who is strong and not untrained, skim the ancient and medieval periods, and concen­ should put the palm of his hand on the trate on more recent events. 1 Yet the classical hump, and the palm of the other on that, texts surely deserve further attention if only to to reduce it forcibly, taking into considera­ decide whether the Greeks merely attempted to tion whether the reduction should natu­ reposition vertebrae displaced through violence, or rally be made straight downwards, or to­ whether they actually performed manipulations of wards the head, or towards the hip. This slightly luxated vertebrae as therapy for a wide reduction method is also very harmless: variety of dysfunctions. The latter opinion, which indeed, it will do no harm even if one sits transforms chiropractic as enunciated by D. D. on the hump while extension is applied, Palmer into a literal rediscovery of ancient practice, and makes succussion by raising himself: has been advanced by Dr. Kleanthes A. Ligeros of nay, there is nothing against putting one's Greece in a book published in 1937.~ I hardly dare foot on the hump, and making gentle argue with a native, but Ligeros does seem to have succussion by bringing one's weight upon read more into the Hippocratic writings than is it.4 obvious to the outsider using translations. Even more effective was the use of a piece of In conventional interpretation, Hippocrates dis­ wood as a lever with which to apply pressure on the tinguished between incurable humpback due to hump beneath. disease and posterior curvature caused by a fall, for which reduction though rarely successful might Later authors such as Galen, Celisus, and be attempted.:i However, he disapproved of the Oribasius, gave essentially the same advice, but, popular method of succussion head down from a by the sixth century A.D., spinal curvature was ladder, not because this treatment seemed un­ also being treated by means of open wounds or natural but because it had been abused: "It is dis­ eschars, induced on either side of the deformity. 5 graceful in any art, and especial(~1 in medicine, to The treatment of pain by invoking local suppura­ make parade of much trouble, display, and talk, and tion was favored by Arab physicians and, as we then do no good." Instead he recommended com­ shall see later, again used extensively in the late bined extension and pressure, exerted on the 18th century. Such treatment was compatible with patient lying prone on a wooden bed. To quote: the humoral theory of disease, but whether in this I I instance its use was an Arab innovation, or one graduate of Edinburgh University in 1784. His derived from Hellenistic sources, I have been career was unusual, even whenju~ged by the stand~ unable to discover. Certainly the extension method ards of his time. 13 In the late 18th century, he was not lost, for it was again expounded at length studied in Paris, a city which apparently then by Albucasis in the I 0th or 1 I th century, and by abounded with institutions for the cure of spinal Guy de Chauliac in the 14th century. 6 distortion. Many methods were used, including Luxations of the spine were discussed in some traction and kneading of the hump, much to the detail by the great French barber-surgeon, Am­ horror of scrofula conscious British critics. 14 -broise Pare. He was not at afl "in favor of tying Later Harrison spent a couple of decades as patients to ladders and dropping them from roof medical practitioner in Lincolnshire, a county then tops, but otherwise his methods of restoration famed for its numerous bone-setters and empirics. 1'> differed little from those described by the ancients! All in all he had plenty of opportunity to learn the What he added was the steel corset to support the art of spinal manipulation. back after manipulation, and the apparently novel In 18 I 7 Harrison came to London. In 1821 he suggestion that much chronic deformity was caused began writing a series of articles for the London by faulty posture during childhood rather than by Medical and Physical Journal entitled: "Observa­ luxation secondary to injury. The same theme was expounded two centuries later by Nicholas Andre tions respecting the Nature and Origin of the com­ mon Species of Disorders of the Spine: with who, as explained by Bick, synthesized the term Critical Remarks on the Opinions of former Writers "orthopaedia" "from the Greek roots orthos on this Disease." Having delivered the necessary (straight) and paidos (child), to express his belief in attack on the views of Pott, Harrison expressed the theory that many of the deformities of adoles­ his own as follows: cence and adult life originate in childhood. " 8 Curvature of the spine could be avoided by atten­ According to this view of the subject, we tion to posture and exercise during youth. Once must direct our attention to some other deformity had occurred Andr~, like many of his tissue to discover the true cause of spinal contemporaries, recommended rest, head suspen­ complaints; and I am of opinion that we sion, and the wearing of corsets whenever shall find it in the connecting ligaments, 9 ambulant. "which seem to have lost part of their Following Percival Pott's pronouncement that power of holding the bones together." caries of the spine was far commoner among young These get relaxed, and suffer a single children than ever previously suspected, many vertebra to become slightly displaced. The physicians went to the extreme of diagnosing all column now losing its natural firmness, cases of early scoliosis or lordosis as due to other bones begin to press unduly upon 10 scrofula. These they treated by rest and by creat­ the surrounding ligaments: they, in turn, ing local discharge through the use of issues, while get relaxed and elongated, by which the condemning extension and manipulation as both dislocation is increased and the distortion useless and dangerous. permanently established. The direction By the beginning of the 19th century, a plethora becomes lateral, anterior, or posterior, of literature existed on disorders of the spine, but according to circumstances: but the absolutely no consensus as to differential diagnosis malady has in every instance the same and treatment. Some. including Shaw, and Dods, origin, and requires the same mode of thought that muscle weakness was the prime cause cure.rn of deformity, and therefore recommended either complete rest or active exercise. 11 Others im­ Thus, the mischief did not originate in the verte­ plicated the vertebrae, as being carious or simply brae, as taught by Pott, nor in the cartilage as too soft. and treated everyone with rest and induced suggested by others, but in the ligaments. For this local ulceration. Each group produced numerous reason people often recovered, an impossible out­ case histories to support its contentions, and all come if the more serious pathology were indeed indulged in polemics to silence any opposition. 12 present. Harrison was full of optimism for the Even in this atmosphere some still prescribed prospects in early cases, so long as his system was manipulation, for example Dr. Edward Harrison, a employed. Usually he was none too clear about the 12 actual treatment applied but. on one occasion, gave pen. We are positively ashamed (if it will the following account: be believed that a REVIEWER can have The patient, being placed upon a couch, any sense of shame) to record such a as usual, had her back and chest well passage from the writings of a physician rubbed with an emollient liniment for more of the present period, on our pages. But than an hour, while the spine was stretched the above extract will characterize the in the machine formerly referred to. It is book under review, better than any thing constructed of steel, upon the principle of which we would say. The pathology is the windlass of a ship, and fixed to the erroneous- the practice is, for the most bottom of the crib. By means of soft part, concealed- and the plates are more leathers surrounding the arms, and con­ calculated to frighten the GENERAL nected with the top of the couch, and other READER than to convey any information to the MEDICAL PRACTITIONER. leathers attached to the ankles, which are fixed to the machine, almost any degree Two added factors probably contributed to of stretching may be safely resorted to, by official disapproval of Harrison. First, he had turning the roller of the machine, provided developed a lucrative practice in London, having the force be gradually increased. The established a clinic favored by many English dig­ prominent vertebrae and ribs were then nitaries and even by the Queen.:! 0 Second, since pressed, and driven in the direction of 1804, while in practice in Lincolnshire, he had their natural situations, with an instrument become leader of a movement for medical reform, held in the right hand. . . . I formerly particularly reform of the antique statutes of the used my thumbs only for pressure: but, Royal College of Physicians which prevented finding the other contrivance much more anyone not a graduate of Oxford or Cambridge powerful and easier to be borne, I have from practicing medicine within seven miles of for a long time given it the preference. A the city of London. A low-grade battle rumbled on firm bandage was afterwards fastened until 1827, when the College summoned Harrison round the chest, to prevent the bones from to give an account of himself and obtain the returning. This bandage being adjusted, required license. This he refused to do, so the she was laid flat upon the back, and College prosecuted him for illegal practice. The directed to remain constantly in the same case came to court in I 828: Harrison defended position. 17 himself on the ground that he had been practicing surgery not medicine and, although this was These manipulations were repeated daily for about patently untrue, the jury found in his favor. From 3 weeks, by which time, according to our author, then on he worked unmolested in London until "the contour of the spine was entirely restored." his death in 1838.:!1 In 1827 Harrison wrote a popular book on the For such reasons Harrison was probably the subject. 18 On the whole this met with professional most notorious British physician to advocate disapproval mainly, it would seem, because the and use manipulation in the treatment of spinal doctrine of vertebral luxation and consequent need disease. But he was not the only one. In 1824 for manipulation was taboo. The M edico-C hirurg­ Andrew Dods had published his Pathological ical Review began by expressing veiled criticism: Observations on the Rotated or Contorted Spine, "God forbid that we should impute to Dr. Harrison, etc., in which he argued that the immediate cause or to any other doctor, the remotest idea of char­ of deformity was "a peculiar affection of the latannerie: but we do believe that it would be muscles of the back" whose "perverted action" led difficult to devise a system better adapted to the to rotation or twisting of the spine.'.!2 Treatment practice of that art, than the spinal pathology here was mainly prophylactic-plenty of exercise for delineated." 19 It ended its review article much children of both sexes - but once the condition was more expressively: established, both friction and manipulation had a After this specimen of the "bolder flight" part in treatment. which Dr. Harrison has taken from the In his popular work On Spinal Weakness and low ranks of his brethren, to the GEN­ Spinal Curvatures, published in 1868, W. J. Little ERAL READER we must lay down the favored both Dods' theory of spinal rotation and 13 the proposition that manipulation had a place in exercises which she then imposed. She believed therapy. Since Little was an important figure that spinal curvature was often caused by slight among mid-century London orthopedists, his displacements of various parts of the body. "which opinion will be quoted at length: were produced. in some instances. by convulsions in infancy. and in others through sudden jerks and During recumbency, manipulations may falls. " 25 The British and Foreign Medico-Chir­ with great advantage be resorted to. Very urgical Review did not think much of her explana­ superficial observation of the beneficial tions, but at least reviewed her book, in company effects of attempting to press the spinal with three others on deformities written by two column into a straighter direction will, Fellows and one Member of the Royal College of unless the patient be much advanced in Surgeons. 26 life, encourage the patient and her friends Such recognition was not usually given to tradi­ to persevere in a proper and sedulous use tional bone-setters. but, by the last third of the I 9th of this means. century, this attitude was beginning to change. The person employed to effect these Early in I 867. the British Medica/Joumal reported manipulations needs to be expressly James Paget's lecture: "'On the cases that bone­ taught in what manner they· can be most setters cure." a lecture in which he warned his advantageously carried out. The surgeon professional listeners that they should pay atten­ can impart the necessary instruction by tion to the activities of empirics, if only to avoid showing where the pressure and counter­ losing patients. 27 More complimentary to bone­ pressure upon the several curves require setting was a series of articles on the subject written to be made. Dr. Harrison, a well-known by Wharton Hood for the Lancet of 1871.28 This practitioner thirty years ago, adopted a orthopedist confessed himself most impressed by peculiar means of endeavouring to press the skills of a famous bone-setter. Mr. Hutton. with the rotated spinous and transverse proc­ whom he had actually worked as an assistant, esses into a more favorable position. The "I was astonished," he wrote. "and often no less instrument used by him resembled that mortified, at the number and variety of instances which is sometimes employed to compress in which the manipulations I have endeavoured to the subclavian artery above the clavicle. describe were followed by almost immediate Although the attempt to effect the object cure. " 2!' These articles were followed by a popular he had in view appears at first sight futile, book on the subject, and Hood's persistence· the reiterated pressure upon particularly seems to have paid off, at least to the extent that projecting parts of vertebrae is fairly a discussion on bone-setting was held at the indicated, and is not unattended by fiftieth annual meeting of the British Medical 2 benefit. a Association in 1882. 30 Manipulation was one of a battery of therapies However, I must hasten to add that bone-setting advocated by Little for lateral curvatures of the was not exclusively practiced in the British Isles. spine. He differentiated this condition from the In the United States, by the mid-I 9th century, the more serious angular curvatures, caused by male members of the Sweet family of Rhode Island necrosis, caries, inflammation or rheumatism of and Connecticut were reputed to possess a hered­ the vertebrae, which were to be treated only by itary skill in bone-setting. According to a skeptic, rest or fusion. "the beginning of this strange delusion happened Dods had at least one other disciple, a Mrs. in South Kingstown, in the State of Rhode Island, · Godfrey of Liverpool, who carried on a business more than one hundred years ago." at More about originated by her husband, a "medical man." The the family and its abilities may be learned from fruits of her spinal practice, and her faith in divine An Essay on the Science of Bone Setting, published providence, were expressed in a book first pub­ in 1829?2 Here the author, Waterman Sweet, set lished in 1851.24 The treatment consisted not of out to prove that surgery and anatomy were "friction," nor of "'shampooing," but of manipula­ intuitive sciences only intelligible to those who had tion, although .. not such as that which has been a talent for the profession, and were divinely previously performed." Rather, careful manipula­ endowed with sufficient ability and the capacity tion was used to prepare the muscles for special for hard work. His own mastery of the art was 14 illustrated by numerous case histories of successful amblyopia, nervous fevers, cough, dyspnoea, manipulations of peripheral joints. Apparently he pleuritis, colic, vomiting, disorders of menstrua­ had a thriving practice in spite of "evil reports" tion, hysteria, asthma and diabetes.ali In any case circulated by doctors and others. As mentioned the diagnosis could be clinched by finding tender­ above, the family was still doing well in the mid- ness of the appropriate vertebrae, i.e. those from 19th century, but I have not been able to follow which emerged the spinal nerves, or beneath which its fortunes further. lay the sympathetic ganglia, whose dysfunction Before concluding this survey, reference should might reasonably account for the prevailing be made to other early 19th century concepts symptoms. pertinent to the later emergence of osteopathy and The treatment was to apply irritants, such as chiropractic. A novel development was the genera­ blisters, leeches, and cauteries, to the tender dorsal tion of intense interest in functions of the spinal point. Today we may be amazed that such heroic cord. Since Galenic times, this structure had been measures could still be advocated in the eighteen. considered merely as a conduit for nerves linking thirties and forties, until we remember that the the brain with the periphery. But following the humoral theory of disease still prevailed. 37 Given enunciation of the Bell-Magendie law, and of this viewpoint the aim was to confine the disease Marshall Hall's theory of reflex action, pathology by local depletion and blistering, and so effect a of the spinal cord was suddenly heralded as the cure. Even harsher measures were at hand should obvious cause of much disease of previously general inflammation and fever appear, but, ac­ unknown origin. To the fore came a new clinical cording to contemporary reports, local irritants entity, "spinal irritation," which embraced a variety were usually very successful, leading to speedy and of nervous symptoms, so long as one diagnostic complete recoveries. sign could be elicited- tenderness on pressure over the vertebral spines. Excellent accounts on the According to Francis Schiller, Andrew Taylor history of the growth of this idea have been given Still was probably influenced by the doctrine of by the American neurologist William Hammond in spinal irritation which continued to have eminent 38 his 187 I Treatise on Diseases of the Nervous supporters until the end of the century. The System, and, more recently, by the historian and founder of osteopathy was probably revolted by neurologist, Francis Schiller, in an article entitled: the style of therapy described above, which fortunately was rapidly becoming obsolete by mid­ '"Spinal Irritation and Osteopathy." 3:1 In 1828 Dr. Thomas Brown of Glasgow coined century. In addition, the pathology of spinal ir­ the term "spinal irritation," although he was not ritation was pertinent, especially as expounded by the first to suppose that subacute disease of the William Hammond in 1871. This neurologist cord could precipitate a plethora of nervous com­ attributed the symptoms to anemia of the posterior plaints. From then onwards this diagnosis became columns of the spinal cord, and proposed as treat­ very fashionable, to be used by such prominent ment the application of direct galvanic current, physicians as Cruveilhier of Paris and Corrigan of with the negative pole at a point above the seat of Dublin.: 14 Indeed the latter considered the discovery pain, and the positive at another, an equal distance to be "the greatest improvement in practical medi­ below.au cine" that had taken place within his recollection. It can therefore be argued that at their genesis, "Other improvements may have been more bril­ both the theory and the practice of osteopathy and liant, but there has been none so useful." Nor dicl it chiropractic depended upon concepts acceptable take long before "spinal irritation" found its way to many eminent 19th century medical practitioners. across the Atlantic. Beginning in 1832 with an This fact has become blurred since such doctrines, article by Dr. Isaac Parrish of Philadelphia, The i.e. spinal irritation, have been abandoned by American Journal of Medical Sciences repeatedly medical scientists. If it is remembered that a carried reports on diagnostic progress both in this century ago the cord was visualized as the center country and in Europe. :15 for the multiplicity of functions, and even by some Taken in toto it would appear that there were few psychologists as the locus of a "spinal soul," one morbid phenomena which could not result from can regard the beginnings of osteopathy and irritation of the spinal marrow. The following is a chiropractic as legitimate offsprings of contempo­ list of possible manifestations: mania, vertigo, rary thought: 10 15 REFERENCES 15. Harrison, E., in: An Address delivered to the Lincolnshire Benevolent Medical Society at their Anniversary Meet­ I. A fuller treatment and bibliography of ·the history of ing i11/809 (London, R. Rickerstaff, 1810), p. 7, stated manipulative therapy may be found in: Eiler H. Schiotz, that after circulating printed queries it was found "that .. Manipulation treatment of the spinal column from the in Lincolnshire Empirical pretenders exceeded the medical historical viewpoint," Tidsskr Nor Laegerforn, regular Faculty, in the proportion of nine to one." 78, 359-372, I 958. (NIH Library translation available.) 16. Harrison, E., "Observations Respecting the Nature and 2. Ligeros, Kleanthes A., How Ancient Healing Governs Origin of the Common Species of Disorder of the Spine: Modern Therapeutics (New York, G. P. Putnam's with Critical Remarks on the Opinions of former Writers Sons, I 937.) on this Disease," London Med. & Phys.J.,45, 103-122, 3. Hippocrates, Hippocrates, with scientific method," Bull. Hist. Med., 35, 1-13, Soul is discussed by E. G. T. Liddell in The Discovery 1961. of Re.flexes (Oxford, Clarendon Press, I 960), pp. 60-87.

17 History of the Development of Medical Manipulative Concepts; Medical Terminology

JOHN McM. MENNELL Chief, Rehabilitation Medicine Service Veterans Administration Hospital Martinez, California

Some in this audience are leaders in the con­ know what I am doing, but it is surprising how temporary development of medical manipulative often it works." concepts. Fundamentally our contributions parallel When we ask what is meant by spinal manipu­ each other. However, there are areas in which we lation, we find the following nonspecific terms in find ourselves in some disagreement, particularly use which do not mean very much scientifically: when we address ourselves to spinal manipulative The bone-setters by their treatment put a little therapy- the topic of this meeting. bone back in place~ the chiropractors treat nerve I am at a loss to discuss a single modality of pressures by correcting subluxations: the osteo­ therapy. I feel that such a discussion is pretty paths treat the osteopathic lesion which impairs meaningless unless we know what we are treating, the circulation. James Cyriax and I had fathers why we are treating it, how to use modality and, who were leaders in the development of medical above all, when we should not use it. This leads manipulation. Those who followed the Senior to what is perhaps the more important part of my Mennen and the Senior Cyriax initially treated a presentation - medical terminology. loss of involuntary movements in joints. Later I find historically that there are significant when disc lesions became fashionable, the Junior problems in discussing manipulative therapy even Cyriax manipulated discs while I maintained the among those who practice it. It is not surprising belief that the only structure which could be moved then that we find difficulty in expressing to others manipulatively was a synovial joint. More recently, what we are talking about. in Europe, it has been suggested by Wolf that Watson-Jones has written that there is no place manipulation frees blockage of spinal synovial for manipulation in orthopedic practice. In con­ joint movement by freeing an intra-articular men­ trast, Wiles has published that manipulation should iscus (in 1974 he suggested that it is meniscoid always be tried before any operation for back pain material) within a joint. Maigne leads a European is undertaken. Neither of these authorities describe school of thought that manipulation releases an what they mean by manipulation. intervertebral mobile segment. For the most part Recently I asked an orthopedic surgeon in charge manipulators in Scandanavia and Europe work of a large residency training program what he according to the osteopathic concept. In the para­ really thought about manipulation. I did not say medical field, Paris, a physical therapist, talks of "spinal manipulation" yet that is how he heard manipulators in Scandinavia and Europe work my question. Paraphrasing his reply he said: "I born, teaching physical therapists, infer that they use it. I twist people around and I really don't are treating joints. But the teaching physical 19 therapists cloud the issue by talking about degrees ( 1) Intrinsic joint trauma, of manipulation using such terms as articulation (2) Immobilization which includes therapeutic and mobilization leading up to manipulation. immobilization. disuse and aging, Where does all this leave us? The implication (3) The healing of some more serious patho­ is that no two people understand what the other logical condition in the musculoskeletal is communicating. Manipulation is used to mean system. anything from the most gentle examining move­ The development of medical manipulative ment through the reduction of a dislocation, the concepts has been held up by three major problems. setting of a fracture to a gross assault on an uncon­ The first problem is language. which I have already scious patient. If medical endeavors were as discussed. The second problem is perpetuated by inexact as medical terminology, we would be in the fact that this conference focuses on spinal the dark ages of vapors and humors, bleeding and manipulation. The third problem is the belief held purging. by many that the pathological causes of pain in That is how manipulation stands today. I think the back are different from those which cause pain it unnecessary to labor this topic of terminology in the extremities. further. Unless we can somehow arrive at a com­ As a result of these problems it is not surprising mon language which does not infringe upon the that the development of manipulation is clouded basic medical sciences, I cannot,..see how we will with prejudice, bias, and ignorance. communicate successfully. The only well-documented history of the I therefore offer the language which I have been development of medical manipulative concepts in attempting to establish for many years with, I the first half of the 20th century comes from my believe, some success. I urge the acceptance of father, the late James Mennell. this language for three reasons: Originally, James Mennell was convinced that (I) it does not fly in the face of the basic sci­ musculoskeletal pain -in the absence of signs of ences of medicine, gross extrinsic trauma, inflammation, metabolic or (2) it adds to the basic sciences of medicine systemic disease, neoplasm, congenital anomalies, concepts from the basic science of physics, vascular or neurological disease -arises from some and mechanical internal derangement of a joint, re­ (3) it is applicable to manipulation in every part gardless of the presence of an intra-articular of the musculoskeletal system. meniscus. We are all acquainted with the tenets of anatomy His interest derived from dissatisfaction about and physiology and the desc~iption of the func­ residual pain resulting from orthodox treatment of tional movements of synovial joints. I ask you to fractures. He could not understand why so many add a concept from the science of mechanics. In patients had post-fracture joint pain after bone everything man makes. there is built in play healing; nor could he accept the idea that this pain between the moving parts which ensures efficient arose from "a little arthritis," as patients of all function. So I postulate the following basic ages were affected, even in the absence of radio­ concepts: logical evidence of arthritis. Conversely he noted (I) There is a normal anatomical range of that some people demonstrating radiographic mechanical play movements in synovial arthritis in their joints suffered no pain after the joints. It is prerequisite to efficient pain­ healing of a fracture. free movement. This is joint play. His observations led to the publication in 1912 (2) Loss of joint play results in a mechanical of his first book "Treatment of Fractures by pathological condition manifested by im­ Mobilization and Massage.'' based on his personal paired (or lost) function and pain. This is experience of handling a number of fractures in an joint dysfunction. unorthodox way. He disclaims originality and (3) Mechanical restoration of joint play by a ascribes his thinking and practice to Dr. Lucas second party is the logical treatment of joint Championiere of Paris whom he had visited. dysfunction. This is joint manipulation. He developed the hypothesis that there is an The etiological factors which give rise to joint involuntary range of movement within joints. dysfunction are: When lost, this causes pain and loss of function 20 without the usual signs of arthritis or other patho­ techniques but therapeutic techniques are quite un­ logical changes. He further recognized that the important for, in the end, joints can only move in usual anatomical descriptions of movement in one way and that is the way they are designed to topographical joint areas were inaccurate and move. Anyone's technique is as good as another's pertained to the dead and not the living. in therapy so long as they do not try to invent From his study of bones and their articulating movements. Invented movements or forced over­ facets and his clinical observations, he described movements are bound to create injury to joint the different voluntary movements of individual structures and to other vital structures which are JOmts and something new -their involuntary in close relation to joints. movements. For instance, he drew attention to the I have little evidence other than logical inference fact that for the most part different functional move­ which supports my unswerving belief that the ments occur at different individual joints in the Mennell concepts are right. But with reference to wrist. Further, he showed that the involuntary the back, I have been able to demonstrate by movements were different in every joint but com­ cineradiography that a facet joint-on the side mon to each joint of the same nature. These findings responsible for a patient's complaint of neck and were incorporated into his second book "Massage­ arm pain-failed to open. The joint was at the level Principles and Practice" in 1920. In subsequent at which pain was elicited on examination. After editions - there were seven of them - the title was manipulating this patient, I demonstrated radio­ changed to "Physical Treatment by Mobilization graphically opening of the same joint and the and Massage." patient was free of his symptoms. This joint opening Independent of the teaching of chiropractic or was the only apparent change in the radiographic osteopathic schools in the United States, he then study. The patient had been unable to work as a considered the spine and concluded that. if there plumber for 4 years. He returned happily to work are synovial joints in the back, then they act and within a month. react in the same way to trauma and disease as they do in the extremities. He worked out the in­ I am unable to endorse the hypothesis that voluntary movement of spinal joints. These findings manipulation does anything to the intervertebral were published in his book "Backache" in 1931. disc. I have personally performed 32 lumbar He continued his research and refined his tech­ discograms in living patients and noted no ap­ niques. He had by now also developed satisfactory preciable change in the appearance of living disc and safe techniques and therapeutic manipulation spaces before and after moving a spinal segment. of synovial joints. These were brought together in Further, I can find no basis in theory nor in the his final outstanding publication The Science and accepted tenets of neurology to change my ac­ Art of Joint Manipulation, Volume I, The ceptance of the principle that manipulation only Extremities in 1939, and Volume II, The Spine, in moves synovial joints. We do not have to invent 1948. etiological factors to explain back pain. Were a Unfortunately, in his teaching, James Mennell manipulatable condition in the back to be shown to never clearly differentiated his examination from be associated with a raised protein in the spinal his therapeutic techniques and it was easy for those fluid, which results from dural irritation, or if an who were disinterested to take the position: "Joint annulus defect were demonstrable by epidurog­ manipulation (the therapy) is all very well but raphy and/or discography, then I could accept this what is it done for?" hypothesis. What contribution I have made is clearly to But the mechanical triad which I present is classify differential diagnosis of causes of synovial common to every synovial joint in the body, joint pain. I emphasize a method of using examining whether in an extremity or the back. It is the only manipulative technique·s in the assessment of hypothesis I know to which there are no excep­ musculoskeletal pain in general and joint pain in tions. The musculoskeletal system is one system. particular. To the basic sciences of anatomy, The back is just a part of that system. I believe that physiology and pathology, I have added the basics the intervertebral disc, when prolapsed, gives of mechanics to explain the syndrome of symptoms rise to neurological signs and, if the prolapse is and signs characteristic of a mechanical cause of central, to dural pain. But the symptom of dural pain. I may have added some innovative therapeutic pain is central or bilateral whereas almost in- 21 variably the pain which responds to manipulative International Federation, little significant research therapy is unilateral. was reported and the programs have almost ex­ Just as when an intraarticular meniscus is injured clusively been geared to spinal manipulation. in a joint in an extremity with resulting mechanical Little attempt has been made by speakers to blockage of motion, l do believe that an injured establish terminology or to elucidate the why and disc blocks facet joint movement at the level of what of manipulation. injury. This would result in joint dysfunction and This leads me to another thought about the the back pain from this should be and is relieved development of manipulation. It has been apparent by joint manipulation. The sacroiliac joints are through the years that many in the medical and synovial and may be the seat of pain from any paramedical professions who embrace manual pathological joint condition of which one is joint medicine come to rely on the use of manipulative dysfunction. The costovertebral joints are synovial therapy exclusively in their practice. Except and are frequently a source of pain in the back with when treating pure joint dysfunction, it is my or without radiation through or around the chest. belief that anyone who thinks he can cure anyone The atlanto-occipital and atlanto-axial junctions of anything in musculoskeletal medicine by have no discs, yet identical syndromes of pain arise the use of one modality of treatment is being from these junctions when they are affected by unrealistic. trauma and disease as they do from junctions where If a patient suffers from a joint problem for any discs are present. The same thought pertains to the length of time you can be sure there are changes sacrococcygeal junction. in the muscles, in the vascular system, in the In the third quarter of the 20th century the lymphatic system, in the nervous system and in the Rockefeller Foundation sponsored a meeting to integument system. It is not unlikely that he may promote manipulation (amongst other things) also develop organ system dysfunctions and psy­ called "Toward Better Understanding." This was chological embarrassments as well. Manipulation between I 960-62. Unfortunately no better under­ then becomes part of a comprehensive medical standing resulted from it. In 1968 Secretary treatment program. Wilbur Cohen's report to the U.S. Congress on The second development which may turn out Independent Practitioners under Medicare (page to be noteworthy has been the founding of an 197) advocates research in manipulation. This International Association of Manipulating Thera­ recommendation, to my knowledge, was never pists in the past year. I am not convinced that the acted on. There have been two other potentially organizers are proceeding in a practical way. There noteworthy developments in medical manipulative is a certain defiance in this development. This is not medicine during this period. surprising, since physical therapists have been The first was the founding of the International excluded by those practicing physical medicine. Federation of Manual Medicine some 14 years I ask: what is manipulation if not a modality of ago. Since then there have been four international physical therapy. I would tend to welcome thera­ conferences sponsored by the Federation. Sixteen pists in order to avoid more fragmentation in countries sent delegates to the Fourth International medical care. Meeting in Prague in I 974. Historically. there has been little significant Until 1974 the Federation required that member­ research in manipulative medicine, though recently ship in the participating national societies should there have been some thought-provoking con­ be limited to doctors of medicine. When one tributions on the subject. In the sixties Cailett dem­ realizes that most of those who practice manual onstrated that radiographically it is impossible (manipulative) medicine were trained by osteo­ to detect opening of a facet joint in the denuded paths - some by chiropractors - we see this con­ lumbar spine even when one is propped open. stitutional requirement as prohibitive rather than Though this is a negative observation, it verifies permissive: the teachers were excluded from mem­ the relative uselessness of diagnostic radiology in bership by it. In 1974 the constitution was changed assessing changes in the interlaminar facet joints so that the membership of national associations in the spine. might include American-trained osteopaths. I mentioned earlier the suggestion by Wolf that At the four conventions sponsored by the there are intraarticular menisci (or at least meniscoid 22 material) in the facet joints of the spine. This associated mainly with therapeutic techniques. hypothesis seems to have been contrived to explain It is immaterial, as I mentioned earlier, how certain clinical facts. In a personal communication, one manipulates so long as the movements used LeCore reported that he has never seen such a in therapy are normal and confined to the restora­ meniscus in over 300 dissections. I myself never tion of lost joint play movements. saw such a structure when I was training in If we are to get anywhere in our deliberations orthopedic surgery and operating on backs. But we must avoid the use of named techniques. Dr. Wolf has contributed convincing material on Please let us talk about joint manipulation and the ·reversible deformation of joint cartilage by not spinal manipulation. Spinal manipulation has pressure, which doubtless has an adverse me­ the connotation of topographical manipulation. chanical effect on joint motion. An English in­ There can be no such thing. Further, I do not dustrial physician, Glover, has recently performed believe that one should be taught spinal manipula­ arthography of the facet joints in the lumbar spine tion until proficient in handling the joints of the in post mortem subjects. He showed that there is extremities. If teaching in manipulation is limited a large superior aspect of the capsule which can be to spinal joints, then error is perpetuated, since blown up by the injected fluid. Could the meniscoid such teaching implies that etiological factors in of Wolf be the crenated, undistended capsule back pain are special and different. which may be pinched between the articulating In the late I 9th century Sir James Paget stated: facets? "Few of you will enter into practice today without Finally, a number of preliminary reports on having the so-called 'bone-setter' as a competitor. clinical observations regarding the interplay of There is little point in presenting a· lecture on the dysfunctions in the spine and organ dysfunctions injuries which these persons cause; it is more were presented at the recent Prague meeting by important to consider the fact that their treatment European workers. Belatedly more clinical re­ can do some good .... Learn then to imitate what search is being undertaken especially in is good and avoid what is bad in the practice of Czechoslovakia. bone-setters. . . . It is advisable to learn from The National Institutes of Health provided I 07 one's opponent." pages of material to help develop my thesis for In a 1925 editorial in the Lancet about the work this presentation. The material was based on 250 of Sir Herbert Barker, England's most noted references to the literature; this must be an in­ bone-setter, the editor states, "The medical history complete reference list, as there is no reference of the future will have to record that our profession to my own books! has greatly neglected this important subject From this material I judge that a large number of (manipulation) ... the fact must be faced that orthopedic surgeons have advocated spinal manipu­ bone-setters have been curing multitudes of cases lation. However, from personal observation, they by movement (manipulation) ... and that by our cannot or do not define the term manipulation; faulty methods, we are largely responsible for their neither are they specific in their indications for very existence." its use. I have not given credit to several people in this In 1889, Dr. William Osler made himself un­ audience who merit a place in the history of the popular by trumpeting that there are sent out yearly development of medical manipulation. Dr. Maigne scores of men called doctors who have never of Paris is foremost in introducing the teaching attended a case of labor and who are ignorant of of manual medicine into the curriculum of a uni­ the ordinary everyday diseases which they may versity medical school. Of comparable stature be called upon to treat. In those days virtually in education is Dr. Lewit of Prague who is not all doctors learned their trade by apprenticing present. themselves to well established practitioners. The Some may consider it unbecoming to belabor pros and cons of manipulation today depend upon Mennell in this paper. I could find nowhere else the dogma of well established practitioners. to turn for recorded history. I have omitted many I close with one final remark. In an editorial in names popularly associated with the development the Archives of Physical Medicine in I 947 the of medical manipulation because their names are editor writes, "While he (James Mennell) is with 23 us in this country (America), we should take ad­ where will take advantage of anyone's special vantage of his special skills and experience to skills and experience to develop the science and develop further the science and art of joint manipu­ art of joint manipulation." Maybe some of you lation." Here we are in I 975-28 years later and will be the people to do so and maybe Bethesda I say: "I hope before I die that someone some- will be the place where it is achieved.

24 History of the Development of Chiropractic Concepts; Chiropractic Terminology

JOSEPH JANSE President. The National College of Chiropractic Lombard, 11/inois

Contemporary definitions of chiropractic are: Original hypothesis: The original hypothesis of chiropractic was formulated by D. D. Palmer I. "Chiropractic is the study of problems of (1845- I 9 I 3 ), a self-educated manipulative practi­ health and disease from a structural point of tioner who found that various complaints of his view with special consideration given to patients recovered following vertebral adjust­ spinal mechanics and neurological relations, ments. :;-9 A concept of homeostasis was expressed presenting the hypotheses that: as follows: (a) disease may be caused or aggravated by disturbances of the nervous system. "Life is the expression of tone. Tone is the (b) disturbances of the nervous system may normal degree of nerve tension. Tone is be caused by derangements of the mus­ expressed in functions by normal elasticity, culoskeletal structures." 1 activity, strength and excitability of the 2. "Chiropractic is a discipline of the scientific various organs, as observed in a state of healing arts concerned with the pathogenesis, health. Consequently, the cause of disease diagnostics, therapeutics and prophylaxis of is any variation of tone." functional disturbances, pathomechanical Having very likely been influenced by the states, pain syndromes and neurophysiological neurological thinking of the mid- l 9th century,:;, 7 • 8 effects related to the statics and dynamics he believed that the nerve impulse originated in the of the locomotor system, especially of the brain and traveled as a vibrational wave 5 • 7 and spine and pelvis." 2 could be influenced by intervertebral derangements 3. ''Chiropractic is the science concerned with causing facilitation or inhibition: defects in the mechanics, statics and dy­ "Displaced vertebrae, by impinging or namics of the hurrian body". 3 stretching, cause contraction of nerve 4. A definition by exclusion relates to chiro­ practic as "the system or method of treating tissue-Tension more or less than normal human ailments without the use of drugs or causes an increase or decrease of vibration . . . " medicines and without operative surgery." 4 This crudely presented concept of facilitation Development of Chiropractic Concepts: and inhibition was postulated by Palmer to be Early chiropractic concepts were formulated responsible for lowered tissue resistance of the during the time that Golgi, Cajal, Sherrington and innervated tissues, making an individual more 1 1 Pavlov were thoroughly investigating the nervous vulnerable to infection and disease. H Probably system and making outstanding contributions. 5 It under the influence of the vitalists, and with the must be assumed that some of the early concepts concept of the "vis medicatrix naturae" still such as Stephenson's model resembling the reflex prevalent at the time, 10 he postulated the existence 5 6 arc • were influenced by these workers. of an .. innate intelligence," seated in the brain, and 25

597-036 0 - 76 - 3 also the origin of the "mental impulse," traveling extensively in chiropractic writing 8 :i,H,2:1,2!l-:11.:H.:15, via the nerves. :n, 4o. 4fi,47 to describe the undue irritation and It may further be stated that he had essentially stimulation of sensory receptors (to include proprio­ a holistic concept, and therefore a Coan approach ceptors) in the articular structures and para­ to the healing arts.7 segmental ligaments under stress from derangement B. J. Palmer (1881 - 1961 ), the son of D. D. of the intervertebral motor unit due to subluxation. Palmer and a very prolific chiropractic author, It is thought that this afferent barrage into the wrote the first book on the subject ( 1906). 9 He nervous system could disturb equilibrium. cause was obviously influenced by his father's thinking aberrant somatovisceral, somato-somatic and and hindered by his own lack of contact with the ~mato-psychic reflexes as expounded upon m scientific community.:. He placed undue emphasis subsequent sections. on the concept of .. innate intelligence" and still 11 The Somatosympathetic Reflex Hypothesis: talked about mental impulses,!-'· - 15 but with recognition of their electrical properties which he The somatosympathetic reflexes have received attempted to measure. 11 He made technic pro­ extensive and repeated attention by the profession. cedures more specific by adjusting segments at and were postulated to be in part responsible the neuromeric levels from which specific organs for the visceral changes often observed after spinal are innervated, called the meric system (1908- adjustment. manipulation. trigger point and 1 7 8 2 1 47 106 121 1920).12-14 and eventually settled on the upper spondylotherapy.= • · · rn- : , · - ! Chiropractic cervical region as the one area that would be the treatment aimed at influencing specific neuromeric key to all disease (1934). 5 • 15 levels has for years been known as the meric system, not unlike an approach. later referred to by The Nerve Compression Hypothesis: Kunert ( 130). Evidence on these reflexes has been Since the earliest beginnings of chiropractic. the presented by Ors. Sato, Korr, Denslow and theory that a nerve could become compressed others. i:ll -161 through impingement from intersegmental spinal The Viscerosomatic Reflex Hypothesis: derangements has been given a great deal of at­ Viscerosomatic reflexes have important diagnos­ tention.7· ll, rn- 2:i and even thought to be a primary cause of disease. H,22 The chiropractic literature tic ✓ connotations for clinicians in most fields. These makes extensive reference to the importance of have been inferred to be important causes of 8 23 subluxations,3, , 2:i, 2H,:i5-:i1, 40, 106,112, 11::1, 111, 118, 121 intervertebral foramen nerve root compression. - 47 11711818 117 and to changes resulting from such compres­ triggerpoints, · • fi and acupunture points. • 154168161 sion. 28,:io, 31,31i, 45, 46 · · ! Not only are these reflexes related to 158168110 174 Other investigators supplied bases or supporting referred pain, · • - but are also responsible evidence for the chiropractic compression theory for spasm of the deep paraspinal musculature, by proposing possible mechanisms of compres­ causing asymmetrical muscle spasm,•H.i and lead sion.48-68 and elucidating upon the effects of such to the establishment of vicious cycles and even dermal changes. 8• 10, 2:i,26, 34, 3:;, 4:;,47,55, 110. 111. 111. mi. compression.fiH-t0 5 Some investigators became 123,128, 1:11. 138. 158, 163, 168-183 It is for this reason that it involved in studying the phenomenon with an awareness of chiropractic hypotheses (Haldeman, is important and necessary that in the overall Sharpless. McGregor. Luttges).81, 82,!H, 96-100 management of patients with visceral symptoms While extensive work has been done on the and if only to break up aberrant cycles. manipula­ 1 105 tive therapy be made available, if necessary. in effects of nerve compression,m - the exact mechanism of compression at various spinal and collaboration with physicians of other disciplines. extravertebral sites leaves a great many un­ The Somato-somatic Reflex Hypothesis: answered questions. The influence of disturbed This mechanism may account for clinical results dural biomechanics. root sleeve fibrosis and obtained through the manipulative treatment of adhesions appear to be promising areas of investigation.as, 63- 68 patients with certain types of intractable somatic pain, triggerzones, and neurogenic dermatoses. 4• 5. The Proprioceptil·e Insult Hypothesis: 8, 10,2:1, 24, :18, 44, 61, 10!1, 115,117,118,125,1:15, 15:l, 154,184,185, 10 Proprioceptive insult is a concept referred to 187• 188- 1! , rn3, rn5 , w8 Empirical clinical results lead us 26 to believe that this would be a useful area for of mensuration. 238- 267 The upper cervical area investigation. probably has received the greatest attention, both The Somatopsychic Hypothesis: in analysis and treatment.238, 2:rn,241, 249-2r,o, 252,253, 255, 257, 259 Tomographic, 266• 2H7 two dimensional 238• Somatopsychic relationships of clinical impor­ 2a9,241-261, 269 and three dimensional, computer­ tance have been suggested by various.chiropractic assisted systems of roentgenologic measurement investigators. um- 212 The interrelationship between have been developed.!16, 100, 240,268 disturbed body mechanics, posture and psychologi­ cal problems has been commented upon• 99- 203, 206- Empirical results as well as extensive clinical 209·212 - 216 and the chiropractic treatment of emo­ use of the methods of 'Subluxation complex analysis dictate further investigation in this area. The system tionally maladjusted individuals studied. 209• 212· 21-1 25 The results were encouraging and offer interesting of measurement used by Suh !' and the stereo­ possibilities for future investigation. The hypothesis metric (orthogonal) system used by Frigerio and 2411268 has been presented that spinal subluxations have others hold greatest promise. • inimical effects upon the ascending pathways of Phase two, concerned with the statics, was a 3 17 269 the reticular activating system, causing stress­ contribution of Carver • · who recognized producing symptoms such as insomnia and the interrelatedness of all parts of the skeletal restlessness. 201· 20 !' frame and considered the subluxation in a larger context. He emphasized gravitational strain and The Neurodystrophic Hypothesis: presented the all important principle of basic and In its simplest form it may be reduced to D. D. compensatory distortion. It involves postural Palmer's concept that .. lowered tissue resistance evaluation of total spinal biomechanics in terms of is the cause of disease" and due to "too much or the static weight-bearing position in man, the biped, 7 too little nerve energy". The concept of lowered both through clinical postural and spinographic tissue resistance is strongly brought out by analyses to determine how the individual copes 17 Dubos,2 and, extensive studies done by Speransky with the forces of gravity. 270· :im, 218• 2rn and others 220illustrate the important role of A four-way scale, developed by llli,288employs the nervous system in the control of immunogenesis. the principle that rotational distortion of the spine Studies on the neuroreflex mechanisms regulating can be expressed in terms of maldistribution of phagocytosis: electrophysiological changes in weight through the soles and heels, each placed on nerves during antigen stimulation of the skin, and four separate scales read simultaneously. Use of a other mechanisms elucidating this role of the single scale for determinations of the center of nervous system,2 18- 220often referred to in the chiro­ gravity in various postures has also been initiated practic literature,2 21- 2:11 definitely require in­ by Jenness. 291 vestigation. Effects of stress, due to subluxation and its Recording and mensuration of spinal curvatures 232233 through the use of mechanical devices has also concomitants, • require much future attention 288 in view of results obtained by Selye and others in been done with the rachiometer (and correlated with radiographic findings), the conformateur,2 91 studying closely related mechanisms. 234- 2:n the posturometer 275· 276· 2u2- 294. w5 , :w5 and Distor­ Development of Biomechanical Concepts: tion Analyzer: 273the latter two being used to arrive Biomechanical concepts in chiropractic de­ at a postural stress index (PSI), the posturometer veloped through three phases, each characterized having been tested on large samples. 275, 305, 306 by related neurological concepts. The mechanical Additional investigations in this area are needed. phase, introduced by D. D. Palmer, found ex­ Systems of spinographic analysis involving full pression in the concept of vertebral subluxation body and full spine radiographs were developed 1 as a focus of nerve irritation and impingement.a, 1. and warrant further investigation. 310 • :i:m i;; Subluxations of the spine could be diagnosed The phylogenetic and pathomechanical implica­ through palpation and corrected through tions of bipedalism have been investigated :i32- adjustment. :i34,338 and special attention given to the asso­ Clinicians and investigators have developed ciated syndromes of postural faults and aberrant methods for analysis of subluxations of the spine, muscle conduct. 3:11- 3:i1-1 Future studies in this area pelvis and extremities, utilizing various systems would be significant to the clinician. 27 Mechanical problems induced by developmental cept that warrants further study. 339 348 defects and asymmetry have been studied - That spinal deviation into a distortion and the hypothesis formulated are: possible facil­ takes place easier than out of a distortion itation of afferent input from the articular facet 288 was confirmed recently.: 391 This re­ joints; conversion of amphiarthrodial sacroiliac quires further elucidation. especially as it joints (primate) into a synovial arthrodial mecha­ relates to the classification into six types nism (Homosapiens) vulnerable to subluxation; of postural scoliotic deviation according 288 392 the production of undue tension in the erector to disturbed muscular dynamics. • spinae muscle groups because of eccentric func­ The production of undue traction upon tion of the motor units; articular instability in case the dural root sleeves and the cauda of developmental defects and their possible role equina by movement of the cervical spine in disc syndromes. spondylotic change, disturb­ with the occipito-atlanto-axial complex 79 390 ance of postural. righting and gait reflexes blocked together ,2 • is an area that (especially in advancing years), neuralgias, inter­ merits extensive further investigation be­ vertebral nerve root entrapment. reactionary cause of the significance of disturbed fibrosis and formation of adhesions in the articular nervous system biomechanics due to elements and myofascial planes-producing articular dysfunction. triggerpoints. Determination of the locations of The dynamic or functional approach designates vertebral pivot points from which the bi­ that phase concerned with the skeletal framework, laterally extending radii of vertebral especially the spine and pelvis, as a complex unit movements arise, and which, if altered where weight-bearing, maintenance of posture in length. size and position as in facet and locomotion are tied in with the behaviour of tropism will lead to the dysarthria of the nervous and vascular systems, and the phys­ subluxation, should be further investi­ iology of the viscera and even the emotive proc­ gated because of its great clinical sig­ esses. 349-382 nificance to the chiropractor and bio­ 278 288 Illi - was mainly responsible for the devel­ mechanical importance. 2 w, 383 opment of the concepts and instrumentations of Development of Manipulative Procedures and this phase. He developed the orthodyn, a special­ Concepts: ized treadmill allowing locomotion on a selective Although it has been stated that the chiropractic incline towards the cephalad or caudad end with technics were quite different from those used by concomitant lateral tilt to either side. enabling any other profession.ii, 12- 14 , :no it must be assumed the investigator to observe alterations in kinematics that extensive interchange of ideas and methods as the center of gravity is caused to shift. took place. From studies involving some or all of the four­ The chiropractic manipulative format was way scale. the orthodyn, rachiometer, cineradiog­ probably broadened because of the influences of raphy, mechanical and cadaveric models. and the medical manipulators such as Hood, Mennel and torsolocomotor treatment device (llli), the follow­ 94 396 Fisher _a - as well as the osteopathic physi­ ing observations were evolved: cians 397 and the early American bone-setters who Sacroiliac movement does take place allied themselves with early chiropractors (Richer 278 ,35°, 383 , 387 (confirmed by Frigerio et al., of Ohio, Reese of Pennsylvania and the Tieszens 240 and it occurs with a figure of eight con­ of the Dakotas): 398 figuration. The sacroiliac mechanism func­ Traditionally, the chiropractic adjustment has tions as a gyroscope-like unit essential to been characterized by a direct thrust: an osseous 278 279 effective spinal balance • concepts process being utilized as a lever. 7 • 9 A straight commanding further investigation be­ arm-body drop procedure 16, 19,21,23, 114,242,399,403

cause of its clinical importance. or a very specific, highly developed toggle recoil 12 • 15 16 23 399 403 16 Torsion and flexion and torsion and • • • • or torsional or leverage technics • lateral bending take place concom­ 19 • 2 1, 23 , 114 , 242 • 2 w- 2s 4 are used. Technics have been mitantly. shown on cadaveric models 27 !', developed and ~dapted to specific mechanical 288 388 389 and confirmed by Farfan; • a con- pathologies 15, 241, 249, 250, 266, 299, 353, 365, 310, a99, 401. 402 28 61 106 and for the treatment of specific syndromes. , • Development of Analytical and Therapeutic 1:!0, 175,187, :!70, :!88, 300, ;341, :!5:l,:!70, 401,402, 406-426 Instrumentation: Soft tissue procedures have been developed, such as triggerpoint, pressure point and reflex Technological advances: technics for physiological input and perhaps utiliz­ 1. Analytical equipment-As early as 455 456 ing a mechanism such as dispersal of triggerpoints 1920 Evins • endeavored to use (Nimmo), reciprocal inhibition of muscles (Good­ sensors in determining possible sites heart) or a gate control mechanism. 421 - 4:n of disturbance of the neurovascular ele­ The concept of somatic physiological input, as ments attending subluxations. Pro­ an aid in pain control, relief of tensions, muscle gressively various devices became spasms, the management of visceral neuroses, and available, the most popular being dif­ the dissipation of the circulus vitiosus of disturbed ferential thermocouples employed for neurological function is not new to chiropractic measuring symmetrical joint tempera­ thinking, but requires extensive future investiga­ ture differences across the spine 4r.:-,-4 " 8 45 tion. Procedures used have included paraspinal galvanometers !1 and infrared de­ vibratory manipulations, pressure contact trigger­ vices. 460-467 Unfortunately, overclaim 4 3 point goading, pressure and massage. = " Locke by users placed the usage of some of foot techniques and the plantar reflex concept and these under question by some chiro­ similar procedures have been used by different practic clinicians as well as government 466 468 disciplines.•m The mechanism involved is sug­ agencies. - Conversely, utilization gested to be that of restoration of exaggerated of infrared photography has become reflexes to homeostatic balance by affecting minute commonplace in clinical practice. 4fi:.!, individual sites in the skin, deep fascia and muscle. 466, 467 Other instruments have been 115,118, 16:l, 4:!5 referred to above (llli 288 ). Autonomic Balancing: l t has been hypothesized 2. Therapeutic equipment- Distinct con­ that the sympathetic or parasympathetic systems tributions to the manipulative art were may be selectively influenced by specific types made through the development of of adjustments at specific levels of the spine, re­ various adjusting tables enabling the sulting in autonomic balancing. 439 • 442 This approach physician to make effective and exact­ is in part based on somatotyping. · ing corrective movements. Upper Cervical Specific: This involves specific adjustment of the upper cervical segments with Outstanding tables were produced (McManis, postulated effects upon the vagus and other neuro­ B. J. Palmer, Thompson and others). Tables have logical elements,:249 • :252 , 253 • a65 • 4:21 and has been been designed for correction of subluxations in used as an exclusive approach. 15• 208 , 285 • :.!:19, 241 specific areas such as C 1 and C2 (Palmer, Thomp­ The neuromeric or meric approach: This has son, Puckett) cervicals (Gonstead) thoracic and been used extensively and involves adjustment, thoraco-lumbar area (Gonstead). The rehabili­ manipulation or percussion at the neuromeric level tation equipment of Illi has been referred to.:288 • 470 - from which an organ is innervated for the purpose 41:2. of influencing that organ. 16• :.!H,a 6 , 89 • 180 The question is raised whether or not the nerve cells within the Development of Procedures Adjunctive to dorsal, anterior and lateral gray cell columns are Manipulation: stimulated in addition to the dorsal root ganglion Various adjunctive procedures have been used and proprioceptors in the articular structures. either preparatory or supplementary and supportive Manipulation of the extremities has been prac­ to adjustments and manipulations, or for pain ticed since the earliest beginnings of chiropractic control and the treatment of various conditions. and is still extensively practiced as an adjunct to These adjunctive procedures have been collectively spinal manipulation for the restoration of bio­ called physiological therapeutics -m and include mechanical integrity reflecting on the spine. electrotherapy, actinotherapy, hydrotherapy, Manipulation of visceral structures through the orthotics, mechanotherapy and traction, spondylo­ parieties and various spine-related muscles (psoas, therapy, massage, clinical nutrition, dietetics, 443 454 piriformis) is also commonly practiced. - fasting and herbology.m- 4s1

29 Cone/us ion: Discogenic: Caused by derangement of an inter­ Chiropractic has become the subject of investi­ vertebral disc. gation of people from outside the healing arts Discopathogenic: Abnormal action or function of profession such as Dr. Wardwell and others 489 • 4t,o a disc resulting in a disorder or condition; and has spread over many parts of the world with originating because of disc degeneration. reputable texts appearing in many languages. 491 - 496 Note: although not in common usage. this is Honest and intense investigation into the science etymologically correct. and art has been made by eminent members of the Disease: Disease may be defined as merely a medical community in different countries, 497 - 505 summation of chemical reactions that have gone some presenting us with astounding clinical obser­ wrong. vations holding great promise for future study. Boyd, W.: Textbook of Pathology. 6th ed., There is a growing body of information suggest­ Lea & Febiger I 958, p. 12. ing that the functional role of inhibition and Dynamics: (1) That phase of mechanics which facilitation is profound in all sorts of neuronal deals with the motion of material bodies taking subsystems. In view of the widespread effects of place under different specific conditions spinal manipulation on the body, it seems probable (Dorland). that the central nervous system is the arena of (2) Science which treats of matter in motion these effects even though a direct relationship (Oxford). between many of these changes and the site of (3) (Including statics, kinetics.) The science of manipulation is often obscure. The effect(s) of actions of forces in producing motion or equilib­ biomechanical aberrations (subluxations) on the rium (Oxford). phenomenon of inhibition in the central nervous Dysarthric Lesions: (See dysarthrosis.) A restric­ system, and on the modulation of neuronal activity tive term used interchangeably (Del Gliesch). deserve extensive investigation. Information about Dysarthrosis: The strict meaning of joint motion spinal, pelvic and costal biomechanics and the pain restriction without the neurological connota­ phenomenon should be greatly augmented to tions. It refers to kinetics. maintain a sound rationale for corrective, pre­ Dyskinesia: Impairment of the power of voluntary ventive and rehabilitative procedures, applied in movement, resulting in fragmentary or in­ the best interest of the sick - the purpose of our complete movements, aberrant motion. deliberations. Functional: ( I )a. Of or pertaining to the function of It might well be that as this workshop proceeds. an organ- not structural, affecting functions only a commonality of interest, concept and knowledge (Oxford). will be brought into profile and provoke the mind­ b. Of, or pertaining to a function: affecting the fulness that an interchange of observations may functions but not the structures (Dorland's). benefit everyone and generate an interprofessional (2) Joint mechanics showing area disturbances dialog. of function without structural change ... subtle joint dysfunctions affecting quality and range CHIROPRACTIC TERMINOLOGY of joint motion, with no obvious attending tissue changes. They are diagnosed with the aid of Adjustment: The chiropractic adjustment is a motion palpation, stress and motion radiography specific form of direct articular manipulation investigation. They are the best indication of utilizing a short lever and characterized by a altered joint physiology and are usually com­ dynamic, forceful, high velocity thrust of con­ pletely reversible. Nothing is out of place, so trolled amplitude. there is no subluxation or misalignment in the Basic Technique: A chiropractic method wherein medical sense. There will be fixations (usually the correction of the sacrum is considered to be partial) and erratic motions within the normal of primary importance. range of joint movement. Chiropractic Analysis: Relates to making assess­ Funiculitis: Spinal nerve irritation within the ments of disharmonies especially along the course l.V.F. leading to radicular syndromes. e.g. -a of the spinal column and its attachments, in­ lateral disc protrusion within the I.V.F. produces cluding physical and clinical diagnosis. a funiculitis: osteophytic spurs may cause a Discopathy: Any pathological changes in a disc. chronic funiculitis leading to a local neuropathy. 30 HI O: Hole-in-one technique, first introduced by Barre-Lieou Syndrome resulting from neuro­ B. J. Palmer, wherein the adjustment of the atlas pathogenic reflexes caused by pathomechanics in relationship to the occiput and the axis is of the cervical spine. considered to be of primary importance. N europhysiological Effects: A general term denot­ Innate Intelligence: The intrinsic biological ability ing functional or aberrant disturbances of the of a HEAL THY organism to react physio­ peripheral or autonomic nervous systems. logically to the changing conditions of the ex­ The term is used to designate nonspecific ternal and internal environment. Probably effects related to: derived from the term "vis medicatrix naturae". (a) Motor and sensory functions of the periph­ lntervertehral Motor Unit: The anatomical ele­ eral nervous system. ments uniting two adjacent vertebrae, including (b) Vasomotor activity, secretomotor activity disc, all ligaments and soft tissues in which neuro­ and motor activity of smooth muscle from the logical elements are found. autonomic nervous system, e.g., neck, shoulder, (Note): (1) Under pathomechanics these arm syndrome - the extremity becomes cool neurological elements generate neuropathogenic with increased sweating. reflexes. (c) Trophic activity of both the peripheral (2) Since visualization of osseous structure is and autonomic nervous system, e.g., muscle our only means of determining the status of the atrophy in neck. shoulder, arm syndrome. motor unit, it would be appropriate to include Pathomechanical States: Joint pathomechanics such structures in any discussion of the motor with structural changes· . . . those architec­ unit. tural changes are the scars of imbalanced motion Listing: Designation of the spatial orientation of and weight bearing. trauma and biochemical vertebrae in relation to adjacent segments: e.g., changes associated with aging and deficiency rotational or flexion malposition. states. These tissues changes may be revealed Manipulation: A maneuver employing long levers by static x-rays, biopsy, and definitely diagnosed for the active, passive, and resistive movement with surgical exposure, e.g., of the body without the use of a dynamic thrust, ( 1) arthrosis aimed at remobilizing parts of the vertebral (2) spondylolisthesis column. (3) disc degenerations Meric System: The treatment of visceral condi­ Prophylaxis: That branch of applied biology which tions through adjustment of vertebrae at the seeks to reduce or eradicate disease by removing levels of neuromeric innervation to the organs or altering the responsible etiologic factors. involved. (Boyd's Preventive Medicine, 7th Edition.) Myodysneuria: A term for triggerpoint designating 1. To prevent occurrence of subluxations due its neurological implications. to poor postural hygiene, physical fitness and Nerve Tracing: The method of tracing the tender­ faulty body mechanics. ness along the peripheral sensory extensions of 2. The prevention of recurrence with followup spinal nerves back to the spinal level of subluxa­ care, e.g., exercise. tion, employed since the beginning of chiro­ 3. Many subluxations are not curable and practic, and not unlike the tracing of tenderness become quiescent with treatments: therefore, of a radiating neuralgia. followup care to prevent further pathology, or N eurodystrophic Processes: The production of at least to retard the pathomechanical process, diseases in various organs by irritating the central is necessary. nervous system. Reflex Therapy: Treatment that aims at stimulating Malnutrition of tissues caused by the nervous afferent impulses and evoking a given response, system -it may occur in all organs and form i.e., neuromuscular. part of every disease -Speransky. Retracing: Sometimes, following adjustments, N eurogenic: This word is often used to mean origi­ patients redevelop earlier symptoms which have nating in nerve tissue, e.g., "the cause of the disappeared under previous treatment, usually disorder is neurogenic." To meet this need see of a suppressive nature. neuropathogenic. Soft Tissue Technique: Manipulation of the Neuropathogenic: A disease within a tissue result­ muscles and fascia. ing from abnormal nerve performance, e.g., Short Leg: An anatomical, pathological, or func- 31 tional leg deficiency leading to a syndrome. 9. Palmer. B. J.: The Science of Chiropractic-its principles Statics: That phase of mechanics which deals with and philosophies, Vol. I, Davenport, Iowa, Palmer the action of forces and system of force on bodies School of Chiropractic, I 906 and 1910. 10. Hoag, J .• Editor: Osteopathic Medicine, New York. at rest (Dorland). Blakiston, 1969. -At rest-in equilibrium pertaining to laws of 11. Palmer, B. J.: Our Masterpiece, Davenport, Iowa, Palmer status. College Press, 1966. - Pertaining to forces in equilibrium, or to 12. Ibid: The Philosophy and Principles 4 Chiropractic bodies at rest (Oxford). Adjustments, Davenport, Iowa. Palmer School of Chiro­ practic. Vol. II I, I 908- I 9 I I. - The science that deals with bodies at rest or 13. Ibid: The Science of Chiropractic-Causes Localized, at equilibrium relative to some given state of Vol. IV. Davenport. Iowa, Palmer School of Chiro­ reference. practic, 1908. - Relating to the weight and its mechanical 14. Ibid: The Scie11ce of Chiropractic, Vol. II, Davenport, effects and to the conditions of equilibrium Iowa, Palmer School of Chiropractic. I 9 I 3-19 I 7-1920. 15. Ibid: The Subluxation Specific- The Adjustmelll Specific, (Oxford). Vol. XVII I. Davenport. Iowa. Palmer School of Chiro­ Spinography: A system of detection of subluxation practic, I 934. by geometric analysis of radiography usually 16. Beatty, H. G.: A11atomical Adjustive Technique, 2nd Ed .. taken in the weight bearing position. Denver. Colo .. I 937. Spondylotherapy: The therapeutic application of 17. Carver, W.: Can·er's Chiropractic A11alysis, Oklahoma City. I 921. percussion or concussion over the vertebrae to 18. Firth, J. N.: A Textbook on Chiropractic Symptomatology, elicit reflex responses at the levels of neuromeric Rock Island. 111.,1914. innervation to the organs being influenced. 19. Forster. A. L.: Principles and Practice of Spinal Adjust­ Subluxation: D. D. Palmer insisted that the word ment for the Use ofStude11ts a11dPractitioners. Chicago, subluxation be applied to the intervertebral 1915. 20. Gregory. A. A.: Spinal Adjustment. Oklahoma City, 1910. disrelationships amounting to less than a locked 21. Loban. J. M.: Technic and Practice of Chiropractic, dislocation. He maintained at the same time that Davenport, Iowa. 19 I 2. there is a functional response within the nervous 22. Logan, H. B.: Textbook of Loga11 Basic Methods Edited system resulting from this structural disrelation­ by V. F. Logan and F. M. Murray, St. Louis. 1950. ship. 23. Janse, J .. Houser, R. H., and Wells, B. F.: Chiropractic Principles and Technic, Chicago, National College, Subluxation: A subluxation is the alteration of the 1947. normal dynamics, anatomical or physiological 24. Baker. F. A.: Speaking of subluxations, nerve pres­ relationships of contiguous articular structures. sures may exist away from the spine. Chiro. 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Idem: Neck and arm pain, Ibid, 1974. 375. Sandoz, R. W.: Technic and interpretation of functional 350. Colachis, Warden, Bechlol, and Strohm: Movement of the radiography of the lumbar spine, Ann. Swiss Chiro. sacroiliac joint in the adult male: a preliminary report, Assoc., 111:66-106, 1965. 39 376. Steffen, E . .I.: Lateral curvature of the spine, National tebral manipulations, Ann. Swiss Chiro. Assoc., V :81- Chiro. J., Vol. XlV, pp. 17-18, July 1944. 92, 1971. 377. Steindler, A.: Mechanics of Normal and Pathological 402. Jaquet, P.: The lmporta11ce of Laboratory Methods in Locomotion in Man, Charles C Thomas, Springfield, Chiropractic Diag11osis, V :215-264, 1971. Ill. 1935. 403. Grecco, M. A.: Chiropractic Tecluzic Illustrated, New 378. Taylor, D. B.: Biomechanics of the spine under stress, York,.larl Puhl. Co., 1953. J. Cli11.Chiro., I :2,61-67, November-December 1973. 404. Lorez, E.: Some thoughts on manipulation, A1111.Swiss 379. Yan Dusen: Chiropractic Relationship to Gral'itational Chiro.Assoc., V:7-14, 1971. Force, Sodus, N.Y., I 968. 405. Sandoz, R.: The significance of the manipulative crack and 380. Watkins, R. J.: Pelvic mechanics, J. National Chiro. of other articular noises, A1111.Swiss Chiro. Assoc., Assoc., Vol. XXX, p. 26, March 1960. 4:47-67, 1969. 38 I. Weiant, C. W.: First X-ray movies of spine and pelvis in 406. Sandoz, R. W.: Problems pertaining to the choice of in­ action shown,./. Natio11al Chiro. Assoc., Vol. XXVII, dications for chiropractic therapy, An11. Swiss Chiro. p. 17, May 1957. Assoc., 111:201-213, 1965. 382. Widmann, B. J.: Electromyography for chiropractic, Ann. 407. Spears, L. L.: Spears Painless System of Chiropractic Swiss Chiro. Assoc., 111:132-160, I 965. and Other Developments, 5th edition rev., Denver, 383. Fryette, H.: Some reasons why sacroiliac lesions recur, 1950. .I.A.0.A., November 1936. 408. States, A. Z.: Spinal tmd Pelvic Technics, National Coll. 384. Kamieth, H.: Distortions of the sacroiliac joints in chiro­ of Chiro .• Lombard, Ill., 1968. practic, Fortschrift Riintgenstr., 89, 1958. 409. Janse, .I.: Cervical syndromes, Natio11al Coll. of Chiro . ./., 385. Solonen, K. A.: The sacroiliac joint in the light of anatomi­ 31:3-13, April 1959. cal, roentgenological and clinical studies, Acta Ortho. 410. Janse, J.: Chiropractic methods of correcting masor pelvic Sca11d., I 957. distortions, National Coll. of Chiro. J., 23:4-10, 386. Weisl, H.: The articular surfaces of the sacroiliac joint and January I 95 I. their relation to the movement of the sacrum, Acta. 41 I. Janse, J.: Basic clinical phenomena as it relates to the Anal., 1954. art of specific reduction of spinal segmental dysarthrias, 387. Weis!, H.: The movements of the sacroiliac joint, Acta. National Coll. of Chiro. Monograph, I 973. Anat., 1955. 412. Beech, R. A.: A history of the intervertebral disc syn­ 388. Farfan, et al.: The effects of torsion on the lumbar inter­ dromes as it applies to manipulative practice, Ann. vertebral joints. The role of torsion in the production of SwissChiro.Assoc.,pp. 7-19, 1961. disc degeneration,]. of Bone and .Joint Sur}!., April 1970. 4 I 3. Bcyeler W.: Scheuerman's disease and its chiropractic 389. Farfan, H. F.: Mecha11ical Disorders of the Low Back, management, Ann. Swiss Chiro. Assoc., 170-177, Lea and Febiger, Phil., 1973. 1960. 390. Reid: Effects of flexion and extension movements of the 414. Beyeler, W.: Experiences in the management of asthma, head and spine on the spinal cord and nerve roots, Ann. Swiss Clziro. Assoc., Ill: 11 I - I I 7, I 965 . .I. Neurosurg. Psychiat., 1960. 4 I 5. Bosshard, R.: The treatment of acute lumbago and scia­ 391. Yochum, R. T.: Stress studies of thoracolumbar scoliosis, tica, Ann. Swiss Chiro. Assoc., pp. 50-61, 1961. J. ofClin. Chiro., September-October 1973. 416. Cox, J. M.: Lumbar disc herniation: statistics on an inno­ 392. Pyzik, L. C.: Stress correction of scoliosis,./. C/i11.Chiro., vative diagnostic and therapeutic approach, J. Clin. 46-63, September-October 1973. Chiro., 20-45, September-October 1973. 393. Farfan, et al.: Instantaneous center of rotation of the third 417. Drum, D. C.: Conservative management of lumbar disc lumbar intervertebral joint, J. Biomech., 1971. degenerations, J. Clin. Clziro., 96- I 13, Winter I 972. 394. Fisher, A. G.: Timbrell: Treatment by Manipulatio11, 418. Egli, A. B.: Long-time prognosis of spondylarthrosis and Lewis & Co., 1948. chondrosis under classic and chiropractic therapy, Ann. 395. Mennel, J. B.: Manual Therapy, Springfield, 111.,Thomas, SwissChiro.Assoc., V:181, 1971. 1881. 419. Fernandez, P. G.: Spondylolisthesis, J. Clin. Chiro., 396. Menne!, J. B.: The Scie11ae a11dArt ofJoi11t Manipulation, 28-32, Winter I 972. Vol. 1: The Extremities; Vol. 2: The Spinal Column, 420. Grillo, F.: The differential diagnosis and therapy of head­ London, Churchill, 1939 and 1949. ache, Ann. Swiss Chiro. Assoc., pp. 121-166, 1961. 397. Schitz, Eiler H.: Manipulation treatment of the spinal 421. Janse, J.: Cervical and occipital involvements and their column from the medical-historical viewpoint, Tidsskr management, National Coll. ofChiro. J., July 1958. Nor Laegefom, 78: in several numbers, 1958. 422. Valentini, E.: The rate of success of chiropractic manipu­ 398. Tieszen, D. Waldo: The Tieszen Tech11iq11e, Tieszen lations in lumbar herniated discs, Ann. Swiss Chiro. Clinic,Marion,S.D., 1937. Assoc., IV:79-86, 1969. 399. Beatty, H. G.: Chiropractic technique-an analysis of 423. Weiant, C. W.: Some observations on blood pressure, various types of treatment, Chiro, ./., Vol. Xl, pp. I 1- National Chiro . ./.,Vol.XIV, pp. 13-14, November 12, January I 942. 1944. 400. Biedermann, F.: Fundamentals of chiropractic from the 424. Weiant, C. W.: Effect of chiropractic on metabolism, a standpoint of a medical doctor, Translated by L. C. J. preliminary report, National Chiro. J., Vol. XVI, p. I 7, lekeler, Davenport, Iowa, lntematio11. Chiro. Research March 1946. Comm., 1959. 425. DeJarnette, M. B.: Sacro-occipital Teclznic of Chiro­ 401. Droz, J. M.: Indications and contra-indications of ver- practic, Nebraska City, I 952. 40 426. Ibid. Sacro-occipital Teclmic of Spinal Therapy. Nebraska aural and Allied Office Techniques for Eye, Ear, Nose City, 1940. and Throat, 3rd edition, Portland, Oregon, Ryder Print­ 427. Goodheart, G. J.: Cross pattern crawling and muscle ing, 1955. spasm, Di1,;.Chiro. Econ., March-April 1969. 452. Forster, A. L.: Forster's System of Non-medicinal 428. Idem: The Intrinsic Muscles and the Persistent Suhluxa­ Therapy, Vol. I and Vol. 11, Chicago, National Pub­ tion, Ibid. lishing Assoc., 1919. 429. Idem: The Principle of Muscle Balancing, Ibid. March­ 453. Lake, T. T.: Treatment hy Neuropathy and the Encyclo­ April 1970. pedia of Physical and Manipulative Therapeutics, Phila­ 430. Idem: Sacroiliac and llio Sacral Proh/ems, Ibid, January­ delphia, 1946. February 1972. 454. Maitland, G. D.: Vertebral Manipulation, London, 431. Idem: The Cervical Challenge, Ibid. September-October Butterworth, 1964. 1972. 455. Dye, A. A.: The Evolution of Chiropractic, Republished 432. Janse, J.: Study of reflex and pressure technics, National by Richmond Hall, Inc., pp. 203-218, 1969. Chiro. J., Vol. XVI. pp. 9-10, December I 946. 456. Palmer, B. J.: Chiropractic Clinical Controlled Research, 433. Janse, J.: A scientific treatise on clinical chiropractic Vol. XXV, W. B. Conkey,publishers, 1951. measures-section one, J. National Clziro. Assoc., 457. Haldeman, S.: First impressions of the synchro-therme Vol. XXII, pp. 11-12, December 1952. as a skin temperature reading instrument, JCCA, April 434. Kenel, F.: Winkler's reflex therapy, Ann. Swiss Chiro. 1970. Assoc., V :262-266, 197 I. 458. Haldeman, S.: Observations made under test conditions 435. Nimmo, R. L.: Receptors, effectors and ton us- a new with the synchro-therme, Canad. Chiro. Assoc., Octo­ approach, J. National Chiro. Assoc., Vol. XXVI I, ber 1970. pp. 21-23, November I 957. 459. Whitby, Morton, M.R.C.S.: Theory of L(le, Disease and 436. Watkins. R. J.: Anthropology in reflex technics, National Death, Cutler Publishing Co., Chicago, I 945. Chiro. J., Vol. XVIII, pp. 14-15, August 1948. 460. Adelman, G. N.: Visual nerve tracing, its importance to 437. Watkins, R. J.: The upper thoracic complex, J. National the chiropractic profession, Chiro. J., 9- 10: Vol. IV, Chiro. Assoc., Vol. XX, p. 33, November 1950. August I 935. 438. Macdonald, J.: Dr. Locke-healer of men, Williamsburg, 461. Adelman, G. N.: Photography through the skin proves Ontario, 1933. chiropractic a science,./. National Clziro. Assoc., Vol. 439. Chillcott, R. L.: The autonomic nervous system in chiro­ XXII, pp. 20-23, April I 952. practic practice, J. National Clziro. Assoc., Vol. XXVI, 462. Dudley, W. N.: Facial thermography and adjustment, pp. 15-16,July I 956. ACA J. l~{Chiro., 54-56, August 1974. 440. Davids, S.: The subluxation as an adaptive autonomic 463. Kimmel, E. H.: Analytical instruments in chiropractic regulator, National Chiro. J., Vol. XVII I, p. 14, April practice,./ NCA, p. 28, February I 961. 1948. 464. Kimmel, E. H.: The derma thermagraph, JCC, Vol. 1, 441. Millier, R. 0.: Autonomics in Chiropractic, Toronto. No. 4, pp. 78-86, I 969. Canada, Chiro. Pub. Co., 1954. 465. Novick, N. D.: The VNT: Photo-electric instrument, 442. Pitzer, B. E.: An interesting study of the autonomic JCC. Vol. 2, No. 3, pp. 78-83, I 969. nervous system,J. National Chiro. Assoc., Vol. XXVI I, 466. Aarons, M. W.: Electro-analytical instrumentation, ACA p. 11, April 1957. .I. of Chir., January 1974. 443. Baker, F. A.: Speaking of subluxations, nerve pressures 467. Ibid: Advanced diagnostic instruments, ACA J. <~fChiro., may exist away from the spine, Chiro. J., 8: Vol. IV. p. S-49, April 1974. August I 935. 468. Maitland and Gerrard: The neurocalometer- a survey to 444. Curchod, G. A.: Sciatic pain and the foot, Ann. Swiss asses its value as a diagnostic in.strument, Med. J. of Chiro.Assoc., V:207-215, 1971. Australia, I :464-468, March 1972. 445. Eisenberg, A. M.: Diversified chiropractic technique, J. 469. Weiant, C. W.: Some preliminary observations on photo­ Clin. Chiro., 24-61, Spring 1971. electric visual nerve tracing, J. National Chiro. Assoc., 446. Janse, J., and Kissinger, R. N.: The relationship of the Vol. XXI, pp. 11-12,January 1951. mechanical integrity of the feet, lower extremities, 470. Cox, J. M.: Chiro-manis Treatment Manual, Privately pelvis and spine to the proper function of the various published, Fort Wayne, Indiana, 1974. structural and visceral systems of the body, J. <~fNa­ 471. Laufenberg, P. C.: Thompson Technic Notes, Privately tional Coll. Chiro., 26:6- I 9, May 1954. published, Sacramento, California 1973. 447. Schmidt, E. G.: A presentation of a mode of therapy for 472. McManis, J. V.: McManis Table Technic, Kirksville, treating rib lesions, ./. National Chiro. Assoc., Vol. Mo. 1938. XXX, pp. 11-12, December 1960. 473. Janse, .I.: The rationale and history of physical therapy in 448. Fox, E. A.: Psoas major muscle, ACA J. of Chiro., 541- chiropractic, Monograph Dept. Clinical Practice, 548, July 1967. Lombard, Ill., National Coll. 4Chiro., l 974. 449. Fox, E. A.: Let us consider the importance of psoas mus­ 474. Bolier, W.: Electrotherapy in coxalgiae accompanied by cle contraction, J. National Chiro. Assoc., Vol. XXVI. vertebral pain, Ann. Swiss Chiro Assoc., 111: 118-122, pp. 11-14,July 1956. 1965. 450. Fielder, S. L., and Pyott, W. H.: The Science 4 Manipu­ 475. Bolier, W.: The spine and internal diseases, Ann. Swiss lative Surgery, Bountiful, Utah, Carr Printing, 1953. Chiro. Assoc., pp. l 67-182, I 961. 45 I. Finnell, F. L.: Constructive Chiropractic and Endona.rnl- 476. Dreyfus, C. E.: The management of disuse atrophy in 41

597-036 0 - 76 - 4 scoliosis, Ann. Swiss Chiro. Assoc., 111: 123-131, 1965. pation, J. Clin. Chiro., 148-161, Winter 1972. 477. Droz, J. M.: Possibilities, limits and results of an elective 491. Betge, Giorgia: La terabia Chiropractica, 2nd edition, vertebral mechanotherapy, Ann. Swiss Chiro. Assoc., Lugano, 1974. 202-;2 I 6, 1960. 492. Janse, J.: Chiropractic Principles and Technic; For Use 478. Droz, J. M.: The trophostatic syndrome of post-meno­ hy Students and Practitioners, Trans. into Japanese by pause, Ann. Swiss Chiro. Assoc., 111:171-184, 1965. Shoji Fujii, Tokyo, Japan, Kazakushimoun-Sha., 1969. 479. Jaquet, P.: The psychosomatic approach to the treatment 493. Lofgren, H.: Orsak och verkan, Stockholm, Seelig, 1959. of backache, Ann. Swiss Chiro. Assoc., pp. 183-197, 494. Moller, E.: /\iropratik; Haender og Helhrecl, Kobenhaven, 1960. Danampress 1968. 480. Johnson, A. C.: Corrective therapeutics enhances the 495. Paper, W.: Tec/111ikder Chiropraktik, 6 Verb. Aufl Ulm. value of chiropractic treatments, National Chiro . .I., Donau, Haug, 1958. Vol. IX, p. 23, May I 940. 496. Pecunia, A. L.: Reboutement Chirosomatotherapie; 481. Keller, F.: Simple auxiliary measures in the treatment of Cinesiologie Passive Occasionnelle, 2nd edition, Paris, lumbalgias, Ann. Swiss Chiro. Assoc., 191-196, 1960. Malone 1971. 482. Kenel, F.: Purpose of sole and heel lifts and their effects 497. Cramer, A.: Possibilities of manual and instrumental treat­ on spine and pelvis, Ann. Swiss Chiro. Assoc., 111:I 61- ment of vertebral disturbances in the segment of motion, 170, 1965. Therap. woche, 7: 1956-1957. 483. Overton, R. M.: Chiropractic treatment for decongestion 498. Gutzeit, K.: The Spine and Internal Medicine, Mun­ of the liver,./. National Chiro. Assoc., Vol. XXV, pp. chener medizinische Wochenschrift. 1953. 19-20, August 1955. 499. Ibid: The spine as a factor in disease from a therapeutic 484. Pasqua, V.: Intensive chiropractic day care,./. Clin. Chiro., point of view, Therapie der Gegenwart, 92:41, 1953. 74- IO I, Spring, I 973. 500. Ibid: The vertebrae in research and practice, Therap. 485. Sandoz, R., and Lorez, E.: Presentation of an original woche 7, 1956-1957. lumbar technic,Ann. Swiss Chiro. Assoc .. 43-55, 1960. 50 I. Hoch rein and Schleicher: On the question of the vertebral 486. Sandoz, R. W.: Suspension plaster cast, Ann. Swiss Clziro. origin of angina pectoris, Medizinische Klinink, 15, Assoc., pp. 70- 77, 1961. 1953. 487. Widmann, 8.: Experiences with intermittent traction of 502. Kamieth, H.: The chiropractic view of disease in internal the lumbar spine, Ann. Swiss Chiro. Assoc., 178-186, organs, Medizin .. 1957. 1960. 503. Rabe, R.: Manual Therapy, Tec/111icsof the Chiropractors, 488. Lindlahr, H.: Philosophy of Natural Therapeutics, Chi­ Osteopaths, Bone-setters and Others, Berlin, Corvus­ cago, Lindlahr, 1918. Verlag, 1958. 489. Wardwell, W. I.: A Marginal Professional Role: The 504. Seuss, W.: Therapy for High Blood Pressure Through Chiropractor, Doctoral Dissertation, Harvard, 1951. Chiropractic, Heilkunst, 73, 1960. 490. White, M., and Skipper, J. K.: The chiropractic physician: 505. Zukschwerdt, L: Gynecology and Chiropractic, Geburt­ a study of the career contingencies of a marginal occu- shilfe und Frauenheilkunde, July 1955.

42 History of the Development of Osteopathic Concepts; Osteopathic Terminology

GEORGE W. NORTHUP Director Center for Rehabilitation Medicine Mesa General Hospital Mesa, Arizona

From the time of the ancient Egyptians the use of the profession." Willis, although critical of Still's manipulations 1 as a therapeutic modality appears, postulates, wrote that "Still's claim that medicines disappears, and reappears like a thread woven were poison and surgery a means of murder were through the tapestry of medical history. In its less ridiculous at that time than medical historians broadest connotation, manipulation ranges all the like to admit. "a way from the manual reduction of fractures, dis­ Still was one of the first to recognize the role of locations, subluxations, and more simple joint the musculoskeletal system in health and disease. dysfunctions to the application of manually ap­ He believed that health and disease were not de­ plied external cardiac massage. pendent on sharply compartmentalized anatomical The role of manipulation in the history and de­ or self-limiting physiological systems of the body. velopment of osteopathic medicine has been both He believed that the body functioned as a unit, and important and controversial. Andrew Taylor Still, that to understand health and to search for the the founder of osteopathic medicine, was essen­ causation and treatment of disease one had to con­ tially a medical philosopher. He lived at that time sider the body as a total unit. He further believed of history when the medical world was just emerg­ that the total unity of the body could not be under­ ing from 18th-century confusion. 'The tubercle stood by excluding 60 percent of the body mass, bacillus would not be introduced for 8 years. namely, the musculoskeletal system. 4 Lister, then in his prime, was trying to introduce In its 100 years of existence, osteopathic medi­ antiseptic surgery against much conservative cine has not attempted to build a system of medical opposition. The use of diphtheria antitoxin and the practice around a single therapeutic modality. It X-ray would not be introduced for several years. is significant that Still did not write a book specifi­ Pasteur, then 54 years of age, had established the cally on manipulative therapy. But in the early days germ theory of disease only 10 years before. Osler, of osteopathic medicine, manipulative therapy was a young man of 25, was beginning his work as a to play a crucial role. professor at McGill University. Another 25 years To understand the place of manipulation in would pass before Harvey Cushing would bring osteopathic medicine either then or today, it must the first blood pressure measuring instrument to be viewed in the context of the profession's basic the United States.":! philosophy. The Still thesis, reduced to its essence, It was also the time _when Dr. Still opened his consists of five major points. 5 first college of osteopathic medicine, although, as modern-day medical commentators have remarked, I. The unity of the body medical schools were numerous and "a disgrace to Still believed in the interrelationship of all body 43 systems including the musculoskeletal system. He Secondly, joint dysfunction and the accompany­ believed that each system, both in function and ing system may mimic the symptomatology of dysfunction, depends upon every other. disease in more remote body systems. This mimick­ ing effect becomes important to clinicians. regard­ 2. The healing power of nature less of their specialty. The mimicking of diseases of Still believed that there were substances within other organ systems is a consideration of great the body. which when in proper balance preserved importance. health and protected against disease. He believed Finally, the possibility that local disorders in that these same substances. when properly mobil­ the musculoskeletal system affect the function of ized, were useful in the treatment of disease. other body systems is a clinical area for further 3. The somatic component of disease investigation. For example, one might cite our growing understanding of the symptomatology The musculoskeletal system is truly the ··mach­ produced in cervical spinal strains in a whiplash inery of life," and its reciprocal communication type of injury. These are often misunderstood, but with the other systems of the body is an important recent clinical research has shown that these anatomical and physiological principle in medical cervical spinal joint dysfunctions cause such care. widely diverse symptoms as palpitation, headache, 4. Structure-function concept vertigo, vague gastrointestinal disturbances, and 8 9 10 other visceral phenomena. • • These investiga- . Structure and function cannot be separated in tions have shown that the stress-strain injury to human physiology. There is an interdependence. the somatic component of the neck reflects itself Structure governs function, and function influences in other body systems through an effect on the structure. In fact, structure and function are so autonomic nervous system. If such a phenomenon closely related they can be considered a single occurs in the area of the cervical spine, it is not component. hard to understand that mechanical stresses and 5. Manipulative therapy strains in other parts of the body can also affect visceral function. The application of manipulative therapy to re­ The somatic-visceral reflex is admittedly a gray store and maintain normal structure-function rela­ area in clinical evaluation. And. it is in this par­ tionships in the musculoskeletal system is important ticular area that there has been a need for increased not only to the function of the musculoskeletal research efforts to further evaluate and understand system itself but through its neural-hormonal com­ the usefulness and specificity of manipulative munication with other body systems. It is a poten­ therapeutics. tially useful therapeutic medium for both the maintenance of normal function and the correction From its early beginnings, osteopathic medicine of dysfunction. i; considered itself to be the complete practice of It should be reiterated that the role of manipula­ medicine. For example, the first college of osteo­ tive therapy in osteopathic medicine must be pathic medicine in Kirksville, Mo., installed one viewed in the totality of its philosophy and not as a of the earliest diagnostic X-ray machines ( 1898) thing set apart. to be found west of the Mississippi. 11 It is a fact From a clinical standpoint, joint dysfunction in that the first arteriography ever performed was done the musculoskeletal system is related to three at the Kirksville College of Osteopathic Medicine 11 broad clinical areas. 7 in 1898. Total medical care. including surgery. First, the local musculoskeletal effects of these was part of the practice of osteopathic medicine 1 joint strains and sprains resulting in pathological from its beginning. '.! limitations of normal joint motion manifest their However, it is also a fact that manipulative more obvious effects in the local area of the lesion. therapy was widely used and recommended by Dr. Musculoskeletal problems such as mechanical low­ Still and his early colleagues. Still divorced himself back pain, functional torticollis, and similar dis­ from the pharmacopeia of his day because he orders are more readily understood than those alleged that those medicinal agents were either joint dysfunctions affecting other areas and placeboes or were outright toxic to an already systems of the body. disturbed psysiology. 44 Some of Still's early antidrug statements are pathic lesion) of the synovial joint is a biomech­ embarrassing to contemporary physicians. Here anical process occurring in the musculoskeletal is the kind of thing he said: ''One of the first duties system with structural-functional changes occurring of the physician is to educate the masses not to in the articular and periarticular tissues resulting take medicine. Man has an inborn craving for in subjective and/or objective signs and symptoms. 7 medicine. Heroic dosing for several generations The manifestations of these biomechanical has given his tissues a thirst for drugs. The desire lesions are mediated through the neurocirculatory to take medicine is one feature which distinguishes system and may appear local to the lesion, in man, the animal, from his fellow creatures." How­ segmentally related but remote portions of the ever, these particular statements were made not musculoskeletal system, or as functional disturb­ by Still but by one of his contemporaries - Sir ances in other body systems. William Osler. 1 a Joint dysfunction can occur either from other To the osteopathic clinic in Kirksville at the turn somatic lesions or from visceral dysfunction or of the century, patients came by the hundreds to both. be relieved. Some responded through the simple Much of the manipulative treatment of early expedient of removing the toxic drug component osteopathic physicians centered around joint manip­ of their treatment. In a recent article Still was ulation and mobilization. Still also paid particular credited as being one of those who contributed to attention to disturbances in the soft tissue, muscles, the abolition of calomel as a therapeutic agent. 14 and fasciae. Many of his treatments for upper Patients also began to show improvement because, respiratory diseases were similar to physio thera­ for the first time in their medical care, an important peutic methods recommended today in the manage­ component of their body function was now being ment of respiratory problems. treated. It is correct to say that in the time of Still and Early osteopathic terminology was as faulty as his early followers both too much and at times too early medical terminology. In those days as now, little was claimed for the therapeutic efficacy of disease names and clinical processes bore only an manipulative care. It is quite probable that the occasional resemblance to the problem to which same weakness exists today. they ref erred. Further medical research into the mechanisms The development of an osteopathic terminology of cause and effect of disorders of the musculo­ to describe disorders of the musculoskeletal skeletal system and total body function are sorely system was, from its beginning, at best confusing needed. Animal experiments were conducted early and less than descriptive. In speaking of joint in the profession's history; in 1898 research experi­ dysfunctions, particularly in relationship to mentation was done on dogs at the American synovial joints, osteopathic physicians have tradi­ School of Osteopathy, parent school of the present tionally referred to them as "osteopathic lesions." Kirksville College of Osteopathic Medicine. Clini­ Recent efforts on the part of a study committee cal observations began to be collected, correlated made up of representatives of the American Osteo­ and recorded at an early period as well. In I 903, pathic Association and the American Academy of Dr. Louisa Burns, a graduate of the Pacific College Osteopathy have been accepted by the Hospital of Osteopathy in California, began the first of her Adaptation of International Classification of many research investigations. Disease, Adapted (H-ICDA), a commonly ac­ At the annual convention of the American Osteo­ cepted publication of medical terminology (Ap­ pathic Association in I 911 it was proposed that a pendix I). research institute be established and endowed to This terminology more accurately, albeit some­ conduct research into "osteopathic phenomenon." times rather broadly, refers to these joint dysfunc­ (This was actually formalizing an institution already tions of synovial joints as somatic dysjimctions. in existence.) With the founding of the A. T. Still Therefore, what used to be referred to as an "osteo­ Research Institute in Chicago, the first organized pathic lesion'' involving joint dysfunction of the attempt by the profession was inaugurated to study zygapophyseal joints between the spinal segments the physiological processes responsible for . the T -3 and T -4 would now be referred to as "somatic effectiveness of manipulative treatment. dysfunction" involving certain anatomical loca­ The institute existed until 1936 when it was tions. Essentially, a somatic dysfunction (osteo- merged with the American Osteopathic Associa- 45 tion. Since that time research programs have been One can do no better than heed Tin bergen 's developed and expanded in all osteopathic colleges. words and emphasis on "the importance for medi­ A large part of the research has been directly in­ cal science of openminded observation - of volved in the study of the mechanisms and re­ 'watching and wondering.' This basic scientific sponses to joint dysfunction and the response to method is still too often looked down on by those 1 manipulative treatment. :; blinded by the glamor of apparatus. by the prestige Research, both medical and osteopathic. in those of tests, and by the temptation to turn to drugs. early days of the profession, was a far cry from the But it is by using this old method of observation more skilled and sophisticated methodologies we that . . . general misuse of the body can be seen know today. Many research projects conducted in in a new light: to a much larger extent than is now both medical and osteopathic institutions would realized. . . . " scarcely be called convincing in the light of modern He concludes. ''Medical science and practice knowledge. But from the beginning, research into meet with a growing sense of unease and of lack the function and dysfunction of the musculoskeletal of confidence from the side of the general public. system, and its mechanisms of effect and response, The causes of this are complex. but at least in one attracted the attention and efforts of the osteopathic respect the situation could be improved: A little profession. 16 more openmindedness, a little more collaboration with other biological sciences, and a little more The modern era of osteopathic research was attention to the body as a whole and to the unity inaugurated by Denslow (] 938) and further im­ of the body and mind could substantially enrich plemented and expanded by Korr, his associ­ the field of medical research. " 20 17 18 19 ates, • • and others. In summary: The osteopathic profession has There is a crucial need for expanded research traditionally and presently thought of manipulative programs both to study the functions and dysfunc­ therapy as something inclusive of. not exclusive tions of the musculoskeletal system and relate to, the total practice of medicine. them to clinical practice. But as Tinbergen, 20 the The importance of the musculoskeletal system. 1973 Nobel prize winner for physiology or medi­ its structural diagnosis and the usefulness of cine. has said, "Medical practice often goes by the manipulative therapy in the total practice of osteo­ sound empirical principle of 'the proof of the pathic medicine can only be totally understood pudding is in the eating.'" In his speech of De­ when placed in context to the basic philosophical cember 12, I 973, when Dr. Tin bergen, professor principles of osteopathic medicine. of animal behavior of Oxford University, received The importance of clinical observation and clini­ the Nobel prize and presented his lecture, he re­ cal reporting cannot be minimized. However. fur­ ported on the amazing influence of the musculo­ ther basic research to achieve a better understand­ skeletal system in a wide variety of clinical prob­ ing of the function and malfunction of the musculo­ lems. He reported from personal experience that skeletal system and the effect of manipulative "corrective manipulation of the entire muscular treatment both on that system and other related system beginning with the head and neck and then systems of the body should be pursued vigorously. very soon the shoulders and chest- and finally the There is a continuing need, as there is in all of pelvis. legs. and feet was considered until the medicine, to progress further toward common whole body is under scrutiny and treatment." agreement on terms and their meanings. One of the Dr. Tinbergen, his wife, and daughter reported barriers to the more general acceptance of the that "striking improvements in such diverse things efficacy of manipulative treatment in the practice as high blood pressure, breathing, depth of sleep. of medicine can be summed up in the two words: overall cheerfulness, mental alertness, resilience research and communication. against outside pressures, and also in such a re­ To paraphrase Tinbergen's 20 concluding state­ fined skill as playing a stringed instrument" were ment. it can be said with truth of manipulative results of a special kind of treatment directed to the therapy that, "a little more openmindedness, and a body musculature. He determined that there must little more collaboration with other biological be some relationship to the proper use of body sciences, and a little more attention to the body as mechanics, posture and body movement, and the a whole and to the unity of the body and mind could function of other body systems. substantially enrich the field ... " 46 REFERENCES 11. Peterson, B., 1898: Radiology in Kirksville, J.A.O.A., 74:167-172. I. Breasted, J. H., The Edwi11 Smith Surgical Papyrus, Vol. I, 12. Still, A. T., Philosophy of Osteopathy, Kirksville, Mo., Chicago, Ill., University of Chicago Press, I 930, pp. A. T. Still, Publisher, 1899. 425-426. 13. Bean, W. B., Ed.: Sir William Osler Aphorisms: From His 2. Page, L., Principles <~f'Osteopathy, Journal Printing Co., Bedside Teachings and Writings. Charles C Thomas, Kirksville, Mo., I 952. Springfield, Ill., 1961. 3. Willis, P. A., Man's Back, Springfield, Ill., Charles C 14. Risse, G. B., Calomel and the American Medical Sects Thomas, 1953, p. 142. During the Nineteenth Century, Mayo Clinic, Proc. 48:57-64,January 1973. 4. Northup, G. W., Osteopathic Medici11e: An American 15. Wright, H. M., Perspectives in Osteopathic Medicine, Reformation. American Osteopathic Association, 1966. Kirksville College of Osteopathic Medicine, 1974, 5. Northup, G. W., Osteopathic Medicine: A Medical Refor­ pp. 40-46. (Monograph prepared for publication.) n:iation,./.A.O.A ., 64:787-794, April 1965. 16. Hoag, J. M., Cole, W. V. and Bradford, S. G.: Osteopathic 6. Northup, G. W., The Role of Manipulative Therapy in Medici11e, McGraw-Hill Book Co., New York, 1969. the Practice of Medicine, .I.A.O.A., 71 :537-542, Feb­ 17. Denslow, .I. S., and Clough, H. G.: Reflex Activity in Spinal ruary 1972. Extensors . ./. Neuro Physiol. 4:430-437, September 7. Northup, G. W., Osteopathic Lesions, J.A.O.A. 7 I :854- 1941. 865, .Iune I 972. 18. Korr, I. M.: Neural Basis of Osteopathic Lesion . .I.A.O.A. 8. Stoddard, A., Manual of Osteopathic Practice, New York, 47: 191-198, December, I 947. N.Y., Harper & Row, 1969. 19. Korr, I. M.: Axonal Delivery of Neuroplasmic Components 9. Cailliet, R., Neck and Arm Pain, Philadelphia, Pa., A. to Muscle Cells, Science 155:324-344, January 20, 1967: Davis Co., 1964. reprinted J.A.O.A. 66: I 057-1061, May I 967. 10. Mennell, .I., Back Pai11.Boston, Mass., Little, Brown & Co., 20. Tinbergen, N., Ethology and Stress Diseases, Science 1960. 185 :20-27,.luly 1974.

47 APPENDIX

Osteopathic Terminology

Records for office and hospita I use - Revised June 197 4

The terminology most commonly required for The term "somatic dysfunction" is used to desig­ requesting payment of third-party carriers for nate "impaired or altered function of related com­ osteopathic procedures is outlined on this sheet. ponents of the somatic (body framework) system; Three types are commonly used: H-ICDA (Hospi­ skeletal, arthrodial, and myofascial structures. and tal Adaptation of l nternational Classification of related vascular, lymphatic, and neural elements.'' Disease, Adapted); ICDA (International Classifi­ The term can then be amplified to indicate specific cation of Disease, Adapted): and CPT (Current areas of the body that are involved. The term is Procedural Terminology). Each of these complete further amplified to denote the specific dysfunction classifications is available in book form at minimal by using such terms as "myositis," "neuralgia,'' cost.* The material presented here is excerpted or or "limited arthrodial motion." The term can be adapted from those publications. further amplified to indicate associated visceral The osteopathic terminology in H-ICDA was pathology, such as "colitis" or "pneumonitis. '' worked out through the cooperation of the Ameri­ Thus, one could indicate on a specific patient, for can Academy of Osteopathy and the American instance, the diagnosis of "lumbar and sacral so­ Osteopathic Association and was first published in matic dysfunction with lumbar myositis and right September 1970. The committee agreed on the sciatic neuralgia." following general points: The term ··osteopathic manipulative therapy" A relatively uniform method for recording dis­ is defined as "a form of manual treatment" applied tinctive diagnostic and therapeutic procedures by a physician to eliminate or alleviate somatic used by osteopathic physicians requires the use dysfunction and related disorders. The term can be of standard anatomic, physiologic, kinesiologic, and amplified to include the area treated and a specific. pathologic terms. type of treatment under this classification of therapy. Thus, one could indicate ··osteopathic *H-ICDA: Hospital Adaptation of ICDA. Second Edition. manipulative treatment, soft tissue, and corrective 1973. Commission on Professional and Hospital Activities. to entire cervical area." 1968 Green Road, Ann Arbor, Michigan 48105, $8.50 (two The above can be put into lay terms in the volumes), $7.50 if prepaid. following example: "Somatic dysfunction is a mal­ ICDA: Eighth Revision, International Classification of Diseases, function of a segment or segments of the spinal Adapted for use in the United States. U.S. Department of Health, Education, and Welfare, Public Health Service, National Center column which may produce limited motion in an for Health Statistics, I 968. For sale hy Superintendent of Docu­ area, muscle spasm, pain, tenderness and even re­ ments. U.S. Government Printing Office, Washington, D.C. mote symptoms." The osteopathic manipulative 20402. Publication no. 1693, $7.75 (two volumes). treatment could be described in lay terms as "a CPT: Physicians' Current Procedural Terminology, Third manipulative or manual type of treatment adminis­ Edition. 1973. American Medical Association, Circulation and Records Department, 535 North Dearborn Street. Chicago, Ill. tered to alleviate or eliminate the result of somatic 60610, $5.00. dysfunction and related disorders.'' 49 Osteopathic terminology-H-ICDA 719.8 Rib cage SOMATIC DYSFUNCTION (OSTEOPATHIC) region: costochondral: costovertebral (719) sternochondrial 719.9 Abdomen 719 Somatic dysfunction 95 MISCELLANEOUS PROCEDURES RELATED Requires: additional code for specific condi­ tion TO ... MUSCULOSKELETALSYSTEM Excludes: vertebrogenic pain syndrome 95.8 Osteopathic manipulative therapy (728.0-728.9) Excludes: manipulationfor: Deflnitiont: impaired or altered function of reduction of dislocation (79.0_-79.8) related components of the somatic (body reduction o.ffracture (79.0-79.8) framework) system: skeletal. arthrodial. and release of adhesions (83.9, 85.0) myofascial structures. and related vascu­ ICDA- possibilities for use by osteopathic lar, lymphatic, and neural elements Additional termst: osteopathic lesion, bony physicians lesion, joint orthodysarthric lesion DIAGNOSIS Etiologyt: strains, viscerosomatic reflexes, 717.9 Other muscular rheumatism, flbrositis, and postural faults. occupational habits and myalgia stress 726 Affection of sacroiliac joint Symptomst: pain, burning, neuralgia, func­ 728 V ertebrogenic pain syndrome tional visceral disturbance 728.0 Cervicalgia Signst: hyperalgesia, autonomic nervous Pain in neck system disturbances manifested in the skin 728.1 Cervicocranial syndrome (hot, cold, dry. wet. smooth. rough), edema. Posterior cervical sympathicus syndrome contracture or contraction of muscles. hy­ 728.2 Diffuse syndrome cervicobrachial permobility or hypomobility, maybe posi­ Cervicobrachial syndrome (diffuse) tional changes Pain, cervicobrachial Complicationst: neuralgia. neuritis, dis­ 728.3 Radicular syndrome of upper limbs ability, visceral dysfunction Brachia! radiculitis Laboratory datat: electrical skin resistance, 728.4 Cervical myelopathy thermography Spondylogenic compression of cervical X-rayt: not definitive spinal cord NOS Pathologyt: inflammation, congestion, ede­ Vertebral artery compression syndrome ma, fibrous reaction, fibrosis 728.5 Pain in thoracic spine 719.0 Head region Thoracic radiculitis (with visceral pain) occipitocervical; temporomandibular 728.6 Thoracic myelopathy 719.1 Cervical region cervicothoracic Spondylogenic compression of thoracic 719.2 Thoracic region spinal cord NOS thoracolumbar 728. 7 Lumbalgia 719.3 Lumbar region Low back pain lumbosacral 728.8 Radicular syndrome of lower limbs 719 .4 Sacral region Lumbar vertebral syndrome sacrococcygeal; sacroiliac Lumbosacral radiculitis 728. 9 Other and unspecified 719 .5 Pelvic region hip; pubic Backache NOS Back pain NOS 719.6 Lower extremities Coccygodynia 719.7 Upper extremities Radicular syndrome NOS acromioclavicular region; sternoclavicular 846 Sprains and strains of sacroiliac region region Lumbosacral (joint) Notet: This represents a,change from the 1970 system, which 847 Sprains and strains of other and unspecified had numerous subclassifications. parts of back 50 847.0 Neck 90050 Limited service Cervical vertebrae Limited effort or judgment, such as abbrevi­ 847.8 Other ated or interval history, limited examina­ Coccyx tion or discussion of findings and/or Spine (lumbar) (sacral) except cervical treatment. Other specified parts of back 90060 Intermediate service 847.9 Unspecified Level of service such as complete history Back NOS and physical examination of one or more 848 Other and ill-defined sprains and strains organ systems, or an in-depth counseling PROCEDURES or discussion of the findings, but not re­ 88.8 Stretching of fascia, muscle and tendon quiring comprehensive examination of the Includes: manipulation for stretching patient as a whole. R9.9 Other nonsurgical procedures 90070 Extended service CPT - possibilities for use by osteopathic Requiring an unusual time, effort or judg­ ment but not a complete examination of physicians the patient as a whole. PROCEDURES 90080. Comprehensive (adult) service 22500 Manipulation of spine, any region, during In-depth evaluation of the patient. office visit 27270 Manipulation of sacroiliac joint (without anesthesia), including office visit Notet: Similar listings are given for extremity manipulation OFFICE MEDICAL SERVICES, as needed, or for manipulation under anesthesia as needed. ESTABLISHED PATIENT . Note:!:: Similar listings are available for new patients and for 90040 Brief service various age groups. Brief period of time, minimal effort or t Additional information supplied by the AOA-AAO com­ judgment by physician. mittee to help with use of this system of terminology.

51 Discussion: The Impact of Spinal Manipulative Therapy on the Health Care System

WALTER I. WARDWELL Professor of Sociology College of Liberal Arts and Sciences University of Connecticut

Since this session is focused on concepts and focus on SMT separates the question of its scien­ terminology, I will suggest a shorthand designation tific merit as a therapeutic technique from the ques­ for the phrase "spinal manipulative therapy." tion of who should practice it' and under what Following the precedent set by osteopaths, who conditions. For too long a time disputes over the refer to osteopathic manipulative treatment (or second question have prevented serious attempts to therapy) as "OMT," I shall use the abbreviation address the first question. I should like to add ''SMT" as a shorthand for "spinal manipulative this fact as a fourth point to John Mennell's three therapy." I understand John Menn~ll's point tha·t reasons why the development of manipulative the concepts and techniques of manipulative concepts has been long delayed. therapy should not be limited to the spine, and I An unquestioned virtue of science is the uni­ note that the word "spinal" is omitted from the versalism of its concepts and empirical conclusions titles of the other papers on this panel: however, once definitional problems and semantic confusions since the topic for the entire conference is spinal are resolved. The previous papers have brought manipulative therapy, and, as John Mennell us a long way toward that goal. The speakers in observes, the term "manipulation" is often under­ the remaining sessions now have a group of con­ stood to mean spinal manipulation, I shall leave cepts and terms with which to debate the research in the "S" for "spinal" and use SMT, recognizing status of SMT. However, since my topic is the at the same time that the concepts and principles impact of SMT on the health care sys'tem, I must that I am discussing may apply as well to the consider the practitioners themselves, their re­ manipulation of other parts of the body. So much lationships with each other and with organized for concepts and terminology. medicine, their reception by the public, and the It was a stroke of genius to focus this conference kind of judgments which legislators and govern­ on the research status of SMT rather than on the ment officials have made about them.:! Therefore, scientific basis of chiropractic. This allows a more I note first that several types of practitioners of precise and a more suitable topic for discussion. SMT are not represented here. There were several More important, it directs attention away from the earlier varieties of practitioners of SMT, some of secondary questions of relative professional which no longer exist-such as neuropaths, competence, legal privilege, patient responsibility, naprapaths, spondylotherapists, mechanotherapists and interprofessional rivalry, which have caused so and naturopaths. And John Mennell has referred much controversy and organizational jockeying to the physical therapists, a few of whom are throughout the past century. (It was in 1874 that beginning to practice SMT. Since the fate of some Andrew Taylor Still first attempted, unsuccessfully, of these groups logically and politically depends to present his osteopathic theories to the medical on the outcome of this conference, they should authorities at Baker University in Texas. 1) The perhaps have been offered an opportunity to con- 53 tribute to it, and they should be considered when SMT from osteopaths, medical doctors. and the policy question is faced of who should practice physical therapists. is an impressive measure of the SMT and under what legal, professional, and impact of SMT on our health care system. I assume reimbursement conditions. that nearly every chiropractic patient receives SMT. Now to the topic of the impact of S MT on our Another type of impact can be seen in the in­ health care system. I conceive the health care creased acceptance of osteopaths by the American system as categories of health practitioners and Medical Association as qualified professional their assistants. plus practice facilities and the associates. While such recognition has been at­ patterns of recruiting, training, paying, supervising. tained in part because most osteopaths no longer and motivating them; also their respective locations use OMT as their principal therapeutic technique, within the system, their numbers, their legal or such recognition by the AMA as professional conventional rights, privileges, and responsibilities; colleagues carries considerable symbolic impact. and their professional relationships with each other Equally important is the North American Acad­ -conflict. competition, cooperation, subordina­ emy of Manipulative Medicine. which John tion, or whatever. The attitudes and behavior of the Mennell he!ped to found about 10 years ago, for public, the consumers of health services, are also now there exists a dedicated group of manipulators relevant. For example, most chiropractic patients, within the medical profession itself. The impor­ while aware of the disapproving attitudes of or­ tance of this group is also partly symbolic because ganized medicine, appear to be satisfied with it still has relatively few members, it lacks accept­ chiropractic treatment. Many patients regard their ance by more orthodox colleagues in physical chiropractor as equal to other doctors, and some medicine and orthopedics, and it has had to suffer even consider chiropractors to be specialists like not a few indignities for its venturesomeness. orthopedists or obstetricians. Another recent development is the establishment The impact of SMT on the health care system by a group of physical th~rapists devoted to has been mediated through legislative action. manipulation of a Section on Orthopedic Physical Despite the fact that its scientific and clinical value Therapy within the American Physical Therapy has been challenged by the American Medical Association. Association, the legislatures of all 50 States and Despite these developments there is still a great the District of Columbia have licensed chiroprac­ deal of ignorance and bias in medical circles con­ tors. All the States have authorized reimbursement cerning osteopaths and chiropractors. The official in Workmen's Compensation cases. Thirty-one position of the American Medical Association States have legislated equal treatment of chiro­ until 1961 was that osteopaths practice sectarian practors by insurance companies. while most medicine; and the decision by the AMA House of insurance companies have decided independently Delegates in that year did not really reverse that to pay chiropractors for services rendered to judgment but merely left it to each State medical patients. And finally Congress has authorized society to decide for itself whether the osteopaths payments to chiropractors under both the Medicare in their State practice sectarian medicine or not. 3 and Medicaid programs. Symbolically important The AMA's judgment on chiropractic has been was the decision last year by the U.S. Office of even more severe. For example, as recently as Education to designate an official accrediting May of last year the Chairman of the Committee agency for chiropractic colleges -a group called on Quackery, Dr. Thomas Ballantine, in testimony the Chiropractic Commission on Education. There before the Advisory Committee on Accreditation are about 6,000 students currently studying in 12 and Institutional Eligibility of the U.S. Office of chiropractic colleges; 850 chiropractors were Education quoted from an earlier report which "de­ graduated from 10 of these colleges last year. scribes the cult of chiropractic as involving the pur­ These figures compare with 3,156 students at 9 ported •healing' through methods or according to osteopathic colleges, which graduated 587 osteo­ theories which do not have a scientifically based paths last year. foundation.'' and goes on to state: "Medical author­ It is estimated that about 17,500 practicing ities unanimously agree that chiropractic has no chiropractors treated 2 ½ percent (i.e., over 5 validity. The cult's theories have never been sup­ million) of the population last year, which. in addi­ ported by objective evidence, and they have been tion to the unknown number of patients receiving thoroughly refuted by medical science.'' Further- 54 more, "Chiropractic treatment often produces the benefit of a medical anthropologist's survey of actual physical damage to patients." It is my strong the variety of primitive and folk practices which impression that such statements cause the AMA to resemble SMT, such as the mili-mili and the lomi­ lose credibility and are probably self-defeating as lomi of the native Hawaiians. regards the attainment of AMA objectives. I George Northup's paper presents a clear state-. realize, of course, that "SMT" is not identical to ment of the position which I would expect from a "chiropractic theories," which. particularly in the "true, tried, and qualified osteopath," to use past, have sometimes emphasized spinal subluxa­ Andrew Taylor Still's phrase. The sharpest dif­ tions and their correction to the exclusion of ferences in conceptualization lie between the other causes of disease and therapies. However, Northup and Janse papers, on the one hand, and the AMA statements distort reality when they John Mennell's on the other. For John Mennell identify chiropractic with the oldest and the most advances a mechanical explanation of "joint cultist views that some chiropractors have held. dysfunction," and he discounts the role of impaired The AMA's statements on chiropractic educa­ circulation and of nerve irritation or impingement. tion are also misleading. While chiropractic colleges I should like to learn his reaction to Northup's have lagged behind medical and osteopathic and Janse's arguments that osteopathic lesions. colleges in lengthening their course of instruction subluxations, and joint dysfunctions, if they are the and improving the quality of their curriculum and same thing, also involve blood circulation and graduates, all chiropractic colleges today require 2 neural inhibition or stimulation; and his opinion of years of preprofessional college credits for ad­ the "reports on clinical observations regarding the mission and a 4-year course for a D.C. degree. interplay of dysfunctions in the spine and organ Indeed, the laws of 38 States now require a mini­ dysfunctions" to which he refers near the end of mum of 6 years of postsecondary education for a his paper. chiropractic license while 15 States require that Based on the papers presented this evening and chiropractors pass the same examinations in basic on my own investigations I have reached the science subjects that medical and osteopathic can­ following conclusions: didates must pass. I am speaking of minimum re­ (I) Osteopathy and chiropractic were not new quirements. The percentage of students entering discoveries by Andrew Taylor Still and Daniel chiropractic colleges who already have the bacca­ David Palmer respectively. On the contrary, there laureate has continued to rise; in Joseph Janse's was a long tradition of irregular practitioners, college this past fall, 43 percent had a bachelor's mainly "bonesetters," who treated patients by degree. putting little bones that were "out" back in place The stereotypes are still with us, however. A by manipulation. Elizabeth Lomax's conclusion physician, who is one of the most well informed I that one can only regard osteopathy and chiro­ know on the subjects of SMT and chiropractic, practic as legitimate offspring of contemporary referred to a chiropractor who is participating in thought explains such metaphysical expressions as this conference in these words: ''He is not really a innate intelligence and also where osteopathy chiropractor.,. When I inquired what he meant, he and chiropractic derive some of their therapeutic said: "He (meaning the chiropractor) does not theories and techniques. As dentists, podiatrists, believe in using chiropractic to treat every disease." optometrists, and mental healers arose as providers What he could have said is: "Some chiropractors of specialized services that orthodox practitioners are not chiropractors," or perhaps even: "Some were unable or unwilling to perform, so osteopaths of my best friends are chiropractors!" and chiropractors found gaps and niches in the In my capacity as panel discussant. I would like health care system which they could fill. to make a few comments on the preceding papers. (2) Theories advanced to explain the clinical I consider sociology to be one of the basic medical benefits of SMT have been numerous and various. sciences, but since I am not a historian or trained The four previous papers all document this. in the medical sciences, my remarks must be (3) Opposition to SMT by regular medical limited with regard to technical questions. practitioners has been strong for at least 150 years, I have a feeling of genuine gratitude to Elizabeth despite its advocacy at fairly frequent intervals by Lomax for the excellent job of historical scholar­ physicians like Harrison, Little, Paget, Hood, the ship which she has performed. I wish we also had Mennells, and the Cyriaxes. A wide gap in com- 55 munication and professional interaction has there­ tion occurred in which differences were exagger­ fore persisted between manipulators and regular ated and common elements minimized. A new ter­ practitioners. Even the rapprochement between minology suggested that chiropractors not diagnose medicine and osteopathy that has been growing in disease but analyze the spine in order to discover the past decade appears to have resulted because the cause of disease. Drugs and inoculations be­ osteopaths have become more like allopathic came defined as poisons antipathetical to true physicians rather than because allopathic physi­ chiropractic. While these policies may have pro­ cians have begun to accept SMT. Actually this vided some minor legal advantages (e.g., it could relationship seems more to be an organizational be argued that since chiropractic is not the practice maneuver than the product of intellectual convic­ of medicine. it therefore should be separately regu­ tion, as attested to by the resentment of traditional lated). they appear mainly to have aided B. J. osteopaths toward their California brethren who Palmer's strategy for condemning his opponents converted to medicine. and retaining his dominant position in the pro­ (4) The major impact of SMT on our health care fession. The present division among chiropractors system appears to have been the development of still hinges on the question of how different from several separate and distinct professions outside and opposed to medicine chiropractic is held to be. orthodox medicine -not only osteopathy and Since osteopathy was not so strongly opposed chiropractic but also naturopathy. Although other to the use of drugs. it could more easily evolve in a healing traditions such as herbalism in America medical direction. And the fact that the osteopaths and natural healing methods from Europe exerted who strongly emphasized OMT risked being identi­ an independent effect on all three of these pro­ fied with chiropractors may have pushed osteop­ fessions. such influences appear to have been es­ athy further in a medical direction. Nevertheless. pecially strong in the case of naturopathy. Due to while osteopathy theoretically could have monopo­ the strength of the opposition by the AMA, even lized the common ground between medicine and the modest amount of accommodation between chiropractic and thus perhaps have bridged the medicine and these other health professions that gap. it has tended to bifurcate through being tom has been taking place in Canada, Germany, and between medicine and SMT. That is the dilemma several other parts of the world has not occurred still faced by osteopathy today.:; in the United States. (7) Since SMT is a highly developed and special­ (5) SMT has remained almost completely neg­ ized skill requiring hundreds of hours of theoretical lected by orthodox medicine, probably to the and practical training for its mastery, it would not latter's disadvantage. A few physicians abandoned be practical to make every medical school graduate medicine over the years in order to practice as a competent manipulator. A possible alternative osteopaths or chiropractors. Those who remained would be for specialists in physical medicine or in medicine and practiced S MT were often stigma­ orthopedics or neurology to become proficient tized and discriminated against. The laboratory and manipulators. But apart from the reluctance of clinical research that should have been done to many such specialists to master SMT, there simply evaluate the efficacy of SMT was not done. The are not sufficient numbers of specialists to meet recent publication in Lancet of a Utah study com­ the needs of all the patients requiring SMT (as­ paring favorably the relative success of chiro­ suming that the consensus of this conference will practic and of medical treatment in 232 Workmen's be that SMT is valuable therapy). Compensation cases with back or spinal problems Another possibility would be for the physician's stands nearly alone in the medical literature. 4 traditional assistants in physical medicine -i.e .. Consequently the benefits of SMT (whatever they physical therapists -to become manipulators. may be) have not been generally available to the which a few of them are now beginning to do. The patients of medical practitioners. difficulty with this solution, however, is that it (6) Because of the hostility of organized medi­ would be as inefficient for a physician to prescribe cine. osteopathy and chiropractic have remained manipulation to be carried out by a technician as more sectarian. Chiropractic became defined not it would be -for a surgeon to stand by while an as­ only as "separate and distinct" from medicine but sistant performs his surgery. The manipulator as the diametric opposite. A process of polariza- should be able to evaluate the patient's suitability 56 for SMT, and make a differential diagnosis; and health. This possibility would seem to justify de­ the manipulator should know the contraindications signing a large-scale prospective epidemiological of SMT, when to refer a patient to another practi­ study in which the incidence of cancer, cardio­ tioner or to a specialist, and when to modify treat­ vascular disease, mental breakdown, and other ment. This requires diagnostic and clinical skill. degenerative and contagious diseases would be To incorporate these skills into the training of assessed in two carefully controlled groups of physical therapists would result in duplication of subjects from the same population -one taking the length and type of training now offered in chiro­ regular SMT treatments, the other not. It would practic colleges. As an alternative, chiropractors be necessary to control for the effects of other could practice under or in cooperation with general relevant variables, especially diet, exercise, smok­ medical practitioners or specialists in physical ing, etc., in order to isolate the effects of SMT. medicine, orthopedics, etc., but such a solution The hypothesis would be that since disease is a would have to overcome very strong resistance. process in which the resistance and level of func­ There is, therefore, no easy solution to the question tioning of the host is a critical factor, efforts at of how specialized practitioners of SMT, like health maintenance should be directed at the chiropractors, can best be fitted into our health natural resources of the human organism as an care system. integral system comprising musculo-skeletal, cir­ (8) Compared to drug therapy and surgery, the culatory, neurological, and other subsystems. If risks of SMT are minimal, if one can judge from "the body is its own laboratory," as the osteopaths the paucity of reported cases of harm done to pa­ have said, and is vitally dependent on its structural tients. The cost of malpractice insurance for chiro­ and neurological integrity, as both osteopaths and practors has remained low while that for medical chiropractors have claimed, then a prospective practitioners, particularly surgeons, has gone up epidemiological study could test the value of SMT sharply. When SMT is carried out by a skilled as a prophylactic strategy. practitioner, there is little risk to the patient, pro­ To summarize, the principal impact of SMT on vided of course that a proper differential diagnosis our health care system so far has been social, has revealed that SMT is indicated and that treat­ economic, and political in that it has resulted in ment by some other means or for some other condi­ several jealously competing professions with tion (e.g., a malignancy) is not prevented or different legal standings, therapeutic philosophies, delayed. and modalities of practice. Although a few medical (9) Consideration should be given to the possi­ physicians like the Mennells, the Cyriaxes, Robert ble role SMT can play in health maintenance and Maigne, and others have used SMT, most practi­ illness prevention. Philosophically most of us tioners of it are still outside the medical main­ would probably agree with Rene Dubos' thesis stream. As a result, the vast majority of Americans that Hygeia, the goddess of right living, should take have not been exposed to SMT and thus have only precedence over Asclepius, the god of healing. 6 vague, possibly erroneous, and generally skeptical Certainly the contemporary ethos has swung far attitudes toward it. Basic research has been limited in that direction. I am referring to the concern and the planning of clinical trials is just beginning especially among young people over environmental (in Toronto, for example). More research is needed. pollution, clean air, clean water, pesticides, organic It is clear that most of the impact of SMT on our gardening, natural foods, aerobic exercises, and a system of health care has yet to occur. simple life. These themes have long been em­ phasized by osteopaths, chiropractors, and naturo­ REFERENCES paths, as well as by many medical doctors. SMT on a regular prophylactic basis has been advocated I. Northup, George W., Osteopathic Medicine: An American as a means by which a healthy person can become Reformation. Chicago, Ill. American Osteopathic Associa­ even healthier. Although the practitioners of pro­ tion, 1966, p. 14. phylactic SMT have sometimes been c~arged with 2. My publications in this area include: Social Strain and Social Adjustment in the Marginal Role of the Chiro­ giving excessive or unnecessary treatment, a real practor. (Ph. D. thesis, Department of Sociology, Harvard possibility exists that such use, along with other University) 1951: "A Marginal Professional Role: the natural healing methods, will result in better overall Chiropractor." Social Forces, 30:339-348, 1952: "Public 57

597-036 0 - 76 - 5 Regulation of Chiropractic." J. Natl Med Assoc. 53: I 66- 4. Kane, Robert L., et al., "Manipulating the Patient." Lancet, 172, 1961; "Limited, Marginal, and Quasi-Practitioners." 7869: 1333-1336, June 29, 1974. in Howard E. Freeman, Sol Levine, and Leo G. Reeder 5. New, Peter Kong-ming, "The Osteopathic Students: A (Eds.) Handbook of Medical Sociology. New York, Study in Dilemma." in E. Gartley Jaco (Ed.), Patients, N.Y. Prentice-Hall, 1972. Physicians, and lllness. Glencoe, Ill. Free Press, I 958. 3. "Osteopathy: Special Report of the Judicial Council to the 6. Dubos, Rene, The Mirage of Health. Garden City, N.Y. AMA House of Delegates." JAMA, 177:774-776, 1961. Anchor, I 961.

58 Chairman's Summary: Evolution and Development of the Concepts of Manipulative Therapy

DONALD B. TOWER Director, National Institute of Neurological and Communicative Disorders and Stroke National Institutes of H ea/th Bethesda, Maryland

In discussion it was pointed out that an impor­ manipulation to treat these conditions. Thus, it was tant figure in the history of manipulation -one who suggested that he ought to be considered a source provided inspiration for both chiropractic and for much of what is under discussion at this osteopathy-had not been mentioned. He was J. workshop. Evans Riadore, a London physician who wrote a The discussion concluded with a plea to establish treatise on "Irritation of the Spinal Nerves" in observable criteria and definitions of terminology. 1843. He attributed many diseases to this condi­ These were perceived to involve questions about tion, stating: " ... if any organ is deficiently the kinds of observable conditions treated with supplied with nervous energy or of blood, its func­ spinal manipulative therapy; about ways in which tions immediately, and sooner or later its structure, such conditions could be observed by groups of become deranged . . . . " independent, unbiased observers; and about the This was a viewpoint subsequently echoed by influences of the therapy and the means for osteopaths and chiropractors. Riadore went on to recognizing and evaluating these influences. Such describe root pain arising from compression in the considerations seemed essential to any scientific intervertebral foramen: disc degeneration and discourse on the problem.

59 Chapter 111.

What Do the Basic Sciences Tell Us About Manipulative Therapy? (Anatomical and Biomechanical Studies)

Philip Greenman, Chairman The Vertebral Motor Unit and lntervertebral Foramen

DAVID C. DRUM Canadian Memorial Chiropractic College Toronto, Ontario, Canada

INTRODUCTION hypermobile), fixated (blocked, hypomobile) or The main goal of all scientific research is to displaying more complex erratic motion? These develop adequate conceptual models about the questions have encouraged clinical investigations relevant problem area. 1 The vertebral motor unit into the relative efficacy and priority of immobiliza­ (bewegungssegment- motion segment) is Jung­ tion and manipulatory techniques and inquiry hanns' term for his conceptual model of the seg­ into therapeutic measures directed at avoidance 29 2 of damage to neurovascular elements. rn- mentally arranged functional unit of the spine. • 3 There are usually 23 typical motor units found from THE TYPICAL VERTEBRAL MOTOR UNIT the junction of C2-C3 to that of L5-S I, each Anatomical Components composed of an intervertebral disc, neurovascular elements concentrated within the neural foramen Junghanns' unit is made up exclusively of soft and intervertebral foramina, posterior spinal joints tissues schematically represented in figure I. and all the connective and muscular tissues sup­ porting and limiting intersegmental motion. The posterior articulations and disc form the mobile elements: the ligaments and muscles form a system \ that ties them together. Certain relatively constant \ intervertebral / disc modifications associated with different spinal I regions are encompassed within the model of the typical vertebral motor unit. ( e.g. Vertebral artery and joints of Luschka 4-ti in the cervical spine, costovertebral articulations 7 and sympathetic chain in the dorsal spine and the transforaminal ligaments and cauda equina in the lumbar spine.) The concept of the functional unit has also been 8 effectively applied to the pelvic girdle. • !J In an attempt to shift prevailing attitudes toward spinal disorders from the skeletal system to the soft tissues, Junghanns created a concept in 1950 that has great relevance to manipulating spinal therapists and bioengineers. It gave them a func­ tional concept of vertebral subluxations by stressing the close relationship between the morphological 10 18 features of the motor unit and its dynamics. - Was the vertebral motor unit loosened (unstable, Fig. 1. The Vertebral Motor Unit (Junghanns). 63 Theoreticians of spinal manipulation, at one time relationships of vertebral motor units may well be or another, have implicated virtually every anatom­ irreversible; that there are permanent intervertebral ical component of the vertebral motor unit in their subluxations that cannot be manipulated back into attempts to explain the mode of action of their .. proper alignment.., Markedly abnormal motor therapy. Studies identifying the pain sensitive units are distorted as a result of advanced break­ tissues of the back have. on occasion. been used to down of their stabilizing elements. A manipulation formulate rigid theories that must be considered would have to instantaneously restore these de­ inadequate if for no other reason than their over­ generated tissues to "hold." This is not to suggest emphasis on single anatomical features. Conceptual that manipulation is contraindicated in all architec­ dogmatism has done little to facilitate interdis­ turally modified motor units. But the therapeutic ciplinary dialogue. In the light of new data some goals are more sophisticated and an advanced level cherished models will have to be abandoned alto­ of sensory (palpatory) and motor (manipulative) gether; others expanded to incorporate these skills is necessary to insure the delicacy of the findings. 30· 31 maneuver, which even in the hands of an experi­ The Usefulness of tlie Vertebral Motor Concept in enced clinician is not without risk.=16 Novices in Spinal Manipulation vertebral manipulation. regardless of their intel­ Employing the concept of the spinal organ system lectual appreciation of the problems, are encour­ containing functional units, clinical procedures aged to develop their neuromuscular and proprio­ have been evolved to discover altered mechanics ceptive abilities by mobilizing vertebral fixations (loosening, blocking. erratic motion) displayed by and avoiding the unstable segments altogether. To the motor unit before there are visible radiographic an inexperienced observer all spinal-pelvic manipu­ changes. Discovering such early functional im­ lations may look the same but they are not. and pairment is of particular importance in the bio­ while the subtleties of discrimination in technique mechanical therapies because most are reversible, application may not be discussed at this confer­ many permanently, with conservative care. ence. they do exist. 3 Except through surgical exposure and special Fisher, • an orthopedic specialist writing about radiographic techniques using contrast media, soft the results of manipulation in lumbar intervertebral anatomical components of the motor unit cannot be disc lesions warns: "The results depend upon adequately visualized. their status generally being careful selection of cases and upon the skill and inferred from the positional and dynamic relation­ experience of the manipulator. I strongly suspect ships of adjacent vertebrae. This explains Parke that many of the sad examples regularly brought and Schiff's 32 incorporation of the opposing super­ forward by opponents of manipulation are due to ior and inferior halves of each vertebra (which also the lack of the necessary qualities in the operator represents an embryologic somite) and Depalma and to the use of brute force." If such advice 28 -:rn and Rothman's 33 inclusion of the adjacent osseous is disregarded in the present atmosphere of en­ segments in their vertebral motor unit models. The thusiasm toward spinal manipulation, I predict an early manipulators· •'bone out of place" concept escalation in the already proliferating reports by clearly overlooked the significance of evaluating neuro and orthopedic surgeons describing serious the integrity of the radiolucent soft elements and complications of ill-advised, ill-performed manipu­ failed to recognize their pathogenetic precedence - lations. Darbert et al.38 warn of the danger of a regrettable limitation, for as Maigne reminds us, combining two therapeutic modalities, back manip­ a manipulation acts only upon these mobile struc­ ulation and anticoagulant medication, without tures.34 (Jackson as in an analysis of more than appropriate interprofessional communication, re­ · 5 .000 patients with symptoms referable to the porting a case of spinal meningeal hematoma. cervical spine found their injuries in 75 percent of Specialists in manipulation have been interested 10 the cases confined to the soft tissue structures.) in the observations of Sandoz, namely, that re­ But this oversight was in the days before the as­ versible, episodic intervertebral motor unit func­ similation and application of Junghanns' concept tional impairment affecting motion in one dimen­ on an international. multidisciplinary basis. sion may be superimposed on grossly malaligned Lewit, 16 Drum, 14 and Howe ta have reminded segments and that manipulation may improve their therapists using manipulation that many congenital, function without alleviating their previous insta­ traumatic, degenerative, or adaptive positional dis- bility. Such patients are, of course, prone to 64 recurrence. Froning and Frohman :m note that an functions in areas remote from the spine. Interest abnormal spinal joint with qualitative abnormal in the intervertebral foramina as a prime area for motion may still move through a full arc of motion, potential neuromechanical conflicts has increased while Jirout 17 describes rotatory blocks (fixation) since Gutzeit; 11 Wendt;t'.2 Duus and Kahlau, 4:i 44 4 in lateral cervical inclination coincident with Reischauer and Pillokat ~' in the I 950's claimed pathological increase in flexion-extension in the that secondary irritation of the cervical ganglia same vertebral motor unit. Gillet and Liekens 11 may lead to organ lesions and functional disorders. also write of hypo and hypermobility manifesting Chiropractors have from their beginning drawn during different planes of movement of the same attention to the intervertebral foramina 4n in spite motor unit and refer to the complexities of incom­ of cadaver studies claiming they were anatomically plete fixations that may reveal themselves in unchanging.47 erratic, jumpy motions at some point during the Breig 48 considers the hind brain, medulla oblon­ arc of movement. German manual medicine spe­ gata, and cord as forming a functional unit together cialists hold the opinion that reducing fixations of with their nerves and ligaments. A remarkable anatomically intact and degenerative motor units mobility of the neural structures (nerve roots, still capable of function and compensation is the posterior root ganglia, spinal nerves), their menin­ main objective of manipulative therapy: 10 If these geal sleeves and fibrous sheaths in the normal findings are substantiated, vertebral motor unit intervertebral foramen permits this ''radicular dynamics are much more complex than hitherto complex'' to adjust to the great range of spinal suspected, and it may be naive to rely on an "all movements. The space between the definitive or nothing" polarity functional classification (i.e. sheaths of the neural structures and the foramen hypo-hypermobile) of the motor unit, which is, of is occupied by fine connective tissue with no course, multiaxial. thickenings attaching the radicular complex to The vertebral motor unit concept redirected bone. Sunderland .rn has recently discovered that attention from the bony confines of the inter­ only the fourth, fifth, and sixth cervical spinal vertebral foramen to its soft tissues and stressed the nerves have strong attachments (to the transverse developmental and topographic interdependence processes). He suggests this is because of the between the fibrous structures surrounding the additional strain of shoulder girdle movements. intervertebral foramen and the function of the He further describes a dynamic "plugging" action structures passing through it. Inquiry has been of the dural funnel at the intervertebral foramen stimulated into the sequential influences of con­ limiting the movement of a laterally tractioned genital and acquired disorders of a single major spinal nerve. Traction on the dura is transmitted component of any one of the spinal motor seg­ via the dentate ligaments to the spinal cord. The ments on both the functions of the other com­ great lengths of the lumbosacral nerves and nerve 50 ponents of the same unit and other levels of the roots dissipate stresses efficiently except perhaps 51 spine. the first sacral nerve which Hollinshead reports to be relatively taut and unyielding with its dural THE INTERVERTEBRAL FORAMEN sheath attached to the margins of the interver­ tebral foramen. Frykholm, 52 in illustrating mal­ The intervertebral foramen is the elipsoid aper­ formation of root pouches and spinal nerve angula­ ture, more of a short canal than orifice, that gives tion, reminds us that a perfect functional anatomy exit to the segmental spinal nerves and entrance to is seldom found, except in a small privileged group the vessels and nerve branches that supply the bone of individuals. and soft tissues of the vertebral canal. I ts neuro­ Neuromechanical conflicts in the intervertebral vascular elements may be influenced by the foramina rarely involve pure statics: advanced intervertebral disc and other motor unit ligaments, radiographic degenerative changes are frequently the posterior spinal articulations and intrinsic found in asymptomatic spines. Rosomoff and Ross­ alterations in their own tissues. man 53 estimated 75 percent of persons over 50 N eurovascular Components have some narrowing of the cervical intervertebral Part of the originality of the chiropractic concept, foramina and encroachment from joint of Luschka and most criticized, has been the hypothesis that hypertrophy is well documented." 4 We may use spinal disturbances are capable of generating mal- the analogy of a "one-two knockout punch," the 65 static reduction of a cushioning, shock-absorption the sympathetic plexus surrounding the vertebral mechanism upon which is superimposed dynamic artery. 63 Macnab 64 questions whether the pain of demands of motion of the spine and extremities. osteoporosis may not be due to venous stasis in The significance of considering dynamics along the vertebral bodies. Olsson 65 associates mechanical with tissue alteration is at least honored by the root pressure with edema formation in the sheaths universally observed practice of removing the and endoneurium. He theorizes the sudden elabora­ mechanical component by suggesting rest and im­ tion and subsequent re absorption of this edematous mobilization devices. The theory of cord, root, and fluid may be mirrored by the acute exacerbation­ dural tension opens a new field for investigations. remission clinical pattern. The small blood vessels (Breig 48 has shown the spinal cord does not move of the roots and ganglia, unlike those in the central up and down axially in the canal, but adapts itself nervous system. are surrounded by large extra­ to varying canal lengths by plastic deformation cellular spaces and do not exhibit the "blood-brain that affects its cross-sectional area. I ts blood barrier phenomenon." 66 Olsson suggests that their vessels are kept open by stiff fibers first described easy permeability in combination with the extra­ 5 by Key and Retzius.'.>) Chronic compression of a cellular spaces facilitates diffusion of edema. radicular nerve by cervical intraforaminal disc Others 67 relate the familiar gradual reduction of protrusion may initiate root-sleeve fibrosis with vibratory sense in aging people to the unusual thickening of the adjoining dural tissue. This places arterial supply to the spinal ganglia where the the nerve root under tension even during physio­ ganglionic vessels branch at right angles or by way logical head and neck movements. "6-6° of recurving arcs against the direction of blood flow Other vertebral motor unit changes may contrib­ in the parent spinal artery. Japanese investigators 68 ute to neurovascular irritation and perhaps com­ have suggested that inflammatory processes play promise hemodynamics. The role played by the an important role in the production of symptoms venous drainage system of the vertebral column of cervical and lumbar disc lesions and that radicu­ is, according to Batson, 61 as important as that of lar pain is closely related to the pathophysiological the other main venous systems in the body-caval, state of the epidural space. portal, and pulmonary. They have soft, almost The I ntervertebral Disc and Other Vertebral valveless walls and are tortuous. It may be appre­ Motor Unit Ligaments ciated that venous blood flow in the spinal complex Interest in the ligamentous elements of the depends to a large degree upon motion in the vertebral motor unit has centered on their ability vertebral motor unit as these veins are deprived to compress neurovascular structures, their con­ 69 of the benefits of active muscular contraction and tribution to shock absorption ("joint-play" ) and relaxation, which elsewhere assist in the propulsion stabilization by limiting intersegmental movements, of venous flow. Fixation subluxations may there­ and their role in the pathogenesis of motor unit fore assume an, as yet, unexplored role in patho­ hypermobility. hemodynamics. Farfan 70 considers a degenerated disc as a ''joint'' Impediments to venous flow, caused by varices, suffering from a chronic sprain and its annulus as obliteration, congestion, are of both morphological the main ligament joining two adjacent vertebrae. 11 77 and functional importance, inasmuch as the verte­ Investigations - centered on the intervertebral bral venous system in an adult of average build disc over the last four decades have been pro­ holds about 200 ml. of blood; in the presence of liferating to the point where "mesmerization" 78 congestion, this volume may be two to three times has been suggested. Shealy .79 in speaking of 700 greater. 61 The extensive anastomoses of the verte­ '•flunk-outs" of disc surgery. comments on the bral venous system with other body venous sys­ frequency with which patients report their pain to tems and the potential for reversal of their blood be exactly the same as it was prior to the first of flow (as for example in raised intra-abdominal their average of four lumbar surgeries. German pressure) involve them in circulation disorders physical medicine specialists 80 state that only in originating in other venous regions. Brain 62 claims the lower lumbar spine do true disc herniae deserve venous compression in cervical spondylosis results their present focus of attention. They reason that in blood stasis and vascular dilatation causing since manipulation is also effective in segments additional compression on neural elements and without discs (e.g. the atlanto-occipital region), the Jones implicates venous congestion in influencing action principle of manipulation must involve more 66 than reduction of disc fragment displacement. of IO spines, found 47 anomalous transforaminal Junghanns:! and Armstrong 81 describe internal ligaments, most cases grossly diminishing the disc derangements with displacement and incar­ space available to the emerging nerve root. These ceration of a disc sequestrum within the disc space are strong, unyielding structures of varied width causing motor unit locking and de Seze 8:! believes and thickness ranging from 2 to 5 millimeters. all fixations are secondary to a disc lesion. While It has been the author's repeated observation admitting that disc derangement is undoubtedly that the most common error in the application of responsible for much lumbar pain, Cover and the modality of spinal manipulation is the failure Curwen 83 feel that the pendulum has swung too to recognize the hypermobile vertebral motor far and diagnosis of a "disc lesion" is apt to be unit. Newman H7 defines instability as the loss of · made too readily. McRae 84 shows that although integrity of the soft tissue intersegmental control. disc protrusions are common, they seldom produce The motor units are bound together by ligamentous symptoms - that overemphasis on the importance systems under tension: degeneration of any one of cervical disc protrusions has led to operations in will alter the dynamic equilibrium of the entire patients with minor abnormalities in the myelogram. complex. Jirout 118 has recently investigated the Many lumbar discs suspected of compressing nerve role of the nuchal ligament in cervical spine dy­ roots show no annular rupture but simply bulge namics and White and Hirsch m, that of the liga­ posterolaterall y. 85 mentum flavum in restraining axial rotation in the Bick 86 has referred to disc changes inducing thoracic spine. motor complex loosening and Macnab 87 has illus­ trated hyperextension subluxations from degen­ Vertebral Motor Unit Innervation eration of the anterior annular fibers. He also The posterior rami of the spinal nerves supply indicates a mechanism of discopathogenetic sub­ sensory fibers to the fascia, ligaments, periosteum luxation caused by loss of intervertebral disc and apophyseal capsules and motor fibers to the 100 101 height where the posterior joints subluxate and the muscles. - The sinuvertebral nerve, a recurrent vertebral body moves downward and backward. branch of each spinal nerve, has a dual spinal and Similar disc narrowing is implicated by Kunert 88 autonomic composition. (Occasionally these two and Nilsson 7 in loosening the rib's costovertebral components are distinct when they enter the fora­ and costotransverse attachments through a "set­ men, but usually they are reflected as a common tling" of the opposed vertebrae with irritation of bundle.) It contains sensory fibers and supplies the the sympathetic ganglia located immediately an­ posterior and anterior longitudinal ligaments, dura terior to the costovertebral joints as a potential mater, periosteum, articular connective tissues sequela. including the capsules of the "joints" of Luschka, 102 The elastic ligamenta flava, between the laminae, vascular structures wa and, according to some, 1114· 109 may bulge forward to encroach on the intervertebral the posterior part of the annulus. Even if the debate foramen and cervical cord 8~H11 but Breig18 considers goes against those who have demonstrated nerve the volume of the ligamenta tlava too small to endings within the outermost laminae of the disc, cause cervical myelographic defects, interpreting their distortion could certainly produce tensions in these as transverse dural folds. the overlying highly innervated connective tissues. Various pathologies affecting the ligaments may The ascending and descending branches of the compress neural elements 92 while others may lead sinuvertebral nerve (the usual distribution being to ligamentous softening. 93 The pelvic and lower one segment up and two down) contributes to spinal motor units may be rendered excessively difficulties in localizing vertebral motor unit lesions mobile by the hormonal environment of pregnancy in the absence of signs of nerve root compression. 110 · and minor ligamentary strains may only cause Macnab 64 emphasizes that pressure on a nerve discomfort premenstrually. 94 It should be recalled root by itself is not painful, but secondary inflam­ that vertebral osteophytosis is an osteogenic process matory, congestive or chemical changes will pro­ representing a local response to ligamentous strain.!'5 duce pain (i.e. chemical plus mechanical factors in Lumbar ligamentous variation, although com­ combination). He further cites the work of Hirsch mented upon by Macnab, 87 is not well documented and Bobechko 111 suggesting that an autoimmune in standard anatomy texts. Golub and Silverman, 96 response may take place in the disc. The occipito­ in an anatomical study of the intervertebral foramina atlanto and atlanto-axialjoints are innervated by the 67 11 anterior branches of the first two cervical nerves. :! tion of secondary apophyseal joint lesions does not The spinal ganglia are usually in the intervertebral guard the patient from recurrence; 130(2) the com­ foramina immediately lateral to the sites where the mon occurrence of articular tropism 131 should nerve roots perforate the dura mater. Each anterior make it obvious that the concept of normality or branch of the spinal nerve is joined by a grey ramus abnormality related to median or off-centered communicans from the corresponding ganglion of vertebral positions is obsolete: 13:! (3) the aim of the sympathetic trunk while the anterior branches "realigning" offending vertebrae with posterior of the spinal nerves from T 1-L2 each contribute a joint arthroses by thrusting toward the side of white ramus communicans containing preganglionic arthrotic block is utopic 13:! and in violation of sympathetic fibers arising from lateral horn cells Maigne's rules: 19 and (4) the tendency of too to the corresponding sympathetic ganglion. The quickly condemning the apophyseal joint when the clinical significance of these sympathetic relations pain may be coming from the mechanically or 88 16 40 is a fertile area for future investigation. • • chemically irritated tissue of attachment of muscle, The Posterior Spinal Articulations tendon, intermuscular septum, and ligament to sensitive spinal periosteum must be guarded The posterior spinal joints are similar to periph­ against. 133-134 eral joints in their construction. They have articular cartilage, a loose capsule with synovial membrane, THE ATYPICAL MOTOR UNIT small menisci and related muscles and ligaments. They are subject to the same insults as other The occipito-atlanto and atlanto-axial motor units are atypical and may suffer additional complication joints 113 and show a higher frequency of degenera­ tive changes than any other synovial joint in the from the presence of congenital and developmental body. 114 Zuckschwerdt 11;; in 1960 rediscovered variations. Anomalies may render any typical small, semilunar .. menisci" filled with adipose motor unit atypical as commonly occurs in the cushions penetrating the intra-articular space of the spinal-pelvic transitional segments. Acquired posterior spinal joints. 116He proposes "blocking'' architectural remoulding of the motor unit may progress throughout life to the point where it has from meniscal jamming. Schmorl :! suggests incar­ ceration of an articular villus or meniscus and been fundamentally altered and could no longer be Kraft 117and Hadley 118incriminate synovial im­ considered typical. Consideration of its morbid pingement in the etiology of sudden, severe low anatomy and pathomechanics is outside the scope back pain. Badgley 119finds no essential difference of this paper. in the pathomechanics associated with free body The Occipito-atlanto-axial A typical Vertebral formation in apophyseal joints from those of knee Motor Units joint derangement. Hirsch t:!o and Lazorthes t:!t Failure to appreciate the structural and dynamic have confirmed the extensive nerve supply while intricacies of the upper cervical motor units, Shealy t:!:! and Rees l:!:i have reawakened interest recently reviewed by von Torklus and Gehle in in apophyseal changes' etiological significance to their text. The Upper Cervical Spine, 135 has con­ back and leg pain t:!4 by surgically destroying the tributed to complications from their manipula­ posterior branches of the dorsal roots supplying tion,t:16·143The incidence of serious iatrogenic the facets. injury has been small and appears associated with The posterior articular processes assist in vertebral artery abnormalities 144-147 and ligamen­ providing motor unit stability i:!;; and normally tous-capsular laxity. Jirout 148 compares the un­ 1 6 bear no appreciable spinal load :! but may become usual mobility of the atlas in the occipito-axial 17 weight-bearing in certain postural distortions. :! dynamic system to that of a meniscus; Paul and Jung, Brunschwig i:?s and Vele 129 conclude that Moir 149 refer to "physiologicar· lateral displace­ much of the proprioceptive stimuli for spinal ments of the atlas during lateral inclination of the balance arises from the holding elements of these head while Cattel and Filtzer, 150commenting on articulations. the hypermobility of the immature cervical spine, Those concerned with spinal manipulation are describe '"pseudo-subluxation" of the axis ventrally reminded of the following: (I) If primary disc on forward head-neck flexion in children. Houle 151 changes have led to distortion and abnormal move­ judiciously suggests the performance of a modified ment within the associated facet joints the reduc- Adson's maneuver to assist in the assessment of 68 vertebra-basilar hemodynamics prior to the pelvic motor unit instability (hypermobility) after performance of any upper cervical manipulation. removing iliac bone for grafting,rn 4 sacroiliac con­ 9 The Vertebral Motor Unit With Congenital- ditions simulating low lumbar disc syndromes.1 " developmental Variations and sacroiliac ligament trauma caused by mis­ While the clinical and pathogenetic significance guided, vigorous, repeated manipulations of a of anatomical variations of the osseous boundaries joint that is already fully mobile Hiu or even hyper­ and soft tissue elements of the vertebral motor unit mobile (as may be found in children, patients with are still a matter of debate, I52 -m their presence often generalized ligamentous laxity, and those engaged confuses diagnosis, leading to excessive thera­ in activity placing very high functional demands on peutic intervention. Practitioners of manipulative the sacroiliacs -ballet, acrobatic and modern therapy must evaluate the unusual dynamics dancers, gymnasts, golfers). 8 associated with vertebral motor unit variation and I Hi's biomechanical concepts • !I explaining the modify their standard mechanical interventions genesis and influence of blocked (fixated) and asym­ accordingly. For example, if one attempts to at­ metric sacroiliac articulation(s) on the spine merit tain "normal" range of movement of a motor unit further investigation. More research is required influenced by imperfect segmentation and rudi­ into the functional significance of Mitchell's mentary disc, the manipulation will predict-:ibly observation 197 that spinal stability is favored by a result in sprain. Any facet tropism requires altera­ more vertical sacral position: on .the mechanical tion in customary patient positioning so the relevance of accessory sacroiliac articulations manipulative thrust will parallel the unusual described by Trotter t!lH,rn!, and Hadley, 118 and into mechanical axes, otherwise apophyseal joint trau­ the validity and hopefully preventive value of ma results. The subtleties of manipulative tech­ hypotheses based on male-female anatomical nique application to anomalous motor units have differences in hip joint placement. 200 not been described in chiropractic or osteopathic Limitations of the Motor Unit Concept-Areas for literature and may never be exhaustively ana­ Additional Research lyzed due to the myriad variations of spinal The muscles limiting and coordinating ranges of morphology.:!, i 18, iss. l!rn motion of individual and multiple motor units have Interest in the configuration of the intervertebral been neglected, but their complexities make even 157 160 161 162 16 disc, • • spinal canal - ·., and neural a cursory description of their attachments too 166 118 arch - ; is generally shared by all clinicians con­ lengthy for consideration here. Additional informa­ cerned with spinal syndromes. Less attention has tion is required on the dynamic mechanical re­ 16 76 been focused on neurovascular !H and ligamen­ sponse of the whole body system to steady state 9 tous variations. u This is unfortunate because it is and impulsive mechanical forces to tletermine injury of these soft tissue variations, particularly the effect of this energy within the spine and on those of the vertebra-basilar vessels. that has led various neural receptors. 201 Breig's monograph, to the most serious complications of spinal Biomechanics of the Central Nervous Systern, 48 111 181 manipulation. - reporting physiologic deformation of the cord and The Pelvic Motor Unit hind brain is an excellent .beginning. The role of 2 182 183 202 203 As Junghanns claims, chiropractors !I, • in thoracic-abdominal pressures • and trunk particular emphasize pain caused in the position musculature in transmitting forces generated in and stability of the sacroiliac joints and have ap­ loading the spine and the deforming effects of plied the concept of the functional unit to the pelvic forces generated by muscle and gravity on the girdle, the sacroiliac joints and pubic symphysis viscoelastic elements of the vertebral motor unit 4 20 1 forming the functional unit. Many investigations also require more investigation,2° - ! as does 184 18 210 of sacroiliac movements • !1 have been performed Johnston's work with three-dimensional spinal since von Luschka 190 first considered the sacroiliac configurations. A limitation of the vertebral motor articulations as true diarthrodial joints in I 854. unit concept is its emphasis on segmental analysis, These have discussed their shock absorption and yet, Junghanns certainly never intended his capacity in dampening the effect of lower limb model to be autonomous. In the introduction to his 8 locomotor activity . •" the physiologic ligamentous text he refers to the .. organ system spine" as ap­ laxity induced through hormonal influences.wt-rn:i pearing "no longer, as in the past, as an isolated, 69 segmental, skeletal organ. Today the spine appears 11. Gillet, H., Liekens M.: Belgian Chiropractic Research in the light of many mutual relationships with the Notes. (Published by the authors) 8th Ed. Belgium. total body: with its equilibrium it exerts influences 1970. and also receives forces all of which are interwoven 12. Inman, 0. B.: Basic chiropractic procedural manual. (Printed by the Amer. Chir. Ass'n) 1973. with the far-reaching chain of motion. In addition, 13. Howe, J. W.: The chiropractic concept of subluxations the spine is able to exercise considerable in­ and its roentgenological manifestations. J. C/in. Chir. fluence upon neighbouring structures as well as 64- 70, September 1973. upon remote organs by its action upon nerves and 14. Drum, D. C.: The nature of the problem, a functional blood vessels." concept of vertebral subluxations. New En[?. J. of Chir. To fully exploit Junghanns' and other anatomico­ 29-31, May I 973. I 5. Rich, E. A.: Atlas of Clinical Roentgeno/of.:y. Rae Pub­ mechanical concepts in clinical practice will require lishing Co. (Indianapolis) 126, 1965. the continuation of interdisciplinary dialogue en­ 16. Lewit, K.: The problem of manual and reflex neurother­ hanced greatly by this conference. apy. Wien. Med. Wschr. 23:473-77 (translated by M. Gauchat, Canad. Chir. College, Toronto), 1971. SUMMARY 17. Jirout, J.: Correlations of the functional disturbances in the cervical spine as seen roentgenographically in frontal The usefulness of Junghanns' concept of the and sagittal projections. Svy. Uni\-. Carocinae Suppl. functional unit of the spine (vertebral motor unit) 21: 128-29, I 965. to those concerned with spinal manipulatory theory 18. Farfan, H. F.: Mechanical Disorders of the Low Back. and practice is presented along with a review of its Lea and Febiger (Philadelphia) 1973. 19. Maigne, R.: Orthopedic Medicine, A New Approach to applied anatomy with special reference to the Vertebral Manipulations. (Translated and edited by clinical significance of the relations and contents W. T. Liberson. Charles C Thomas (Springfield), 1972. of the intervertebral foramen. 20. Droz, J. M.: Frequency and causes of recurrence of sciatica. Annals of the Swiss Chiropractors' Ass'n. REFERENCES 4:69-77, 1969. 21. Haldeman, S., Drum, D. C.: The compression subluxation . 1. Sub, C. H., West, H. 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Anna/es de Medecine Physique. bosacral articulation, a roentgenologic and clinical 9:283-298, 1966. study with special reference to narrow disc and lower 181. Lyness, S. S., Wagman, A. D.: Neurological deficit lumbar displacement. Surg., Gynec. & Obst. 87:549, following cervical manipulation. S urg. N eurol. 2: I 21- 1948. 24, March I 974. I 62. Murone, I.: The importance of the sagittal diameters 182. Weiant, C. W., Janse, J.: The work of Dr. F. W. H. llli, of the cervical spinal canal in relation to spondylosis an analysis and preliminary evaluation. The J. of the and myelopathy. J. Bone Joint Surg. 56-B:No. I, National Chir. Ass'n .• December t 955. February t 97 I. t 83. Parker, B. L.: Aiomechanics of sacroiliac union in walking. 163. Mayfield, F. H.: Cervical spondylosis, observations The J. of Clin. Chir. Arch. Ed. 3:40-8, Spring 1973. based on surgical treatment of 400 patients. Postgrad. 184. Frigerio, N. A., Stowe, R. S., Howe, J. 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W.: The anatomy and movements of the genol. 108:796, I 970. sacroiliac joints. Ma1111elle Medizin und ihre wissen­ 167. Hollinshead, H. W.: Anatomy for surgeons, spondylolysis schaftlichen Grundla1,:en, 1970. and spondylolisthesis, Harper & Row (New York) 189. Colachis, S., Worden, R., Bechtol, C., Strohm, B.: Move­ 2nd Ed. 3:137-42, 1969. ment of the sacroiliac joint in the adult male, a pre­ t 68. Wiltse, L. L.: The etiology of spondylolisthesis. J. Bone liminary report. Arch. of Phys. Med. & Rehab., Sep­ Joint Surg. 44-A, t 962. tember 1963. I 69. Horwitz, M. T.: The anatomy of (A) the lumbosacral I 90. von· Luschka, H.: Die Kreuzdarmbeinfuge und die nerve plexus - its relation to variation of vertebral schambienfuge des menschen. Virclwws Arch. Path. segmentation and (B) the posterior sacral nerve plexus. Anal. 7:299-316, 1854. Anat. Rec. 74:91, 1939. t 91. Abramson, D., Roberts, S. M., Wilson, P. D.: Relaxation 170. Batson, 0. V.: The function of the vertebral veins and of the pelvic joints in pregnancy. Sur!f. Gynec. their role in the spread of metastases. Ann. Surg. 112, & Obst. 58:596-6 I 3, March I 934. 1940. I 92. Thorp, D. J., Fray, W. E.: The pelvic joints during preg­ I 71. Norgore, M.: Clinical anatomy of the vertebral veins. nancy and labor. J.A.MA. 111:l 162-66, September Surgery 17, I 945. 1938. 172. Hassler, 0.: Blood supply to the human spinal cord, a I 93. Borell, U., Fernstrom, I.: The movements at the sacroiliac microangiographic study. Arch. Neurol. 15:302, 1966. joints and their importance to changes in the pelvic I 73. Turnbull, I. M., Breig. A., Hassler, 0.: Blood supply of dimensions during parturition. A eta Obst. & Gynec. the cervical spinal cord in man, a microangiographic Scadinav. 36:42-57,.lanuary I 957. cadaver study. J. Neurosurg. 24:951, 1966. 194. Coventry, M., Tapper, E.: Pelvic instability, a con­ 174. Hutchinson, E. C., Yates, P. 0.: Cervical portion of the sequence of removing iliac bone.for grafting. J. Bone vertebral artery, clinico-pathological study. Brain JointSur!f. 54-A:83-101, 1972. 79:319-331,.lune 1956. 195. Norman, G. F., May, A.: Sacroiliac conditions simulating 74 intervertebral disc syndrome. W. J. of S11rg. Gynec. & lieving the pressure on the lumbar intervertebral discs. Obst.461-62,August 1956. J. Bone.Joint Surg. (Brit.) 39-B:718, 1957. 196. Stoddard, A.: Manual <~fOsteopathic Practice. Harper & 203. Nachemson, A., Morris, J. M.: In vivo measurements of Row (New York) 184-190, 1969. interdiscal pressure: discometry, a method for the I 97. Mitchell, G. A. G.: The lumbosacral junction . ./. Bone determination of pressure in the lower lumbar joints. Joint S11r,.:.16:233, 1934. _ .I. Bo11e.loi111Surg. 46: 1077-92, 1964. 198. Trotter, M.: Accessory sacroliac articulations in East 204. Morris, J. M., Lucas, D. B., Bresler, B.: Role of the trunk African skeletons. Am. J. Phys. Anthrop. 22:137-42, in stability of the spine. J. Bone Joint Surg. 43 :327-51, 1964. 1961. 199. Trotter, M.: Accessory sacroiliac articulations. Am. J. 205. Olsen, G. A., Allan, J. H.: The lateral stability of the spine. Phys. Anthrop. 22:247-55, 1937. Clin. Orthop. 65: 143-56, I 969. 200. Tichauer, E. R., Miller, M., Nathan, I. M.: Lordosimetry, 206. Morris, J. M.: Biomechanics of the spine. Arch. Surg. I 07, a new technique for the measurement of postural September 1973. response to materials handling. Amer. lndust. Hyg. 207. Hildebrandt, R. W.: The clinical basis of chiropractic J. 1-12,January 1973. postural roentgenology . ./. Clin. Chir. Arch. Ed.3, 1973. 201. Coermann, R. R., Ziengenruecker, G. H., Wittwer, A. L., 208. Michele, A. A.: lliop.was, Development of Anomalies in von Gierke, H. E.: The passive dynamic mechanical Man. Charles C Thomas, Springfield, 1962. properties of the human thorax-abdomen system and 209. Northup, G. W.: Osteopathic lesions. J.A.O.A., 71 :854, the whole body system. Aerospace Med. 31 :No.6, June 1972. 443-47, June 1960. 210. Johnston, L. C.: The paradox of the functional spine . ./. 202. Bartelink, D. L.: The role of abdominal pressure in re- C

75 Spinal Geometry: Normal and Abnormal

EDMUND B. WEIS, JR. Division of Orthopaedics Ohio State University

INTRODUCTION variables such as age and size are clearly important in treatment but may be deferred for consideration This report is an attempt to bring together di­ until mechanical and anatomical factors can be at verse research studies and clinical experiences into least organized. a coherent consideration of the role of basic physi­ The considerations lead to the designation of the cal and physiologic factors in spinal geometry. It categories in figure I. The remainder of this report attempts to set up categories based on qualitative will be devoted to presenting the practice and re­ estimations of basic factors and then fits clinical search in each of these categories. entities into the categories. The fit is procrustean at best with little assurance that a vital part has not I. TRACTION been cut off. The analysis of spinal geometry must include Traction on the spine is a familiar clinical expe­ consideration of pertinent anatomic, physiologic, rience. It is probably the only static large deviation and mechanical variables. Among the mechanical of spinal geometry with normal anatomy. The most variables one might include at least a qualitative spectacular clinical situation is the Halo-hoop ap­ 1 separation as to the size of deviations as well as paratus shown in figure 1. My o~n experience to the time history. These separations are important with this device is presented in figures 3. 4, and 5. before proceeding to quantification of factors. As This is a case of idiopathic scoliosis, long neglected a minimum consideration of anatomic factors one in which an attempt to straighten the curve was might include the presence or absence of abnormali­ made. The attempt failed inasmuch as an abducens ties of the bone structure of the spine. Physiologic nerve palsy supervened. Note the decrease in the SPINAL GEOMETRY curve shown in figures 4 and 5 and the dramatic change in intervertebral disc height shown in fig­ ure 3. There are many less dramatic demonstrations of traction in the spine but the widening of the cer­ NORHALANATOHY ABNORMALANATOMY vical discs in this case and the abducens palsy im­ ply many things about the future of such treatment.

LARGEDEVIATIONS SMALLDEYIATIONS LARGEDEVIATIONS SHALL DEYIATIONS 2. SPINAL MODELS High speed transportation has stimulated much study of the spine. The era of escape and restraint system research produced models by Weis, :!, 3 STATIC DYNAMIC STATIC DYNAMIC STATIC DYNAMIC STATIC OY:IAMIC Kaleps; 1 Orne:-, and King. 6 These models represent Traction S• 11t Scolf os 1s Arthrltl> Congentt1l Fr1c;tur1s SponJ1lo• Herniated Ejection l(yphosts Dts loc1t1cn1 1 lsthesh 1lucleus the large loads and deviations incurred in crash Trop1sas Pulposus situations. Only Orne 's model accounts directly for Fig. I. Categorization of spinal geometry. the spinal curvature as shown in figure 6 but gives 77 verted to unit vector representations for each vertebra and subjected to computer analysis for curvature and rotation of the unit vector (figure 8). This study points to the location of the apex of the curve for most patients with scoliosis (usually TS or 9) as the location in the spine with the greatest cur­ vature and rotation inherent in the normal and scoliotic spine. The other type of study is that by Schultz. 11 This is a study of the structural and kinematic aspects of the intervertebral joints. It calculates the config­ uration assumed by the spine associated with changes in the components of the intervertebral connection (figure 9). The results of the calculations reveal, among other things, that when the vertebra are normal, scoliotic curves can be reproduced within the normal range of motion of the vertebra. It also confirms the coupling of deformation modes 1 inherent in the spine as observed by White. '.!

4. DEGENERATIVE JOINT DISEASE

The class of normal anatomy, small deviation, dynamic movements of the spine is almost certainly the largest group of all. It includes most of the .. back pain" patients seen in the practitioner's of­ fice. There is no quantitative way and few quali­ tative guides to include the majority of these pa­ tients in the discussion. Therefore, by going to what is very likely the end stage of all these proc­ esses or afflictions, it may be possible to give some basis for future studies. Fig. 2. Halo-hoop traction apparatus (redrawn from DeWald). Degenerative joint disease afflicts the spine in a no consideration to the posterior elements. These remarkable way. It focuses on two areas, the lum­ models predict locations of high risks of injury in bosacral spine and the cervicothoracic spine. These the spine as well as critical modes of exposure. two areas correspond roughly to the location of There are other studies of the physiologic aspects complaints of the "back pain" patient. These loca­ 7 8 tions are, mechanically, very significant. One. the of crash situations such as by Weis. • ·H These stud­ ies give tolerance limits for crash exposure and the lumbosacral area. is most surely a high stress, low tolerance limiting factors are closely related to the deformation area in a mechanics sense. Some of the 13 spine. details of this reasoning are given by Weis. The other, the cervicothoracic area is again a transition region, mechanically, and no doubt incurs stress 3. SCOLIOSIS because of that. The other transition region, the Studies of the spinal geometry in scoliosis are thoracolumbar is not a region of high incidence of plentiful in the literature. Two types of these stud­ complaints and of degenerative joint disease. It is. ies are pertinent. One is the quantification of curva­ however, the most likely location of a fracture­ ture and rotation as for example by Weis. 10 This dislocation. study derives mathematical representation of the These clinical observations can be interpreted in curvature and rotation of the vertebra from X-rays terms of the dynamics of a curved tapered beam of the spine. The data is obtained by direct measure­ which is the subject of ongoing research. The curved ment (figure 7), corrected for X-ray distortion, con- tapered beam model was applied to problems of 78 Fig. 3. La teral cervical spine film in (left) and out (right) of halo-hoop traction.

1 1 spine mJury by Bened ict. • T he pertin ent deriva­ a chronic hea ling reac tion at the high stress, low tion s of thi s author are given in figure I 0. Superfi ­ deformation regions. The solution would see m to cial inspec tion shows that bend ing ca nnot occ ur be the indu ctio n of significant long-te rm changes in without rotat ion and lateral deviation and in fact , such thin gs as leg length , gait, weight , and posture. none of the motion s is indepe ndent of the others. As menti oned ea rlier, Sc hult z and Whit e have 5. CO NG E NITAL VERTEBRA found this also. T he curved tapered beam (figure I I) ABNORMALITIES is intuitiv ely satisfying as a mode l of the sp ine: study of the beam model shows that it has the sa me Pass ing on to the situ ations of abnorm al vertebra kind of critica l loca tion s as the spine. T hese are anatomy and using the same ca tegoriza tion sc heme, high stre ss, low deformation at the upp er and lower co nsider the situation which ar ises when the verte .:­ ends and a low stre ss, high deform ation loca tion in bra are abnorma l from the beg innin g and get worse the middle. as gro wth occur s. Ther e are thr ee basic typ es see n Studie s, using thi s mode l, are devo ted to clinica lly; hemivert ebra, block vertebra , and de­ measurem ent of the transmiss ion charac teristics fects of the pos terior eleme nts. Hemi vertebr a leads of the cadave r tor so from head to pelvis so that the to severe progressive scolio sis. Block vertebr a coupl ing charac teristics may be ca lculated. Ulti­ lead s to se vere progress ive kyp hosis. Posterior ele­ mately the parameter s for the curv ed tapered beam ment defe cts leads to a co mbin ation of scolios is and can be developed from this. kyphos is, bot h severe but not always prog ress ive. At this point in time, extra polation of the curved T he prob lem of hemivertebr a is illustrated in tapered bea m mode l to clinica l pro blems of "back figure 12. T his you ng ch ild has bee n adv ised to be pain" may be interpre ted in terms of indu cement of in a Milwaukee Brace immed iate ly with ca reful ob- 79 Fig. 5. Anterior-poster ior roent enogram of sco lios is after halo-hoop tra ction.

fusion yea rs ago to preve nt the extreme defor mity. She has now und ergo ne the sa me surgery with much higher risks and much poorer cos metic effect. Th e myelomeningoce le has many probl e' ms above and beyond the spine defor mity but it is instructi ve to consider the spine defo rmit y because it is unstab le. Th e defec t is the absence of th e pos terior elements along with much of the neuro logica l func­ tion. Thi s leads to scolio sis and kyphosis which are only correctab le surgica lly. T his is des irab le be­ cause wheelc hair sittin g is otherwise difficult and dec ubiti are co mmon. Fig. 4. Anterio r poster ior roentenogram of sco liosis befor e ha lo-hoop tract ion. 6. F RACTUR ES AND DI S LOC ATI O NS Th e basic question whic h must be answered re­ servation and the atmost sure ex pec tation of exten­ garding the spine in such cases is; is it stab le? Th e sive spine fusion. high incidence is at TI 2-L I. Statistics abo ut how Th e probl em of block vertebra is illustrated in many have neurological problems are difficult to figure 13. Thi s 20-yea r-old female should have had inte rpret. It is small if th e IO to 30 perc ent co mpres­ an anter ior osteo tom y and an anterior and posterior sion frac tur es are includ ed and high if the y are not . 80 l

X INTERVERTEBRAL DISC VERTEBRAL BODY

RIGID LINK

W·(. (VERTEBRAL BODY)

TYPICAL ELEMENT DEFORMABLE LINK ( INTERVERTEBRAL DISC}

Fig. 6. Schematic illustration of spinal model by Orne.

The history of treatment of fractures and dislo­ tion or operative treatment was applied. A case of 1 cations of the spine is pertinent. " In the past these fracture-dislocation is shown in figure 16. The pa­ injuries were treated aggressively by manipulation. tient was immediately paraplegic. Laminectomy The complication of neurological injury secondary was performed without benefit. Anterior fusion to manipulation was recognized and manipulation was carried out without reduction. The patient is was reduced to traction with hyperextension. Still still paraplegic. more recently the deformities have been neglected if the assessment could be made that the injury is structurally stable from the onset or if it is expected 7. SPONDYLOLISTHESIS AND to become stable by spontaneous fusion. Operative SACRALIZATION reduction at the time of fusion of dislocations is not often undertaken, particularly in the absence of a Whether acquired or congenital, abnormalities neurological lesion. of the lumbosacral joint are a dilemma. A case of There is much uncertainty about the relationship spondylolisthesis is illustrated in figure 17. This between fracture or dislocation, including reduc­ patient was symptomatic and had a posterior ele­ tion, and neurological treatment. A case of fracture mentectomy and posterior interbody fusion and is with extrusion of a portion of the vertebral body now asymptomatic. There is no difficulty in findi: 1g into the spinal canal is shown in figure 14. There a similar case in which the patient was not relieve, was no neurological disease, no reduction or opera­ Nonsurgeons treating the same problems are ofte1 tive treatment was applied. and the patient is fine. of the opinion that surgery is contraindicated and A case of fracture-dislocation is shown in figure 15. that physical therapy is the correct approach. There The patient was immediately paraplegic but the is no difficulty finding patients unrelieved by physi­ disease receded to become a Brown-Sequard syn­ cal therapy. drome with little functional impairment. No reduc- Sacralization is only one of the variations of in- 81 12

6

Fig. 9. Rigid links used in calcu lat ion of geometr ica l varia­ tions (redrawn from Schultz ).

Fig. 7. Measurement X-ray for evaluation of curvatur e and aP a•;;; a•,t, rotation (Weis). I 'ih = pA at' + pAr at'

8 ( a,t,) ( au auo ) a•,t, a2w II 'ih EI, 'ih + kAG 'ih - ai° - 4' = pI, 0 12 + pA r at• RIGHT PEOICLE• SPINE CURVATUREAND TORSIONVALUES FOR A 12 YEAR OLD FEMALE WITH MILD SCOLIOSIS. 14 .42 • eee CURVATURE o o o O TORSION

Ill p = EA [ ~ + ...!...( ~)' _ ...!...( auo)' ] al 2 al 2 Ol i • • -~ Fig. 10. Partia l differential equa tion represent ing a curved ~ tapered beam. '"0 ...:, ~ ~ clusion of the las t lum bar vertebra in the sacrum , "'~ • exclusion of the first sac ral vertebra from the sac­ rum and abnorma l shape , size, and placement of the lumb osacra l facet joint s. Sacra lization is see n • • in figure 18. Stud ies 16 of the relati onship between • . . ' • • • X-ray abnorma lities of the spine and symptoma­ .o ~D-,~· -,-•'--v-',:,-RT_E_BR_A~L-S-EG-M~EN_T_L-EVT""E_L_~- o~,z-- -~- - L-,' 5 tology show a ve ry poor corre lation with abnorma li­ ties of L5 and S I being the second ab normali ty Fig. 8. Ca lculated curvat ure and tors ion from case shown in when sco liosis is included and first when it is not. Figure 7. Given this uncertain situation it is nearly impo ssi- 82 TAP

Fig. JI. Curve d taper ed beam repr ese ntati on of the sp ine. ble to convince anyone that there is any benefi t in ated on and found to have a disc protru sion but it treating symptoms thought to be related to radio­ was co mpo sed mo stly of spur formation seco ndary logica l abnormality. to the degenerative joint disease . He was reliev ed Studies of the mechanic s of the lumbo sacra l junc­ by the operative procedure . The case illustrate s the tion have been undertaken by several authors coincidence of the two diseases or rather the tran­ 17 (Weis 1:i and Krause ). These tend to show that sition from one to th e other which may occur. the margin of safe ty for this joint is quite low and Studies of the intervertebral disc by Markolf 20 , 2 1 that it is probably subjected to near failure load s in and Belytschko 22 are providing insight into the normal activity. It is not surprising then that in­ pathologic process of herniated disc. Markolf has terior linemen on football teams and Eskimos in pre sented his studie s of the st iffne ss of the inter­ 18 11 their igloos have low back problems. • i vertebra l disc (as shown in figure 20) and the change in the disc subjected to operative treat ment. He defines the tor sional strength variation along the 8. HERNIATED NUCLEUS PULPOSUS spine and finds that operative treatment of disc A case of radiculopathy of the first sac ral nerve disease does not change its mechanical character root is shown in figure 19. This patient was oper- much. Belytschko is studying the stress distribu- 83 Fig. 12. Scoliosis due to co ngenital anomalies of the vertebra. Fig. 13. Co ngen ita l kyphosis due to block vertebrae. tion within the interverteb ral disc by comput er anatomy, usually produced by a dege nera tive mode ling and may be ex pected to contribute grea tly proces s. to the under standing of the significance of the struc­ T he role of manipul ative therap y seems no more ture of the disc. or less well established than surgica l thera py. T he efficacy of both are difficult to assess in patients SUM MA RY AND C ON C LUS ION S in whom the relationship betwee n anatomy, func­ T he para de of clinica l entities given in the fore­ tion, and sympto ms is indistinct. T he most hopeful going pages is distinguished by arra ngement into approach seems to be to model the mechanics of categories based on attempts at quantification. It an abnormality or co ndition, when it can be defined, seems clea r that beca use of the highes t incidence of by laborat ory derivation of pro perties. Th e mode ls prob lems, the most inte rest should lie in the normal of such measurements can then be manipulated by anato my, small devia tion, dynamic loading regimen. people and co mputers to stud y the effect of manip­ In par ticular, the overall res ponse of the spine ulative treatment in a gross way. Para llel prospec­ needs to be charac terized better to allow one to tive studies of the efficacy of manipul ative therapy assess therapy effects as well as to understand by statistica lly sound method s must be condu cted pathogenesis. T he seco nd critical area or regimen to answer the question of whether there is any ef­ is for small dev iation s, dynamic loa ding, abnormal fect in addition to the " placebo effect."

84 {J,,111,., 11,S

Fig. 14. Fract ure of the L I ve rtebra l body with ex tru sion of a fragment into the spina l ca nal (lam inogram right ).

85 Fig. 16. Post-oper.itivc rocntcnogram of L I frac ture-disloca ­ tion (anterior deco mpression and fusion).

Fig. 15. T9- 10 fracture-dislocation with Brown-Sequard syndro me.

86 '

Fig. 17. Fir st degree sponclylolisthes is.

87 Fig. 18. Sacra lization of the fifth lumbar ver tebra.

88 Fig. 19. Degenerati ve jo int disease at L4-5-S I with disc protru sion at L4- 5.

89

507-036 0 - 76 - 7 Intact discs 400 U') E 0 [Q_ I,... a, 3 loading cycle 0 st 1 loading cycle ~ 300 ------'-...... LL ' ---- ' w u 0:: 0 200 LL z 0 - (./) (./) w 100 0:: Q_ ~ 0 u

0 0 0.5 1.0 1.5 2.0 2.5 30 DEFLECTION 6 (mil Ii meters)

Fog. 20. Stiffness of the intervertebral disc (redrawn from Markolf).

REFERENCES e11Ri11eeri11gApproaches to Problems of the Spin£', Sep­ tember 1970, p. 15. I. DeWald, R. L. and Ray, R. D., "Skeletal Traction for the 7. Weis, E. B. and Mohr, G. C., "Cineradiographic Analysis of Treatment of Severe Scoliosis," J.B.J.S. 52-A, March Human Visceral Responses to Short Duration Impact," I 970, p. 233. Aerosp. Med. 38(10), October 1967. p. 1041. 2. Weis, E. B., Clarke, N. P., Brinkley,J. W., and Martin, P. J., "Mechanical Impedance as a Tool in Human Response to 8. Weis, E. B., Pearce, W. L., and Shoenberger, R. W., "Meas­ Acceleration," Aerosp. Med. 35: 10, October 1964, p. 945. urement of Human Responses to Short Duration Impact," 3. Weis, E. B. and Primiano, R. P., "Motion of the Human Journal of Biomechanics, Vol. 6, I 973, pp. 7 I 9-728. Center of Mass and Its Relationship to Mechanical Im­ 9. Weis, E. B., Clarke, N. P., and Brinkley, J. W., "Human pedance," Human Factors, October 1966, p. 399. Response to Several Impact Acceleration Orientations 4. Kaleps, I., Yon Gierke, H. E., and Weis, E. B., "A Five­ and Patterns," Aerosp. Med. 34(12), December I 963, Degree-of-Freedom Mathematical Model of the Body," p. I 122. Paper No. 8, Proceedings of the First Biodynamics Sym­ 10. Weis, E. B., "Quantitation of Curvature and Rotation in posium, Aerospace Medical Research Laboratory, Wright X-rays of the Spine," Proceedings of Workshop on Bio­ Patterson Air Force Base, October I 969. engineering Approaches to Problems of the Spine, Sep­ 5. Orne, D. and Liu, Y. K., "A Mathematical Model of Spinal tember 1970, p. 177. Response to Impact," Journal of Biomeclwnics, Vol. 4, 11. Shultz, A. B., Larocca, H., Galante, J. 0., and Andriachhi, pp. 49- 7 I , I 971. T. P., "A Study of Geometrical Relationships in Scoliotic 6. King, A. 1. and Vulcan, P., "Elastic Deformation Character­ Spines," Journal of Biomechanics, Vol. 5, No. 4, July istics of the Spine," Proceedings of W orkslwp on Bio- I 972, p. 409. 90 12. White, A. A., "Analysis of the Mechanics of the Thoracic 18. Ferguson, R. F., McMaster, J. H .. and Stanitski, C. L., Spine in Man," Acta Ortlwp. Scand., Supp. 127, 1969. "Low Back Pain in College Football Lineman," J. Spts. 13. Weis, E. B., "Stresses at the Lumbosacral Junction," Orth. Med., Vol. 2, No. 2, 1974, p. 63. Clin. N.A., January 1975. 19. Kettlekamp, D. B. and Wright, D. G., "Spondylolysis in the 14. Benedict, J. V .• "The Investigation of Vertebral Injury Sus­ Alaskan Eskimo," J.B.J.S. 53-A, No. 3, April 197 J, tained During Aircrew Ejection," Final Technical Re­ p. 563. port, Contract NAS2-5062, Technology, Inc., San An­ 20. Markolf, K. L., "Deformation of the Thoracolumbar ln­ tonio, Tex. tervertebral Joints in Response to External Loads," 15. Bick, E. M., Source Book of Orthopaedics, Hafner Pub­ J.8.J.S. 54-A, No. 3, April I 972, p. 511. lishing Co., N.Y., 1968, p. 306. 21. Markolf, K. L. and Morris, .I. M., "The Structural Com­ I 6. Splitoff, C. A .• "Roentgenographic Comparison of Patients ponents of the lntervertebral Disc," J.B.J.S. 56-A. No. 4, With and Without Backache,"./.A.M.A., 152: 1610, 1953. June 1974, p. 675. I 7. Krause, H., Robertson, G., and Farfan, H. F., "On the Me­ 22. Belytschko. J., Kulak. R. F .• and Schultz, A. B., "Finite chanics of Weight Lifting," Proceedings <~f the New Element Stress Analysis of an I ntervertebral Disc," England Bioengineering Conference, April 1973. Journal of Biomechanics, Vol. 7, 1974, pp. 277-285.

91 Spinal Kinematics

AUGUSTUS A. WHITE, Ill MANOHAR M. PANJABI Engineering Laboratory for M usculoskeletal Diseases Section on Orthopaedic Surgery Yale University School of Medicine

INTRODUCTION ceived with gratitude, disdain, confusion, or indif­ ference, depending on the individual reader. Kinematics is that phase of mechanics concerned with the study of motion of particles and rigid Coordinate System bodies with no consideration of the forces involved. The right-handed orthogonal (Cartesian) coordi­ To describe the kinematics of the spine, the an­ nate system is recommended.:2 Its orientation in 1 alogy of the train used by Lovett is employed and space is shown in figures I and 2. Motion is de­ adjusted to the imagination of the present authors. scribed in terms relative to the subadjacent verte­ If each vertebra is thought of as a train, one could bra as shown in figure 2. begin to describe its kinematics with answers to the following questions. What points does the train run Motion Segment between? What course does it take? How far apart The motion segment which is the traditional unit are these points? What alterations of the train will of study in spinal kinematics is constituted by two change the course it takes, the distance it travels, adjacent vertebrae and their intervening soft tissues. or the smoothness of the ride? How far outside its Translation usual course can it travel without being in danger of malfunctioning? What happens to the route taken A body is said to be in translation when move­ and the distance traveled as the train progresses ment is such that all particles in the body at a given from a new to an old train? What are the methods time have the same velocity relevant to some for precisely defining the course and distances reference. traveled by a given train? As this presentation de­ Rotation velops it will become apparent how answers to A body is said to be in rotation when movement these hypothetical questions describe the normal is such that all particles along some straight line in kinematics of the spine and relate it to some of the the body or a hypothetical extension of it have a important abnormal situations of clinical interest. zero velocity relative to some reference. There is a considerable amount of information available on this complex topic. In order to stay Degrees of Freedom within the limitations of this presentation, only the One degree of freedom is motion in which a rigid major aspects of the subject will be covered and not body has the possibility of translating back and in detail. forth in either direction along a straight line. Or if a given body can rotate back and forth clockwise and TERMS AND DEFINITIONS counterclockwise in either direction, that too is a This section contains some guidelines and ground degree of freedom. Figure 3 gives examples of one, rules for clear and accurate communications. I ts two, and three degrees of freedom. V ertebras have contents, in part or in toto, will no doubt be re- the possibility of six degrees of freedom. 93 ,------1 I I I I I I I I I I I I I I I I I I I I I I I I

Fig. 2. Her c a motion segment is shown with the reference point at the tip of the spi no us proc ess of the subadjaccnt ver­ tebra. The orthogona l system is presented in the y. z or sagittal plane. The x axis is thus indicated by conventi on show ing the cros s to repr esent the base of the arr ow.

Co upling Co uplin g is app lied to motion in which rota tion or translation of a rigid body abo ut one ax is is co n­ sistently associ ated with ro tati on or translation of tha t same rigid bo dy about anot her axis. Co up ling is dia gra mmed in figure 4. Patt ern of Moti on Thi s is defined by the config urat ion of a line th at the centroid of a body in motion form s as it moves Fig. I. The suggested centr al coo rdin ate sys tem with its from one point to anoth er . origi n be twee n the comu a of the sacrum is shown . Its orienta­ tion is such that negative y-axis is described by the plum b line Instantaneous Ax es of Rotation s (/AR ) dropped from the orig in. the positive x-axis point s to the left , At ever y instant , for a rigid body in plane motion and the positive z-axis points forward . The human bod y is shown in the anatomic position . there is a line in the bod y or a hypot he tical exten­ sion of it which does not move . Thi s line is the in­ stanta neo us axi s of rotation. Plane motion is fully Range of M otion defined by the position of the I A R and the magni­ tude of the rotation abou t it. (See figure 5.) An indicati on of the two points at the extremes of the phy siological range of translation and rota­ Helical Axis of Motion (HAM ) tion of a vertebra for each of the six degrees of The instant aneo us motion of a rigid body in freedom. three-dimensional space can be analyzed as a 94 ONE

AXIAL ROTATION AXIAL MOMENT AND o------• F { - LATERAL BENDING

TRANSLATION

HORIZONTAL FORCE { AND ROTATION

THREE Fig. 4. Diagrammatic representation of some important forms of coupling involved in spinal kinematics. The loads employed to effect the various movements are shown by the dotted line.

proach an idealized comprehensive description of the important basic and clinical aspects of spinal kinematics. The complete description would in­ clude the information in table I presented for each motion segment from occiput to sacrum using the SIX orthogonal coordinate system or some other reli­ able system. If one accepts this table as a compre­ hensive outline, there are a large number of blanks to be filled in. Rather than concentrate on what would be necessary to fill the empty portion of the "glass," the authors have chosen to present their own brief summary of that which is currently in the "_glass."

Fig. 3. The concept of degrees of freedom involved in the engineering analysis in kinematics is shown diagrammatically. simple screw motion. The screw motion is a super­ POSITION2 position of rotation and translation about and along the same axis. This axis has the same direction as I I the resultant of the three rotation components I / / I I / about the x, y, z axes. For a given moving rigid body \ I / / in space the location of this axis and the designation \ ! I/ of the quantity of its rotation and translation con­ \A3 I / / stitute a complete, precise, three-dimensional de­ \ T/i scription of the motion. (See figure 6.) C,AR

A COMPREHENSIVE DESCRIPTION OF SPINAL KINEMATICS Fig. 5. This shows a concept and the actual method of determining the instantaneous axis of rotation in uniplanar One of the goals of this presentation is to present motion. The telephone moves from position I to position 2. what is known, what is not known, and what would Two lines are drawn from the two points in the original position I to the same points in position 2. These are indicated by be useful to know about spinal kinematics. Table I A 1, A2 and B 1, B 2. Perpendicular bisectors are then erected outlines information which, if available, would ap- upon these two lines. The point at which they meet is the IAR. 95 TA BLE I HELICAL AXIS OF MOTION A Compr ehensive Desc ription of Spinal Kinematics

I. Range of motion: for all six degrees of freedom. * t'* a) Tran slation e,o xy plane b) Rotation

2. All couplin g char ac terist ics and their ratios. ' \ 3. Patt erns of motion in the traditional physiologica l pattern s. a) Flexion Extension xz plane b) Lat eral Bending c) Axial Rotati on

4. IAR' s loca ted for motion segme nt in the traditional planes. a) Sagittal: (y, z) plane b) Co ronal: /y, x) plane c) Horizontal: /x, z) plane

5. H A M's loc ated throu ghout the range for eac h motion seg­ ment in the trad itional planes. ..______.:;;...... ;,_ _, y z plane 6. Analysis and co mpariso n of the regional variations for all the abov e. a) Ce rvica l b) Th oracic c) Lum bar

7. Analysis of the functions of the variou s anatomic elements in spinal kinematics. Fig. 6. Helical axis of motion. Th e screw motion is a super­ a) What ·are the roles played by the va rious anatomic ele­ position of ro tation and translation abou t and along the same ments in determinin g 1-6 ? ax is. T his axis has the sa me direc tion as the res ults of the thr ee b) Wh at happ ens 10 1-6 , if an y particul ar co mbination of rotation co mpo nents ab out the .r, .ran d ;: axes. Vec tor quanti­ anatomic e lements are destro yed or una ble 10 functi on? ties o• for rotation and ll for translation lie on this ax is. Th e above desc ribed axis is referred 10 as the helica l ax is of motio n ­ HAM. (N ote this diagram has not used the reco mmended orientati on of the orth ogo nal coo rdinate system.)

C URRENT KNOWLED G E OF FLEXION-EX T ENSION LATERAL BENDING AXIAL ROTATION SPINAL KINEMA T ICS

This section of the presentati on see ks to report on the major aspec ts of contemporar y spinal kine­ matic s. For a det ailed review of th e literatur e and E an exhau stive bibliograph y, the reade r is refe rred E uCJ T5·6 to oth er referenc es .:1, 4 , 5 • 5 ., ~ :::TT-8 L Ran ge of Moti on I- 19-10 Tll42 ~C Fe w studie s have been carri ed out to carefully *T12•L I Ll •'Z l anal yze , quantit ate and report translation ran ges .,a: I!; L~-4 in spin al kinem atics . The inform ation was gener­ ::, .J 1..,-s1 ~ l ated in several theses done in Profess or Hir sch's - L-.J_J L______l____J 0 :I IO 15 20 0 5 IO 0 5 10 1 5 6 laboratori es in Sweden.· • • However , in the re­ DEGREES porting of these work s, most of th e attention was focu sed on the rot ary aspect s of the motion . Values Fig. 7. Th is is a co mposite of rota tion in the traditional modalities and the traditional planes of moveme nt for the for translation in all planes, espec ially in the different regions of the spine. Sec tex t for exp lanation of how sagittal (y, z) plane are of pra ctica l imp ortance in these figures were der ived. 96 clinical evaluations of traumatized spines. There averages but are derived from a weighing which is information in the radiological and orthopedic includes a consideration of the experiments that literature that offers some guidelines about the generated them as well as their "fit" with our over­ upper limits of certain translatory displacements. all knowledge of the subject. The reader is re­ However, we are not aware of studies that report minded that in the literature these figures en­ the ranges in all the traditional planes. compass a broad range. This is due to large To follow are a graph and a table which sum­ differences in experimental techniques as well as marize the current information on the rotary sizable individual biological variation. For spinal ranges and representative figures for the human kinematics, instead of a "bell-shaped curve" spine. These figures represent the best opinion there is a "cymbal-shaped curve." The figures are of the authors based on a review of the litera­ submitted with these qualifications and the belief ture=L4 • 5 • 6, 7 , 8 and their own analysis. The '"rep- that they represent a pattern characteristic of resentative values" are neither true mediums nor most human spines. See figure 7 and table I I.

TABLE II Estimated Range and Representative Degrees of Rotation Based on Review of Literature and Authors' Analysis

Flexion-extension, x-axis rotation Lateral bending, z-axis rotation Axial rotation, y-axis rotation

Compiled Representa- Compiled Representa- Compiled Representa- range tive angle range tive angle range tive angle

Occiput-Ci 4-33 13 4-14 8 () 0 C.-C2 2-21 10 0 0 22-58 47 C2-Ca 5-23 8 11-20 10 6-28 9 Ca-C4 7-38 13 9-15 11 10-28 11 C4-C-, 8-39 12 0-16 11 10-26 12 C5-C.; 4-34 17 0-16 8 8-34 10 CH-C1 1-29 16 0-17 7 6-15 9 C1-T1 4-17 9 0-17 4 5-13 8

T1-T2 3-5 4 6 6 14 9 T2-Ta 3-5 4 5-7 6 4-12 8 Ta-T4 2-5 4 3-7 6 5-11 8 T.1-Ts 2-5 4 5-6 6 4-11 8 Ts-T6 3-5 4 5-6 6 5-11 8 T5-T1 2-7 5 6 6 4-11 8 T1-T11 3-8 6 3-8 6 4-11 8 Ts-T~ 3-8 6 4-7 6 6-7 7 T9-T10 3-8 6 4-7 6 3-5 4 T10-T11 4-14 9 3-10 7 2-3 2 T11-T12 6-20 12 4-13 9 2-3 2 T12-L1 6-20 12 5-10 8 2-3 2

L,-L2 9-16 12 3-8 6 < 1-3 2 L2-L3 11-18 14 3-9 6 < 1-3 2 L3-L4 12-18 15 5- 10 8 < 1-3 2 Le Ls 14-21 17 5-7 6 < 1-3 2 Ls-S, 18-22 20 2-3 3 < 1-3 5

97 Coupling Characteristics and Their Ratios segments was actually reversed in direction. That The coupling patterns of C ,-C:! have been de­ is, a negative z-axis rotation was associated with a negative y-axis rotation. This observation led scribed by Werne 3 and others. 8 , ~, The pattern is one of a coupling of lateral bending with axial to speculation about some relevance to idiopathic 1 rotation. This pattern was well described by scoliosis. ° Figure 8 demonstrates the thoracic L_yse115in the lower cervical spine where he cal­ spine coupling and its possible relation to scoliosis. We are not aware of data on the coupling pattern culated the ratios of coupling for all of the motion that exist in the lumbar spine. Studies to provide segments below C 1• The ratio of coupling is the proportionality between the amount of one motion this information are now in progress in the En­ gineering Laboratory for Musculoskeletal Diseases and the amount of its associated motion. In this Section of Orthopaedic Surgery, Yale University case the ratio of the rotations about the z- and School of Medicine. y-axes. Details are available in Lysell's thesis. There is another salient coupling pattern that The directions of this coupling will be described here. The relationship is such that if one laterally exists in all three regions of the spine. This is the coupling of z-axis translation with x-axis bends one's head to the left, the axial rotation in the cervical spine is such that the spinous processes rotation during flexion and extension. (See fig. 4.) tend to go to the right. On bending the head to Patterns <~fMotion in the Traditional Physiological the right the spinous processes would of course RanRes go to the left. In the coordinate system the de­ Fielding has carried out cineroentgenographic scription is as follows: A positive z-axis rotation studies of motion in the cervical spine. This is coupled with a negative y-axis rotation and vice technique is the most dramatic and effective way versa. to get a realistic feel for motion patterns, which In the thoracic spine the coupling is the same can be difficult to vividly describe. The technique as in the cervical spine but not quite as strong. 6 developed by Lysell for kinematic studies of the That is, each degree of lateral bending gets some­ cervical spine included an effective method and what less axial rotation than it did in the cervical manner of presentation of patterns of motion. spine. In the middle and lower portion of the Detailed descriptions are included in his thesis. thoracic spine this same pattern still exists. How­ The method was adopted and employed to analyze

ever, in these areas, it is neither cis marked nor as patterns of motion in the thoracic spine. (j Figure 9 consistently present. Moreover. in these regions shows an example of thoracic spine motion pat­ the direction of the coupling in some motion terns demonstrated through this method. The

C DIRECTION OF LATERAL • DIRECTION OF LATERAL BENDING - PHYSIOLOGICAL DEFORMITY - PATHOLOGICAL

I ·. I ·. I A B C C B A

AXIAL ROTA TION TO CONCAVITY AXIAL ROTATION TO CONVEXITY HOWEVER, THERE MAY BE SOME NORMAL AXIAL ROTATION TO THE CONVEXITY

Fig. 8. Diagrammatic representation of the axial rotation coupled with physiological lateral bending is shown on the left. A comparative diagram of the same characteristics in the diseased scoliotic lateral curve is shown on the right. 98 AX IAL ROlATI O N FLEXION LOADING y

s1 y SP &, A B C

SR'\\ /;'SL - 0 ------0------0-z 6R 6A/P I

CONSTANT NCREASl'ro I I I I 1 I 1 1 II J D FORCE MOMENT 10mm Fig. 10. Demonstrate s diagrammatically various mcth9ds of loading employed in some exper imental studies to determine the instantaneous .ixis of rotation dur ing nexion.

rim or the vertebra moves very little. Thi s will 51/,f become important when IAR 's are disc usse d. \\SL Current Co nsiderat ions R egard ing IA R Fig. 9. This is a diagrammatic representation of the patt ern The instan taneou s ax is ·of rotation is a unique of motion in a representa tive thorac ic vertebra (T,). Points charact eristic of plan e motion. It has theoretical SR and SL arc loca ted to the right and left respect ively. Points SA and SP represent points 'in the midsagittal plane anteriorly as we ll as clinical impli ca tion s. Wh en co mbined and posteriorly. with the angle of rot ation it give s a comp lete de­ scripti on of the plan e moti on . lines show th e movement of certain point s of the A given IAR dep end s upon the st ruct ur e as vertebrae in space. Th e upp er figure show s the well as to the type of load ing. In other wor ds, it reference subadjace nt vertebra Tr; with th e move­ is not sufficient to say th at, for exampl e, verte bra

ment of T 5 in ax ial rotation as see n from the front T:1h as its IAR , with respect to its adjacent fellow, in the coronal plane . The lower figure show s located 3 millimeter s ant eriorl y and 23 millimet ers th at same motion of T , in the hori zo ntal plane as caud al to the anatomic cen ter of its body. In ad­ see n from above . Note that thi s coordinate sys tem dition , we must also spec ify the typ e of loading, in the figure is orientated differently than the one which in itse lf is an ambiguou s term. Let us take, sugges ted in figure I. The se points do not repre­ for exa mple, tlex ion load ing. Althou gh we all sent th e ce ntroid , but the y se rve to depi ct th e under stand what we mea n by tlexion , i.e. forwa rd pattern s more read ily as th ey ass ist in anat omic bending , when it comes to simul ating thi s loading orientation. These diagr ams show the pr eviou sly in cadaver ex perim ents , different resea rch ers use described co upling pattern of the upper thoracic different loadings. Figur e IO show s so me versions and the cervical spine quit e clear ly. They also de­ of tlex ion loading. A compressive force anteriorly pict path s of motion that are not co mpletel y plac ed, show n in figure I O(A), was used by Ro­ smooth . Howe ver, ther e is wide variation among land er ·1 when he studied the lum bar sp ine and motion segments from different individu al sub­ Whit e6 who studied th e thoracic spine. Flexion j ects as regards the smoothne ss or jagge dne ss of ca n also be crea ted by appl ying a moment about the pat hs. Thi s is an example of one motion seg­ a hori zontal axis, see figure I 0(8), as was done by ment of a normal spine. Pre sumably a motion seg­ Markolf 11 or by app lying a horizont al force to the ment with degen erative changes will show a center of the body directed forward , Panjabi , more jagged pattern of motion. Fina lly, it should Brand, an d White 12 as show n in figure I O(C) . be pointed out that point 5A which is loca ted We may also ta ke multiple seg ments of spines in th e anterior inferior midp ortion of the lowe r and fix its lowes t vertebra and apply a transverse 99 load to the top vertebra. In this flexion loading FLEXION/ LATERAL AXIAL EXTENSION BENDING ROTATION we have a situation where all intermediate vertebrae are subjected to varying amounts of loads. (See E~r R~L fig. I OD.) This load type was used by Lysell5 CERVICAL and White 6 in the three dimensional kinematic L,_ (:.) 'Jf"~ studies of the spine. The top vertebra is loaded ~ ~ through a pure transverse force. just as in figure I O(C). while all the intermediate vertebras are loaded with a combination of the transverse force which is the same at all levels, and the bending moment which is increasing in magnitude in a THORACIC cephalocaudal direction. As the I AR is a function of the load applied. it is clear that for the loading situation depicted in I 0(0) the IAR calculated for the various vertebras are going to differ as a result E~F of the different combinations of force and moment at different levels. The above discussion applies Rs~LJ, L.~R-- . equally to extension and lateral bending although &~:l LUMBAR~ axial rotation has been treated quite consistently (0)' in the literature. This implies that one has to be careful in comparing and interpreting the results Fig. 11. Shows diagrammatically the approximate locations of different workers in the field. of instantaneous axis of rotation in the three regions of the spine In the composite. figure 11, we have attempted undergoing rotation in the three traditional planes. E -shows to present the collective knowledge available approximate location of IAR's in extending from neutral posi­ tion. F -shows them inflexion from neutral position. L-shows on the IAR 's in the three regions of the spine them in left lateral bending or left .axial rotation, and R -shows involved in the three traditional motions. There is, them in ri~ht lateral bending or right axial rotation. to our knowledge. only one study which gives indications of the location of I AR ·s in the cervical magnitude in comparing the atlanto-axial joint, the region. 5 The locations were not quantitatively lower cervical spine and the thoracic spine. Axial determined but are based on judgment from obser­ or y-axis translation occurs in decreasing order in vations of the patterns of motion (Fig. I I). The the cervical, thoracic, and lumbar spine. This is thoracic spine has been studied by White. Ii The based on impressions from the literature and the results have been averaged for the different levels author's experience. not on specific controlled and are presented in the middle of figure 11. Data experiments. There are not enough data on x-axis on the IAR ·s in the lumbar region is included in translation for even an impression. the work of Ro lander 4 and Cossette et al. 13 Their Rotation: Figure 7 is designed to point up re­ findings are summarized in the lower portion of gional variations in rotation in the traditional physi­ figure 11. ological motions. Current Status of Helical Axis of Motion There is no axial (y-axis) rotation between occi­

This valuable concept has to our knowledge been put and C 1 • There is no lateral bending between used in only one instance in spinal kinematics. C 1 and C2 (z-axis rotation). About 50 percent of In this instance, examples of thoracic spine mo­ head-and-neck axial rotation occurs at the occipito­ tion were described with the HAM primarily to atlanto-axial complex. The remaining one-half introduce the use of the concept to depict spinal occurs between C:.!and T1. Most of the movement kinematics. 6 considering the three modalities. flexion extension. lateral bending, and axial rotation, occurs in the Analysis and Comparison r~f Regional Variations cervical spine.:i,!I Translation: The translation data have not been In the thoracic spine. the amount of flexion ex­ systematically presented. It is available in only a tension at each motion segment increases in the few of the numerous considerations. In the sagittal cephalocaudad direction, while the axial rotation plane the z-axis translation occurs in decreasing decreases. The lateral bending is about the same )00 throughout. Though the intersegmental motion in of spinal kinematics to stiffness and damping the thoracic spine is relatively modest in most coefficients and mathematical modeling has not modalities, its total capacity for movement is been included. formidable. The upper thoracic spine tends to The outline in table I has been developed in an behave more like the cervical spine and the lower attempt to focus on what is known and offer some thoracic spine tends to behave more like the suggestions about future topics for investigation. lumbar spine. B It is apparent that there is a good deal of research In the lumbar spine, flexion extension is the remaining in order to fully describe the kinematics major activity with little axial rotation. There is of the human spine. more axial rotation and probably more flexion at There are, as with any research, numerous prob­ the L5-S1 joint than in the other lumbar segments. lems involved. The kinematics of interest is that There may be relatively less lateral bending at that of the living spine. The experimental techniques level. Flexion extension is generous here as it is for precise no-risk in vivo measurement in the in the cervical spine. There is less lateral bending human are yet to be developed. The physiological and axial rotation in the cervical spine and less muscle forces have not been simulated. The char­ axial rotation than in the upper thoracic spine:• acteristics of the force vectors that cause in vivo physiological motion are not known. Studies are Analysis of the Functions of the Various Anatomic done to simulate vertebral motion, but it is not Elements in Spinal Kinematics known whether the motion experimentally pro­ Studies have been carried out on mechanical duced is the same as that which is physiologically properties of some of the specific anatomic ele­ produced in vivo. The vectors that should repre­ ments, including the anterior and posterior longi­ sent the existing physiological preloads are not tudinal ligaments, 14 the annulus fibrosus, 15, w, 17 known and at present we are not aware of pub­ the yellow ligaments, 18 and the interspinous liga­ lished studies of kinematics that take them into ments. rn Not much attention, however, has been consideration. paid to the role of these elements in determining It is possible to fully describe the normal kine­ the characteristic functions of the motion segment. matics of the human spine. A good deal of that One approach is to compare the kinematics of description is presently available. There is still a a given motion segment under controlled con­ considerable amount to be carried out. However; ditions before and after the elimination of anatomic given the available current knowledge, and re­ structures. A biomechanical analysis of the search techniques, it is no longer necessary to translation and rotation in the cervical spines speculate and deliberate about spinal kinematics (tested in flexion and extension) as a function of or alignment. It is possible with defined limits of sequential ligament transection including facet validity to observe and measure the spatial rela­ ablation has been carried out. These studies showed tionships between vertebras, and in most cases, to subtle changes in kinematics up to a point after determine whether or not those relationships are which dramatic changes were evidenced. 20 It has normal. been shown that removal of posterior elements in thoracic spine motion segments significantly REFERENCES alters ~he kinematics in extension and axial I. Lovett, R. W.: The Mechanism of the Normal Spine and 1 rotation.2 its Relation to Scoliosis. Boston Med. & SurR, J., J 53:349, This is an area of spinal kinematics in which 1905. a good deal of valuable basic and clinical informa­ 2. White, A. A., Panjabi, M. M., and Brand, R. A.: A System tion can be generated. for Defining Position and Motion of Human Body Parts. Journal of the International Federation for DISCUSSION AND CONCLUSION M edirnl and Biological Engineering, 1n Press. 3. Werne, S.: Studies in Spontaneous Atlas Dislocation. The preceding is an overview of current spinal Acta Orthop. Scand., Supp. No. 23. 1957. kinematics. Large amounts of data have been 4. Rolander, S. D.: Motion of the Lumbar Spine With Special Reference to Stabilizing Effect of Posterior Fusion omitted as have some relevant topics. The latter (Thesis). Acta Orthop. Scand., Supp. No. 90, I 966. includes the effects of age, occupation, and disease 5. Lysell, E.: Motion in the Cervical Spine (Thesis). Acta on spinal kinematics. The important relationship Orthop.Scand.,Supp. No.123, 1961. IOI 6. White, A. A.: Analysis of the Mechanics of the Thoracic the Third Lumbar lntervertehral Joint. ./. of Bio­ Spine in Man. An experimental study of autopsy speci­ mecha11ics, Vol. 4, pp. 149- I 53, 1971. mens. (Thesis.) Acta Orthop. Scand., Supp. No. 127, 14. Tkaczuk, H.: Tensile Properties of Human Lumbar 1969. Longitudinal Ligaments. Acta Ortlwp. Scand., Supp. 7. Fielding, J. W.: Normal and Abnormal Motion of the No. I 15, 1968. Cervical Spine from C2 to C1, Cineroentgenography. 15. Galante, J. D.: Tensile Properties of the Human Lumbar J. of Bone and Joint Surg., 46-A, p. 278, 1959. Annulus Fibrosus. Thesis. Acta Ortlwp. Scand., Supp. 8. Hohl, M., and Baker, H. R.: The Atlanto-Axial Joint No. 100, 1967. Roentgenographic and Anatomic Study of Normal and 16. Horton, W. G.: Further Observations on the Elastic Abnormal Motion. J. of Bone a11dJoint Sur1-:., Mechanism of the I ntervertebral Disc. J. <~fBone and 46-A, pp. 1739-1752, 1964. Joint S11rgery,40- B, p. 552, I 958. 17. Virgin Experimental Investigations Into the Physical 9. Shiparo, R., Youngberg, A. S., and Rothman, S. L. G.: Properties of the lntervertebral Disc. J. of Bone and The Differential Diagnosis of Traumatic Lesions of the Joint Surgery, 33-B, p. 607, 1951. Occipito-Atlanto-Axial Segment, Radiolic Cli11ics of I 8. Nachemson, A., and Evans, J.: Some Mechanical Prop­ North America, Vol. XI, pp. 505-526, I 973. erties of the Third Lumbar lnterlaminar Ligament. 10. White, A. A.: Kinematics of the Normal Spine as Related J. of Biomechanics, Vol. I, p. 211, 1968. to Scoliosis. J. of Biomechanics, 4:405, 1971. 19. Walters, R .• and Morris, J.: An In Vivo Study of Normal 11. Markolf, K. L.: Stiffness and Damping Characteristics of and Scoliotic Interspinous Ligaments. J. of Biomecha11ics, the Thoracic-Lumbar Spine. Proc. of Workshop on Vol. 6, p. 343, 1973. Bioengineering Approaches to the Problems of the 20. White, A. A .. Johnson, R. M., Panjabi. M. M., and South­ Spine. NIH, September I 970. wick, W. 0.: Biomechanical Analysis of Clinical Stability 12. Panjabi, M. M., Brand, R. A., and White, A. A.: Three­ in the Cervical Spine. Cli11.Orthop., In Press. Dimensional Load Displacement Curves of the Human 21. White, A. A., and Hirsch, C.: The Significance of the Thoracic Spine. J. of Biomeclw11ics, In Press. Vertebral Posterior Elements in the Mechanics of the 13. Cosette, J. W., Farfan, H. F., Robertson, G. H., and Thoracic Spine. Clin. Orthop., Vol. 81, November­ Wells, R. V.: The Instantaneous Center of Rotation of December, 1971.

102 Biomechanical Aspects of Subluxation

C.H. SUH Professor and Chairman Department of Engineering Design and Economic Evaluation University of Colorado

1. INTRODUCTION 2. PRECISION X-RAY METHOD FOR THE VISUALIZATION OF BIOMECHANICAL Next to the word "chiropractic," the term "sub­ ASPECTS OF SUBLUXATION~,a luxation," or "spinal subluxation" is perhaps the most important and most frequently used word 2-1. A Review of X-ray Methods in Biomechanics employed by chiropractors. Some discussion on Needless to note, the X-ray has become an in­ this term is therefore in order. The definition of valuable means of examination in health care. ··subluxation" varies, depending on whether it is The graphical output of anatomical or physiologi­ viewed from a chiropractic or medical point of cal data of the human body produced by X-rays view. For example, Stedman's Medical Dictionary 1 generally serve as "true pictures'' of the X-rayed simply defines it as: ··semiluxation; an incomplete object. However, due to the large amount of dis­ luxation or dislocation; though a relationship is tortion in the X-ray image generated by its in­ altered, contact between joint surfaces remains." herent central projection characteristics and The major difference bet ween the medical and other geometrical errors associated with the chiropractic viewpoint is that chiropractic includes X-ray equipment, an accurate measurement from "neurophysiological disturbances" in the definition the X-ray image of fundamental biomechanical of subluxation. This implies that "subluxation '' data, i.e. distance, angle, and relative position, has a living character which includes both bio­ is impossible unless proper scientific techniques mechanical and neurophysiological abnormalities. are developed and applied. Therefore, any conclusion regarding subluxation Techniques known categorically as "photo­ that is based solely on the study of cadavers is grammetry ," developed mainly for geographical not acceptable. surveys and map production, have been recently This paper will concentrate on the biomechanical extended to X-ray photography. Numerous at­ aspects of subluxation. It will summarize what is tempts and contributions in this area appear in 4 8 known and unknown, indicate necessary areas of various literature. - In spite of these activities, research and suggest methods to carry out the the techniques are generally not sufficiently formu­ research. Research at the University of Colorado lated for application by practitioners in the health pertaining to this field has focused on the following care profession. Recent literature in medical two major areas in the last several years: radiology rarely includes use of three-dimensional correction techniques.!) In 1970, B. H. Dawson I. Precision X-ray method for the visuali­ and mechanical engineers in Lancashire, England, zation of biomechanical aspects of sub­ published an outline of a new method which uses luxation the computer to study the relative positions of 2. Computer model of the spine for simu­ the brain and the axes of the operating instrument lated study of spinal subluxation. in stereotactic surgery. 10 103 The spine. because of its importance in far­ reaching neurological and vascular disturbances. has been of particular concern in the development of accurate X-ray analysis. A review of develop­ ments made in the past indicates the seriousness of the efforts in improving accuracy. A special process and apparatus developed by Dr. T. Vladeff for spinal X-ray was patented in 1942 (U.S. Patent No. 2,630,536): another apparatus developed for spinal X-ray by Dr. E. A. Fox was patented in 1956 (U.S. Patent No. 2,774,884). Still another device. known as a "'Protractorscope," includes a method for upper cervical X-ray analysis. 11 This apparatus, developed by Dr. J. Kuhn, was patented in 1960 (U.S. Patent No. 2,942,347). This paper presents a rigorous fundamental analytical method of precision analysis of spinal X-rays, but the method is also applicable to other parts of the body. It is based on the reconstruction of three-dimensional geometry from X-ray films. The analytical method is developed in such a way Fig. 1. The helmet for computer aided X-ray analysis. as to utilize the efficiency and accuracy of digital computers. To extend the scope to practical use, Figure 2 illustrates the reconstruction and nota­ the method is developed in such a way that a tions used in the computation. The rectangular typical single X-ray machine can be used. reference frame has dimensions A, B, C, A 1 , B 1 , B2, C1, ~X. LlY1, ~Y2, and LlZ which are constant 2-2. Development of Reconstruction of X-ray Geometry For practical reasons, it is necessary to re­ construct the geometry from the information appearing on the X-rays themselves without the need to record the relative positions of the focus points, the object, and the image planes. To solve this problem, it was necessary to include a ref­ erence frame that is X-rayed along with the object. For example, in cervical X-ray analysis a "Helmet" type reference· frame illustrated in fig­ ure I can be used. It is made of plastic plates with lead wires imbedded in them. When a cervical X-ray is taken with this "Helmet'' in place. the lead wires of the "Helmet" are clearly projected and appear around the cervical vertebrae on the X-ray film. Each of these lines on the X-ray film will, in general, appear to be longer than the pre measured true lengths of the lead wires in the ·•Helmet." For the three-dimensional analysis, at least two different views are required. In general, orthogonal projections are preferred because of the clear identifications of the images and better intersections of X-ray projection lines in the reconstructed Fig. 2. Geometry and notations for localized computer-aided geometry which give higher accuracy. X-ray analysis. 104 known lengths measured with extreme accuracy. y, = m1X1 + h1 (a) Two of the opposite side frames are identical. For the sake of simplicity in illustrating the basic (A) z, = m'2x, + b'2 (b) method involved in the reconstruction, assume { that P and Q image planes are orthogonal and Yi= m:1X1 + ha (c) parallel to the corresponding faces BC and AB of the reference frame. Obviously, solving this set of three linear equa­ Fixed coordinate axes (X, Y, Z) are established tions can be done by solving first for x, and Y1 as reference axes in the geometrical system. The from linear equations (a) and (c) then substituting ''right hand rule" axes (X, Y, Z) are attached to X1 in equation (b) to solve for Z1. the reference frame in such a way that any point For a graphical analysis of this simple algorithm, in the reference frame is measured in the positive in figure 3 we see the front (F) and top (T) view direction of X, Y, and Z as shown in figure 2. The of the reference frame with P and Q image X-rays. reconstruction then requires the location of the two focus points P and Q and the image Pi and Q1 Q Image a1 with respect to the fixed coordinate axes (X, Y, Z).

Since most biomechanical measurements such X as distance, angle, and relative position can be P Image calculated by using the coordinates of a series of z points in one fixed coordinate system, the process of using only coordinates of points (rather than p attempting to measure angles or other geometric features) is sufficient. To illustrate the procedure, the problem may be stated as follows:

Problem: Let it be required to locate the point (x,, y,, zi) with respect to the lo­ calized fixed (X, Y, Z) coordinate axes using the two X-rays; P image and Q image. Besides the two X-ray films, the only known parameters are the reference lengths A, B, C, A,. B,, B'2, Ci, LlX, LlY,, LlY'2, and.:lZ.

Solution of this problem is presented in detail in references 2-3 with all the formula derivations and a numerical example. It consists of eight steps in a sequential method developed with analytical spatial geometry and algebraic manipulations. It gives four different sets of three linear equations X which will give four different sets of solutions to (c) X1,Y1, and Z1 instead of one set. -~ At this point it was apparent that further analysis was required in the selection. Fig. 3. Intersecting rays.

2-3. The Error Analysis and the Selection The first equation of (A) is the x-y view of the Criterion ray (a) which comes from the focus point P and similarly the third equation of (A) is the x-y view Let us assume one of the sets of the linear of the ray (c) which comes from the focus point equations as Q. Solving these two linear equations simul- 105

597-036 0 - 76 - 8 taneously simply means that we are finding the This means, then, if one has a choice in selecting intersection of these two lines. We see this inter­ an intersection point from these two cases and if all section in the F view; then we find x 1 and Y1 by the end points Ai. B 1, ••• , C 2, D2 have the same measuring the x-y coordinates in the' F view. degree of possible error, then one should select The second step of the algorithm is to substitute case / which gives a more accurate point of inter­ one of the known values. x 1- into the second equa­ section. tion to solve for z 1- In selecting one solution out of four, one can use Thi s process begins, again graphically, by ex­ this error analysis as a criterion. To do this one tending a perpendicular line from the intersection computes a and f3 angles for each set of four point in the front view into the top view. Then, let solutions. That solution which gives these angles this line intersect the line (b) that represents the more nearly 90° than the others is selected. De­ second equation of (A) which shows the x-z view fining the angles a and f3 as the first and second of the ray coming from the focus point P. intersection angles respectively. one must notice Let the first angle of the intersection of the line that the angles a and f3 of a particular solution (a) and (c) be a1, and the second angle of the inter­ could be found in the F or T view, but not both in section of the perpendicular line and (b) be /31.It the same view. is important to notice that a key for the error 2-4. Computer Implementation analysis can be found in these two angles a I and /31. The •·good intersection" which gives an accurate The procedure, including error detection and position of the intersection point on a plane is discriminative measure, is a stepwise sequence when the angle of the intersection is close to 90°. and thereby renders itself to formulation with a Figure 4 illustrates a "good intersection" and a simple computer program. Various computer pro­ "bad intersection.·· grams written in BASIC and FORTRAN IV for conversational time-sharing terminals and con­ ventional batch processing, respectively, are availa­ ble together with appropriate user manuals. The simplicity of the program, as well as the recently improved time-sharing computing network, should make this system practical for any physician or researcher with the mere addition of a single remote console and common telephone.

2-5. Discussion and Further Research Needed

In securing the highest accuracy from the X-ray analysis, the following four points should be added:

(I) Grid size of the reference frame In general, it may be preferred to reduce the lead wired grid in the frame because of the obvious CASE I CASE II economy involved in using a smaller X-ray and the "Good Intersection" "Bad Intersection" better X-ray images of the lead wires themselves due to the wires being closer to the local object Fig. 4. Good and bad intersections. focused. However, a clear disadvantage must be Suppose the point A I and point A 2- the ends of noted which will limit the reduction. That is, the the lines, have some error, ~A, in position. The shortening of the reference lead wire lengths will effect of changing the position of the intersection naturally make shorter images of these wires on point / due to this error is much more serious in the the X-ray, which will in turn reduce the accuracy "bad intersection" case than in the "good intersec­ involved in the entire numerical procedure. Thus. a tion" case because it jumps far more from the true reasonable optimum size of the wire grid is intersection point as illustrated in figure 4. necessary. 106 (2) The po int iden tifica tion (3) The structural errors Since an X-ray is actu ally a shadow of the objec t, Th e pro pose d meth od of X-ray analysis is base d there always ex ists co nsiderab le inherent hum an on co rrec ting th e distorti on of ce nt ra l proj ec tion. error in loca ting the sa me geometrica l po ints on H oweve r, th e X-ray foc us is not trul y a geo metrica l the bones from differ ent X-r ays . T his co uld be point and furth erm ore the neg ative X-ray image largely overcome by th e followin g efforts: planes ar e not trul y geo metric al planes du e to (a) Throu gh yea rs of experience, ph ysicians and shrink age and lack of flatn ess. Anoth er stru ctur al radiolog ists have acquired acc urate anatomica l erro r du e to oppos ite sides of th e refe rence frame insight which should increase th e acc uracy of not being para llel also ex ists. loca ting co rres pondin g points on the X-rays . In a se ries of expe rim en ts ca rried out with proto­ (b) Coo rdin ate digitize rs are co mmerc ially ava ila­ ty pe reference frames for cer vica l spinal ana lysis ble which ca n more acc urate ly de termin e point such as show n in figure 5, it was foun d that effects coo rdin ates on th e X-r ay film. Th ey also store th e du e to these struct ura l error s are much less serious data automat ica lly, e liminating the nee d for hand th an the two prev iously discusse d fac tors. T he reco rding. total of these erro rs ca n be es timat ed by a ca libra­ (c) Most of the X-ray an alysis will involve pos i­ tion proce dur e using a prec isely known objec t and tions and displac em ent s. Th e rigid body co ndition plac ing it in the reference frame. of ea ch bon e should be used in th e kinematic Our experience in using thi s X- ray method in a analys is to co rrec t and/o r impro ve the data point s rea listic environment re veal s th at th e prob lem meas ured and stored. which is oriented to the point identifi ca tion is mos t

Fig. 5. Th e expe ri rncnla l '"hc lme1"' of reference frame for cervical X-ray analysis. 107 pressing and needs further research to obtain higher y accuracy of this entire X-ray method. Since a spinal subluxation is associated with the displacement of a vertebra, with respect to other vertebra, theories in kinematics of the rigid body displacement have been used in research 1 13 since I 973 at the University of Colorado. ~• The X-ray data of spatial coordinates are re­ quired for the displacement analysis but unlike other biomechanical analyses, such as distances between two points, angle between two lines, etc., displacement calculations require more accurate data. Therefore, it became necessary to correct the X-ray data before the displacement analysis. 0 By the definition of a rigid body, any displace­ ;------X ment of a rigid body in three-dimensional space should not change its shape. In other words, the distance between any two points in a rigid body should remain constant. Therefore, when the coordinates of the same points on a rigid body are measured at different position and the dis­ / tances between these points are calculated, they Fig. 6. Coordinates of rigid hody in space. must be the same in any position. Since there is usually inherent measurement error involved, Assuming there is some measurement error in it is not necessarily true that the measured data A 1, B1. C 1 • A~. B~. and C2, the calculated dis­ will give the same lengths with accuracy. tances with these data (between these points) Two methods to correct the data which use the may not be equal. i.e., properties of a rigid body are proposed with an 13 objective function in and also the problems - - involved in the numerical solutions are also A1 B 1 =/:-A2 B 2 discussed. Unfortunately, most of the facts discussed and A 1 C 1 =1:-A~C~ (I) developed in the report are difficult to prove by { B 1 C 1 =/:-B~ C:! analytical geometry. Instead, numerical checks by computer outputs for the many possible cases The problem is to change the coordinates such are given to sup-port the development by cross that these constant-length equations hold; that is checking. fulfill rigid body conditions. Let the corrected The most essential part on the optimization pointsbeA' ,B' .C' ,A' 2 • B' and C' • then problem is in the construction of an objective 1 1 1 2 2 function which then will be minimized. It is known that the establishment of an objective function in A;B;=A;B; analytical form is a difficult matter and often there is no universally systematic way to approach A; c; =A~ c; (I ') it. { -- -- We shall formulate the data correction problem B; c; = B~ c~ as follows: Assume that three points on a rigid body are measured at the two positions with some amount of measurement error. The reason why the For a solution to this problem. which obviously three-point problem is important will become has innumerable solutions, we know that the clear from the kinematics. Figure 6 shows the sym­ corrected points depend on the selection of bols and coordinates for each point; these symbols the objective function. Let us intuitively define are used throughout the report. the objective function as the sum of the corres- 108 ponding distances between the original data points are not very appropriate for modeling attempts.

(A 1 , B 1, C 1, A 2 , B2, and C 2) and the corrected data While existing studies may represent creative points (A;, B{, c;, A~, B;, C~), i.e., simulations of automotive or aeronautical eventu­ alities, they do not lend themselves to realistic 1 f(x a1 , Ya'i, Zai, X1i{, Ybt, Z1,{, Xe{, Ye{, Zc{, approaches to most chiropractic disorders. What are required are studies on small. quasistatic dis­ placements of the spinal column. yet such studies are quite rare. It follows that the necessary bio­ mechanical data for a comprehensive model of the spinal column are also rare or nonexistent. Pre­ cisely what measurements are required remains uncertain because only a comprehensive model will reveal the gaps in existing biomechanical in­ formation on the spine. + V(ax,,.)2+ (aybi) 2 + (aZii, )2 A model of the spinal column must accurately + Y(LlXc1F+ (ayc,F + (~c1F conform to mechanical constraints of geometry and force. In addition, such a model must provide + \/(axazF+

~Zat = Zai - z'a,,etc. mechanics research for many years. To study mechanical and structural behavior of the spinal Now the data correction problem can be stated system there have been numerous attempts to as an optimization problem as follows: Minimize construct a model of the spine. l n 1951. Dr. Fred W. the objective function f of eq. (2) subject to the Illi, a Doctor of Chiropractic in Geneva, Switzer­ constant-length equations of eq. ( 1) '. land, published a book entitled, The Vertebral Column. He constructed a hardware model by placing an axis in the vertebral canal and assem­ 3. COMPUTER MODEL OF THE SPINE FOR bling wedged discs connected by means of a wire. SIMULATED STUDY OF SPINAL SUB­ He used it to demonstrate among other things that LUXATION1-1-2o the spinal cord constituted the axis of the torsional 3-1. A Review of Spinal Models movements of the spine itself. Creating a model of the complicated bio­ In I 957, S. Werne at the Department of Ortho­ mechanics of the spinal column presents a difficult pedic Surgery, University of Lund, Sweden, pub­ challenge. The osteoid processes of the spinal lished a book, Studies in Spontaneous Atlas Dis­ column exhibit awesome complexity and multiple location. l n his work he described a conceptual irregularities in structure. Supportive tissues of the biomechanical model of the spine's odontoid liga­ spine express characteristically nonlinear behavior. ments in an attempt to illustrate the role of the Even static and dynamic tolerances of the spinal delicate alar ligaments in the spinal displacement. column seem erratic under various measurement In 1969, H. P. Kopell, M.D., an orthopedic sur­ attempts. Nevertheless, a model of the spinal geon, described a spinal model in his book, Help column is obligatory for the eventual compre­ for Your Aching Back. He used this model to ex­ hension of relationships between imposed mechani­ plain an acute back derangement by illustrating cal force and resulting spinal displacements. faulty stabilizing systems and muscle spasms. In Existing biomechanical data for the spinal column I 972, K. Markolf, Research Engineer at the 109 University of California, Berkeley. constructed the preliminary research carried out with respect another hardware model of the spine. This model, to the spinal model, readers are referred to litera­ made by bending and twisting metal, was made ture given in references I 4. 16, 17. 20. also for those aching backs, as it can aid in the In developing the three-dimensional computer design of braces and other supports in order to model of the spine for the biomechanics study in­ immobilize the spine. volved in chiropractic. the following characteristics These physical and mechanical hardware models and capabilities are required: are useful in many cases, particularly to demon­ (I) The model should be basically elasto­ strate the basic spinal mechanics to a certain ex­ static in nature to be useful at any par­ tent, to laymen and researchers, if they are built ticular position of equilibrium of the with enough mobilities. However. modeling is spine or spinal segment, whether the obviously seriously limited in representing the position is within normal or abnormal complex spine accurately, mainly because it is range. practically an impossible task to find or manu­ (2) The model at the same time is to facture real artificial materials to duplicate the possess the capability of performing mechanical properties of the tissues involved. such voluntary spinal movements for the as spinal discs. ligaments. and muscles. At the study of motion patterns and to in­ same time this type of modeling does not utilize vestigate various kinematic param­ many of the recent scientific and engineering de­ eters involved in the displacements. velopments made in modeling techniques. (3) The digital computer model should A contribution, perhaps the most important and have the capability of storing the linear relevant work to our particular approach, is due and nonlinear characteristics of discs. to the work of A. B. Schultz at the University of ligaments. muscles and other tissues 1 Illinois, at Chicago Circle.~ Chiropractic prob­ involved. All these characteristics of lems. such as subluxation analysis were not his experimental biomechanics data concern. but since 1970 he has utilized digital should continuously interact with the computers and engineering mechanics on spinal geometry involved in the simulated problems. Most of the work was closely associated spinal motion. with scoliosis and his attempt at solving spinal (4) This model should also be developed movement problems with highly nonlinear relations simultaneously with computer graphic is still in its initial stages of development. The diffi­ techniques so that the performing culty becomes obvious when one has to face many simulations are clearly, accurately, highly nonlinear equations to solve simultaneously and continuously displayed graphi­ and repeatedly for continuous motion simulations. cally. Presently, at the University of At the University of Colorado a highly efficient Colorado most of the essential non­ computer program was developed to attack and linear computations involved are overcome this difficulty. At the same time relevant programed and executed with the use chiropractic analyses were initiated with the de­ of the University's dual CDC 6400 velopment of the nonlinear equation solver. system with CDC Computer Graphic 3-2. Mathematical Modeling of the Spine system while new equipment such as Evans and Sutherland's Picture Sys­ Beginning in I 970. Suh and others at the Uni­ tem are being proposed to be used versity of Colorado initiated spinal modeling to mainly for the display of the outputs meet the needs of the biomechanic analysis. Since in graphical forms, taking advantage of its inception, it has been based on digital computers the increased line-drawing capacity. for numerical computations and computer graphics output. The results of the developments were 3-3. Computer Graphics of Spinal Biomechanics continuously presented at the Annual Bio­ mechanics Conferences on the Spine in October Computer graphics, which couples intuitive I 970, October I 971. November l 972, November graphical presentations with high-speed computing. I 973. and December I 974. For detailed review on is being utilized in various health care systems and 110 analyses. These are now major areas of research. Accelerating use of computer graphics is a result of the health crisis and the ever sophisticated tech­ niques applied in diagnosis of diseases and dis­ orders. Physicians are, in generaL laymen in understanding computer techniques. Frequently only computer-generated graphics can provide "the picture" necessary for a decision in intricate health care problems. Fig. 8. The three-dimensional perspective view of the From a structural point of view, the spine is the atlas (the first cervical vertebra). A different point of view. main column of the human body. Physiologically, it is the container of the spinal cord which, together with the brain, forms the central nervous system. A spinal subluxation is formed with abnormal dis­ placement of one or more vertebra with respect to others. This causes various direct disturbances such as backache and also is known to lead to other serious diseases as well. Evaluation of these neuro­ physiological concomitants of mechanical dis­ placements in the spinal nervous system demands Fig. 9. The three-dimensional perspective view of the accurate analysis of relative position and displace­ atlas. (the first cervical vertebra). Another different point of ment of the living spinal system. view. Recent developments in X-ray research have included various cineradiographic procedures for Investigation of three-dimensional computer continuous displacement analysis by Fielding,~~ graphics for accurate perspective views of the and Howe. ~3 Meanwhile, a more realistic and de­ complex, irregular, and anomalously shaped human tailed computer simulation model has been develop­ vertebra was initiated to study the potential as ed for the biomechanical study of the spine. The well as the limitations. Figures 7. 8, and 9 are need to animate the spine displacement arose in examples of three-dimensional perspective plots working with this simulation model. of the atlas (the first cervical vertebra) generated At the Biomechanics Laboratory at the Univer­ by a Tektronix 40 I 0-1 interactive graphics terminal sity of Colorado, Boulder, recent developments (with Hard Copy Unit Tektronix 4610). These of spinal computer graphics are revealed in two views reflect use of the program PPLOT package major areas: The first deals with three-dimensional based on program PICPER developed by L. D. computer graphics of the vertebra, and the second Matheson of the National Oceanic and Atmos­ with the computer graphics of spinal displacement. pheric Administration of the U.S. Department of a. Three-dimensional Computer Graphics of the Commerce, Boulder Laboratories, and H. Akima's Vertebra 15 Smooth Curve Fitting,, Procedures. ~4 The data of three-dimensional points are taken from a human atlas with a mechanical XYZ measuring device designed and developed at the Biomechanics Laboratory. h. Computer Graphics of Spinal Model The major objective of developing computer graphics routines 18 is to compare the displace­ ments predicted by the mathematical and bio­ mechanical model of the spine with those of a real living human spine revealed by means of the cineradiographs. Fig. 7. The three-dimensional perspective view of the atlas To digitize the spine in the sagittal plane, a (the first cervical vertebra). series of X-rays are taken on a human spine for 1 I 1 the full lateral spine ranging from skull to sacrum. LGA=CI:RVICAL LIGAME~T AND LIGA1-1ENT NUCHAE Using these X-ray films and an overlay method. DSK=CERVICAL DISK SCM=S'I'ERNOCLEID0?1ASTOIDEUS approximately 7 .000 data points are digitized by SCP=SCALENUS POSTERIOR the cursor on the screen of the Tektronix 4610-1. LOC=LONGUS CAPITIS These points are used to generate any segment RCA=RECTUS CAPITIS ANTERIOR RCL=RECTUS CAPITIS LATERAL of the spine in real scale or the full spine with SCA=SCALENUS ANTERIOR skull in reduced scale as shown in figure 10. SME=SCALENUS MEDIUS LCS=LONGUS COLLI SUPERIOR LCI=LONGUS COLLI INFERIOR LCV=LONGUS COLLI VERTICAL

LLG=LUMBAR LIGAMENT LDS=LUMBAR DISK PSO=PSOAS EOB=EXTERNAL OBLIQUE IOB=INTEfu~AL OBLIQUE RAB=RECTUS ABDOMINIS

Fig. 11. Coded muscle names and ligaments.

puter screen. The modeling of these ligaments and muscles included anatomical studies to de­ termine geometrical shapes and connecting end points for the ligaments. and the origins and insertions for the muscles. Figures I 2 and 13 display ligament and muscle models for the cervical spine and lumbar spine, respectively. The computer graphic applications are made both in the spinal curvature study and the natural spinal movement study using this spinal model with the displacement matrix method. 26

c. Spinal Curvature Study The curvature of the spine is partitioned into primary and secondary curvatures. Physiologi­ cally, the thoracic curve is known to be present during fetal life and is called a primary curve, while the cervical and lumbar curves are due to development after birth under gravitational force and are called compensatory or secondary curva­ tures. It is also known that various spinal disorders including spinal subluxations are often closely related to the rapid change of these curvatures. Fig. 10. The computer graphical output of spine from skull Applying different sets of acting muscular forces to sacrum. which are statically balanced with the gravitational To simulate the displacement all the spinal discs force. the changes of curvatures are observed on are mathematically modeled 16 using recent meas­ the screen and studied along with the change of the urement data of mechanical properties of discs center of the curvatures. The computer is pro­ obtained from a fresh human cadaver. 25 Also, gramed to draw three circles for each of the major representations of various spinal ligaments and spinal curvatures and to print out the radius and muscles are included in the model. To study the center for each of the curvatures on the screen as individual effects of some of these ligaments and shown in figure 14. muscles in the spinal displacement, some of d. Spinal Displacement Study these names are coded by three letters as shown in figure 11. which is also displayed on the com- Due to the advent of cineradiography the study I 12 7 LCIJ 7 LC1 7 LCS ? SHE 7 SCA 7 RCL ? RCA ? LOC ? SCP ? set-, '? OSK '? LGA 7 STO

Fig. \2. The biomechanic model of the cervical ligaments and muscles.

\ \3 ? RAB The spinal model developed here calculates each 1 IOB vertebral position of the spine under a group of ? EOB applied muscular forces. The elasto-static equilib­ 1 PSO rium positions are computed using displacement 1 LOS matrices by either a nonlinear simultaneous equa­ ? LLG ? STO tion solver or a nonlinear optimization program, depending on whether the equations are based on a free body force and moment summation type or the principle of minimum potential energy of the spinal system. Figure 15 shows a computer graphics output generated by this system on the Tektronix screen for six different positions of a cervical spine including the skull. Inclusion of the skull enables us to study the motion pattern of the altanto-occipital joint which often becomes the center of study on the upper cervical subluxa­ tion complex. In order to study the path of each vertebra during the flexion of the cervical spine a certain number of positions were superimposed as shown in figure 16. A similar study was done on the lumbar spine with the same computer model and is shown in figure 17 for six different positions and in figure 18 for a superimposed output. 4. CONCLUSION This paper summarizes the present status of two major aspects of research on biomechanical aspects of subluxation: Development of better methods for visualizing subluxation and development of a com­ puter simulation model of the spine to understand analytically the nature of subluxation. As in medical research on the spine, there is a Fig. 13. The biomechanic model of the lumbar ligaments large body of descriptive information available and muscles. in the chiropractic literature on spinal subluxation. but few numerical or analytical relations are known. of normal and abnormal spinal motion has pro­ The computer-aided X-ray method can help doctors gressed significantly. Summaries of such studies'.!'.!,'.!3 of chiropractic obtain accurate numerical data suggest directly and indirectly that spinal disorders while at the same time supporting the development and dysfunctions are closely related to patterns of of the computer model of the spine, which is essen­ the voluntary movement of the spine. tial for systematic study of spinal subluxation.

114 15.971 1- 33.359 F~AOIU:3= 14.685 CEtffE~'. HT --9. 603 2~3. 931 + RADIUS~ CENTERAT 1t1. f179 E: 9~3.2 RADIUS= 9. 11~~

+

Fig. 14. Curvatures of vertebral column.

115 ~ \l

3rd displacement 1st displacement

Fig. 15. The displacement analysis of cervical spine. Fig. 15. (Continued)

116 Fig. 16. Superimposed displacements of cervical spine.

5th displacement

Fig. 15. (Continued)

I 17 Fig. 17. The displacement analysis of lumbar spine.

Fig. 17. (Continued)

118 10. Dawson, 13. 1-1., Dervin E., and Heywood. 0. B., "Geo ­ metrical Problems in Stereotactic Surge ry: A Three Dimensional Analysis for Use With Compu ter Tech ­ nique s," J. of/Jiomeclwnics, Vol. 3 . pp. 175 -180, 1970. 11. Kuhn , J.. "l' rotrac to rscopic and Stercoprotractorscopic Spinograph Analysis ," The Parthenon Pre ss . Nash­ ville. Tenn .. I 956. 12. Suh , C. H. , "Displaceme nt Analysis of Spinal Sys tem," 2 1 pages , Proceedings or the 4th Annual Biomechanic s Confere nce, University of Co lorad o, November 1973. 13. Suh, C. H., and Hong , S. W. , '•Co mput er Aided X-Ray Data Co rrection Method with Use or Rigid Body Conditions, " pp. 53- 126, Proceeding s of the 5th Annual Biomechanic s Confe rence , University of Colorado, December 1974. 14. Dalsania. V. , "A Mathematical Model for Elasto-stati c Systems and Application to Spi nal Analy sis."' Bio­ mechani cs Lab .. University of Co lo rad o. Boulder , Co lo. , Nove mber 1972 (51 page s). 15. Tsukatani, T., ··co mputer Graphic s or Spi ne," Bio­ mechanics Lab. , University of Co lorad o, Boulder, Co lo. , November 1972 (50 pages). I 6. Suh, C . H .. and Dal sania, V., "Computer Implementation of Spinal Discs in Biomechanical Mod els," Proceed ings of the 4th Annual Biomechanic s Conference, University of Colorado. November 1973 (49 page s). I 7. Suh , C. H .. Dal sania , V. , and Hong , S. W .. ··Program 'Spine' for So lution of Elastostatic System."' Proceeding s or the 4th Annual Hiomechanics Co nreren ce, Univer sity of Colorado , November I 973 (39 pages). Fig. 18. Superimposed displacement s or lumbar spine . I 8. Suh, C. H .. and Hong, S. W., "Computer Grap hics for Spina l Analy sis," Proceedings of the 4th Annual Bio­ REFERENCES mec hanics C onference. University of Co lorado, No­ I. Stedman's M edirnl D1ctio11ary, 22nd Edition, p. 12 I 0, vember 1973 (39 pages). The William s and Wilkin s Co., 1972. I~. Suh, C. H .. et al. , "Researching the Fundamentals of 2. Suh. C. H .. " Computer-Aided X-ray Analysis or the C hiropractic ," Pro ceedi ngs or the 5th Annual Bio­ Spine," Part I and Part II , Biomcc hanics Lab. , Uni­ mechani cs Co nrerence, University of C olorado , Decem­ versi ty of Colorado, Boulder. Colo .. November I 972 ber I 974. pp. 1-52. (29 pages & 35 page s). 20. Suh . C. 1-1.. and Kwak. Y. K., ""Initi al In ves tigation for 3. Suh, C. H., "The Funda mental s or Co mputer-Aided Three-Dim ensiona l Simu lation of the Spine as an Elasto­ X-ray Analy sis of the Spine:· Jouma/ of Biomeclwni cs, Stati c System." Proceedin gs or the 5th Annual Bio­ I 974. Vol. 7, pp. 16 I - I 69, Pergamon Pre ss. mechanic s Co nreren ce, University or Co lorad o, De­ 4. Wictorin , L.. ··Bone Resorption in Cases with Complete cember 1974 , pp. 127-196. Upper Denture. A Quantitative Rocntgenographic­ 21. Schult z. A. B., "Mechanic s of the Human Spine," Ap­ Photogrammetri e Study ."' Acta f?adiol. Suppl. 228: plied Mechanics Reviews , ASME, November 1974, 97 pp., 1964. pp. 1487- 1497. 5. Wictorin, L.. "Measurements on Roentgenographs . A 22. Fielding , .I, W .. "Cineroentgenograph y or the normal Comparison I:lctween Two Method s,"' A cta Odo mol. cervical spin e, " Joumal of Bon e and .Joint Surgery , Scam/., 24(4):5 17-53 1, I 966. 39-A: 1280-1288. December I 957. 6. Hallert. B .. "X-Ray Photogrammetry , Basic Geometry 23. How e . .I. W., ·•Cineradiographic Evaluation of Normal and and Quality."" Elsev ier Publi shing Co .. Am sterdam .. Ab normal Ce rvical Spina l Function:· Joumal of Clinical London. N ew York. 1970. Chiropractic, Arc hive s Edition 2 1972. pp. 76 - 88. 7. Dodge , H. T.. Sandler , H. , Ballew , D. H., and Lord, 24. Akima. H .. "A New Method of Interp olation and Smoot h T .. D .. "The Use or Biplan e Angiocardiography for the C urve Fitting Based on Local Procedure s," .Journal of Measurement or Lert Ventricular Volume in Man ,"" Association for Compu ting Machiner y , Vol. 17, No. 4, Am . Heart.l.,60:762, 1960. October I 970, pp. 589-602 . 8. Nelson, C. N .. and Lipchik. E. 0 .. "A Computer Method 25. Markolr. K. L .. ''Defor mation of the Thoracolumbar Inter ­ for Calculation of Left Ventricular Volume from Bi­ vertebral Join ts in Respo nse to External Load s," .Joumal plane Angiocardiogram s," In vest igative f?acliology, of /Jone and .Joint Surgery, 54-A, No. 3, 5 11- 533, Vol. l , No. 2. March-April 1966.p p. 139- 143. April 1972. 9. Lusted , L. B.. and Kea ts, T. E., "'Atlas or Roentgenograp hic 26. Suh, C. H .. "Des ign of Space Mechanism s for Rigid-Body Mea surem e nt."" Seco nd Edition. Chicago Year Book Gu idance ."./ oumal of Engineering for Indu stry, TRANS . Medical Publishers Inc. , 1967. ASME. Vol. 90, Series B. Augu st 1968. pp. 499-507 .

I 19 Discussion: Anatomical and Biomechanical Studies

JAMES H. McELHANEY Professor of Biomechanics and Director of Graduate Studies Department of Biomedical Engineering Duke University School of Engineering

The preceding four papers dealt with the me­ The first two papers presented by Ors. Drum chanical aspects of the spine from a basic science and Weis deal with the first and seventh category - point of view. This point of view was well charac­ anatomy and geometry over the life of the system. terized by Sir Isaac Newton when he said, "Unless These papers present overviews of the state of the we can assign numbers to the behavior of a system, art but are lacking in numbers. However, of all we know very little about it indeed." Galileo the papers dealing with spinal morphology, only Galilei was also a great proponent of the scien­ a relatively few offer any measurements. Lanier tific method when he said, "Measure everything (1939), Davis (I 957), Perez ( I 957), and Nachem­ that is measurable and then make measurable son ( I 960) offer limited measurements of gross some things that are not." vertebral body geometry, such as heights, diam­ I think that modern science takes a more catholic eters and cross-sectional areas. Allbrook (I 956) point of view in recognizing that measurement and Roaf ( 1960) give some information on the requires precise definition, that many words are increase in vertebral dimensions with age. Schultz needed to describe complex systems before mean­ (1974), after an exhaustive literature review, con­ ingful measurement can be made. In this context, cluded that a quantitative characterization of shape one should distinguish between the soft sciences does not appear to have been made. where verbal description suffices and the hard The external geometry of the facet and processes sciences where numerical description IS a determine to a large extent the ranges of motion. prerequisite. However, descriptions of these geometrics are The basic types of measurement that can be made also largely qualitative and those few measure­ on the spine may be classified accordingly: ments that have · been made were not complete and were not directed toward qualitative geometric I. size and shape description. It is in this area of quantification that 2. motion Dr. Suh's report of his work on precision X-ray 3. structure or load-bearing responses and computer aided spinal geometrical analysis 4. material properties assumes significance. One reason that much of 5. nerve activity human anatomy has not been quantitatively 6. chemistry described is that this is tedious and uninspiring 7. changes in responses and/or properties work. Modern computer aided photogrammetry with time offers a particularly attractive method for this 8. there are, in addition, many types of work. It appears, therefore, that many of the derived measurements that deal with problems associated with complex geometrical combinations of these basic categories. descriptions may be solved with the application 12 I

597-036 0 - 76 - 9 of existing technology. R. E. Herron of the Bio­ the most complete was reported by Sonada ( 1962). stereometrics Laboratory, Baylor College of He provides data on tensil. compression, and Medicine, recently ( 1973) used this method with torsional loads, stresses and strains of vertebral good fidelity in the Biostereometric Measurement bodies, intervertebral discs. vertebral trabecular of body form. His results are being used by the bone. and isolated annulus fibrosus material. He Department of Transportation to specify crash shows that. under static loading, except in the test dummy geometry. cervical spine, the vertebral body crushes before The state of the art or, "'how full is the glass," the disc fails. Figure 1 shows some of his results of measurements of spinal motion was sum­ in terms of stress-strain curves for vertebrae at marized by Dr. A. A. White. As Dr. White in­ various levels in the spine. dicated, there have been many studies dealing with so-called spinal kinematics. The majority of these studies assume. based on the relative stiff­ ness of the vertebral discs, ligaments and sur­ 2 rounding soft issue, that the bony elements act kg/mm as rigid bodies. An additional but frequently tacit 1.4 assumption is that the properties are time inde­ Cervical vertebra pendent. Because of the viscoelastic nature of the tissues involved. this is not true and can yield 1.2 misleading conclusions. Consider, for example, that the intervertebral discs account for approximately 1.0 a third of the length of the spinal column. The nucleus pulposus is a gel-like material which Ill creeps or changes shape under load. This can lead ; 0.8 to significant changes in facet spacing. Tempera­ ..... ture is another important variable that affects the "' material properties and thus, the kinematics of 0.6 .. free motion." This leads us to the third and fourth categories, structural and material responses. This type of 0.4 response, though of vital importance, has been neglected in the discussions so far. 0.2 In the engineering disciplines, material properties such as ultimate strength and stress-strain relations are of great importance. A designer starts with a basic building material and shapes it into a structure 0 2 4 6 8 10 with specified load and deformation responses. Contraction Since the human body exi~ts. its load and deforma­ tion responses cannot be changed. Knowledge of Fig. 1. Stress-strain curves in compression of wet vertebrae the properties of the materials of which the body of persons 20 to 39 years of age (Sonada). is composed is only useful insofar as it leads to a better understanding of the structural responses. By definition, structural responses are those load I would be remiss if I did not indicate also work and deformation characteristics that are related to done by McElhaney ( 1970). the size, shape, configuration, and material of which Based on extensive testing of cuboidal cancellous a structure is composed. Material properties in bone specimens from the femur, vertebral body and contrast are generally represented as being inde­ the cranium, a model relating the porosity, distribu­ pendent of the structure or shape of the material tion to the strength and modulus was developed. under consideration. Figure 2 shows typical stress-strain curves for There have been a variety of studies of the load­ various bone types in compression. Tests results deformation properties of spinal elements. One of from 72 donors are given in the following table. 122 TABLE I

Density #/in:i No. of No. of Age range Mean Standard donors specimens deviation

Femur 32 160 28-86 yrs. 0.067 0.027 Vertebral Body 72 288 I mo.-89 yrs. 0.017 0.007 Cranium Full Section 14 240 56-73 yrs. 0.051 0.019 Cranium Compacta 7 27 56-73 yrs. 0.068 0.007

Modulus #/in 2

Femur Long Axis 32 160 28-86 yrs. 1.84 X I 0 6 0.4 X 106 Vertebral Body 72 288 I mo.-89 yrs. 0.22 X 105 0.17 X 105 Cranium Full Section Radial 26 237 39-81 yrs. 3.5Xl0 5 2.1 X 105 Tangential 14 219 56-73 yrs. 8.1 X 10" 4.4 X 105 Cranium Compacta 7 27 56-73 yrs. I.81Xl0 6 0.6X 106

Ultimate Strength #/in 2

Femur Long Axis 32 160 28-86 yrs. 2.6 X 10:1 6.1 X 103 Vertebral Body 72 288 I mo.-89 yrs. 0.6 X 103 0.5 X 10:1 Cranium Full Section Radial 26 237 39-81 yrs. 10.7 X 10:1 5.1 X 10:i Tangential 14 210 56- 73 yrs. 14 X 10:1 5.2 X )():! Cranium Compacta 7 27 56-73 yrs. 20.9 X 10:i 6.8 X 10:i

Poisson's Ratio

Femur Long Axis 7 28 37-86 yrs. 0.3 0.06 Vertebral Body 7 28 45- 79 yrs. 0.14 0.09 Cranium Full Section Radial 14 122 56-73 yrs. 0.19 0.08 Tangential 18 327 56-81 yrs. 0.22 0.11 Cranium Compacta 7 27 56- 73 yrs. 0.28 0.04

The vertebral bodies in figure 3 were generally following linear regression equations were taken at autopsy in the lumbar region at L'.!.,La, obtained: 6 ~. and 4,. A variety of specimen sizes were tested E (3-0.023) X 10 ; C 0.61 unembalmed, ranging from the whole body with the processes removed down to one-fourth inch cubes. 0 (300-5.9) X I o:i; Cc 0.67 The vertebral body properties also correlated

2 well with the dry weight density (figure 4). The 0 (3.2 X 10- ) E; Cc 0.71

123 25,000 ...... 11•£U l!Cl!SSIO• 0.9 VIU(UII L !ODIIS 20,000 "'t oo.a -~ 15,000 Tangential Cranial t/l .,, 0.7 wt/l ::::::, a: Radial .... ti; 10,000 ::::::, ------Cranial 0.6 =Q :IE 5,000 ....= 0.5 Vertebrae ...... 0 .4 0 10 20 30 40 50 60 70 80 C :IE 0.3 STRAIN x 10"' cc Q z: Fig. 2. Typica l stress-strain curves for human bone in 0.2 comp ression . 0.1

0 0 10 20 10 40 so 60 10 ao ,o 100 POROSITY%

Fig. 4. Porou s block model responses.

,000

"c aoo -:::.•

Fig. 3. Vertebral body specimen.

400 where

E = .Modulus of elasticity (PSI) = Density (pound per cubic inch) = Ult imate Strengt h (PSI) Cc= Corre lation Coefficient Fig. 5. Strength-aging characteristi cs of the human vertebral body. The vertebra l body data also show a strong linear corre lation between modulu s and strength , indicating that a maximum strai n theory of failure of ver1ebral bone corre lated at the 0.52 level applied also to ca ncellous bone from the vertebrae (figure 5). with a maximum failure strain_of 3.2 x I 0 - 2 • These Many of the mechanical responses of cancellous regre ssion equations give approximately valid bone are strongly influenced by the structural results for dry weight densitie s between 0.022 arrangement of the trabeculae . Thus, in these and 0.0 IO pound per cubic inch. tests, properties, such as compressive stre ngth While no significant correlation of the femora l and modulus , are structural properties, and the or cranial bone was found with age, the strength large values of the standard deviation s observed for 124 these properties are primarily due to variations in load sharing was linear in the range tested. the porosity and internal arrangement of the No one has yet assigned numbers to the pressure trabeculae. The similarities of the properties and buildup in the marrow spaces of cancellous bone histology of compact bone indicates that a single as it deforms under load but it is known that it material porous block model is justified as a first happens. approximation in describing the relation between Axial force-deflection properties of intervertebral structure and mechanical response. Relating the discs have been reported by several investigators. value of a property to the density raised to some Virgin (I 951) tested single discs attached to thin power n and then determining n empirically pro­ slices of their inferior ~nd superior vertebrae in vides a means of incorporating in the model many compression. He presented load-deflection curves of the structural elements that influence the which exhibited various degrees of nonlinear response but are too complex to be included in behavior, and report(?d that the intervertebral discs detail. The porous block model is, therefore, behave visco-elastically. complex enough to explain much of the property Brown (I 959) et al., conducted axial compres­ variation observed but much too simple to explain sion tests on fresh vertebra-disc-vertebra segments the mechanisms involved. The model shows that of the lumbrosacral spine with the posterior the modulus of bone is approximately proportional elements removed. to the third power of the density. Thus, small Ro lander ( 1966) performed a series of mechan­ porosity changes in bone of low relative density ical tests on lumbar discs and by macroscopic result in only small changes in strength and mod­ examination classified the excised discs according ulus, while small porosity changes in bone of high to degree of degeneration. A comparison between relative density result in large changes in strength compression responses of normal and degenerate and modulus. The porosity distribution in a given discs shows a significant difference in behavior: sample of bone is much more significant in its For equal load levels, the degenerate discs deflect effect on strength and modulus in bone of low much more than the normal discs. relative density than in bone of high relative Markolf ( 1972) conducted axial compression and density. Of interest is the fact that the homogeneous tension tests, among other tests, on thoracolumbar version of this model fits much of Coble's data discs. His results indicate that there are significant ( 1956) on various porous ceramics, indicating that differences in behavior betweeFl lumbar and bone is not unique in its response to porosity thoracic discs. In addition, each disc shows variations. differences in response between tensile and com­ The material properties in the small, i.e., hard­ pressive loading. Markolf also reported that ness, density, and local compression strength intervertebral discs behave visco-elastically. of various bone types, are not significantly dif­ Galante ( 1972) experimentally established that ferent. The amount and distribution of the tra­ the annulus fibrosis is inhomogeneous and ani­ beculae, however, is quite variable, and, there­ sotropic, and that it exhibits hardening stress­ fore, the structural responses, in particular the strain characteristics. energy absorption, gross stiffness, and damping Kulak (1974) proposed a nonlinear stress-strain characteristics, which are strongly dependent on relation representing the behavior of annular structure, will vary greatly. The properties of the material. Incorporation of the relation into an intervertebral disc have been studied from a existing finite element model yields results which variety of viewpoints. Since the disc is an essential are in good agreement with available experimental element in supporting the body and in permitting results, such as radial bulging, nuclear pressure, the mobility of the bony elements, its mechanical and level-to-level variations. responses are important factors in spinal manip­ These studies (Kulak et al. 1974) have shown the ulative therapy. Hakim (1974) showed from importance of including the nonlinear material in vitro static loading of a spinal element that the behavior in the analysis of the mechanical function disc supported 7 5 to 80 percent of the load at the of soft tissue structures, such as the disc. Although L3 level while the articular facet supported 20 a basic understanding can often be gained with less to 25 percent of the load. In addition, in his studies complex linear models, the predictive value of on three embalmed cadavers, he indicated that the linear models is severely limited because they are 125 Fig. 6. Bone remodeling in response to load. restricted to small load ranges. This is illustrated the bone spaces are narrowed. Just the opposite by the marked differences in the response to occurs on the other side which is relati vely un­ tension and compression and in the case of a void loaded. The trabe cu lae are resorbed. The y become nucleus. Thus , the analysis of the intervertebral thinner and fewer and the marrow spaces wider disc over the norm al in vivo range of loading than norm al. Thus, the bone tries to minimize the require s the inclusion of nonlinear material eccentricity by shifting its center of mass toward behavior. the load axis through se lective deposition and The role of the ligaments in maintaining proper resorption. There are, of course , severe limita­ relations between the bony elements of the spine tions in that the external shape and dimension can is easily demon strated but poorly understood. The be changed very little , so that the remodeling is amount of prestre ssi ng on other structural prop­ primarily confined to the interior. erties is difficult to mea sure in vitro. The literature Associated with stresses in bone is an electric in this area is sparse. field , thought to be piezoelectric in nature. Labora­ tory experiment s demon strate that electric fields Two most important aspects which have . re­ and currents do influence bone growt h. However. ceived little attention are: much research is needed before this phenomenon I. The role of load directed grow th in can be used in therapy. the spine Perhaps the most important measurements that 2. The relation between deformation and co nceivably co uld be made involve the last two neurophy siology. categories. Very little is known abo ut the effect of To demonstrate: consider figure 5 from Weinmann load and deformation on nerve function and metab­ and Sicher ( I 955). They observed that lack of olism. Is incre ased nervou s activity a direct result function leads to loss of bone tissue or osteoporosis of pres sure or shear , or tension ? Or is it related to while increased function leads to the formation metabolic changes that occur over time? Are these of more than the normal amount of bone or effects reversible? What is the nature of pain from osteosclerosis. This can be see n in kyphosis , mechanical trauma? We could fill pages with such wherein certain vertebrae are unevenly stressed . que stions. Our greatest hop e for the answers lies One side of the vertebrae may be under increased in modern technology which · is providing con­ compression while the other may be relieved of sta ntly improving measurement techniques. any load and, in fact , may be in tension. In the part I would like to close with this metaphor. Birds of the vertebra which is under increased compres­ and bees know well how to fly without knowing sion, the number of the trabeculae is increased and anything abou t aerody namics or biomechanics , each one is thicker than normal. As a consequence , but it took man centuries of careful research , study 126 and analysis before he too could fly. The basic J. 0. ( 1974), "Nonlinear Behavior of the Human Inter­ sciences tell much about manipulative therapy. In vertebral Disc Under Axial Load." ASME Paper No. 74- particular. they tell us many thing~ it cannot do. It WA/810-3. Lanier, R. ( 1939), "The presacral vertebrae of American White remains for science to document and detail the and Negro Males," Am. J. Phys. A11throp. 25, 341-420. many things manipulative therapy can do. Markolf, K. L., "Deformation of the Thoracolumbar Inter­ vertebral Joints in Response to External Loads,'' J. Bone Jt. REFERENCES Surg .. Vol. 54A, No. 3, April I 972, 511-533. Allbrook, D. ( 1956), "Changes in lumbar vertehral body height McElhaney, J. H., Alem, N., and Roberts, V. ( 1970), "A Porous with age," Amer. J. Phys. Anthrop. 14, 35-39. Block Model for Cancellous Bones." ASME Paper No. Belytschko, T., Kulak, R. F., Schultz, A. B.. and Galante, J. 0 .• 70-WA/BHF-2. "Finite Element Stress Analysis of an Intervertebral Disc." N achemson. A. ( I 960), "Lumbar I ntradiscal Pressure," A eta .I. of Biomeclw11ics, Vol. 7. Orthrop. Scand. Suppl. 43 . Brown, T., Hansen, R. J., and Yorra, A. J., "Some Mechanical Perez, 0. ( I 957), "Fracture of the vertebral end-plate in the Tests on the Lumbo-Sacral Spine with Particular Reference lumbar spine," Acta Orthrop. Sca11d. Suppl. 25. to the lntervertebral Disc."J. BoneJt. Surg. Vol. 39A. No. 5. Roaf, R. ( 1960), "Vertebral growth and its mechanical con­ October 1959, 1135-1164. trol,'' J. of Bone a11dJoint Surg. 428, 40-59. Davis, P. ( 1957), "Studies on the functional anatomy of the Rolander. Svante D., "Motion of the Lumbar Spine with human vertebral column with special reference to the thoracic Special Reference to the Stabilizing Effect of Posterior and lumbar regions." Ph. D. thesis, University of London. Fusion," Acta Orthop. Scand., Suppl. 90. Galante, J. 0., "Tensile Properties of the Human Lumbar Schultz, A. B. ( 1974), "Mechanics of the Human Spine,'' Annulus Fibrosis." Acta Ortlwp. Scand., Suppl. I 00. I 972. Applied Mechanics Reviews, 1487-1497. Hakim, N. S., and King, A. I., ( 1974), 'The Load-Bearing Role Sonoda, T. ( 1962), "Studies on the Strength for Compression, of Articular Facets During Static Loading of a Spinal Tension and Torsion of the Human Vertebral Column," Column." Advances in Bioe11gi11eeringPuh. ASME. (in Japanese, with English summary) J. Kyoto Pref. Med. Haut, R. C., and Little, R. W., "A Constitutive Equation for Unfr. 71. 659- 702. Collagen Fibers." J. Biomeclw11ics. Vol. 5, No. 5, I 972. Virgin, W. J., "Experimental Investigations into the Physical 423-430. Properties of the lntervertebral Disc." ./. B011e Jt. Surg., Herron, R. E. ( 1973 ), "Biostereometric Measurement of Body Vol. 33b, No. 4, November 1951, 607-61 I. Form."./. Amer. Assn. of Physical Anthropology. Vol. I 6. Weinmann, J. R., and Sicher, H. ( 1955), Bone and Bones, Kulak, R. F., Belytschko, T. B., Schultz, A. B., and Galante, C. V. Mosby Co., St. Louis, Mo. Pub.

127 Anatomical Perivertebral Influences on the lntervertebral Foramen

SYDNEY SUNDERLAND Department of Experimental Neurology University of Melbourne . Australia

Of the many anatomical perivertebral influen ces OPEN l EPIDURAL on the intervertebral foramen , those of particular CONDENSED TISSUE relevance to the subject under scrutiny concern the joints directly related to the foramina and the nerves in the vicinity. This contribution to the statu s of spinal manipulative therapy is devoted to a con sideration of these matters. While confirm­ ing constriction of the foramen as a cause of nerve involvement , attention will be directed to the posterior vertebr al joints as a less well-recognized potential site of trouble so me pathology involvin g nerve pathways. Fig. I. The nerve comp lex and its meningeal cove rings in I. THE SPINAL NERVE ROOTS AND the intervertcbral foramen. The arrangement is not to sca le and SPINAL NERVE IN RELATION TO THE has been drawn to accent uate relative relation ships. INTERVERTEBRAL FORAMEN the surface of the dura is continuous with the Opposite the foramen each pair of anterior and epineurium of the spinal nerve. The formation of posterior nerve root s invaginate the dur a and this perineurial-epineurial sheath adds to the · arac hnoid to form a funnel-shaped depression at . thickne ss of the spinal nerve so that its cross- the bottom of which each perforates the meninges sec tional area exceeds the combined cross -sectional independently carrying with it, as it doe s so, an areas of the nerve roots from which it is formed. individu al and separate bilaminar sleeve of dura The nerve roots , posterior root ganglion and and arachnoid (fig_!Jre I). The extension of the spinal nerve together with their connective tissue subarachnoid space formed in this way is continued coverings will , henceforth, be referred to as the along the nerve roots usually as far as the ganglion, nerv e complex. occasionally to involve its inner pole but never to (i) Th e numb er and localizat ion of sensory and envelop it completely. The dural layer is continued mot or fibers in the nerve comp lex. The posterior along the nerve roots for a short distance before nerve root is thicker than the corresponding finally blending with the anterior root and the anterior · root by a factor of three in the cervical ganglion to form an outer fibrous sheath for the se nerve roots, 1.5 in the thoracic and two in the structures. This connective tissue is continued out­ lumbar . 1 • 2 The two- root s remain separate as far wards to become the strong perineurial sheath as the ganglion and so may be selectively involved of the single bundle of nerve fibers of the spinal in pathological processes central to thi s level. ln nerve formed by the fusion of the two root s. The the spinal nerve , immediately distal to the ganglion, · somewhat condensed layer of epidural tis sue on the nerve fibers are contained in a single funiculus 129 in which the motor fibers are concentrated antero­ and the periosteal linin g of th e foramen. Thi s inferiorly (figure 2). In the case of the e ighth cer ­ space is occupied by loo se areo lar connective vica l to the seco nd lumbar nerve s and the second , an d adipose tissue containing the sp inal artery. third and fourth sac ral nerve s , these motor fibers and its a nterior and posterior branches, with include sy mpathetic (C8 - L2) and parasympathetic numerous ve ins which often surround the comp lex. (S2, 3, 4) e lements . Within a fe w millim eter s th e lymp hati cs and the recurrent meningeal nerve. single funiculu s of nerve fiber s divides into several (iii) The position of the neurol compl ex in the bundles which engage in ple xus formations. This i11terver1ebraljorame11. The first cervical root is effects the first mixing of sensory and motor aligned horizont ally while the rem ainin g roots are fibers. directed dow nw ards with gradually increas ing ob liquit y until th e lum bar and sacral roots descend ver ticall y before reaching th eir re spective foramina. The usual arr ange ment is for the ner ve roots to pass throu gh th e dura , ensheathed in th eir menin-

2

2

. 3

3 4 Fii.:. 3. Diagram illustrating variations in the position occupied Fig. 2. Transver se sect ions across the nerve complex. il­ by the nerve complex in the foramen. For simplification the lustrating the transition from nerve roots, enclosed in their complex has been represented as a single bundle. separate bilaminar sheaths. 10 the formation of the single funicu­ lus of the spinal nerve and its division into several funiculi (not gea l sleeves , opposite the corresponding foramen to scale). The only attachment of the nerve complex to bone is in the cervical region where the spinal nerve is adherent to the so th at the neural co mple x occ upi es a centra l posi­ gutter of the transverse process. S=s ensory fibers: M= motor tion on ente rin g the foramen (figure 3). Variation s fibers. in the leve l at which thi s occurs may bring the nerve roots close r to the upp er or lowe r mar gin of the (ii) The cross- se ctional area of the fora111en foramen; in the case of the ob liqu ely and vertically occupied by the nerl'e complex. Values given in aligned roots an increasingly superior position on the literature for the space occupied by the nerv e entry is favored , the comp lex becoming incre as ­ vary from IO to 50 percent ; -s th ough it is not clear ing ly oblique ly a ligned in the foraminal canal. from the se acco unt s whether the term " nerve" However, in the lower cervica l and upp er thora cic included or exc luded the investing shea th . More region s , it is common for th e ner ve root s to descend recent observations for nerve and shea th gave intradurall y to a level wh ich may be as much as values of 35 to 50 percent.H The significa nt point 8 millim eter s be low th e foramen which th ey are to 11 1 is that th ere is a mple space between the complex enter . 1-2 They th en perforate the dura in th e 130 usual way but must ascend acutely, enclosed in on its initial length, short nerve roots suffering their dural sleeves, in order to reach the foramen earlier and failing structurally before long roots. 33 over the lower margin of which they are again Nerve roots range in length from IO to 168 milli­ angulated as they pass outwards. Such angulated meters, the shortest being the cervical roots and nerve roots occur in about 40 percent of cases the longest the sacral. 32 In addition, the long roots under the age of 25 years: between 25 and 40 the are slacker in the spinal canal. incidence increases to from 71 percent 18 to 76 Two anatomical features protect nerve roots percent.:! 1 from being overstretched. One concerns the ar­ Finally the position of the complex in the rangement of the dura at the entrance to the foramen changes with movements of the head and foramen and the other the attachment of certain neck. With ventroflexion the nerve roots are of the cervical spinal nerves to the vertebral tensed and the complex is drawn inwards and transverse processes. upwards toward the upper margin of the foramen: (i) The arrangement of the dura. Because the in dorsal extension the complex is relaxed and dural sheath of connective tissue becomes adherent returns to its original position. u;, :!:!-:!7 The nerve to and part of the nerve complex laterally, traction roots maximally involved in this way are the on the spinal nerve pulls the entire system outwards eighth cervical to the fifth thoracic,:!8 but ventro­ so that the dural funnel is also drawn laterally into flexion of the cervical spine also tenses the lumbar the foramen and, being cone-shaped, plugs the and sacral nerve roots.:!4 ,:w.3o foramen in such a way as to resist further disloca­ tion of the nerve laterally (figure 4). Thus the 2. THE MOBILITY OF THE NERVE COMPLEX IN THE INTERVERTEBRAL FORAMEN The nerve complex is not attached to the wall of the foramen, the arrangement permitting it to move within and through the foramen. 11 There is abundant evidence, dating from Dana's observa­ tions reported in 1882 down to the present time, 3:! that traction on peripheral nerves tenses nerve roots. Reference has already been made to the ten­ sion developed in the nerve roots and the displacement inwards of the complex with ventro­ flexion of the head and cervical spine. The elastic properties of the nerve roots allow them to accommodate to the tension generated in this way though there are limits to this elasticity. It is important that the roots lack the tensile strength of peripheral nerves for it has been shown that under increasing tension nerve roots fail before peripheral nerves.:i:i The greater vulnerability of nerve roots to traction deformation is due to structural differences. In nerve roots the nerve fibers are arranged in parallel bundles, each fiber being enveloped in an endoneurial sheath in which the collagen fibers are fewer and finer than those surrounding nerve fibers in peripheral nerve I•'ig. 4. Diagram showing the manner in which nerve roots trunks.: 14 Nerve roots also lack a protective are protected from being overstretched during lateral traction epineurial and perineurial connective tissue sheath on the spinal nerve. Lateral displacement of the nerve complex which gives added tensile strength to the peripheral is limited because of the attachments of the spinal nerve to the cervical transverse process and subsequently, and where no nerve. such attachments exist, by the plugging action of the dural The extent to which a nerve root can be stretched funnel as it is drawn into the foramen. For simplification, only before structural failure occurs depends, inter alia, one dorsal rootlet is shown. 131 strength and integrity of the system are due, not to whereas the incidence of avulsion injuries is much any strong meningeal attachment to the foramen , higher in the case of the lower nerve roots , which , but to the continuity of the nerve sheath with the anatomically, are at greater risk. 35 dural sac.9 Such protective attachments are not needed for (ii) Attachments of the spinal nerves. During the the other spinal nerves. wide range of movements occurring at the cervical spine, shoulder girdle, and shoulder joint , additional 3. THE NERVE COMPLEX AND THE strains are generated which fall maximally on the POSTERIOR VERTEBRAL JOINT SYSTEM upper spinal nerves forming the brachial plexus which , if transmitted directly to the corresponding Cervical Re gion. The first and second cervical short cervical nerve roots , would expose them to spinal nerves are unusual in that they leave the traction injury. In order to protect the roots against spinal canal behind the joint (figure 8). The first­ such injuries, the fourth, fifth , sixth , and seventh occupies a groove on the upper surface of the cervical nerves are securely attached to the posterior arch of the atlas where it is behind and vertebral column. Each, on leaving the foramen , is a little below the capsule of the atlanto-occipital immediately lodged in the gutter of the transverse joint and beneath the vertebral artery . In this process to which it is securely bound by its situation the nerve and the vessel traverse an epineurial sheath , by reflections of the prevertebral osseo-fibrous foramen outlined by the bony arch fascia , by slips from the musculo-tendinous attach­ and the lower border of the posterior atlanto­ ments to the transverse processes and by fibrous occipital ligament. The second cervical nerve slips that descend from the transverse process crosses the arch of the axis immediately behind above to blend with the epineurium of the nerve and in contact with the capsule of the lateral below (figures 2, 5, o). The nerve is also held back­ atlanto-axial joint. Here it leaves the spinal canal wards against the posterior bony bar of the trans­ through a small osseo-fibrous opening formed by verse process by the vertebral artery whose a deficiency in the bony attach~ent of the liga­ adventitial coat blends with the sheath of the nerve mentum flavum. (figure 7). The full significance of this arrangement In the case of the third to the seventh spinal emerges when the relative susceptibility to avulsion nerves the nerve complex is lodged in the gutter injury of the several nerve roots contributing to the formed by the articular pillar posteriorly , the brachia! plexus is examined. Traction injuries , pedicle of the subjacent vertebra and the extension which do not avulse nerve roots , more commonly upwards of the crested lateral lip (processus involve the upper spinal nerves of the plexus uncinatus) of the vertebral body anteriorly (figures

Figs. 5 and 6. Diagrams ofcervical vertebrae illustrating the boundaries of the intervertebral foramen, the formation and depth of the gutter of the transverse proces s and the relationship of the nerve roots and spinal nerve to these anatomical features. The apophyseal joint is above and behind the nerve complex. It can also be seen that any reduction in the distance between adjacent vertebral bodies can not alter the vertical diameter of the foramen but results in tilting which would stretch the joint capsule. 132 5, 6, 7). Th e foramen is co mpleted super iorly by Beca use of the dispo sition of the verteb ral joint , the pedicle of the ve rtebr a above. Th e eighth any red uctio n in the thickness of the disc wou ld cerv ical nerve emerges from the foramen betwee n have little , if any, effec t on the vertica l diameter the last cervica l and first thorac ic ve rtebrae and of the foramen. Th e caps ule , however , would be then desce nds to unit e with the first thorac ic nerve nipp ed betwee n the superior margin of the articular anterio r to the nec k of the first rib. face t be low and the pedicle of the ver tebra above Th e loose jo int ca psule of the arti cular pillar while tiltin g of the ve rtebr a l body wo uld stretc h is locate d postero -supe riorly with , further medially, the poste rior part of the caps ule of the joi nt. the lateral margin of the ligamentum flavu m (figure Thoracic R egion. Here the loose capsu le of the 6). T he intervertebra l disc and the neuro-ce ntra l apop hysea l jo int is be hind the nerve co mplex joi nt space, if such ex ists, form the antero-s uperior with, further media lly, the latera l margin of the boundary of the fora men. ligamentum flav um. H oweve r , the leve l of the jo int with reference to the com plex varies. In the upper thorac ic region it is situ ated pos tero­ superiorly as in the cer vical region. It then grad ually moves dow n the pos terior wa ll of the fora men until it is finally loca ted postero-i nferior ly as in the lum ba r region. Th e interve rtebra l disc forms the

Fig. 7. Diagra m to illustra te the manner in which the spina l Fig. 8. D iagram illustrat ing the cou rse of the first a nd nerve is forced against th e posterio r bony bar of the tra nsve rse seco nd ce rvica l spina l nerves, and the ir primary rami , in rela­ proce ss by the vertebra l artery. tion to the atlas and the ax is.

133 antero-inferior mar gin of the foramen (figu re 9). Nar row ing of the disc would re sult in sublux ation of th e joint and a reduction in the ve rtica l diameter of th e foramen.

Fig. 10. Diag ram illustrating the relation ship o r nerve roo ts to the inter vertebral discs as they desce nd in the spinal cana l Fig. 9. Diagram illustrat ing th e formation of the boundari es to rea ch their res pectiv e foramina . The nerve leave s the foram cn of a typica l thorac ic inte rve rtebra l fora men. The apophy sea l pro ximal to the disc form ing its lower anter ior bo und ary but j oint is behind the nerve comp lex. is direct ly related to th e disc above.

co mpl ex which are mos t intim ately related to th e Lumbar R egion. As they de sc end in the sp inal j oint. cana l, the lumb ar nerve roots cross the dis c imm edi ately above th e foramen th rough which 4. CHANGES RES U LTIN G IN A RE- they are to leave the spinal ca nal (figure I 0). Th ey DU CT ION IN THE DIM ENSION S OF TH E then enter th e for amen beneath th e pedicle form ing FO RAM EN its upper margin wi th the liga mentum flavum posterior and th e body of the ver teb ra anteri or I. Th e fora mina are narro we d in do rsa l exte nsion (ligur e 11). As th e nerv e complex incline s down­ of th e sp ine and are widened dur ing ve ntro ­ wards, outwards and forward s, th e spinal nerve flexion :1- 7• 15· ~!,, :rn cros ses the ant erior aspec t of the join t, but , by the 2. Whil e co nges tion of th e many vein s in th e tim e it is at the leve l of the dis c, it has emerg ed from foramen wou ld red uce th e free space ava ilable , the foramen to pass, with the exception of the fifth , th e profu se ve nous anastomotic netw or k chara c­ between the slips of orig in of th e psoas to enter th e terizing th e vertebra l venou s sys tem makes such a substan ce of that mu scle . co mpli cat io n unlik ely. Narrowing of the intervert ebra l disc wou ld lead 3. Pathological change s affec ting th e inter­ to sublux ation of the joint so th at th e superior vertebral disc wh ich redu ce the dimensions of th e arti cular process of th e subjacent vertebra wou ld foramen includ e: mov e upw ard s tow ard the pedicl e of th e vertebra (i) narrow ing of th e di sc wh ich, in above , th ereby encroaching on th at part of th e turn , fora men co nt ainin g th e nerve. (a) bring s th e ped ic les toge th er and so Summari zing , th e apophyse al j o int is behind and redu ces th e vert ica l diameter of th e above the ner ve co mpl ex in th e cerv ica l region , foramen : directly behind it in th e mid-th orac ic regio n and (b) res ult s in subluxa tion of th e apophy ­ behind and be low it in th e lum bar reg ion. It should seal joint with stretchin g of th e caps ule also be noted th at it is the se nso ry fibr es of th e and other joint changes: 134 (c) leads to folding of the ligamentum (i) jo int swe lling. Injec ting sa line into navum which may bulge sufficie ntl y far " the joint ca psule" narrows the foramen forwards to encro ac h on the entran ce to by 2 millimetersY the fora men. (ii) osteoph yte forma tion. (ii) herniation of the disc and osteo phyte 6. T he anatomy of the foramen and its content s formation invol ving the vert ebral rim , both suggests that the reduction in the dimensions of of which encro ac h on th e foramen the foramen would need to be co nsidera ble be fore anteri orly. the nerve co mplex would be co mpr esse d. More­ ove r, nerve tiss ue tolerat es slow compr ess ion reaso nabl y well. Th e arrange ment favo rs fricti on fibros is and the formation of adhes ions, indu ced by the repea ted movement of the nerve co mplex ove r or aga inst periforaminal pathol ogy of th e typ e outlin ed abo ve, as a mor e like ly ca use of nerve invo lve ment and the deve lopment of symptom s.

5. T HE BRAN C HES OF TH E SPINAL NE RV ES IN R E LATION TO THE PO S­ T ERIOR VE RT E BRAL JOINT S First and seco nd cervical nerves. Eac h gives a recurr ent mening ea l branch for the dur a before di viding into ve nt ra l and dorsal ra mi. In eac h case the ventral ramu s, on its wa y to a prev ertebr a l position (figure 8), curves anteriorl y und er th e over­ hanging rim of the latera l mass of the verteb ra and ac ross the base of its tran sve rse pro cess where it is immedi ately below the lateral surface of the capsule of the neighbourin g joint whi ch it inne rva tes. Th e do rsa l ramu s of the first nerve has no cutan eou s distribution but provid es a sen sor y innervation to th e atlant o-occ ipital joint , the ligament s of the region and th e suboccipit al musc les for which it also provid es a motor supply . The dorsa l ra mu s of th e seco nd nerve is th e larges t dor sal ramu s of the spin al seri es. It carrie s so me motor but mos tly sensor y fibers and divides Fig. 11. Diagra m illustratin g the passage or the lumbar into a small lateral and large medial bran ch. which , nerve thro ugh the upper part of th e fora men where it is beh ind after a circuitous co urse as the gre ater occipit al the verteb ral body and im mediate ly be low its ped iclc. T he nerve, pierce s the se mispinali s and th en the co urse or th e dorsa l ramu s ac ro ss th e late ral sur face orth e ar ticular process is also show n alo ng with the pas sage of th e tra pezius musc le at its att achment to the skull medial br anch or th e ra mus th ro ugh a tunnel be nea th the where it trav erses a tendinou s tunn el or pass es ligamen tous tiss ue joi ning th e ma millary and acce sso ry proc­ und er a tendin ous arcade to bec om e cut aneou s. esses-on ly the latera l fibe rs of this ligamcnt o us arch arc shown. Th e remainin g spin al nerves. Imm ediately on emerging from the fora men each spinal nerve gives 4. Patho logica l thickenin g of the liga mentum a rec urr ent me ningea l branch whic h passes bac k tlavum produc ing the sa me effec t as in 3(i)c. throu gh th e foram e n to be distribut ed to the du ra, 5. -Patholo gical cha nges involvin g the apophyseal the interverteb ral disc and assoc iated stru cture s. joint whic h e ncroach on th e foram en from behind Th e spinal nerve termin ates after a co urse of are: a few millimeters by dividing into ventr al and dorsa l 135 rami ; with the exception of the upper cervical fibrou s tunnel by the posterior inter-tran sverse nerves , the ventral are larger than the dor sal. ligament and muscle. On emerging from the tunnel The ventral rami are directed outwards away the ramu s gives branche s to the vertebral joint from the vertebral column. Juxtavertebral branches above and be low. On its way posteriorly the eighth are the sympathetic grey rami to each branch and ramus cro sses and grooves the upper surface of the white sy mpathetic rami of the eighth cervical the first rib. It then establi shes a relation with to the second lumbar nerves de stined for the the vertebral joint which is essentially the same ganglionated sympathetic chain and those from the as that to be de scribed for the thoracic nerve s. seco nd, third , and fourth sacral nerve s for para­ Each ramu s terminate s behind the articular sympathetic ganglia in the pelvi s. pillar by dividing into a larger medial and smaller On its way to the posterior compartment of the lateral divisions. Both se nd branch es to ligament s back, each posterior ramus is accompa nied by and muscles . In addition, the medial provide s an artery and its associated vein to form a neuro­ furthertwig s to the joint before becoming cutaneou s vascular bundle. Thi s bundle and the medial and just later al to the midline to inne rvate the skin ; lateral branches into which it divide s establish cutaneous fibers may be absent from the lower important relation s with the apoph ysea l joint cervical rami. sys tem which merit further attention. Th e thoracic dorsal rami. The nerve passe s backward s across the apophy seal joint to enter 6. THE DORSAL RAMI a roomy osseo-fibrous opening forme d medially by the apop hysis, superiorly by the tran sverse The cervical dorsal rami. These diminish rapidly process , inferiorl y by the neck of the rib and the in siz~ from above downw ard s (figure 12). The first upper border of the subjace nt transverse process, two have already been described. Those of the and laterall y by the superior costo-transverse and third to the seven th cervical nerve s cross the intertransverse ligaments and the intertran sverse latera l surface of the articular pillar which is muscle. In its course the nerve is in contact with grooved to carry the nerve and an acco mpanyi ng the joint capsu le to which it sends branches. artery , the groove being converted into an osseo- Posteriorly the nerve curves mediall y for a short distance before dividing into medi al and lateral branches. The medial continues inward s and downward s to give articular , muscu lar , ligamentous and , in the case of the upper thoracic nerve s, cutaneous branches. The lateral branch run s outwards between the laye rs of the superior costo-transverse ligament to reach and innervate the deep muscle s of the back: tho se of the lower thora cic nerves also ha ve a cutaneou s distribu tion . The twe(trh thoracic and lumbar dorsal rami (figures I I , 13, 14). The dorsal ram us runs down­ ward s and backwards across the lateral surface of the adjacent superior articular proces s from a point immediately above and anterior to the vertebral joint , to which it gives twigs, to reach and cross the upp er surfa ce of the base of the transverse process . The nerve , with an accompanyi ng· artery , enters the posterior co mpartment of the back by passing throu gh a large oval foram en ( 15 mm x 4 mm) out­ lined laterall y by the curved concave inner edge of the intertra nsve rse ligament and medially by the articular proces ses . On ente ring the com partment Fig. 12. Diagram illustrating the co urse of the ce rvical the ramus divides into medial and late ral divisions dorsal rami in relation to the articular pillar s. The rami dimini sh as do the accompanying vesse ls. Th e site of this in size from above downward s. bran ching is rea dily located on the tra nsverse 136 proc ess at the bottom of a co nnective tissue plane between the multifidus muscle mediall y and the longissimus group latera lly (figure 14). Th e finer medial branch , so mewh at less than I millimeter in diameter , contin ues freely before ente ring the groove betw ee n the acces sory and mammill ary processe s beyond which it curves medially following the lower border of the joint. In the groove and over this infra-articular section , the neurovascul ar bundle is covered and tightly bound to bone by exceedingly dense tissue formed by fibrous extensions from the capsu le of the joint , the intertran sver se ligame nt and the tend inous attachments of the longis simus thoraci s, multifidu s, rot atores, and medial intertransver se muscles. Peder se n, Blunck and Gardner 38 refer , in passing, to a co nnectiv e tissue cov ering for the nerve at this site but make no mention of either its thickne ss or den sity or to the nerv e being confined in an osseo-fibrous tunnel. Aft er a course of about I cent imeter in thi s tunnel , the nerve emerges to pass on to the lamina. It se nds branches upw ards before

Fig. 13. Diagr am illustrating the co urse or two lumbar turnin g downwards to descend for so me distance , dorsal rami and their branch es. The medial bra nch passes branching as it doe s so to form an openly arranged through an osseofibrous tunnel outlined by the ligamcntou s and plexu s along with cor respond ing branche s of neigh­ musculot endinou s tiss ue arching betwee n the mamillary and boring rami. Th e media l branch innervates liga­ accesso ry proc ess es. ment s and musc les medi al to the line of the vertebra l joints, while the joint itse lf is rich ly supp lied by multipl e articu lar twigs from both the parent ramus and its media l branch. In the curved transver se sec tion of its cour se the medi al bran ch also sends twigs downwards to the capsule of the joint be low. The larger latera l bran ch , 1.5 millimeter in diameter, passes outwards and down.wards to innervate musc les and ligament s latera l to the line of the vertebra l joints . In the case of the 12th thoracic and upper three lum bar nerve s the lateral branch descend s thro ugh muscle to pierce the lumb o-do rsal fascia just above the iliac cre st before descending vertically across the crest to innervate the skin of the buttock as far down as the greater trochanter. Th e fifth lumbar ramu s crosses the sacrum immediately lateral to the lum bosacra l joint where it divide s into med ial and latera l branche s (figure 15). The former turn s inward s be low the j oint to supply Fig. 14. Diagra m illustrating the site or branc hing of a it before co ntinuin g on to te rminate in the multifidu s. lumbar dorsa l ramus on the transverse process at the bottom The lateral is lost in the sac roiliac ligame nt. of a tiss ue plane betwee n the multifidus mu scle medially and The sacra l dorsa l rami and the plexus on the the longi ssimu s mu scle latera lly. T he cour se of the medial dorsal swface of the sac rum (figure 15). On emerging branch is also shown in relati o n to the vertebra l jo int. The from the posterior sacra l foramina eac h dor sal terminal fiber s of the latera l branch are not shown . 137

597-036 0 • 76 • 10 cutaneo us branche s throug h th e gluteus maximu s muscles to the sk in.

7. SOME GENERALIZATIONS ON TH E TERMINAL DISTRIBUTION OF T H E DORSAL R AM ! The line of th e pos terior ve rtebra l joints mark s a , tissue plane at the base of which the dorsal ra mus divides into medial and late ra l branches. Thi s tiss ue plane represe nts a watershed for the distribution of the termin al branches of the two divisions of the ramu s. Mu scle s and ligament s medial to thi s plane are innervat ed by the medi al bra nch and muscles and ligament s latera l to it by the latera l branch. Eac h verteb ral joint is suppli ed by seve ral fine branches from the rami of at leas t two sp inal nerves; the se co me from the main trunk of the ramus and its medial branch . Th e inferi or parts of the capsule are inner vated by the ramus below and the superior parts of the capsule by the ra mus above. In the case of the cervical and upper seve n thoracic ner ves, the medial branch is the large r of the two and , additionally , contains cu taneou s fibers . Below this level the rever se arra nge ment obta ins. the latera l being the larger and co ntaining the cutaneous fiber s. With the except ion of the grea ter occipital (C2 ) and third occipital (C3) nerves all the cuta neous branches beco me subcut aneous at a lower leve l than the origin of their parent ramus , the distance between the se two levels incre asing from above Fig. 15. Th e nerve plexus formed on the do rsum of the sacru m by the dorsal rami of the lowe r lumbar and sacra l downwards. nerves. "" Th e overlap of nerve branches from differe nt cord The cutaneou s senso ry territ ory inne rvated by segme nt s is show n (by kind permi ssion of Dr . K. C. Bradley). the dorsal rami cove rs an extensive area extending from the vertex above to the coccyx below. ramus divides into a finer medial and a larger lateral Laterally it ex tends to a line which follows the branch. Th ese are in turn linked by a co mplic ated outer border of th e tra pez ius to th e acro mion, sys tem of overlapping branchings and anastomotic then to the lower angle of the scapula from which loopin gs to form a ple xus which is deepl y situated it co ntinu es vertic ally downwards along the on bone and ligamentou s tiss ue beneath the po ster ior axillary line to th e greate r trochanter multifidu s and sac rosp inalis muscle s with exten­ before turnin g medially to th e coccyx. sion s between the deep and superfi cial parts of the On their way to the sk in, the cutaneou s branches (X)sterior sacroili ac ligament. The plexus is joined pass through muscles befor e finally emerging by the desce nding medi al divisions of the fourth th rough the tough fasc ia! tiss ue coa ting th e supe r­ and fifth lumb ar rami which reach as far distally as ficial muscles of the back. Th e grea ter occ ipital at least the seco nd sac ral seg ment. T er minal medial nerve emerge s benea th a tendin ous arca de at the branche s of the sys tem inner vate muscles while the att ac hment of the trapez ius to the skull while the lateral are distributed to muscles along with the later al branche s of the first three lum ba r ram i are sac roiliac , sac rotub erous , sacros pinou s and ilio­ co ntained in tunn e ls of the lumbodor sa l fascia lumb ar ligaments; in add ition , those branches where they pierce thi s sheet to desce nd acros s der ived from the first thr ee sac ral nerves send the iliac crest. 138 Both the medial and lateral divisions of each Traite d'anatomie humaine. Paris. Masson et Cie. 1899, dorsal ramus achieve, by a plexus pattern formed Vol. 3, Fasc. 3, 2nd ed, pp. 923-944. by long ascending and descending branches, a 2. Hovelacque, A. Anatomie des nerj:\"craniens et rachidiens et du systeme 1-:rand sympathique che;:, l'homme. Paris. considerable degree of overlap with the correspond­ Gaston Doin et Cie. 1927. p. 300. ing branches of neighboring rami. This overlap 3. Swanberg, H. The intervertebral foramina In man. Med. may extend over several segments. Thus fibers Rec. 87, 176-180, 1915. from the fourth lumbar ramus reach at least as 4. Hadley, L. A. Anatomicoradiographic studies of the spine. far distally as the second piece of the sacrum. N. Y. State J. Med., 39, 969-974, 1939. 5. Hadley, L. A. Roentgenographic studies of the cervical spine. Amer . .I. Roe11tge110/., 52, 173- 195, 1944. CLOSING COMMENT 6. Hadley, L. A. Constriction of the intervertebral foramen . Recapitulating, anatomical features worthy of .I. Am. Med. Assoc., 140, 473-476, 1949. 7. Payne, E. E., and Spillane, J. D. The cervical spine. special attention as potential sites of nerve involve­ Anatomico-pathological study of 70 specimens (using ment are: a special technique) with particular reference to the I. The intervertebral foramen. Normally, the problem of cervical spondylosis. Brain, 80, 571-596, dimensions of the foramen in relation to the cross­ 1957. 8. Cyriax, .I. Cervical Spondylosis. London. Butterworths, sectional area occupied by its neural contents leave 1971,p.50. ample room for the latter. The narrowing of the 9. Sunderland, S. Meningeal-neural relations in the inter­ foramina which occurs during extension of the ver­ vertebral foramen . ./. Neurosur~ .• 40, 756- 763, I 974. tebral column does not embarrass its contents. The 10. Pfitzner. W. Ober Wachstumsbeziehungen zwischen nerve complex is free to move in the foramen which Riickenmark und Wirbelkanal. Morph. Jb., 9, 99-116, allows it to adjust throughout the normal range 1884. 11. DuVal, P., and Guillain, G. Pathogenie des accidents of vertebral movements. While pathological nerveux consecutifs aux luxations et traumatismes de changes in and about the foramen may reduce its l'epaulc. Paralysies radiculaires traumatiques du plexus dimensions and lead to nerve compression, more brachia). Arch. Gen. Med., 2, 143-191. l 898. likely causes of nerve involvement at this site are 12. Baldwin. W. M. The topography of spinal nerve roots. Anat. Rec., 2, 155-156, 1908. friction over osseo-fibrous irregularities or trac­ 13. Cordier, Coulouma, and Van Varseveld. L'anatomie et tion on a nerve or nerve roots fixed in the foramen ('importance clinique du nerf ganglio-radiculaire. by adhesions. Enceplwle, 31, 139-158, 1936. 2. The passage of the medial branch of the 14. Frykholm, R. Deformiti(;s of dural pouches and strictures lumbar dorsal ramus and its accompanying vessels of dural sheaths in the cervical region producing nerve root compression. J. Ne11rosur1-:.,4, 403-413, 1947. through an osseo-fibrous tunnel and the intimate 15-. Frykholm, R. Cervical nerve root compression resulting relationship of this neurovascular bundle to the from disc degeneration and root-sleeve fibrosis. A clinical capsule of the apophyseal joint represents a investigation. Acta Chir. Scand., suppl. 160, 1951. potential site of fixation and entrapment following 16. Frykholm, R. Lower cervical nerve roots and their invest­ pathological changes involving the joint. ments. Acta Chir. Scand., IO I, 457-471, I 951. 17. Reid, .I. D. Ascending nerve roots and tightness of dura 3. The passage of the cutaneous branches mater. N. Z. Med.J., 57, 16-26, 1958. through the muscles and fascia of the back should 18. Reid, .I. D. Ascending nerve roots . ./. Neurol. Neurosurg. not be overlooked as potential sites of entrapment. Psyc/iiat., 23, 148-155, 1960. This applies particularly to the greater occipital I 9. Roth, M. Caudal end of the spinal cord. I. Normal pneumo­ nerve and the cutaneous branches of the dorsal graphic features. Acta Radio/. (Diag.), 3. 177-188, 1965. 20. Shapiro, R. Myelography. Chicago. Year Book Medical rami of the upper three lumbar nerves. Publishers, Inc., l 968. When investigating the problem of back pain and 21. Nathan, H., and Feuerstein, M. Angulated course of spinal the status of spinal manipulative therapy, one nerve roots . ./. Neurosurg., 32, 349-352, I 970. cautions against concentrating exclusively on the 22. Inman, V. T., and de C. M. Saunders, J. 8. The clinico­ intervertebral foramen as the site of the offending anatomical aspects of the lumbosacral region. Radiology, 38, 669-678. 1942. lesion lest this obscure the significance of etio­ 23. O'Connell, .I. E. A. Sciatica and the mechanism of the logical factors originating in the posterior vertebral production of the clinical syndrome in protrusions of the joints and ligaments, and in the osseo-fibrous canal lumbar intervcrtebral discs. Brit. J. Sur1-:.,30, 315-327, where a neurovascular bundle could be entrapped. 1943. 24. O'Connell, J. E. A. Protrusions of the lumbar intervertebral REFERENCES discs. A clinical review based on five hundred cases treated by excision of the protrusion . ./. Bone Jt. Surg., I. Soulie, A. Nerf,; rachidiens. P. Poirier and A. Charpy. 33 B, 8-30, I 95 I. 139 25. O'Connell, J. E. A. Discussion on cervical spondylosis. Spinal Cord and Column. In the press. Proc. Roy. Soc. Med. (Section of Medicine), 49, 202- 33. Sunderland, S., and Bradley, K. C. Stress-strain phenomena 208, )956. in human spinal nerve roots. Brain, 84, 120-124, 1961. 26. Frykholm, R. The mechanism of cervical radicular lesions 34. Gamble, H.J. Comparative electron-microscopic observa­ resulting from friction or forceful traction. Acta Chir. tions on the connective tissues of a peripheral nerve Scand., 102, 93-98, 1952. and a spinal nerve root in the rat. J. Anat. (Lond.), 98, 27. Cave, A. J. E., Griffiths, J. D., and Whiteley, M. M., Osteo­ 17-25, I 964. arthritis deformans of the Luschka joints. Lancet., I, 35. Sunderland, S. Mechanisms of cervical nerve root avulsion I 76-179, I 955. in injuries of the neck and shoulder. J. N eurosurg. 4 I, 28. Reid, J. D. Effects of tlexion-extension movements of the 705-714, 1974. head and spine upon the spinal cord and nerve roots. 36. Turner, E. L., and Oppenheimer, A. A common lesion of J. Neurol. Neurosurg. Psychiatry, 23, 214-221, 1960. the cervical spine responsible for segmental neuritis. 29. Breig, A. Biomechanics of the Central Nervous System. Ann. Int. Med., JO, 427-440, 1936. Stockholm. Almqvist and Wiksell, I 960, pp. 22, 23, 98. 37. Magnuson, P. 8., Differential diagnosis of causes of pain in 30. Breig, A., and Marions, 0. Biomechanics of the lumbo­ the lower back accompanied by sciatic pain. Ann. Surg., sacral nerve roots. Acta Radio/. (Diag.), I. 1141- I 160, I 19, 878-891, 1944. 1963. 38. Pedersen, H. E., Blunck, C. F. J., and Gardner, E. The 3 I. Dana, C. L. The mechanical effect of nerve-stretching anatomy of lumbosacral posterior rami and meningeal upon the spinal cord. Med. Rec., 22, 113-115, 1882. branches of spinal nerves (Sinu-vertebral nerves). J. 32. Sunderland, S. Avulsion of nerve roots. R. Braakman. Bone .It. Surg., 38A, 377-39 I, I 956. Handbook of Clinical Neurology. Amsterdam. North­ 39. Bradley, K. C. The anatomy of backache. Aust. N.Z. J. Holland Publishing Co., V ?L 25, Part I: Injuries of the. Surf.:., 44, 227-232, 1974.

140 Pathology of Spinal Root Compression

H. H. SCHAUMBURG Associate Prof essor of Neurolog y P. S. SPENCER Assistant Prof esso r of Patholo gy and Neuroscience A /be rt Einstein College of Medicine

I. INTRODUCT ION the entire cauda equina and of the individual nerve root s (figure 2). Cerv ical and thoracic vertebra l body Disease of the human spine with compromi se of and disc disease may compress the spina l cord in nervou s tiss ue is of great importance in manipu­ addition to the spinal roots. Becau se of the seg- lative medicine. The relationship of the cerv ica l spinal cord , spinal root s and meninges to the correspo nding vertebra l body is illustrated in figure I. Both the cord and the roots are well

Dura mote, Subdurol space stptum im1/11~ •:

Dorsal romus \JI.\\'::±( IO 1fl\\\Ld II le::::::' 12 Gray romus

White romus I\\;::::;'.. u

Rom• communicontes Vertebral artery 1\~ 2

Fig. I. Diagram of the spinal cord, nerve root s, and meninge s by H. K. Co rning (from Truex and Carpen ter , Human Ne11ro• anatomy. I 969 ; courte sy of the Williams and Wilkins Co.). r,::,-...;:._5

SI protected from outside trauma by the vertebral z body, neural arc h and a tough , fibrou s dura. How­ ! 4 °' 5 ever, when distorted by degenerative bone and ~ Cod joint disease or a variety of space-occupy ing lesions, these same protective layers may damage Fig. 2. Diagra m of the position of the spinal cord segment s the delicate neural structures . Thus , in the lumbar with referen ce to the bodies and spinous processes of the region, verteb ral body and intravertebral disc vertebrae (from Ha ymaker and Woodh all, Periph eral Nerve disease are potential sources of compression of Injuri es, 1945; courte sy of the W. B. Saunders Co.). 141 mental variation in pathology, a know ledge of the ana tomy of the spinal root s, their normal relat ionship to the vertebra l body and to the intervertebral foram ina, is esse nti al to an under­ stand ing of spinal root neuropathology.

II. ANATOMI CA L FA CTORS Each dor sal root is composed of myelinated (A) and unmyelin ated (c) nerve fibers. The ir axons are the centra lly projecting proce sses of the dor sal root gang lion neuron s, whic h are located within the intervertebral foramina. The large myelinated fiber s co ndu ct rapidly and tran s mit impul ses from elabora te special receptor s in the periphery: Fig. 3. Cross sec tion of a portion of a normal hum an sc iatic the smaller myelin ated fiber s and the ve ry small ner ve. The arrow indica tes the prominent pcrin eurial sheat h unmyelin ated fiber s conduct slow ly and transm it around a fascicle of nerve fibe rs. Blood vesse ls arc prominent impul ses from less specialized receptor s in the in the ep ineuria l connective tissue (pho sphotung stic acid­ hematoxy lin, X40). per iphery. C lassica lly, the ventral roo ts have been held to be composed o nly of myelinated fibers. Recent work has dete rmin ed that there are also many unm ye linated axons in the mammalian ventra l roo t. 1 The myelinated fiber s in ventra l root s are: large myelinated A-alpha fiber s carrying motor impul ses to extrafusa l mu sc le fiber s, small gamma effe rent motor fiber s inn ervating the int rafusa l fiber s of mu sc le spindle s and, in seg­ ments T1 through L~, pregang lio nic, sympathetic efferent , B fibers. Prega nglion ic, viscera l efferent fibe rs of the parasympathetic system are also pre se nt in the ventral root s of sac ral nerve s 2, 3 , and 4.~ Nerve root axons are ensheat hed by Sc hwann Fig. 4. Cross sec tion of a bund le of normal human lumbar ce lls. In the case of myelinated fiber s, Schwann spinal root fibers in the subarachnoid spac e (S). T he con nective ce lls form regu larly repeating lengths of myelin tissue sheat h around th e bund le is spar se when contrn stecl with throughout the ent ire length of the root s. The the perineuria l and cpincurial sheaths around th e per ipheral Schwann ce lls are present up to the junctio n zones nerve fasc icle in Figure 4 (phosphowng stic acid -hematoxy lin. X40J. between the root s and the sp inal cord. After entry into the spin al co rd , the myelinating function of the Schwann ce ll is undertaken by the oligo­ the roots very vul nerable to pressure and to dendrogial cell. Some dorsal root fiber s continue stre tch:' wit hou t sy napse as sp inal tracts extendi ng up to Th e spina l ganglion is located with in a foca lly the leve l of the cervica l-medu llary junction. Eac h en larged portion of the dor sa l root which is sited bund le of root fiber s is encased within a th in sheath, at the inte rvertebral foramen. Di stal to the ganglion , the outer part of whic h is cont inu ous wit h the pia dorsal and ventra l roots joi n to form the spinal mater surroundin g the spinal cord. '1 In contrast nerve and the dura appear s to be continuous with to per ipheral nerve s (figure 3), nerv e roots have a the perineurium and the epi neurium of the sparse endoneuria l connective tiss ue, a very thin peripheral nerve." Dor sa l root s (exce pt for C 1) root sheath and no ep ineuri um (figure 4). Further­ are approximate ly three time s larger than the cor­ mor e, root fiber s run in parallel non-plexiform respondin g ve ntral roots. There is also a regio nal strand s. A ll of the above factors probably make variation in root size: the lumbar and cerv ica l roots 142 are the larges t, since they co ntain nerve fibers either a bulging of the nu cle us pulpos is and which suppl y the limbs. Both the att ac hment of the surro undin g fibrous annulu s, or a frank ruptu re of rad icular co mplex at th e inte rvertebra l fora men and the annu lus wit h ex tru sio n of mate rial around the the rela tionsh ip of root size to fora men size ofte n da maged poste rior longitudinal ligament. probab ly are of critica l imp ortan ce in the produ c­ Th ese herni ations are mos t commo n in the lum ba r tion of co mpressio n sy nd ro mes. Sunde rland has spine, affect yo ung or middl e-age d ad ults, ofte n are rece ntly determin ed th at th e hum an ce rvica l roo t~ related to exe rtion and us ua lly occ ur in a do rso­ and du ral pouch are only loose ly attac hed at the latera l direct ion. with co mpress ion of nerve roots fora men and th at they ac count for 35 to 50 perce nt within , or adjace nt to th e fora min a. T his type of of the cross-sec tional area of the fora men. " Since intervertebra l disc disease is res ponsible for the lumbar and sac ral roots are longer than the many cases of the sc iatic pain sy nd ro me. 8 cerv ica l and thorac ic, and pursue a long subd ural 2. T he second pa tholog ic react ion of the inter­ course before ex iting from the spine th rough their vertebral arti culation occ urs with aging or with interve rtebra l forame n, they may be co mpr essed repea ted tra uma, is seco ndar y to the gradual des ­ by vertebra l dege nera tion at severa l leve ls. By sica tion of the nucleus pulpos is, and is acco m­ co ntras t, the shorter ce rvica l and thorac ic roots panied by dege nera tion of the disc and of the are usually co mpr esse d only at the leve l of their articular ca rtilages of th e ve rtebra l bo dies adjace nt respec tive inte rverteb ral fora men. Eac h ce rvica l to the bulging annulu s. Thi s· new ly-fo rm ed bony root ex its immed iately above the bo dy of the spur is refe rred to as an osteo ph yte a nd, in co m­ segmentally co rres pondin g verteb ra while the bination with th e bulging disc , eve ntu ally may thorac ic , lumba r, a nd sac ral nerves ex it in foram ina form an ep idura l ridge ex tendin g across much of below their cor res ponding ver teb ra. the spinal ca nal. Co mm only, ost eoph ytes also form at the uncinate processe s (Lu sch ka joints) on the 111. PA T HO LOG Y dorsa l-late ral margins of the verteb ral bod y, and Since this sym pos ium is co nce rned primarily inden t the ve ntra l portion of the intervertebra l with sp inal misalignme nt , degenera tive disease fora mina, thereby impinging on th e roo ts (figure 5). of the intr ave rtebra l disc and arthri tic changes in th e intervertebra l joint s, the prese nt pape r will be confined large ly to the effec ts on the spinal roots. However, it is imp ortant to real ize that there are ot her so urces of prog ress ive sp inal roo t compress ion which are by no mea ns ra re. Promi ­ nent among these con diti ons are malignan t neo­ plas ms within the subarac hn oid space. Metastases affect ing eit her th e ve rteb ral body or the ep idura l space are also so urces of roo t and spinal co rd com press ion, and slowly growi ng lymph omas in the epidur al space clinica lly may mimic disc disease . Benign neop las ms (meningiomas, ne uro­ fibromas, and schw annomas) and th e effec ts or many non-n eop lastic co ndit ions (tuberc ulos is, arac hnoid cysts, co ngenital bo ny and vasc ular ano malies) may also res ult in spinal root compress ion. u, 7 a. Pathology of the Spine R elevan t to Nerve R oot Comp ress ion Th ere are two bas ica lly diffe rent pathologic reac tions of the intervertebra l articulations which Fig. 5. A. Ra

148 Chairman's Summary: Anatomical and Biomechanical Studies

PHILIP GREENMAN Professor and Chairman Department of Biomechanics College of Osteopathic Medicine Michigan State University

This session was devoted to presentations Edmund B. Weis, Jr., presented a paper on focusing upon the known anatomical features of Spinal Geometry: Normal and Abnormal, and spinal biomechanics and particularly of the inter­ stated that the analysis must include consideration vertebral foramina, and the effects of this anatomy of anatomical, physiological and mechanical on the emergent nerves and nerve roots at the variables. He presented a format of looking at intervertebral foraminal level. spinal geometry from the basis of normal and The first presentation by David C. Drum focused abnormal anatomy. Each of these areas was then on the vertebral unit and the intervertebra/ foram­ addressed in terms of large and small deviations. ina. This paper focused on the vertebral motor Each deviation was further divided into static unit as the conceptual model made popular by and dynamic subsets. The presentation was sup­ Junghanns. The vertebral motor unit, according ported extensively by radiographs of the spine to this concept, is composed of an intervertebral demonstrating the multiple possibilities of altered disc, neurovascular elements concentrated within spinal geometry. Included were scoliosis, de­ the neural foramina and intervertebral foramina, generative joint disease, congenital vertebral posterior spinal joints, and all the connective and abnormalities, fractures and dislocations, spondy­ muscular tissues supporting and limiting inter­ lolisthesis and sacralization, herniated nucleus segmental motion. This concept was developed in pulposus, and numerous others. Dr. Weis con­ this presentation and the role of soft tissue struc­ cluded that the highest incidence of problems were tures was clearly delineated. A description of the in the area of normal anatomy, small deviations, 23 typical motor units was made together with the and dynamic state. The same small deviations and atypical motor units of the occipital-atlantal and dynamic loading on abnormal anatomy appeared at Ianto-axial levels. Additionally, the concept of to be produced by degenerative processes. He the pelvic motor unit including the sacroiliac concluded that prospective studies on the ef­ joints and the pubic symphysis was noted. The ficacy of manipulative therapy, as well as other need for research into the muscles limiting and forms of therapy, should be conducted to answer coordinating motion of the individual or multiple questions about effectiveness in patient care. motor units was indicated. A need for study into Spinal Kinematics, by Augustus A. White II I, the mechanical response of the whole body was was presented and was defined as "that phase of also noted. It was concluded by this paper that mechanics concerned with the study of motion of J unghanns' concept might be useful as a focus for particles and rigid bodies with no consideration continuation of interdisciplinary dialogue and of the forces involved." He developed the analogy research. of a train first used by Lovett to apply to the 149 vertebral unit. A series of terms and definitions of Anatomical Perivertebral Influences on the possible vertebral motion was developed and lnten·ertebral Foramina. Sunderland presented provided a basis upon which a comprehensive de­ the anatomical and physiological properties of the scription of spinal kinematics was made. The author intervertebral foramina and the relationship of the points out that few studies have been carried out contents. Changes in the dimensions of the to analyze and quantitate the ranges of spinal foramina were detailed. The author concluded by kinematics. He presented the ranges of motion noting that the dimensions of the foramina provided in tlexion-extension. lateral bending. and axial ample room for the neural contents. He cautioned rotation based upon the review of the literature "against concentrating exclusively on the inter­ and experience of the author. A concise overview vertebral foramina as the sight of the offending of the work being done by the author and others lesion." There appear to be other explanations in the area of spinal kinematics was made. Some for the clinically observable phenomena. of the problems in this area are based on the fact The Pathology of Spinal Root Cornpression, by that most of the work has been done on autopsy Schaumburg. then followed. Building upon the material and there is a need to study kinematics preceding presentation by Sunderland. he de­ in the living spine. The development of measure­ veloped the pathologies of the spine in inter­ ments for this type of work are needed. vertebral foramina and what is known about nerve The fourth paper addressed Biomechanical root compression. Pathologies relevant to spinal Aspects of Subluxation, by Chung Ha Suh. who root compression included herniation of the presented two areas of work in which an attempt intervertebral disc. pathology of intervertebral has been made to study and define the term of articulation with aging and trauma. particularly subluxation. He focused on I) precision x-ray at the arthrodial joint and at the joint of Luschka. method for the visualization of biomechanical He points out that few experimental pathology aspects of subluxation. and 2) computer model studies of nerve root compression had been re­ of the spine for simulated study of spinal subluxa­ ported. Most of the work in the area has been done tion. The former dealt with a review of the x-ray with peripheral nerve. He described the patholo­ analysis of the spine and the problem of image gies which occurred in the nerve including de­ geometry associated with this x-ray procedure. myelination. axonal degeneration and their varie­ Methodology was developed to correct for the ties. Possible varieties of repair to degeneration distortion. as well as single plane aspects. of and subsequent regeneration were presented. spinal radiology. It was unfortunate that the In open discussion following these presenta­ author was unable to further develop this work tions. Gurjian reported on studies involving with examples of practical application. The second acceleration-deceleration injuries to the neck; portion of the presentation dealt with a computer these studies were supported by high speed model for the spine. The development of a three­ movies of individuals being subjected to simulated dimensional computer model of the spine was injuries at the level of IO miles per hour and 15 deemed useful for further work in the area of miles per hour. The varieties of response of the "subluxation." The two methodologies addressed head and neck to the position of the patient were by this paper point out the need for numerical­ clearly delineated. The role of muscle spasm and analytical data to support the large amount of tone was noted. literature based on subjective clinical observa­ The general discussion which followed demon­ tions. Such methodologies appeared to the author strated varying opinions of the participants rela­ to be essential for systematic study of the spinal tive to the role of the various anatomical struc­ subluxation. tures described in the papers and observations In the discussion of the foregoing four papers. of the practitioners of manipulative therapy. It James M cElhanney provided a brief review of the appeared that there was consensus on the need state of the art in the anatomical and biomechanical for better techniques and methodologies to measure studies of the spine. those abnormalities of spinal biomechanics and Two additional papers were presented in this the associated changes described by the manipula­ session. The first by Sidney Sunderland focused on tive practitioner. It was apparent that the neural 150 compression theory at the intervertebral foramina total emphasis on the bony relationships appears did not satisfactorily explain all of the phenomena to be inappropriate. clinically observed. The need for methodologies This session demonstrated the need for ad­ to study the biomechanics of the spine and its ditional collaborative research studies in the component parts on living subjects was noted. area of the biomechanics of the spine and the Attention must also be given to the soft tissues associated structures. Emphasis on a single struc­ in and about the vertebral segments, in which ture or concept appears to be less than appropriate.

15 I Chapter IV.

What Do the Basic Sciences Tell Us About Manipulative Therapy? (Neuroscience Studies)

Horace W. Magoun, Chairman

597-036 0 - 76 - 11 Susceptibility of Spinal Roots to Compression Block

SETH K. SHARPLESS Professor of Psychology Department of Psychology University of Colorado

Fontana, as early as 1797, observed that pres­ mechanical stress than peripheral nerve. Thus, sure on a nerve blocks conduction without causing according to Sunderland and Bradley ( 1961 ), stimulation (cited by Meek and Leaper, 1911 ). spinal roots yield more readily to tensile stress The effect of local compression on conduction has owing to the fact that they lack the perineurium been the subject of extensive, if desultory, investi­ and funicular plexus formations of peripheral gation since. In the last few years, interest in nerve nerve. Gelfan and Tarlov ( 1956), in one of the few compression has revived, owing partly to the at­ physiological studies on the effects of compression tempt of bioengineers employing computer simula­ on spinal nerves and roots, reported their im­ tion techniques to develop a realistic model of pression that the spinal roots were also more the spine as a mechanical system. l t is hoped that susceptible to compressive forces than peripheral such efforts will ultimately yield estimates of the nerve. They did not, however, vary pressure sys­ forces brought to bear on structures of the spine, tematically, nor did their compression apparatus including spinal nerves and roots, under various permit a direct comparison of spinal and peripheral conditions of loading. Needless to say, this objec­ nerve. Even in the studies of peripheral nerve, it tive is a long way from realization, but if it is ever is difficult to find useful values for the minimal to be achieved and its clinical potential is to be pressure increments required to produce significant exploited, detailed information will be required nerve dysfunction. Indeed, in only a few studies on the susceptibility of nerve to tensile and com­ was the compression apparatus calibrated in such pressive forces. a way as to permit translation of values obtained Given the long history of study of the effect of to standard measures of pressure (e.g., mm. Hg.). compression on nerve and the relatively simple In most instances, too, the investigators were technical requirements of such studies, it might be interested chiefly in pressures required to produce supposed that such information would be found in complete block (at least of the rapidly conducting the literature. This appears not to be the case for fibers) rather than minimal impairment of con­ several reasons: First, most previous work has duction which would be of greater clinical interest. been on peripheral nerve, and it may well be that Even these values vary greatly in different experi­ spinal nerve and roots are more vulnerable to ments, as indicated in table I.

TABLE I

Pressure Time to Recovery Authors to hlock block time Nerve (mm Hg)

Mitchell, Weir, I 872 508 10-12 secs. 10-12 secs. Rabbit sciatic Meek and Leaper 191 I 1034 19 mins. Rat gastroc.

155 TABLE I·-continued

Pressure Time to Recovery Authors to block block time Nerve (mm Hg)

Edwards and Cattell 1928 1200 10 mins. Frog sciatic Bentley and Schlapp 1943 130 2.5-3 hrs. No recovery Cat popliteal . Denny-Brown and Brenner 1944 762 ,,_ mms. 6 mins. Cat sciatic Causey and Palmer 1949 150-400 20 mins. 5-65 secs. Rabbit gastroc.

Table I gives a fair idea of the kind of quantita­ contact area increases as the balloon is lowered tive data available on blocking pressures. In most onto the nerve, there is some confounding of cases, the compressed area was a short segment of length of nerve compressed with pressure applied. nerve, less than one centimeter in length (in the Thus, the length of nerve compressed increases experiments of Bentley and Schlapp, 2-4 cm. seg­ from 2.5 mm. at about IO mm. Hg. to a maximum ments were compressed). There is little useful of 4.5 mm. at about 50 mm. Hg. , information in the table, other than that com­ pression does produce conduction block, and that PRESSURE the block may become progressively more severe TRANSDUCER if the pressure is maintained. Of the investigators mentioned, Causey and Palmer ( 1949) used the most novel and probably the most accurate tech­ nique for measuring the compressive force. They actually immersed a segment of the nerve in a bath of mercury attached to a mercury column. RACK The minimum pressures required to block rabbit & gastrocnemius in their experiments ( 150 mm Hg) PINION agree closely with the values we have obtained for rat and cat sciatic nerve. Methods and Apparatus ELECTRICALSIGNAL An attempt was made to devise a compression -DORSAL ROOT apparatus which would be simple, accurate, suit­ P\..ASTICFOOT

able. for use in small animals, and, so far as possible, Fig. 1. Compression apparatus. The increment in pressure consistent with these requirements, one that as the balloon makes contact with the nerve is taken as the pres­ would mimic the situation in which nerves are sure applied to the nerve. compressed against bony facets by soft tissues in confined spaces. According to Sunderland (1968), Experiments were performed on cat and rat it is this kind of situation that most often gives sciatic nerves and dorsal roots, L4-L 7. The rise to idiopathic peripheral nerve compression nerves were dissected free of surrounding tissue syndromes. as in the carpal tunnel. on the recording (or proximal) side of the compres­ The apparatus is shown in figure 1. In fact, it sion shelf and covered with mineral oil which had is a modification of the technique originally used been agitated with room air and saline. The same for this purpose by Weir Mitchell, who allowed a procedure was used with dorsal roots, except that chamois leather bag filled with mercury to rest on the dura was opened, and the roots were freed the nerve. A miniature rubber balloon (2.5-5 mm. of their attachments for not more than 2-3 cen­ in diameter) filled with fluid is lowered by a timeters from their entry to the cord. In both cases, manipulator onto the nerve which rests on a plastic an effort was made to keep the blood supply shelf with rounded edges: the shelf is 4.5 mm. in intact to within a few millimeters of the plastic width. The increment in pressure produced by shelf on the distal side of the compression ap­ contact with the nerve is taken as the pressure paratus (the side of stimulation). Compound action applied to the nerve. Owing to the fact that the potentials were recorded relative to the killed

156 ends, digitalized, and led directly to a computer eluded in the results and the curves are indis­ for storage and analysis. Only the A components tinguishable both in the case of the roots and of the action potentials were examined. Cat and rat peripheral nerve. This indicates, incidentally, nerves and roots appeared identical with respect that nerve diameter is probably not a crucial factor to blocking pressures. in determining resistance to pressure. With the procedure used. a complete conduction Results block in the sciatic nerve could not be achieved The single most important finding to emerge with pressures of less than 150 mm Hg. This is from our re-examination of this old problem is consistent with the results of Causey and Palmer the astonishing sensitivity of spinal roots to ( 1949), mentioned previously. In our experiments, compression. This is shown in figure 2. In the the area (mv.-msec.) of the A components of the compound action potential were reduced to about half-value at I 00 mm. Hg. Compressive forces of less than 50 mm. Hg. blocked only a small number of fibers, even when the forces were long main­ tained. In contrast, dorsal roots were able to withstand only minute pressures, the potentials being reduced to about half their initial values by pressures of 20-25 mm. Hg. A spectacular demonstration of the sensitivity of spinal roots to compression is shown in figure 3, in this case from a rat, but cat roots have yielded

2...5

2..0

1...5

1..D

30 60 90 120 150 180 0...5 mm.ho. 10 10 20 MMHG

Fig. 2. Susceptibility of spinal roots to compression block. 0 Compound action potentials integrated and expressed as percent of initial value. Pressures applied for 3 minutes only. 100 200 300

experiments depicted here, the pressure was MJNUTES applied for 3 minutes, relieved for 3 minutes, and then a higher pressure was applied, this procedure Fig. 3. Effects of sustained pressure. Computer-generated plot of average areas (mv. - msecs.) in A components of action being continued until a substantial conduction block potentials from rat dorsal root during application of very small was evident. Although the three-minute periods pressures. Note progressive character of conduction block were not sufficient to allow full recovery with and recovery. the higher values of pressure, so that cumulative effects tend to be confounded with the effects of similar results. In this experiment, the sciatic nerve pressure per se, the design is adequate to reveal was stimulated 1/sec. for 5 hours and the com­ the remarkable difference between spinal roots and pressor was applied periodically to a dorsal root. peripheral nerve. Rat and cat preparations are in- In the computer-generated plot, each point repre- 157 sents the average area (mv.-msecs.) of 10 suc­ for compression block, since compression af­ cessive potentials led from the cut end of the root. fected large fibers first. whereas with anoxia the A pressure of only IO mm. Hg. produced a sig­ smaller fibers were more vulnerable. nificant conduction block, the potential falling to If the observations of Gelfan and Tarlov ( 1956) about 60 percent of its initial value in 15 minutes on the effects of anoxia are valid, it would appear and to half its initial value in 30 minutes. After that even the small pressures employed in our such a small compressive force is removed, nearly experiments produced conduction block in dorsal complete recovery occurs in 15 to 30 minutes. roots by mechanical deformation rather than With higher levels of pressure, we have often ob­ hypoxia. Figure 4 shows the effects of small served incomplete recovery after many hours of recording. It is difficult to appreciate the significance of the minute pressures capable of affecting root conduc­ 100 i' : I < I': l: It,- ;:'+j tion. It seems doubtful that the most skillful and _J -, • , O mm hg , deft surgeon could touch a spinal root or the balloon 80 of our compression apparatus with his gloved forefinger without producing a pressure increment of at least 5 mm. Hg. One may well consider what % happens to the spinal roots when they are manipu­ lated by the far less dextrous electrophysiologist. Figure 3 also brings out the importance of an­ other parameter, time. One thing that is amply documented in the old literature is the importance of the duration of compression. A few fibers only 10 15 20 25 30 may be blocked by a transient increment in pres­ mm hg sure, whereas the same pressure maintained for a Fig. 4. Curves representing changes in the fast ( F) and long time may produce a substantial conduction slow (S) components of the A potentials as a function of pres­ block. What is the cause of gradual failure of sure. There is some slowing of the fast unit discharges, in­ nerve fibers during local compression? dicated by the increase in the "slow" components as pressure is increased. However, the fast components are generally more In the older literature, there was much con­ susceptible to block even at pressures of 20 mm. Hg. or less. troversy regarding the relative roles of ischemia Dorsal root from rat. Inset: computer-writeout of average and mechanical deformation in compression block. potentials. I schemia might account for the progressive charac­ ter of compression block, but it is my impression increments in pressure on the fast and slow that the roles of ischemia and mechanical deforma­ components of the action potential led from a tion have not yet been entirely disentangled. Thus. dorsal root. It is evident that pressures of as little Bentley and Schlapp ( 1943) were able to show that as 20 mm. Hg. affect primarily the rapidly con­ a 4 cm. segment of peripheral nerve could be ducting fibers. The differentiation between slow rendered completely ischemic by compressing it and fast fibers was especially clear in this experi­ between rubber cushions to a pressure of 60 mm. ment: more commonly the differentiation was Hg., and yet maintain conduction for hours,, less conspicuous; however, rapidly conducting owing to the diffusion of oxygen from the ends of elements were always somewhat more susceptible, the compressed region. On the other hand, Causey which makes it unlikely that the block could be and Palmer ( 1949) described one experiment in ascribed to hypoxia. which they had unsuccessfully attempted to The susceptibility of large diameter fibers to achieve conduction block by air pressure alone. compression block, first observed in peripheral suggesting that ischemia may have contributed to nerve by Gasser and Erlanger (1929), provides a conduction block in other instances in which the clue to the mechanism of compression block. nerve was compressed by the weight of mercury. Assuming that a nerve fiber is a pressure vessel, Gelfan and Tarlov ( 1956), in their work on spinal something like a sausage, then the contents nerve and roots, concluded that mechanical would tend to be squeezed out of a compressed deformation rather than anoxia was responsible zone, the pressure exerted by the displaced fluid 158 being balanced by hoop stresses in the surrounding transient increase in pressure would have little membrane. A simplified model (figure 5; Mac­ effect. It is only when the joint is fixed in a position Gregor et al.. 1975) can be used to show that the .yielding a significant increase in pressure that one larger fibers will require larger hoop stresses to would expect compression block to develop. This match a given internal pressure and will undergo a consideration is relevant to the chiropractic defini­ greater percentage decrease in cross-sectional area. tion of a "subluxation" as "a fixation of a joint within its normal range of movement, usually at deforawd shapo the extremity of that range" (Weiant, cited by inillol shape Harper, 1964 ). It may also account for the observa­

W, __{'\r,_;'------___------..LLH 0~' tion that many instances of idiopathic compression syndrome are associated with occupations in which ~ ... ~------f-fTr·' an awkard position must be maintained for some ~8j+---i ------6 ~ time (See Sunderland, I 968, for references). P=K'(~4 ~ -- The spinal roots. floating in their bony canal, are well protected from local fluctuations in 8 ;,/~ -, ulL pressure. and it is for this reason, perhaps, that they .,_ p __. ..~ ~ ~. l / j"' ; • ~ ! have not developed other mechanisms to protect ------4 them from compressive forces. But it is scarcely credible that spinal nerves within the intervertebral Fig. 5. Pressure vessel ("sausage") model of compressed foramina, where considerable pressure fluctua­ nerve fiber. Pressure applied in delta region displaces con­ tions must occur, could be so vulnerable. Some­ tents to other regions where the pressure is opposed by hoop stresses. Elastic properties of membrane represented by where along their course from the cord to the springs. This model predicts that larger fibers will undergo periphery. nerves acquire a resistance to com­ greater percentage deformation than small fibers. From pressive forces. We have carried out some experi­ MacGregor. Sharpless and Luttges (I 975). ments to determine where along the course of the spinal nerves these protective features become If the safety factor for the longitudinal internal re­ manifest. In one series, cat spinal nerves, still sistance is approximately the same in large and encased in their sheaths, were compressed just small fibers, the conduction of the large fibers proximal to the dorsal root ganglia - i.e., within the being compensated by greater internodal distances, spinal canal before the nerves enter the foramina. etc., the larger proportional deformation of the For this purpose, the plastic shelf was removed large fibers might account for their susceptibility from the compression apparatus and the nerves to compression block. Of course, other factors were compressed against the floor of the spinal may be involved. including invagination of the canal. Records were taken from the corresponding myelin (Causey, 1948; Ochoa, et al., 1972). dorsal roots, exposed near their entry to the cord. This analysis would suggest that the slow onset Figure 6 is a computer-generated plot of the re­ of compression block is due to the viscosity of sults from three L6 and L 7 nerves. The nerves the displaced fluid. Whatever the mechanism were relatively resistant to pressure, a force of responsible for the gradual onset of compression approximately 90 mm. Hg. being required to block, it may have adaptive value, for it would tend reduce the response to half-value. to protect nerves against transient fluctuations in To determine whether the sheath surrounding local pressures. Although we do not have data on the nerves at this point afforded significant protec­ the increments in pressure in the intervertebral tion, the sheath was slit and partially dissected foramina during motion of the spine, there must away so that the balloon made direct contact with surely be considerable fluctuations of pressure, the nerve. This had no effect on resistance to pres­ particularly during extremes of motion. In other sure. notwithstanding the fact that the dissection confined spaces through which nerves pass, damaged some of the fibers. Thus, the dissected there are such fluctuations in pressure. For ex­ nerves yielded initial responses smaller than the ample, the pressure in the carpal tunnel is in­ intact nerves, but a plot of the magnitude of the creased during both acute flexion and hyperexten­ response relative to its initial value as a function of sion of the wrist (Tanzer, 1959; Robbins, 1963). pressure (fig. 6 -see Xs) corresponded exactly Given the slow onset of compression block, a with a similar plot from intact sheathed nerve, 159 w the nature of the conduction block itself. It is U) curious that in the latter part of the 20th century, :z 100 0 we should still be confirming Fontana's observa­ Q_ tion, and that we still know so little about the U) 80 w pathophysiology of compression syndromes. 0::: _J 60 CONCLUSIONS 1---1cc /-- 1---1 40 I. Dorsal roots are far more susceptible to com­ :z 1---1 pression block than peripheral (sciatic) nerve. /-- 20 When pressure is applied for 3 minutes followed :z w by 3-minute recovery periods, I 00 mm. Hg. must u 0 be applied to sciatic nerve to achieve the same 0::: w conduction block that can be produced in spinal Q_ 0 20 40 60 80 100 120 roots by 20 mm. Hg. 2. As little as IO mm. Hg. pressure, maintained MM HG for I 5-30 minutes, reduces the compound action potentials of dorsal roots to about half of their Fig. 6. Effects of compressing spinal nerves just proximal to ganglion. Nerves compressed against floor of spinal canal. initial values. With such small pressures, nearly Partially desheathed nerve identified by X's shows same vulner­ complete recovery occurs in about 30 minutes. ability to pressure as intact nerve. Note that nerves have 3. It is probable that the compression block become resistant to pressure before they enter the foramina. produced even by such small pressures is due to mechanical deformation rather than ischemia, the response being reduced to half with about since the larger fibers are blocked first, whereas 90mm. Hg. anoxia is believed to affect small fibers first. Thus, well before they enter the intervertebral 4. It has been shown elsewhere (MacGregor foramina where they might be expected to experi­ et al., I 975) that a pressure vessel model of nerve ence significant fluctuations in pressure, spinal predicts that large fibers would be most com­ nerves have acquired some structural feature pressed, which may account for their susceptibility which protects them against compressive forces. to block. The pressure vessel model might also Sunderland and Bradley ( 1961) have suggested account for the progressive character of compres­ that the funicular plexus formations of peripheral sion block, assuming a viscous flow of the fiber nerve trunks protect the nerve fibers from tensile contents. stresses, the load being resisted by the perineurium 5. The slow onset of compression block would associated with the undulating nerve fibers of the have adaptive value, since transient increments funiculus. Spinal roots lack this feature and of pressure which occur in confined spaces during accordingly are more vulnerable to stretch. It is extremes of motion would have little effect. not clear, however, why this feature should also 6. Spinal nerves acquire a structural feature protect against compressive forces. In fact, we do which protects them from compression block be­ not know what constitutional specialization is fore they enter the intervertebral foramina. The responsible for protecting nerve fibers within sheath does not appear to play an important role. peripheral nerve trunks against compression, The nature of this protective feature is still nor how such a feature may be altered by disease unknown. or aging. Fontana, it will be recalled, made two observa­ REFERENCES tions in 1797: that compression blocks conduction I. Bentley, F. H. and Schlapp, W. ( 1943) The effects of pres­ and that it does not cause nerve stimulation. sure on conduction in peripheral nerves. J. Physiol., Patrick Wall and his associates (197 5) have just 102. 72-82. published a paper confirming the second observa­ 2. Denny-Brown, D. and Brenner, C. ( 1944) Paralysis of nerve induced by direct pressure and by tourniquet. tion, that compression injury produces only a Arch. Neural. Psychiat., Chicago, 51, 1-26. transient burst of impulses before conduction 3. Causey, G. (1948) The effect of pressure on nerve fibers. block sets in. Here, we have been concerned with J. Anal., 82, 262-270. 160 4. Causey, G. and Palmer, E. (l 949) The effect of pressure 12. Ochoa, J., Fowler, T. and Gilliatt, R. (1972) Anatomical on nerve conduction and nerve fiber size . ./. Physiol., changes in peripheral nerves compressed by a pneumatic 109, 220-231. tourniquet../. Anal., 113:3, 433-455. 5. Edwards, D. J. and Cattell, M. (1928) Further observations 13. Robbins, H. ( 1963) Anatomical study of the median nerve on the decrement in nerve conduction.Amer. J. Physiol., in the carpal tunnel and etiologies of the carpal-tunnel 114, 359-367. syndrome . ./. Bone .It. Surf?., 45-A, 953. 6. Gasser, H. S. and Erlanger, J. (1929) The role of fiber size 14. Sunderland, S. ( 1968) Nerves and Nerve Injuries, Edin­ in the establishment of a nerve block hy pressure or burgh, Churchill Livingstone. cocaine. Amer. J. Physiol., 88, 581-591. I 5. Sunderland, S. and Bradley, K. (I 96 I) Stress-strain phe­ 7. Gelfan, S. and Tarlov, I. M. (I 956) Physiology of spinal nomena in human spinal roots. Brain, 84, 12 1-124. cord, nerve root and peripheral nerve compression. Amer. J. Physiol., 185, 217-229. 16. Tanzer. R. C. ( 1959) The carpal-tunnel syndrome: A clinical and anatomical study. J. Bone Jt. Surg., 41-A, 626. 8. Harper, W. D. Anything Can Cause A11ythi111-:.San Antonio, Texas: By the author. I 7. Wall, P., Waxman, S., and Basbaum, A. (I 975) Ongoing 9. M acG reg or, R., Sharpless, S. and Luttges. M. ( I 97 5) A activity in peripheral nerve: injury discharge. Exp. pressure vessel model for nerve compression. J. Neural. Neurol., 45, 576-589. Sciences (In press). I should like to thank the American Chiropractic I 0. Meek, W. J. and Leaper, W. E. ( 191 I) The effect of pressure Association and the International Chiropractic on conductivity of nerve and muscle. Amer . .I. Physiol., 27, 308-322. Society for supporting this research. I should also 11. Mitchell, W. (1872) Injuries of Nerves and Their Conse­ like to thank Susan Cobb, Peter Lund, and Stephen quences, Philadelphia, J. B. Lippincott Company. Young for their participation.

161 The Somatosympathetic Ref1exes: Their Physiological and Clinical Significance

AKIO SATO 2nd Department of Physiology Tokyo Metropolitan Institute of Gerontology Tokyo.Japan

1. INTRODUCTION ongoing tonic activity of sympathetic neurons, which is continuously modulated by influences Some of the important functional aspects of related to the respiratory and cardiac cycles, somatosympathetic reflexes may be summarized in impedes the quantitative measurement of excita­ this quote from A. Kuntz: 1 "'Reflex responses of tory or inhibitory effects of afferent volleys on the the viscera, including the splanchnic blood ves­ sympathetic nervous system. Fortunately, modern sels, elicited by stimulation of localized cutaneous electrophysiological · techniques have largely over­ areas with the same segmental innervation as the come these obstacles. In recent years progress has viscera in question are common physiologic been made in the analysis of the effects of somato­ phenomena. The efficacy of cold and warm appli­ sensory afferent activity on the sympathetic cations in the treatment of visceral disease un­ nervous system as well as in the analysis of the doubtedly depends upon reflex responses elicited central reflex pathways of somatosympathetic by the localized cutaneous stimulation. The seg­ reflexes. mental character of the reflex mechanisms em­ A detailed history of these studies was recently ployed appears to be obvious, but the distribution published by Sato and Schmidt (1973)2 in which of the autonomic innervation of the viscera, par­ the authors presented a summary of these new ticularly the gastrointestinal tract. is less strictly findings obtained by recording nervous activity segmental than that of the sensory innervation of and also attempted to correlate these findings with the skin. Localized cutaneous stimulation, like each other and with the results obtained by studying painful stimulation of other somatic tissues, may the effector organs. At first I will give a brief sum­ also elicit intersegmental and suprasegmental mary of this review article, and then I will discuss reflexes through autonomic nerves." recent experimental results in the cutaneo-visceral Detailed electrophysiological analysis of these reflexes. Those results are important for clinical reflexes has long been delayed, and apart from application of the basic somatosympathetic reflex rare exceptions, has largely been restricted to the system in the future. study of changes in effector organs. Several factors There are various reflex responses of the sym­ seem to be responsible for this situation, which is pathetic nervous system produced by somatic so much in contrast to the much faster progress afferents. These include reflex responses in the made in the analysis of the sensory and motor cardiovascular system, the gastrointestinal tract, functions of the nervous system: For example, it micturition, the galvanic skin reflex, etc. However, is certainly much more difficult to record action let me begin with a brief history of the somatosym­ potentials in the thin myelinated and unmyelinated pathetic reflexes in relation to the cardiovascular nerves than those in motor axons. Further, the system only, since the nervous control of the

163 cardiovascular organs has been investigated in reflexes have been performed on cats with chlora­ more detail than that of other effector organs under lose or a mixture of chloralose and urethane. The the control of autonomic nerves. first detailed evaluations of the potency of the vari­ About a century ago Carl Ludwig and his co­ ous groups of myelinated somatic afferents in. workers recorded blood pressure changes after evoking sympathetic reflexes were initiated by electric stimulation of limb nerves and studied Sato and Schmidt (I 966)7 and investigated in more the modification of these responses on transections detail by Schmidt and Schonfuss ( 1970) 8 and of the brain stem. They concluded from their re­ Sato and Schmidt ( 1971 ). n It was always seen sults that the pathways of somatosympathetic that low threshold (< 2T) cutaneous nerve stimu­ reflexes run from the spinal cord up to the medulla lation evoked sympathetic reflex discharges which oblongata and back to the preganglionic neurons. reached their maximal size at about 5T. At this In 1916 Ranson and Billingsley 3 reinvestigated the stimulus strength, all cutaneous group I I afferent problem and with weak electrical stimuli examined fibers were included in the volley. There was the medulla oblongata. They introduced the con­ always a further but small increase when the cept of the pressor and depressor centers. Cor­ stimulus was increased to include the group III rections and additions were made later by others: afferents in the volley. The effects of muscle nerve Sherrington in 1906 4 and Brooks in 1933 5 described stimulation were distinctly different from those a spinal pathway for the somatosympathetic reflex. obtained with cutaneous nerve stimulation. In Alexander ( 1946) 6 seems to be the first person who muscle nerve stimulation, the sympathetic reflex recorded somatically evoked sympathetic reflex never appeared at stimulus strength in the 2T discharges directly from sympathetic nerves. It range, i.e., at stimuli that excited practically was soon recognized that a single electrical stimulus all group Ia and lb fibers from the primary muscle to a somatic nerve can provoke a reflex discharge spindle receptors and the Golgi tendon organs, in sympathetic nerves, whereas a single shock respectively. Only when the stimulus strength usually cannot produce a detectable response in included all group II fibers (8- I OT) and ex­ cardiovascular effectors. From 1952 on Schaefer tended into the group I I I range (< I OT) was and his colleagues studied various aspects of the a large reflex observed. The effects of the various somatosympathetic reflex connections. They con­ somatic afferent fiber groups on the reflex activity firmed Alexander's results and, in addition, re­ of single sympathetic nerve units have been studied ported that, according to their findings, somatic meanwhile on the preganglionic site by Janig and afferent inputs usually elicit generalized massive Schmidt ( I 970) 10 and Sato (1972) 11 as well as on reflex discharges in all types of sympathetic effer­ postganglionic units in cutaneous (J anig, Sato ents followed by a generalized postexcitatory and Schmidt I 972) 12 and muscle nerves (Koizumi depression. and Sato 1972). 13 In the investigation of somatosympathetic re­ Unmyelinated somatic afferents. It has been flexes, direct recording of the action potentials from known that high-threshold electrical stimulation sympathetic nerves has advantages over recording of somatic nerves produces increases in blood from effector organs, particularly when studying the pressure (see Ranson's Review I 921 14 ). With central organization and the mode of operation of modern electrophysiological techniques it was these reflexes. In addition, one avoids the blurring shown by Laporte and Montastruc ( 1957) 15 and of time relationships introduced by the great inertia Laporte, Bessou, and Bouisset (I 960) 16 that these­ of the neuroeffector transmission. It is surprising, pressor effects were clearly related to the activa~ therefore, that almost 20 years elapsed between tion of unmyelinated afferent fibers. More re­ the pioneering work of Alexander and the begin­ cently there have been demonstrations of mass ning of a detailed and rigorous investigation of the reflex discharges in sympathetic nerves induced by somatos ympathetic reflexes. group IV somatic afferent volleys (Fedina, Ka­ tunskii, Khayutin, and Mitsanyi I 966, 17 Coote II. SOMATIC AFFERENT SYSTEMS and Perez-Gonzalez 1970, 18 Khayutin and Luko­ PRODUCING SOMATOSYMPATHETIC shkova 1970, 19 Koizumi, Collin, Kaufman, and REFLEXES 0 21 Brooks I 970/ Schmidt and Weller I 970 ). The Myelinated somatic afferents. Most of the physi- group IV reflex, as it may be called, usually re­ ological experiments on somatosympathetic quires a temporal facilitation of afferent volleys. 164 The much longer latency of group IV reflexes afferent input relative to the segmental level of relative to those induced by group I I and 111 vol­ the white ramus from which it is recorded: Its leys is practically entirely due to the low conduc­ amplitude was largest when the afferent volley tion velocity of the unmyelinated afferents. entered the spinal cord at the same or adjacent Analysis of the influence of somatic group IV segment of the white ramus under observation. In afferents on single postganglionic units on cu­ contrast, the size of the late reflex was rather taneous nerves was covered by J anig, Sato, and independent of the segmental level of afferent input 12 26 27 Schmidt ( I 972) on muscle by Koizumi and Sato (Sato and Schmidt 1971, Sato 1972 ). (1972). 1:3 Spinal reflex potentials in nonanesthetized spinal cats were first reported by Beacham and Perl in III. CENTRAL PATHWAYS OF 8 2 1 1964,2 • r who showed that the potentials have a SOMATOSYMPATHETIC REFLEXES polysynaptic pathway by measuring their central In this section the evidence regarding the various reflex time. central pathways of the various somatosympathetic The results reviewed so far can be summarized reflex components will first be taken from experi­ by saying that afferent volleys in myelinated ments where the recording was done from the somatic afferents have a twofold action on the lumbar sympathetic trunk and from lumbar white sympathetic nervous system: A more generalized rami, because, at these recording sites, the latency action via the supraspinal sympathetic reflex differences between the various components are centers and a more circumscribed action on the most pronounced: The reflexes evoked by myeli­ preganglionic neurons at the segmental level. This nated somatic afferents (group 11 and 111 fibers) generalization is in line with the results and con­ have reflex pathways at three different levels of clusions of a variety of investigations where the the central nervous system; the spinal, medullary, somatically evoked reflexes were recorded from supramedullary. On the other hand those reflexes more peripheral sites of the sympathetic nervous evoked by unmyelinated somatic afferents (group system, such as the renal and cardiac sympathetic IV fibers) have only two pathways; spinal and nerves (Sell, Erdelyi, and Schaefer 1958,30 medullary. Weidinger, Fedina, and Kehrel 1963,a1 Coote and Central pathways of reflexes induced by myeli­ Downman I 966,=i2 Katunsky and Khayutin 1968,33 34 nated somatic afferents. In cats anesthetized with. Kirchner, Sato, and Weidinger 1971 ). Usually in chloralose, single-shock electrostimulation of the these experiments peripheral limb nerves were sciatic nerve produced two mass reflex discharges stimulated, so the reflexes were more or less of the in the lumbar sympathetic trunk with latencies of medullary variety only. 25-50 and 80-120 msec, respectively, termed In addition to the early spinal and late supra­ the "early" and "late" reflex potentials (Sato, spinal reflex components induced by myelinated 22 Tsushima and Fujimori 1965 ). It was shown somatic afferents, Sato (1972) 35 has recently re­ that the early response was transmitted via spinal ported the existence of a "very late" reflex dis::­ pathways, the late one via the medulla oblongata. charge with a latency of 300-350 msec when In mass recordings from lumbar white rami it was recorded from lumbar white rami. This late reflex seen that the late reflex was evoked by low- and is seen only in animals under light chloralose high-threshold myelinated afferents (group I I anesthesia, which may be the main reason why it and II I afferents), whereas the early component has not been previously recognized. It was con­ appeared only when the high-threshold afferents cluded that the very late reflex discharge has a group I I I were also included in the volley (Sato, suprapontine reflex pathway. Kaufman, Koizumi, and Brooks 1969). 23 In Central pathways of reflexes induced by un­ chronic spinal cats the low-threshold (group 11) myelinated somatic afferents. The various and myelinated afferents also evoked the early reflex often conflicting reports on somatosympathetic but the late component never reappeared (Koizumi, reflexes evoked by unmyelinated somatic afferents 24 Sato, Kaufman, and Brooks 1968 ) even if the (group IV reflexes) have been reviewed in some spinalized animal was kept for 3 months or longer detail by Schmidt and Weller ( I 970). 21 More 25 after the operation (Sato 1973 ). recently Sato in I 973 25 in a series of experiments The size of the early reflex component seems to on intact, acute, and chronic spinal cats was able depend to a great extent on the segmental level of to resolve most of the existing discrepancies and 165 to present a coherent picture of the group IV by the four major reflex pathways -the early. late. reflex pathways: (I) Afferent inputs entering the and very late group I I and 11I afferent reflex path­ spinal cord at the same or adjacent segment of ways and the group IV reflex pathway (figure 1). the sympathetic outflow under observation evoke All 16 combinations of response behavior have group IV reflexes. The group IV reflexes are seen been found. and surprisingly, there were as many after single volleys and do not need temporal neurons showing a high degree of specificity (22 facilitation. The pathway for these reflexes is neurons were excited via one pathway only) as complete at the spinal level. (2) Afferent inputs neurons having a high degree of convergence (36 entering the spinal cord at segments different from had convergence from all 4, 24 from 3 pathways). those in which the sympathetic outflow is measured At present it is an open question as to what extent evoke the group IV reflexes in the anesthetized the great variety of reflex response patterns of animal with intact neuraxis. Temporal facilitation preganglionic units reflects different functional is needed to obtain maximum reflex effects. This roles and/or destinations in different effector reflex disappears after spinal transection; its path­ organs. way is presumably complete at the medullary The various central pathways of somato-sym­ level. (3) In well-kept chronic spinal cats. about 3 pathetic reflexes ending in preganglionic units months after operation. afferent inputs entering are outlined in figure 1, which contains all the the spinal cord at segments different from those information presently available in regard to the from which the sympathetic outflow is measured convergence of the central excitatory and inhibitory elicit the group IV reflexes that are not seen in the effects of somatic nerve activity on the pregan­ intact anesthetized animal and do not need temporal glionic side of the sympathetic nervous system. facilitation for maximum reflex effects. In the postganglionic fibers of the cutaneous Convergence of various reflex pathways on nerves of the hindlimb, stimulation of hindlimb preganglionic and postganglionic neurons. By nerves evokes the late medullary reflex in the testing the discharge properties of single pregan­ majority of nerve units. whereas the group IV glionic neurons in lumbar white rami it is possible reflex is elicited in a much smaller percentage of to determine to what extent the preganglionic units (Janig, Sato, and Schmidt 1972 t:!). In muscle neurons serve or do not serve as a final common nerves of the hindlimb the situation is reversed: path for the different reflex pathways (Kaufman and More units show group IV reflexes than medullary 16 11 1 Koizumi, 1971 = ). So far. Sato (1972) tested reflexes (Koizumi and Sato 1972 :1). All these 76. sympathetic single units for their excitation units, both in muscle and cutaneous nerves, are

Somata-sympathet,creflex d,scharges: functionalreflex pathwaysin CNS

supromedullary suprnmedullary I ? reflex reflex center center

L WR L or 1 spinal 1 2 reflex sp,nal afferents center A B Group l'l afferents

hind-limb afferents t11nd-l1mb 'llferenls

Fig. 1. Central reflex pathways of somato-sympathetic re­ tlexes. A: Central pathways of those reflexes induced by myelinated somatic afferents. B: Corresponding pathways for unmyelinated afferents. Thicknesses of various pathways are a measure of their potency. Excitatory or inhibitory effects are indicated by + and - signs. respectively. Sizes of signs provide a rough measure of effectiveness of excitatory or inhibitory action. 166 considered to be vasoconstrictors, the difference those at the effector organ level. For the last year in their response behavior indicating their different our laboratory has been carrying on a systematic functions. series of experiments of the somato-visceral re­ flexes both at the level of visceral organs such as IV. RECENT STUDIES ON THE CUTANEO­ the heart, gastro-intestinal tract and urinary blad­ YISCERAL REFLEXES der and at the level of the autonomic nerve fibers. The purpose of this series of the experiments is As noted above some of the most interesting first to determine the existence of somato-visceral and important recent findings in the field of neuro­ reflex responses and second, if there is any reflex physiological studies seem to be the establishment response, to analyze the neural control mechanism of propriospinal as well as supraspinal components of the reflex. I would like to introduce some of the in the somato-sympathetic reflexes and the analysis results of our recent series of experiments on the of the segmental organization of the propriospinal cutaneo-visceral reflexes in rats (Sato, Sato, reflex. The question then arises: Can the results Shimada, and Torigata 1975:i7.aH,:rn), since I be­ of this recent neurophysiological analysis of the lieve these results are important not only in the somato-sympathetic reflexes be actually applied field of basic research of the somato-sympathetic to the reflex responses of the visceral organs in reflexes, but also for developing clinical appli­ response to somatic afferent excitation? Little cations of these reflexes. is known concerning the somato-visceral reflex Cutaneo-gastric reflexes. When the intra-pyloric responses, and there is a great gap between the balloon pressure was increased from O to about results of recent studies at the nerve level and the I 00 to 130 mm H'.!O levels, pyloric contractions

2 2 2kg stim.A __ _J l ______J o B. _fl ______1 o =--s-1.--C ___ ] o

pyloric :,',/J'IJ'v\ vVvv'vVvl.J]150N0;, 1\ H~iJJi,:]150 'M!~}f',]150 pressure \ .)'l ~ ~uUVVv ~ mmH20 vv 100 v 100 100 B.P. t ...... I I ]'50 •rs: rommHg ....___~ 0 .____, 0 60s D~ E I 40

~ 30 ~ : 20 Cl) C: 0 ~ 10 \ cf{') ~ 0 CD a) ® © ® ® (J) ~N stimulated areas Fig. 2. Effect of cutaneous nociceptive stimulation on the gastric movement. Examples of changes in pyloric pressure (middle traces) produced by nociceptive stimulation of the abdominal skin (as indicated in top traces) are shown in three different rats (A, B, and C) with simultaneous recordings of blood pressure (lower traces). A: CNS intact chloralose anesthetized rat. B: Decerebrated nonanesthetized rat. C: Spinalized anesthetized rat. D.: Various areas on the left mammillary line used for nociceptive stimulation. E: Histogram summarizing the results of changes in pyloric pressure produced by stimulation of various areas indicated in D in the seven rats before spinal transection (white column) and in the seven rats after spinal transection (hatched column) (from Sato et at.:i 7 ).

167 of five to six per minute were observed and con­ recorded from sympathetic nerve tinuously recorded. The pyloric pressure decreased after nociceptive stimulation of the abdominal control ( vagi cut) skin in the CNS intact anesthetized, the decere­ imp/s brated nonanesthetized and spinalized rats as , ,"./:,' ,· 25 (.':,_."-f'",",':-j~•-•·1/'_,·/'~ • '·.•.-,./,.,. ~ ..f1,.,r},,[,jh,..J,:'iftr,;'~,J'','r,~] shown in figure 2(A. B, C). This inhibitory pyloric A •• , -. ;"J• J 'J ·,1•- •'" , JJ. .~·- 0 response was completely abolished after destroy­ \.--I ing the spinal cord between Th5 to Th 11 by passing a small wire cable back and forth in the after spinal transection vertebral canal several times. Therefore the ~-. imp/s inhibitory pyloric response must have been pro­ duced as a result of cutaneo-gastric reflex re­ B ...... /~-:-Ji:--,·.j:::-'_._ \.~·\,r.~./\--_~:i./'--~->--:.:·~r:--t~~.] 205 sponse. Transection of the bilateral vagal nerves L...... :J at the cervical level did not abolish the inhibitory cutaneo-gastric response. On the contrary the inhibitory cutaneo-gastric response was abolished completely after ( 1) cutting the bilateral splanchnic nerves, or (2) crushing bilateral coeliac ganglia recorded from vagus_ in the rat whose vagal nerves were intact. These imp/s results indicate that the sympathetic nerve activity rv,, ,,,.. is essential for the inhibitory cutaneo-gastric C -,;,:;,.,,..,,.,,,.--:v-~... ""'""-: Js~ response. Nociceptive stimulation of the abdominal skin produced an increase in the discharge activity stim.(20s) of a postganglionic sympathetic nerve branch to Fig. 3. Effect of cutaneous nociceptive stimulation on dis­ the stomach in the CNS intact anesthetized rat charge activity of the autonomic nerves innervating the stomach. and as well as in the same rat after spinal transec­ A and B: Discharge activities recorded from a sympathetic tion as shown in figure 3(A and B). On the contrary, nerve branch going to the stomach, before (A) and after (B) spontaneous nerve activity recorded from gastric spinal transection in the same rat. C: Recorded from a vagus nerve branch going to the stomach. Nociceptive stimulation vagal nerve branches was not influenced by was given to the abdominal skin for 20s as indicated by under­ nociceptive stimulation of abdominal skin as shown bars (from Sato et al? 7). in figure 3(C). From the data on denervation and action potentials of the gastric sympathetic as reflex response is primarily a propriospinal somato­ well as parasympathetic nerve branches it was sympathetic reflex. concluded that the reflexly increased discharge Cutaneo-cardiac reflexes. In CNS intact chlora­ activities of the gastric sympathetic nerve branches lose anesthetized rats or in the decerebrated are responsible for producing the inhibitory cu­ nonanesthetized rats, nociceptive cutaneous stimu­ taneo-gastric reflex responses and that the reflex lation of the various areas on a mammillary does occur at the spinal level. The vagal efferent line could reflexly produce changes in the heart activity does not seem to be directly responsible rate as shown in figure 4(A and B). When the rectal for producing the cutaneo-gastric reflex. The total temperature was maintained at around 38.5° C, results of pyloric pressure response to nociceptive stimulation of all these skin areas caused an in­ stimulation of various localized skin areas (as crease in the heart rate. However after spinal shown diagrammatically in figure 2(0) of the 7 CNS transection at the cervical level, a large response intact and 7 spinal rats are presented in a histogram in the heart rate could be obtained only by cu­ in figure 2(E). This histogram shows that the taneous stimulation of the chest (see figure 4(C)). pyloric pressure was strongly decreased by stimu­ Therefore. in this excitatory cutaneo-cardiac lation of the abdominal or near abdominal skin reflex. it should be emphasized that the segmental areas and that stimulation of other areas had little organization of the reflex is clear in the spinalized effect. Especially it should be emphasized that preparation and that this segmental organization the reflex responses in the CNS intact as well is modified into a generalized reflex response by the as in the spinal rats are almost identical. Those existence of the supraspinal structures (see figure results indicate that the inhibitory cutaneo-gastric 4 D and E). Furthermore. it was shown that the

168 A B C beats/min ]480 530 420 __,,..______]490 ---r----- ]380 HR ..... A 440 200 BP ] 150mmHg •]2°°100 100 ...... ] 50 stim.(20s) stim.(20s) stim.(20s)

30 D C E E '­ a, ; 20 ::c C

(I) ~ 10 C, a, '­u C 0

stimulated areas

Fig. 4. Effect of cutaneous nociceptive stimulation on the heart rate. Examples of changes in heart rate (upper traces) produced by nociceptive cutaneous stimulation of the chest are shown in three different rats (A. B. and C) with simultaneous recordings of blood pressure (lower traces). A: CNS intact chloralose anesthetized rat. fl: Decerebrated nonanesthetized rat. C: Spinalized rat. Stimulations were given for 20s as indicated by bottom bars. D: Various areas on the left mammillary line used for nociceptive stimu­ lation. E: Histogram summarizing the results of changes in heart rate produced by stimulation of various areas indicated in Din the same rat before (white column) and after (hatched column) spinal transection.

A 100nmf20 vesicol pr@SSlle l 50 pelvicn. octivity ______.~-~___,l~------.....,.--J~ mp~

50 imp/s -44--~.,,._.....,...._....,._,,."""""'_.,.,..--~~ ] 0

BP 115:mmHg

stim.(20sl stim.(20s) stim.(20s) stim.(20s) touch pinch touch pinch

Fig. 5. Effect of perinea! cutaneous stimulation by touching and pinching on vesical pressure. Results in A and B were ob­ tamed in the same rat, anesthetized with chloralose-urethane. Results in A were taken before spinal transection, and those in B were taken after spinal transection at the second cervical level. Intravesical pressure (the top traces in A and B). Pelvic nerve activity (the second traces from the top). Hypogastric nerve activity (the third traces from the top) and blood pressure (the fourth traces 38 from the top). Each stimulation by touching and pinching was given for 20s as indicated by the bottom bars (from Sato et al. ).

169

597-036 0 - 76 - 12 increased activity of the cardiac sympathetic nerve middle thoracic level. This excitatory cutaneo­ branches is essential for producing such an ex­ vesical reflex was shown to be a propriospinal citatory cutaneo-cardiac reflex. In other words. the reflex whose efferent pathways are the pelvic somatosympathetic reflexes are responsible to the nerve branches. This is the somato-parasympathetic excitatory cutaneo-cardiac reflexes. reflex. Cutaneo-vesical reflexes. When the intravesical When the intravesical pressure was set to about balloon pressure was slightly increased by inject­ 2 I 5 ± 55 mm H20 by injecting water 0.1 to 0.7 cc ing water into balloon from 0 to a low intravesical into the balloon, fairly large rhythrnical contrac­ pressure of about 40 ± 25 mm HzO spontaneous tions, called micturition contractions. with ampli­ contractions with a low amplitude of about 10 ± 5 tude of 610 ± I 50 mm H20 of a frequency of about mm H20 could be continuously recorded. These 0.6 to 3 per minute were obtained. These micturi­ vesical contractions were observed essentially tion contractions were completely abolished either in the same manner in the CNS intact anesthetized. after denervation of the bilateral pelvic nerve the decerebrated nonanesthetized and the spi­ branches or after spinal transection at the cervical nalized rats. Touch or nociceptive cutaneous or at the middle thoracic level. Therefore. these stimulations to the perinea) area caused an abrupt rhythmic micturition contractions must have been increase in the intravesical pressure of about 20- activated by pelvic efferent nerve activity due to 60 mm H20 as shown in figure 5. Corresponding to the existence of the supraspinal structures. Simul­ increases in the intravesical pressure due to taneous recordings of the efferent discharge activity perinea! stimulation. there were always marked· of the pelvic vesical nerve branches showed rhyth­ increases in discharge activity of the pelvic nerve mic discharges corresponding to the large vesical branches to the bladder. Simultaneously, some contractions. Cutaneous nociceptive stimulation very slight changes in discharge activity of the localized in the perinea! area most often caused hypogastric nerve branches to the bladder were an inhibition of the large contractions as well as noted. These responses essentially remained the the disappearance of the rhythmic discharges of same in the animal after spinal transection at the the pelvic vesical nerve branches as shown in

vesicol pressure pelvicn. activity

stim.(20s)

vesical pressure

stim.(20s)

Fig. 6. Effect of cutaneous nociceptive stimulation on micturition contractions of the bladder. Micturition contractions (upper traces in A and B ). Pelvic nerve activity (bottom trace in A) and hypogasyric nerve activity (bottom trace in B ). The results in A and B were taken from the same CNS intact chloralose anesthetized rat. Nociceptive stimulations were 8 given to the perinea( skin for 20s as indicated by the bottom bars in A and B (from Sato et al.:i ).

170 figure 6. These results indicate that perineal taneously active single preganglionic sympathetic units. stimulation can reflexly affect bladder function, in Arch. Ges. Physiol. 333:70-81, 1972. 12. Janig, W., Sato, A., and Schmidt, R. F. Reflexes in post­ either an excitatory or inhibitory way depending ganglionic cutaneous fibers by stimulation of group I on whether the bladder is or is not resting. to group IV somatic afferents. Arch. Ges. Physiol. 331: 244-256, 1972. V. CONCLUDING REMARKS I 3. Koizumi, K., and Sato, A. Reflex activity of single sym­ began with a brief review of neurophysiolog­ pathetic fibers to skeletal muscle produced by electrical stimulation of somatic and vago-depressor afferent ical studies on the somato-sympathetic reflexes nerves. Arch. Ges. Physiol. 332:283-301, 1972. and, in particular, of recent results of somatic 14. Ranson, S. W. Afferent paths for visceral reflexes. Physiol. afferents producing sympathetic reflexes and the Rev. I :477-522, 1921. central reflex pathways of these reflexes. Then I I 5. Laporte, Y., and Montastruc, P. Role des differents types discussed recent studies on the cutaneo-visceral de fibres afferentes dans les reflexes circulatoires ge­ neraux d'ori~ine cutanee, J. Physiol. (Paris) 49: 1039- reflexes performed in rats. I would like to empha­ 1049, I 957. size again that the functions of the various visceral 16. Laporte, Y., Bessou, B., and Bouisset, S. Action reflexe organs can be influenced by a proper cutaneous des differents types de fibres afferentes d'origin mus­ stimulation as a result of the somatosympathetic culaire sur las pression sanguine. Arch. Ital. Biol. 98: or the somatoparasympathetic reflexes. I trust 206-221, I 960. 17. Fedina, L., Katunskii, A. Y .. Khayutin. V. M., and Mit­ that such research will be expanded to include a sanyi, A. Response of renal sympathetic nerves to stimu­ higher species of mammals, i.e. cats and monkeys lation of afferent A and C fibers of tibial and mesenterial and that finally, this knowledge of the cutaneo­ nerves. Acta Physiol. A cad. Sci. Hung. 29: 157-176. visceral reflexes will be clinically useful in altering 1966. the visceral functions of humans. 18. Coote, .I. H., and Perez-Gonzalez, J. F. The response of some sympathetic neurones to volleys in various afferent REFERENCES nerves. J. Physiol. ( London) 208:261-278, I 970. I 9. Khayutin, V. M., and Lukoshkova, E. V. Spinal mediation I. Kuntz. A.. Anatomic and physiologic properties of cutaneo­ of vasomotor reflexes in animals with intact brain studied visceral vasomotor reflex arcs. J. Neurophysiol. 8: hy electrophysiological methods. Arch. Ges. Physiol. 421-430, 1945. 321: I 97-222, 1970. 2. Sato, A.. and Schmidt, R. F. Somatosympathetic re­ 20. Koizumi, K .• Collin, R., Kaufman, A., and Brooks, C. McC. flexes: Afferent fibers, central pathways, discharge Contribution of unmyelinated afferent excitation to characteristics. Physiol. Rev. 53:916-947, I 973. sympathetic reflexes. Brain Res. 20:99-106, 1970. 3. Ranson, S. W., and Billingsley, P. R. Vasomotor reac­ 21. Schmidt, R. F., and Weller, E. Reflex activity in the cervical tions from stimulation of the floor of the fourth ventricle. and lumbar sympathetic trunk induced by unmyelinated Studies in vasomotor reflex arcs. I I I. J. Physiol. ( London) somatic afferents. Brain Res. 24:207-218, 1970. 41:85-90, 1916. 22. Sato, A., Tsushima, N., and Fujimori, B. Reflex potentials 4. Sherrington, C. S. The lnte~ratil'e Action of the Nerwms of lumbar sympathetic trunk with sciatic nerve stimu­ System. New Haven, Conn: Yale Univ. Press, 1906. lation in cats. Japan. J. Physiol. 15:532-539, 1965. 5. Brooks, C. M. Reflex activation of the sympathetic system 23. Sato, A., Kaufman, A., Koizumi, K., and Brooks, C. McC. in the spinal cat. Am. J. Physiol. I 06:251-266, I 933. Afferent nerve groups and sympathetic reflex pathways. 6. Alexander, R. S. Tonic and reflex functions of medullary Brain Res. 14:575-587, I 969. sympathetic cardiovascular centers. J. N europhysiol. 24. Koizumi, K., Sato, A., Kaufman, K., and Brooks, C. McC. 9:205-217, J 946. Studies on sympathetic neuron discharges modified by 7. Sato, A., and Schmidt, R. F. Muscle and cutaneous affer­ central and peripheral excitation. Brain Res. 11:212- ents evoking sympathetic reflexes. Brain Res. 2 :399-40 I, 224, 1968. 1966. 25. Sato, A. Spinal and medullary reflex components of the 8. Schmidt, R. R., and Schonfuss, K. An analysis of the reflex somato-sympathetic reflex discharges evoked by stimu­ activity in the cervical sympathetic trunk induced by lation of the group IV somatic afferents. Brain Res. 51: myelinated somatic afferents. Arch. Ges. Physiol. 314: 307-3 I 8, I 973. 175- I 98, I 970. 26. Sato, A., and Schmidt, R. F. Spinal and supraspinal com­ 9. Sato, A., and Schmidt, R. F. Ganglionic transmission of ponents of the reflex discharges into lumbar and thoracic somatically induced sympathetic reflexes. Arch. Ges. white rami. J. Physiol. (London) 212:839-850, 1971. Physiol. 326:240-253, I 971. 27. Sato, A. Spinal and supraspinal inhibition of somato­ 10. Janig, W., and Schmidt, R. F. Single unit responses in sympathetic reflexes by conditioning afferent volleys. the cervical sympathetic trunk upon somatic nerve Arch. Ges. Physiol. 336:121-133, 1972. stimulation. Arch. Ges. Physiol. 314:199-216, 1970. 28. Beacham, W. S., and Perl, E. R. Background and reflex 11. Sato, A. The relative involvement of different reflex path­ discharge of sympathetic preganglionic neurones in the ways in somato-sympathetic reflexes, analyzed in spon- spinal cat. J. Physiol. (London) 172:400-416, 1964.

171 29. Beacham, W. S .• and Perl, E. R. Characteristics of a spinal 35. Sato, A. Somato-sympathetic reflex discharges evoked sympathetic reflex. J. Physiol. (London) 173 :43 I -448, through supramedullary pathways. Arch. Ges. Physiol. 1964. 332:117-126, 1972. 30. Sell, R., Erdelyi, A., and Schaefer, H. Untersuchungen 36. Kaufman, A., and Koizumi, K. Spontaneous and reflex i.iber den Einflu,8 peripherer Nervenreizung auf die activity of single units in lumbar white rami. In: Research sympathische Aktivitat. Arch. Ges. Physiol. 267:566- in Physiology, A Liber Memorialis in Honor of Prof. 581, 1958. Chandler McC. Brooks, edited by F. F. Kao, M. Vasalle, 31. Weidinger, H .. Fedina, L., and Kehrel, H. Der Einflu,8 and K. Koizumi. Bologna: Aulo Gaggi Publ., pp. 469- von Adrenalin auf die Tatigkeit des "Sympathicus." 48 I, I 971. Arch. Ges. Physiol. 278:229-240, I 963. 37. Sato, A., Sato, Y., Shimada, F., and Torigata, Y. Changes 32. Coote, J. H., and Downman, C. B. B. Central pathways in gastric motility produced by nociceptive stimulation of some autonomic reflex discharges. J. Physiol. ( Lon­ of the skin in rats. Brain Research, 87:151-159, 1975. don) 183:714-729, 1966. 33. Katunsky, A. Y., and Khayutin, V. M. The reflex latency 38. Sato, A., Sato, Y., Shimada, F., and Torigata, Y. Changes and the level of mediation of spinal afferent impulses in vesical function produced by cutaneous stimulation to the cardiovascular sympathetic neurones. Arch. in rats. Brain Research, 94:465-474, 1975. Ges. Physiol. 298:294-304, I 968. 39. Sato, A., Sato, Y., Shimada, F., and Torigata, Y. Varying 34. Kirchner, F., Sato, A., and Weidinger, H. Bulbar inhibition changes in heart rate produced by cutaneous nociceptive of spinal and supraspinal sympathetic reflex discharges. stimulation of the skin in rats at different temperature. Arch. Ges. Physiol. 326:324-333, I 97 I. Brain Research (in press).

172 Pain: Spinal and Peripheral Nerve Factors

EDWARD R. PERL Professor Department of Physiology University of North Carolina

This discussion is not meant as an extensive Figure 1 provides a simplified, diagrammatic survey of the peripheral and spinal cord mechanisms representation of some neural processes or steps associated with physical pain, but rather as a selec­ that appear common to all sensations, regardless of tive consideration of morphological, physiological modality. Sensations begin with a certain state (or and pathophysiological factors of importance to change) of the body's internal or external environ­ this question. The emphasis has been dictated as ment. In this regard, the apparent variety and much by what is known about pain-related neural ubiquitous effectiveness of environmental altera­ mechanisms as by what might be germane to the tions or stimuli responsible for pain puzzled early question of the alteration of pain by manipulation. observers. Sherrington 5 provided insight by point­ Pain as a sensation. It is now generally accepted ing out that stimuli threatening the physical integrity that pain is a somatic sense, a perceptual experi­ of tissue regularly cause pain. On this basis, he ence akin to the appreciation of touch and tempera­ suggested labelling stimuli which tend to, or ture.1 It has been argued that pain has special actually damage tissue as noxious, thereby implying attributes which set it aside from other sensa­ a damaging quality. Noxious stimuli can be of any tions 2, 3 ; however, our present understanding type - mechanical, chemical, radiant: the intensity suggests that there are more similarities than which becomes noxious can be expected to differ differences between pain and other sensations. 4 according to the tissue type and its location. Thus, a starting point for considering the sensory mecha­ RECEPTIVE nisms leading to pain consists of determining the PROCESSES means by which noxious circumstances (stimuli) are detected. In figure 1 this step is indicated as i "receptive processes"; the latter are followed by PERIPHERAL transmission of information centrally. The neural TRANSMISSION discharges produced by every sensory receptor are projected to more than one nucleus or locus of the central nervous system and in the process are CENTRAL/_. REACTIONS modified or operated upon by other neural mecha­ TRANSMISSION nisms. Finally, with varying directness, reactions take place, one of which is associated with con­ - SUBCONSCIOUS ~ ABSTRACTION} ______+t (REFLEXES) '~ scious or perceptual recognition of the stimulus. INTEGRATION f: ----- CONSCIOUS \) Figure 1 suggests the existence of considerable PROJECTION - - - _ +t (PERCEPTION) /; interaction between the various concomitants - ... AFFECTIVE /I of sensation, a consideration which must be kept (EMOTIONS)~ in mind whenever modification of an endpoint such Fig. 1. Schematic representation of neural processes as­ as conscious appreciation of pain is considered. sociated with conscious sensation. Receptive processes. The events in the detection 173 of the stimulus by a sense organ deserve brief however. there is recent evidence that a number of attention in view of later pathophysiological con­ fine diameter (unmyelinated) ventral root fibers are 7 8 siderations. The stimulus, in our case a noxious sensory in function • • This fact may be significant event, causes a change in the tissue surrounding in pain associated with the back and its alteration specialized sense cells or a sensory nerve terminal. by manipulation. The results of the changes in the tissue -mechani­ cal distortion. a physiochemical interaction and/or the liberation of a substance -in turn cause a decrease of the transmembrane potential of specialized sense cells or directly of a sensory A 100 25 nerve terminal. Only then are the conducted action 15 potentials initiated. This process involves the trans­ duction of the energy of the stimulus into a series of discontinuous events, action potentials, in the B elongated extensions of sensory nerve cells in the dorsal root ganglia which make up the sensory component of the peripheral nerves. Fig. 2. Compound action potential recorded from a human cutaneous nerve in 1·itro. A - response to a supramaximal Peripheral transmission. Conveying information stimulus. 8- stimulus intensity evoking report of pain in par­ by impulses places constraints on the quantity of tially conscious patient before leg amputation. Weaker stimuli, information which a given channel (nerve fiber) can not exciting group conducting at 25 m/sec, did not cause report transmit. It seems apparent that a single kind of of pain. Figures are calculated conduction velocity in meters/sec. (From Heinbecker, Bishop and O'Leary, 1933.) nerve element does not have the capacity to provide information necessary to distinguish be­ tween the various stimuli man or animals encounter The sense organs or receptors associated with in their natural history and to give data on the in­ pain. There are many different types of somatic tensity of such events. Somatic sense organs (sen­ sense organs. It has been postulated from time to sory receptors) exhibit specialization in sensitivity time that those associated with other sensations, for to various kinds of stimuli; one type readily excited example, touch-pressure, respond in some unusual by a class of events as, for example, a transient way to noxious stimuli and thereby signal pain­ mechanical distortion, is poorly excited by others 3 causing circumstances • This possibility has been such as temperature changes. Clues to a specializa­ systematically tested for a number of types of tion of sense organs for noxious stimuli and pain somatic sense receptors by comparing the responses came from experiments originally done over 40 9 10 evoked by non-noxious and noxious stimuli. • • years ago. which demonstrated that only part of the Per! unpublished An example is illustrated in figure 3, afferent fibers making up typical peripheral nerves which in graphic form displays the impulse by are critical for the evocation of pain or pain-like impulse pattern of activity in a slowly-conducting reactions. Figure 2, taken from a paper by Hein­ primary afferent fiber initiated by controlled 6 becker, Bishop and O'Leary published in I 933 • mechanical stimuli. Figure 3A and B show the shows compound action potentials recorded from a pattern of impulses to mechanical deformation of man's peripheral nerve; several deflections the skin by a blunt probe which did not damage the appearing after a single electric shock result from skin (and was not painful to man.) Figure 3A' and the different conduction velocities of impulses B' show the responses initiated by a mechanical in fractions of the population of fibers making up movement of the same amplitude and location by a the nerve. By graded stimulation or selective block sharp needle which penetrated the skin. The of the different fibers contributing to components graphs show no systematic difference in the re­ of the compound action potential. it became known sponse patterns. Similar results have been obtained that for pain to result. slowly-conducting, fine- whenever somatic sense organs with a low threshold · l 16 calibered afferent fibers must con d uct 1mpu ses . (high sensitivity) to non-noxious stimuli, including It has been generally assumed that afferent those with slowly-conducting peripheral nerve fibers producing pain, like most afferent fibers, fibers, have been subjected to a deliberate test of enter the spinal cord through the dorsal spinal roots: differences in response between non-noxious and 174 noxious stimuli. These data have two implications: more vigorously when a still more damaging ( 1) ordinary receptors do not provide appropriate stimulus, pinching with a sharp toothed forceps, signals to allow the central nervous system to was used. distinguish between noxious and non-noxious Several kinds of high threshold sensory recep­ events and (2) not all primary afferent neurons with tors have been identified. In the skin certain high slowly-conducting fibers are important for the threshold receptors are responsive only to mechani­ process of nociception and pain. cal stimuli. while others are excited by a variety

BO- A 80 8 70 70 60 60 50 .. 50 ., 40 f 40 . 30 30 •!, 20 . 20 . C) - - .. z ,.,·,·.. ·:., 0 10 10 -... u ... ·- . . w ...... Cf) . . ,------I 0 0 1 I sec 1 ct: I sec w a... en 50 A' 50 B' w . Cf) \ 3 40 40 a... ,, .. ~ 30 ••.. 30 . , ,. 20 ~ 20 ..... ,_,...... ,_ -. 10 ...... 10 . .. . 0 0 1 I sec I I sec

Fig. 3. Plot of responses of a low threshold cutaneous mechanoreceptor with a slowly conducting "C" afferent fiber to non­ noxious (A, B) and noxious (A'. B') stimuli. Stimulus timing and form shown in tracing below the graphs. Stimuli were 1200 µ. move­ ments by an electromechanically controlled probe with a blunt ( I mm diameter) for A, B and sharp (needle) tip for A', B '. A series were the first and B series the third of a sequence with each probe. Graph ordinates show "instantaneous frequency," i.e .• the re­ ciprocal of the time interval between successive impulses. (From Bessou, Burgess, Perl and Taylor, 197 I.)

Such conclusions emphasize the importance of of noxious events, heat, strong mechanical stimu­ studies which have shown that a fraction of primary lation and irritant chemicals. High threshold recep­ afferent neurons with slowly-conducting peripheral tors in muscles are excited by intense pressure or afferent fibers have elevated thresholds for all kinds other non-physiological muscle distortion and by 11 14 of somatic stimuli.!'· , I:! An example is shown in certain irritant chemical agents. ia, Joint receptors figure 4. In figure 4A. pressure was directed against have been identified which discharge only when a a spot on the skin by a small disc with forces ex­ joint is extended beyond its normal or physiologi­ ceeding I 00 gm. and no impulses were evoked in cal range. 15 It is interesting that the unmyelinated the afferent nerve fiber. In figure 48. the small afferent fibers recently demonstrated in ventral disc was replaced with a sharp needle and the same roots are reported to be largely of the high thresh- spot on the skin was pressed upon, the needle old type: in a sacral root, the majority of un­ penetrating the skin at forces exceeding 5 gm.~ myelinated afferent fibers were found to innervate impulses were regularly initiated by this clearly visceral structures.7· 8 noxious form of stimulation. Figure 4C shows Hyperalgesia and inflammation. Noxious stimu­ that this "high threshold" receptor responded even lation of the skin and certain other structures is 175 A repeated stimuli have been observed for nocicep­ tors with unmyelinated afferent fibers. The poly­ modal nociceptors of the skin, a sensory receptor neuron with an unmyelinated or (C) fiber, respond vigorously to intense mechanical stimuli, noxious heat and irritant chemicals. The response of one such element to a controlled heating of the skin is graphically shown in figure 5A. After the heating phase in which the receptor was activated, the B receptor began a low frequency discharge at skin If.11 temperatures below its original threshold. Such on­ 1:1: going or persisting discharge is a regular postactiva­ tion feature for this kind of nociceptor and lasts for hours. Figure 5 B plots the responses shown for the first I 50 sec of figure 5A as a function of temperature. Figure 5C shows the responses to an equivalent 150 sec for a second similar heating C cycle which began immediately after that shown in figure 5A. More impulses and a higher frequency 11 If of activity were evoked by the second heating , I (figure 5C) than by the initial phase of stimulation (figure 5B). In addition to the background activity

I sec

1601 A Fig. 4. Responses of a primate cutaneous nociceptor (upper traces) with a slowly conducting myelinated afferent fiber. For 120j A and B, force of mechanical stimulus indicated by deflection of lower traces (calibration in grams). All stimuli applied to same aoj skin area. A - pressure exerted by 2. 2 mm diameter probe: B- pressure exerted by a needle: C - forcible pinch with ser­ rated forceps {at deflection of lower beam). ( From Perl, 1968.) ~ 1~------.-·------••· _.;.:---•-.·-r::' F,'o ' 60 ' ,b ' ,10:;:, ,00' 2io' 240' 270' ,~,;. TIME known to be associated with persisting changes in sensibility. This change in sensation takes the form 100 B of a lowered threshold for the production of pain 80 80 (hyperalgesia), not only at the injured site, but 'T also in surrounding tissue. 16 Pain from ordinarily 60 60 I nonpainful stimuli is also a regular concomitant 40 40 .i.. of inflammation practically anywhere in the body. The correlation with inflammation has long been 20 20

common knowledge and serves as an important 0 0 30 40 50 60°C 30 40 50 so·c diagnositic sign of an inflammatory process. TEMPERATURE Several hypotheses have been put forth to explain hyperalgesia and the pain of inflammation. One Fig. 5. Responses of a nociceptor ("C" fiber, polymodal presumes the release of a diffusible substance type) to skin heating. Filled circles positioned on the ordinate by injured tissues which serve to lower the thresh­ scale according to instantaneous frequency (see Fig. 3). A - old of sensory fibers responsible for pain and thermode temperature shown by unbroken line {right scale). another suggests the existence of a special periph­ B- plot of results for initial 150 sec of A as function of thermode temperature {abscissa). C - plot of initial I 50 sec of a second eral nerve network excited by noxious events. 16 similar heating cycle for the same receptor. {From Perl, in Sensitization of nociceptors. A remarkable change Cervical Pain, C. Hirsch & Y. Zotterman, eds., Pergamon in responsiveness and the lowering of threshold with Press, New York, I 972.)

176 and enhanced responses after an initial exposure to NOXIOUSSTIMULUS ------TISSUE DAN\AGE damaging stimuli, polymodal nociceptors also often : (Some) t Y AGENTFORI NFLAMN\A Tl ON exhibit significant lowering of threshold. The ACTIVATIONOF NOCICEPTORS • i threshold change may be such that innocuous • ~ INFLAMMATION stimuli, previously ineffectual, can provoke a ACTIVATIONOF PERIPHERAL ~ t significant amount of response. In light of these AND CENTRALPATHWAYS FOR PAIN PRODUCTSOF INFLAMMATION observations, background discharge and enhanced responses of nociceptors should be a consideration Fig. 7. Representation of possible steps linking nociceptor in analyses of hyperalgesia and the pain of activation to inflammation from trauma or disease. inflammation. The mechanisms underlying sensitization or nerves or spinal roots. In pathology of the vertebral enhanced responsiveness of nociceptors are not musculoskeletal system, spinal roots and the asso­ known, although the question is under active inves­ ciated connective tissue may be subjected to tigation. One hypothesis illustrated by figure 6 unusual stresses. These unusual stresses could proposes that damaged and inflamed tissue pro­ lead to an inflammatory reaction which, in tum, duces an unknown substance, "P" rn, which acts could cause the liberation of substances capable upon the nerve terminals to partially depolarize of changing the excitability of nerve fibers in the them and thereby lower their threshold for the root or trunk. including those which are central initiation of action potentials. Figure 7 diagrams a processes of the nociceptive terminals. It is pos­ scheme carrying this hypothesis further by sug­ sible that chemical substances related to inflam­ gesting that a noxious stimulus may directly acti­ mation can partially depolarize unmyelinated fibers vate some nociceptors and at the same time produce and hence, render such fibers responsive to stimuli tissue damage which releases an agent causing which previously could not generate impulses. inflammation. The agent for inflammation then In this fashion, ordinary mechanical stresses which activates nociceptors. The inflammatory process do not evoke action potentials in root fibers with a itself may produce other substances also capable normal transmembrane polarization could tum of exciting nociceptor terminals. The essential them into effective "receptors". This possibility point being proposed is that the system leading to has been brought to the fore by observations sug­ pain may be triggered at a much lower level by gesting that low concentrations of certain algogenic stimuli in the presence of inflammation. In par­ substances when applied to nerve trunks can ini­ ticular, subthreshold events for receptors leading tiate vasomotor reflexes of the type typically asso­ to pain in normal circumstances can become effec­ ciated with pain. 17 tive for exciting such sensory terminals in inflamed Pathology and disturbed anatomy. Alterations or damaged tissue. of structure can be expected to alter conditions for activation of nociceptors. When a ligament is tom, an intervertebral disc degenerates or a joint is NOCICEPTOR displaced, major changes take place in the position FIBER and stresses upon parts of the musculoskeletal system. Figure 8 diagrams a hypothetical example. Figure 8- I diagrams a normal situation for several vertebrae and ligaments A and B connecting their processes. In figure 8-1 I an intervertebral disc has partially collapsed (marked by stippling), causing angulation of one vertebra; as a consequence,

INFLAMMED TISSUE ligament B is shortened and ligament A lengthened. Any additional tension on ligament A produced

Fig. 6. Diagram showing postulated action of a substance by movements associated with ordinary activity (P) on nociceptor terminals leading to sensitization. could create unusual stresses in it and on its attach­ ments, activating high threshold sensory termina­ tions normally unexcited by the usual range of Another possible factor is the effect of inflam­ activity. In time inflammatory changes at the mation directly upon nerve fibers in peripheral attachments of ligament A as shown in figure 177 18 19 211 8-lll could cause a still further reduction in the nociceptors. • • Many details of the organiza­ amount of movement or stress necessary to excite tion of this specific projection system for high nociceptors located there. threshold sense organs are unknown; however,

I. II. 111.

A

B

Fig. 8. Diagramm::1tic representation of the po-;sible place of altered spinal architecture due to disease in activation of noci­ ceptors. See text for additional explanation.

Details of the nature and distribution of nocicep­ direct evidence for a specific central pathway for tive terminals within the musculoskeletal system the transmission of information about intense or are only partially understood. It is known that noxious stimuli is important for explaining the high threshold sense organs with characteristics phenomenon of referred pain. Figure 9 diagrams appropriate for nociceptors exist in and around some features of the spinoreticular-spinothalamic joints, within muscles and in tendons and ligaments. system and illustrates one of the hypothesized Their distribution around the vertebra has not explanations for referred pain. Pain resulting from been directly studied. We do not have direct pathology or stimuli to one part of the body and studies of sensory terminations in or around spinal referred, in perception, to another body region is roots, although circumstantial evidence suggests known to have a segmental organization: the their presence. So far, every tissue studied which affected body part and the reference point are both is likely to be exposed to unusual stress and nox­ usually innervated by nerve roots entering the ious circumstances in the ordinary life cycle of an spinal cord at the same segmental level. An ex­ animal has been found to contain sensory terminals planation of referred pain suggested by Ruch:!1 with features suggesting a special responsiveness implicitly demands a specific projection system. to stimuli intense enough to threaten the integrity It proposes that under normal circumstances of that tissue. noxious events ordinarily are initiated at the body Central mechanisms for pain. For many years a surface or some other exposed structure. By system of nerve fibers running rostrally through organization and/or habit. the perceptual reference the ventrolateral funiculi of the spinal cord (the of neurons carrying nociceptive information cen­ spinothalamic and spinoreticular tracts) has had trally is to these structures. Ruch 's concept further accepted importance for pain sensation. It has suggests that some of the same spinal neurons become increasingly clear over the past 5 years receive a convergent excitatory input from noci­ that part of this central projection system originates ceptors of muscle or tendon or other deep struc­ from neurons of the spinal dorsal horn which tures. When the noxious event takes place in the receive rather specific excitatory inputs from deep structure, the dorsal horn neuron projecting 178 centrally over the spinothalamic tract is activated The influence of reactions parallel to those in the same fashion as when a skin nociceptor causing sensation. Few, if any, primary afferent excites it. The central nervous system interprets fibers in their central distribution solely engage a the input as if it had come over the more usual single neural mechanism. It is well established that channel. This same kind of mechanism could ex­ noxious input or activation of nociceptive neurons plain the pain of central nervous system origin. evokes a number of different kinds of reflexes. Activation of a neuronal system normally excited Some are reflexes to skeletal muscle while others by the specific input from nociceptors would be involve the autonomic system. Clinical observa­ interpreted perceptually as if it originated from the tions have shown that reflex contractions can be usual source. Convergent inputs could come from persistent and powerful after musculoskeletal physically close structures such as parts of the injury. These reflexes may have important protec­ vertebral column and the nearby skin or muscu­ tive functions in splinting injured parts; however, lature. In this way a referred locus could, in fact, prolonged muscle contraction in such a reflex can represent a trigger point since the inputs from two contribute to discomfort, as suggested by figure I 0. different sources could converge upon one central Limitation of circulation to the contracting muscles neuron. A mechanism based upon this organization and undue stress upon ligaments and other struc­ could represent the underlying cause of persisting tures by maintained powerful contraction can lead back or other musculoskeletal pain long after the to activation of nociceptors in other structures than initiating event had ameliorated. Convergence of the injured part. In addition, voluntary movement deep (visceral) and cutaneous input upon dorsal in the face of a powerful reflex contraction could horn neurons has been demonstrated, making the cause opposing muscles to generate pathological convergent hypotheses for the explanation of re­ degrees of stress. 22 23 ferred pain all the more attractive. • Mention must also be made of nonspecific central NOXIOUSSTIMULUS pathways and their possible relation to pain. Some ! spinal neurons projecting centrally receive excita­ ACTIVATIONOF NOCICEPTORS -----REFLEX --MUSCLE CONTRACTION tory input from nociceptors and from low threshold receptors. It seems probable that such nonspecific ACTIVATIJ OFPERIPHERAL A:------___ LOCALCIRLLATORY LIMITATION CENTRALPATHWAYS FOR PAIN (ACCUMULATIONOF PRODUCTS). central pathways contribute in some way to the MAINTAINEDSTRESS overall reaction to a noxious input, including perception. It is possible that in primate and man, Fig. IO. Representation of possible steps linking concurrent some of the nonspecific or convergent pathways muscular reflexes to reported pain. also follow the route of the spino-reticular-thalamic system. 24 A corollary to this concept is that manipulation, which tends to depress reflex contractions related to some continuing inflammatory or nociceptive passes, may alleviate part of the discomfort. One long-established reflex, the lengthening 'reaction (clasped-knife effect) is initiated by externally imposed lengthening of contracting muscles. At some point in the forced lengthening, inhibition of the motoneurons, causing the muscle to contract, dominates and causes a sudden relaxation of the muscle. The sense organ responsible for the length­ ening reaction has been considered to be the Golgi tendon organ of the contracting muscle, although MUSCLE SKIN or TENDON recently there is mounting evidence that the Group I I ending of the muscle spindle is the probable Fig. 9. Schema indicating possible explanation for referred source of the inhibitory effect. In any case, the pain on diagram showing the ventrolateral spinal tracts and lengthening reaction of muscle deserves special some of their regions of projection. consideration in view of the probable importance

179 of reflex contraction in the generation of certain 4. Perl, E. R. Is pain a specific sensation? J. Psychiat. Res. kinds of pain. 8: 273-287, 1971. The modulation of pain mechanisms. Figure I I 5. Sherrington, C. S. The lntegratfre Action of the Ner"vous System. New Haven: Yale University Press, 1906. diagrams some known and some postulated inter­ 6. Heinbecker, P., Bishop, G. H., and O'Leary, J. Pain and actions to a sensory process. It emphasizes the touch fibers in peripheral nerves. Arch. Neurol. Psychiat. complexity of the interrelations. Given this situa­ (Chic.) 29: 771-789, 1933. tion, one should expect that the sensation of pain 7. Coggeshall, R. E., Coulter, J. D., and Willis, W. D., Jr. can be a variable reaction and that many forms of Unmyelinated axons in the ventral roots of the cat physical and psychological manipulation may alter lumbo-sacral enlargement. J. Comp. Neural. 153: 39-58, 1974. it, even though there may be highly specific mech­ 8. Clifton, G. L., Vance, W. H.,Appelbaum, M. L.,Coggeshall, anisms for the detection and signalling of strong R. E., and Willis, W. D. Responses of unmyelinated stimuli. afferents in the mammalian ventral root. Brain Res. 82: 163-167, 1974. 9. Perl, E. R. Myelinated afferent fibers innervating the primate skin and their response to noxious stimuli. J. Physiol. 197: 593-615, 1968.

~ HeadRegicc - , 10. Bessou, P., Burgess, P. R., Perl, E. R., and Taylor, C. B. ~ _ _m~~l~a2'~n~u~ ~ Dynamic properties of mechanoreceptors with unmyeli­ nated (C) fibers.]. Neurophysiol. 34: 116-131, 1971. 11. Burgess, P. R., and Perl, E. R. Myelinated afferent fibers Endocrine Vasorr,otor responding specifically to noxious stimulation of the skin. Secretory J. Physiol. 190: 541-562, 1967. 12. Bessou, P., and Perl, E. R. Response of cutaneous sensory Fig. 11. Schema showing known and hypothesized mecha­ units with unmyelinated fibers to noxious stimuli. J. nisms initiated by a somatosensory stimulus and some possible Neurophysiol. 32: 1025-1043, 1969. interactions between such processes. I 3. Bessou, P., and Laporte. Y. Etude des recepteurs mus­ culaires innerves par les fibres afferentes du groupe 111 SUMMARY (fibres myelinisees fines), chez le Chat. Arch. Ital. Biol. 99: 293-321, 1961. It has been emphasized that pain is a complex 14. Paintal, A. S. Functional analysis of group 111 afferent reaction to a definable set of circumstances. It is fibers of mammalian muscles. J. Physiol. 152: 250-270, 1960. ordinarily initiated by activation of specific sense 15. Burgess, P. R., and Clark, F. J. Characteristics of knee organs whose major characteristics include a high joint receptors in the cat.J. Physiol. 203: 317-335, 1969. threshold to all kinds of stimuli. Some high thresh­ 16. Lewis, T. Pain. New York: MacMillan Company, 1942. old sense organs show a remarkable enhancement 17. Khayutin, V. M., Baraz, L.A., Lukoshkova, E. V., Sonina, of sensitivity after an exposure to noxious stimuli: R. S. and Chernilovskaya, P. E. Chemosensitive Spinal Afferents: Thresholds of Specific and Nociceptive this enhancement of sensitivity bears considerable Reflexes as Compared With Thresholds of Excitation similarity to the hyperalgesia associated with in­ for Receptors and Axons. Progress in Brain Research, flammation and tissue damage. Reflex reactions to lggo, A. and llyinsky, O.B. eds. Elsevier Scientific pain-producing stimuli can contribute to the overall Publishing Company, Amsterdam, 43: 1976. sensory experience and modification of such re­ I 8. Christensen, B. N., and Perl, E. R. Spinal neurons specifically excited by noxious or thermal stimuli: mar­ flexes may explain the success of some therapeutic ginal zone of the dorsal horn. J. Neurophysiol. 33: maneuvers. The central connections of nociceptors 293-307, 1970. are in part specific, an organization which provides 19. Trevino, D. L., Coulter, J. D., and Willis, W. D., Jr. Loca­ an explanation for ref erred pain and pain of central tion of cells of origin of spinothalamic tract in lumbar origin. enlargement of the monkey. J. Neurophysiol. 36: 750- 761, 1973. REFERENCES 20. Willis, W. D., Trevino, D. L., Coulter, J. D. and Maniz, R. A. Responses of primate sponothalamic tract neurons I. Dallenbach, K. M. Pain: history and present status. Am. J. to natural stimulation of hindlimb. J. Neurophysiol. Psycho/. 52: 331-347, I 939. 37:358-372, 1974. 2. Beecher, H. K. Measurement of Subjective Responses. 21. Ruch, T. C. Pathophysiology of pain. Chapter 15 in Oxford University Press, New York, 1959. Medical Physiolo~y and Biophysics. T. C. Ruch and 3. Melzack, R. and Wall, P. D. Pain mechanisms: a new J. F. Fulton, eds., Philadelphia: W. B. Saunders, 1960, theory. Science 150: 971-979, 1965. pp. 363-364.

180 22. Selzer, M., and Spencer, W. A. Convergence of visceral Res. 14: 349-366, 1969. and cutaneous afferent pathways in the lumbar spinal 24. Boivie, J., and Perl, E. R. Neural substrates of somatic cord. Brain Res. 14: 331-348, 1969. sensation. Chapter 8 in Physiology, Series One, Vol. 3 23. Selzer, M., and Spencer, W. A. Interactions between Neurophysiology, MTP International Review of Science, visceral and cutaneous afferents in the spinal cord: C.C. Hunt ed. London: Butterworths, 1975, pp. 303-411. reciprocal primary afferent fiber depolarization. Brain

181 Discussion: The Importance of Neurophysiological Research into the Principles of Spinal Manipulation

SCOTT HALDEMAN Vancouver, B.C., Canada

This conference is extremely privileged to have_ disease which interfered with the development of neurophysiologists of the stature of Ors. Sharpless, scientific research into the effects of the adjust­ Sato, and Perl present papers on the subjects ment. However, it is promising that practically all for which they have become internationally practitioners of spinal manipulation have now renowned. Excellent summaries of the more passed through this phase of their history and are pertinent experimental results and physiological willing not only to look for alternate explanations principles of nerve compression, somatovisceral for their form of therapy but to finance research reflexes. and pain have been presented. It is inter­ by independent basic scientists. esting to note that. with the exception of the work The original concepts of nerve pressure have done by Sharpless during the last 2 years, none of changed with increasing awareness of the patho­ the research quoted has been initiated through an physiology of the spine and nervous system. There interest in the practice of spinal manipulation. is now general agreement that nerve compression Nonetheless, these physiological principles are can exist at a spinal level but that it is not the extremely important in the understanding of the primary lesion to which the adjustment or manipula­ pathophysiology of spinal lesions and probably tion is directed. hold the answer to the mechanism of action of the There has already been extensive discussion of spinal manipulation. nerve compression at this symposium. However, The most pertinent way of discussing these two questions have not yet been answered: papers would be to see how the concepts which I. Does compression of nerre roots cause pain? have been presented have been used by clinicians It has often been presumed that pressure on a to explain observed clinical results, how a lack of nerve could stimulate the pain fibers in the nerve or physiological research has led to errors of excessive surrounding sheaths thus causing local and referred claims and unreasonable criticism, and how some pain along the nerve. This is often referred to in of the newer developments in neurophysiology diagnostic textbooks as the cause of sciatica and have opened exciting theoretical considerations other neuralgias of spinal origin. Patrick Wall which may be important in the future practice of addressed this question at a recent international spinal manipulation. symposium on cervical pain. 1 At that time he ex­ pressed doubt that such an irritable lesion at the NERVE COMPRESSION level of dorsal roots could exist. Since then Wall One of the earliest explanations given for the et aJ.:! have reproduced the earlier experiments of results obtained by spinal adjusting was relief of Adrian.:i They showed that acute injury to a nerve nerve compression at the intervertebral foramen. root by pressure, stretching or bending, results in It is unfortunate that this concept was often incor­ a volley of impulses being initiated at the time of porated into complex philosophies of health and insult. but that this initial volley is shortlived. It is 183 possible that the sciatic pain from nerve root com­ visceral dysfunction through this mechanism. For pression is not caused by direct injury to the nerve this to be true the following requirements must be but instead by irritation of the dura, which is pain met. sensitive, or through stimulation by products of I. The spinal lesion must produce continuous inflammation as suggested by Perl. stimulation of a large number of receptors. 2. What is the significance of the difference in the With the exception of the internal lamina and sensitivity of large and small nerve fibers to nucleus pulposus of the disc, all structures which pressure? make up the functional spinal column are con­ The observation by Sharpless that large nerve sidered to have sensory receptors of one type or fibers are more sensitive to compression than another. U nmyelinated fibers have been found in small nerve fibers leaves the impression that it the fascia, ligaments, periosteum, the intervertebral may be possible to determine the degree of com- joint capsule and the outer lamina of the inter­ pression by monitoring the modality of nerve func­ vertebral discs. 7 Gardner 8 feels that the vertebral tion which has been lost. This assumption is based joints have the same basic position and movement on the fact that larger nerve fibers have been shown receptors as other peripheral joints and it is likely, to conduct motor impulses. proprioception and but not established, that the paraspinal muscles touch sensation, while the smaller nerve fibers and tendons have a full complement of muscle carry pain and temperature sensation and sympa­ spindle, Golgi tendon apparatus, pressure receptors thetic impulses. Although there is a great deal of and the group II I chemoreceptors which are con­ confusion in the literature on this topic ( reviewed sidered to be responsible for the cardiovascular 4 by Sunderland ), the majority of researchers seem responses to exercise_!! to agree that motor fibers are more susceptible to These receptors each have their own charac- compression than sensory fibers. and that sensory teristics of response to repeated stimulation. Perl loss occurs in the following order: proprioception, has demonstrated how small unmyelinated fibers touch, temperature. and pain. It is interesting to can become sensitized so that the responsiveness note that sympathetic fibers are the most resistant of the receptor increases with repeated stimulation. to pressure. Therefore, in order to get visceral Other receptors such as the Pacinian corpuscle changes from nerve pressure, there must be suf­ and primary receptors of the muscle spindle react ficient compression to cause motor and sensory to repeated stimulation by adapting to extinction. paralysis. It must, however, be remembered that These factors must be taken into account when this progression in the loss of function of nerve determining the final "sensory bombardment" of fibers is not absolute and that there is some loss the central nervous system. in both fast and slow conducting fibers at all levels The manifestations of the spinal lesion which are of compression. the target of manipulation, i.e. pain, muscle spasm, joint malposition, joint fixation, or hypermobility, THE SOMATOVISCERAL REFLEX all have the potential of stimulating these receptors. Nonetheless, with the exception of pain, it remains Somatovisceral interaction has gradually become to be demonstrated that these lesions produce one of the major theories currently being used sufficient constant irritation of receptors to cause to explain the results on visceral dysfunction repeated discharge of sensory neurones. which have been claimed by practitioners of spinal manipulation. Once again, however, a lack of re­ 2. Stimulation of these particular receptors must search and discussion on the role of this physio­ result in a measurable somatosympathetic logical principle has led to its incorporation into a response much wider philosophical concept of a so-called Sato has demonstrated that sympathetic re­ .. holistic" approach to patient care by certain sponses do occur on stimulation of cutaneous and 3 6 academics in the field of spinal manipulation. • deep somatic receptors. However, it does not If the theory of abnormal somato-visceral re­ necessarily follow that the spinal lesion will bring flexes is to be used to explain the results of spinal about this type of reflex response. The quality and manipulation, it is necessary to dissociate this quantity of the response is dependent upon both theory from vague philosophical concepts and the type of receptor affected and the frequency of establish that the spinal lesion does in fact cause stimulation. Both these factors are unknown quan- 184 ti ties in the spinal lesion. It would appear that an 5. Correction of the spinal lesion must result in experiment could be designed in which the spinal cessation of the reflex activity and improve­ lesion was reproduced in test animals while re­ ment in the visceral dysfunction. cording from sympathetic nerves. Such an experi­ This requirement is probably the most important ment would throw some light on these first two from a clinical point of view. However, since it is requirements of the somatovisceral reflex theory of the subject of another paper at this conference it spinal manipulation. would be inappropriate to discuss it at this time. 3. These reflexes must not habituate to any sig­ Suffice it to say that the general rules of clinical n(ficant degree. research regarding experimental design and adequate controls must be adhered to if the results Habituation and facilitation in the spinal cord are to be considered valid. may result in significant alteration of the visceral response to repetitive or continuous stimulation of PAIN somatic nerves. For example, Schmidt and Schon­ fuss 10 found that when the stimulus interval was By far the greatest number of patients attending 0.25 second the somatosympathetic response to practitioners of spinal manipulation are doing so group 11 and 111 somatic afferents was less than in an attempt to obtain relief from pain. Most of the 10 percent of that obtained at a stimulus interval controversy which has taken place between author­ of IO seconds. On the other hand, consecutive ities in spinal manipulation has been on locating group IV volleys appear to recruit greater numbers the irritating lesion. The structures which have of sympathetic units with increasing frequency of received the greatest attention are the posterior stimulation. 11 Since most of these experiments joints and the intervertebral discs, with lesser have been carried out on acute animals which are emphasis on paraspinal muscles and ligaments. sacrificed after a few hours, some of the results Detailed histological examinations have revealed may not be directly transferable to a spinal lesion that, with the exception of the central portions of which theoretically produces these reflexes over a the disc, all of these structures are well-endowed period of days or weeks. with pain fibres and capable of reacting to injury in the manner described by Perl. 4. Sympathetic stimulation of the type produced A lack of understanding of the physiology of by these reflexes must cause fimctional dis­ pain, together with inadequate diagnosis, could be orders in visceral or[?ans. one of the reasons for excessive claims by early This is probably the most controversial issue of practitioners of spinal manipulation. Lewis and the entire theory of "'structure-function" relation­ Kellgren 12 showed that pain from paraspinal struc­ ships. There can no longer be any doubt that direct tures could mimic the referred pain characteristic electrical stimulation to sympathetic nerves can of certain visceral diseases. They found that the influence blood flow, smooth and cardiac muscle injection of saline into the interspinous ligaments contraction and glandular secretion in many in­ of the vertebral column could produce subjective ternal organs. Sato has just demonstrated that signs of pain, superficial and deep tenderness, and cutaneogastric, cardiac, and vesical reflexes can muscle rigidity indistinguishable in quality and be of sufficient strength to produce measureable similar in quantity to that produced by renal colic, changes in the function of these organs. It is angina pectoris, gastric ulcers, cholecystitis and therefore likely that such changes occur following acute appendicitis. Furthermore, relief from these stimulation of other somatic receptors which have symptoms in other patients was achieved by the been shown to cause somato-sympathetic dis­ injection of novocain . into spinal muscles which charges. The problem is whether or not these func­ exhibited deep pain. i:i In addition, Fernstrom 14 tional changes play any part in the etiology of described pain in the abdominal-anogenital region known visceral pathology and functional diseases. caused by intervertebral disc lesions which could This question can easily be sidestepped in this be confused with a number of common obstetrical discussion by stating that it would require another problems. It can be seen that lack of cooperation conference of at least this magnitude to begin to between practitioners of spinal manipulation and cover the literature on the role of the autonomic the rest of the health team, who were often more nervous system in visceral pathology. qualified in the diagnosis of these internal disorders,

185

597-036 0 - 76 - 13 could have resulted in claims of cures for visceral search on the gate-control theory has shown that disorders when their symptoms were mimicked by the most effective inhibition of small fiber high­ spinal lesions. threshold (pain) receptors is achieved by the The mechanism of referred pain has generally stimulation of other high-threshold receptors. 21 been considered one of convergence of nerve It is likely, therefore. that the most successful in­ fibers from two different areas onto single neurones hibition of pain would be by procedures which in the spinal cord. Such convergence has been cause the greatest degree of stimulation of sensory demonstrated by recording from single neurones in receptors. It must be remembered. however, that the dorsal horn of the spinal cord while stimulating the inhibition of pain by this mechanism. if valid, independently visceral afferent nerves, small would last only for short periods of time. The myelinated cutaneous nerves and unmyelinated original pain producing lesion must be corrected 15 16 nerves from muscles. • The observation that by some other method such as the manipulation there are considerably more primary afferent pain (where applicable) in order to get permanent relief. fibers in the posterior roots than secondary affer­ Another mechanism through which neurones ents in the spinothalamic tract has been used as carrying pain impulses can be inhibited is the further evidence for convergence at the level of stimulation of higher brain centers. Liebeskind the spinal cord. 1i et al. 22 have shown that the stimulation of specific Recent research into spinal integration of pain areas in the reticular formation such as the dorsal impulses has opened some new possible mecha­ raphe and the periventricular grey matter can cause nisms by which spinal lesions could cause referred complete inhibition of those neurones in the spinal pain and tenderness. The observation by Kibler cord which carry pain impulses and in this way and Nathan 18 that the pain of nerve root compres­ cause complete analgesia. Similar effects following sion could be relieved by anesthetizing distal stimulation of structures in the limbic system 2:1 structures tends to support the suggestion by Wall 1 together with observed psychological reactions to that the site of noxious stimulation is in the periph­ pain have led to the conclusion that pain may be ery rather than in the root itself. The gate-control inhibited completely via psychogenic mechanisms. 24 theory proposed by Wall and Melzack w incor­ Clinicians who practice spinal manipulation often porated a model in which input from large sensory become very defensive when their detractors neurones had the ability to inhibit impulses entering derisively state that all results can be explained on the spinal cord along small nerve fibers. If. as has the basis of psychological effects of the manipula­ been shown by Sharpless, the large fibers were to tion. However, there are very few therapies which be blocked preferentially by nerve pressure, there have the advantages of laying on of hands. relaxing would be a reduction of this peripheral inhibition tense muscles, causing a sensation at the area of with a subsequent hyperalgesia and pain along that pain (the "click" of the adjustment) and a clinician dermatome. It is true that the original model of the who has confidence in the therapy. It is a pity that gate-control theory has not stood up to closer this possibility has been considered a criticism of experimental examination. Nonetheless, the basic the therapeutic procedure instead of one of its concept of impulses along one set of nerves in­ advantages. hibiting pain impulses in a second set of nerves has been repeatedly demoristrated.:w. 21 Except Finally. Perl has shown that one of the most when practiced in its purest form by one school of important effects of pain impulses is protective thought in chiropractic, spinal manipulation has reflex contraction of adjacent muscles and sug­ had a variety of fellow travelers which are often gested that stretch of the contracting muscle was applied at the same time as the manipulation. These one of the mechanisms by which spinal manipula­ adjunctive procedures have included simple mas­ tion and traction might relieve pain and muscle sage, deep friction massage, connective tissue spasm. This may be one reason why the specific massage, the application of heat, cold, ultrasound. adjustive thrust on a deviated or subluxated microwave, or galvanic stimuli. the stimulation of vertebra from the side of deviation, which is also trigger points and more recently, acupuncture. the side of the muscle contraction, has been con­ Stimulation of peripheral receptors is one of the sidered to be more effective in achieving results effects of each of these procedures which could in certain patients than the more general manipula­ thus be considered counterirritants. Recent re- tive techniques.

186 CONCLUSION 11. Schmidt, R. F., and Weller, E.: Reflex activity in the cervical and lumbar sympathetic trunk induced by unmyelinated Although the three concepts under discussion somatic afferents. Brain Res. 24:207-218, 1970. are those used by most practitioners of spinal 12. Lewis, T., and Kellgren, J. H.: Observations relating to manipulation to explain their results, there is still referred pain, visceromotor reflexes and other associated insufficient experimental data to state, with any phenomena. Clin. Sci. 4:47-71, 1939. I 3. Kellgren, .I. H.: Somatic stimulating visceral pain. Clin. Sci. certainty, exactly why the manipulation is an effec­ 4: 303-309, I 940. tive therapeutic procedure. It appears, however. 14. Fernstrom, U.: Ruptured lumbar discs causing abdominal that no single theory can be utilized to explain all pain. Acta Chir. Srnnd. Suppl. 357: 160-161, 1966. results of manipulation. 15. Fields, H. L., Meyer, G. A., and Partridge, L. D., Jr.: Convergence of visceral and somatic input onto cat spinal REFERENCES neurons. Exp. Neurol. 26: 36-52, I 970. I. Wall, P. D.: "The mechanisms of pain associated with 16. Pomeranz, 8., Wall, P. D., and Weber, W. V.: Cord cells cervical vertebral disease." In C. Hirsch and Y. Zotter­ responding to fine myelinated afferents from viscera, man. (Editors). Cervical Pain. Wenner-Gren Centre muscle and skin. J. Physiol. 199: 511-532, 1968. International Symposia series. Pergamon Press ( Oxford), I 7. Ruch, T. C.: Visceral sensation and referred pain. In 201-210, 1971. Fulton .I. F. (Ed.) Howell's Textbook of Physiology. 15th 2. Wall, P. D., Wanman, S., and Basbaum, A. I.: Ongoing Edition. Saunders ( Philadelphia) 385-40 I, I 947. activity in peripheral nerve: Injury discharge. Exp. I 8. Kibler, R. F., and Nathan, P. W.: Relief of pain and para­ Neurol. 45:576-589, 1974. esthesiae by nerve block distal to the lesion. J. Neurol. 3. Adrian, E. D.: The effects of injury on mammalian nerve Neurosurg. Psych. 23: 91-98, I 960. fibers. Proc. Roy. Soc. Ser. B. I 06: 596-618, 1930. 19. Melzack, R., and Wall, P. D.: Pain Mechanism: a new 4. Sunderland, S.: Nerves and Nen·e !,{juries. E. and S. theory. Science, 150: 971-979, I 965. Livingstone Ltd. (Edinburgh & London), 1968. 20. Price, P. D., and Wagman, I. H.: Relationships between 5. Hoag, J. M., Cole, W. V., and Bradford, S. G. (Editors). pre- and postsynaptic effects of A and C fiber inputs to Osteopathic Medicine. McGraw-Hill Book Co. (New dorsal horn of M. Mulatta. Exp. Neurol. 40:90-103, York), 1969. 1973. 6. Stonebrink, R. D.: Neurological features of the chiropractic 21. Whitehorn, D., and Burgess, P. R.: Changes in polarization philosophy. J. Am. Chiropractic Assn. Vol. I I.S:33-40, of central branches of myelinated mechanoreceptor and 1968. nociceptor fibers during noxious and innocuous stimula­ 7. Pederson, H. E., Blunchk, C. F . .1., and Gardner, E.: The tion of the skin. J. Neurophysiol. 36: 226-237, 1973. anatomy of lumbosacral posterior rami, meningeal 22. Liebeskind,J. C., Guilbaud, G., Besson,J. M.,and Oliveras, branches of spinal nerves (sinu-vertebral nerves). J. Bone J. L.: Analgesia from electrical stimulation of peri­ Jt. Sur,:. 38A: 377-399, 1956. aquaductal gray matter in the cat: behavioral observations 8. Gardner, E.: Pathways to the cerebral cortex for nerve and inhibitory effects on spinal cord interneurons. Brain impulses from joints. Acta Anat. Suppl. 56:1 and 73: Res. 50:441 -446, 1973. 203-216, 1969. 23. Lico, M. C., Hoffmann, A., and Covian, M. R.: Influence of 9. Hnik, P., Hudlika, 0., Kucera,J., and Payne, R.: Activation some limbic structures upon somatic and autonomic of muscle afferents by non proprioceptive stimuli. Am. J. manifestations of pain. Physio/. Behav. 12: 805-811, Physiol. 217: 1451-1457, 1969. 1974. 10. Schmidt, R. F., and Schonfuss, K.: An analysis of the reflex 24. Perl, E. R.: "Mode of action of nociceptors." In Hirsch, D., activity in the cervical sympathetic trunk induced by and Zotterman, Y.: (Editors) Cervical Pain. Wenner-Gren myelinated somatic afferents. Arch. Ges. Physiol. 314: Centre International Symposium Series. 17: 157-164, 175-198, I 970. 1971.

187 A Brief Review of Material Transport in Nerve Fibers

SIDNEY OCHS Professor, Department of Physiology Indiana University School of Medicine

INTRODUCTION a linear advance with time at a rate of 410 ± 50 In recent years we have become aware of the (S.D.) millimeters per day. The general plan of relatively high level of protein synthesis present in injection and the sampling of activity in the sciatic the neuron cell body I with a subsequent movement nerve is shown in figure I. At a predetermined time of proteins and other materials out into the nerve after the injection, the animal is sacrificed, the fiber to be carried along by an internal system of nerve removed, and sectioned as shown. The transport. Wallerian degeneration, the failure of characteristic outflow is seen as a crest of advancing excitability and disruption of fiber structure seen activity followed by a plateau, typically with less to occur in nerve fibers a few days after their activity in it compared to the crest. Large numbers separation from their cell bodies, long ago suggested of labeled components remain in the ganglion cells, the loss of some key substance supplied by the cells part of which are transported later. to the fibers. 2 Additionally, the failure of neuro­ The crest advances at a linear rate down the muscular transmission and the changed properties fibers as shown in five nerves taken at different of muscle appearing after nerve transection has times after injection (figure 2). The rate determined been ascribed to the loss of materials or "trophic" in a large number of such experiments was 410 substance normally conveyed by the nerve fibers. :i millimeters per day. 2 The rate is independent of This brief review describes some of the properties nerve size, or of the diameter of myelinated fibers, of the transport mechanism of mammalian nerve. and the same rate is also present in nonmyelinated fibers 12 , 13 even in the nerves of several non­ Characteristics of transport mammalian species. The garfish olfactory nerve 14 • 15 Materials moving down the fibers are found to and frog nerve 16 with a temperature correction to accumulate above a site of ligation or constriction 4 38° C, was used for comparison. with, in some cases, several peaks of accumulation A range of soluble proteins, polypeptides and 17 19 of materials normally present in the nerve fibers. particulates are carried down at a fast rate, • as Monitoring of the flow of labeled proteins sub­ are glycoproteins, glycolipids and phosphatidyl­ 2 sequent to the incorporation of labeled amino acids choline/0· ~ along with specific components related by nerve cell bodies suggests two or more rates of to transmission, catecholamines 238 and enzymes 5 9 3 downflow. - A direct measure of the rate and related to their synthesis,2 h acetylcholinesterase 24 25 characteristics of downflow was shown by the (AChE). • pattern of labeled activity found in long lengths of nerve present in mammals, e.g. the cat sciatic, The Transport Mechanism-a Model after injection of :iH-leucine or 3 H-lysine into The similarity of the rate of transport found for either the lumbar seventh (L 7) dorsal root ganglia a wide range of materials with molecular weights 10 11 or into the motorneuron region of the cord. • The known to extend from small molecules to particles of characteristic crest found in the sciatic nerve has comparatively large size is of theoretical interest.

189 SENSORY G - PIPETTE FIDERS

DR "' SCIATIC NERVE :;..-_.-;r;:::::r=.:c:::c:I:~ic::::c:c:I:::cc:::c:J:::::i:::::::I:::::c::I::l:

107 / NX,L ---BB •---VIALS i

MOTOR FIBERS 30 20 10 O 10 20 30 40 50 60 70 80 90 100 1 IO 120 130 140

Fig. I. / njection and sampling technique showing transport. The L 7 ganglion shown in the insert contains T-shaped neurons with one branch ascending in the dorsal root, the other descending in the sciatic nerve. A pipette containing 3 H-lcucine, is passed into the ganglion and after its injection and the incorporation of precursor, the downflow of labeled components in the fibers is sampled at various times by sacrificing the animal and sectioning the nerve. Each segment is placed in a vial, solubilized, scintillation fluid added and the activity counted. The outflow pattern is displayed on the ordinate log scale in CPM, the abscissa is in mm, taking the distance from the center of the ganglion as zero. A high level of activity is seen remaining in the ganglion region with more distally, a plateau rising to a crest before abruptly falling at the front of the crest of baseline levels. The left hand side of the cord shows for motoneurons an injection of the precursor into the ( 7 cell body region followed by removal of ventral root and sciatic nerve at a later time for a similar treatment and display of outflow.

It indicates that a common carrier, a .. conveyor the transport filaments as are the fast transported belt" type of system. is involved in the mechanism components, and so can more readily leave the of transport. A hypothesis to account for fast transport filament to become locally incQrporated axoplasmic transport was proposed based· on the into various nerve structures: 31 an example is sliding-filament theory of muscle.:!6 , 27 A ··transport the mitochondrion. It is seen microscopically filament" is considered to bind the various mate­ with Nomarski optics to have fast movement for­ rials moving along the microtubules and/or neuro­ ward or retrograde with a net slow transport. 32-34 filaments of the axon by means of cross-bridges This could be due to binding and unbinding from (figure 3 ). The heterogenous range of labeled com­ the transport filaments. ponents are thus moved quickly down the nerve Evidence that the microtubules are an integral axon at the same fast rate. The plateau behind part of the transport mechanism comes from the the crest is made up of materials exported into the effect of the mitotic blocking agents. colchicine and fibers at later times from some "compartment" in the vinca alkaloids. These substances, when in­ the cell bodies with a portion of the labeled mate­ jected under the epineurium of a nerve trunk. rials being locally deposited in the fibers. Still were shown to block fast axoplasmic transport by later. over a period of hours, days, or weeks, more the failure of catecholamines 35 and AChE 36 to labeled components come from the cell body at accumulate at a ligation downstream from the site earlier times and more distally later. thereby ac­ injected with colchicine or vinblastine. At first it counting for the characteristic outflow pattern of was presumed that this comes about through a dis­ slow transport. With this "unitary concept," slow assembly of the microtubules, the basis for their transported materials are not so firmly bound to antimitotic action. Electron microscopy of crayfish

190 106 Na

105

104 10 HR

103

2 10 "" a b C D, [:: 8 llf! u 102 n "O Fig. 3. Transport .filament hypothesis. Glucose (G) enters :;, the fiber and after glycolysis, oxidative phosphorylation in the 6 IIR t::: mitochondrion (Mil) gives rise to ATP. The ~P of ATP sup­ plies energy to the sodium pump controlling the level of Na· t 103 4 llll and K · in the fiber and also to the cross-bridges activating the ::] !02 transport filaments. These arc shown as black bars to which 103 2 IIH the various components transported are hound and so carried down the fiber by crossbridge activity. The components trans­ 102 G HOOT--~ ·• NERVI•: ported include the mitochondria (a) attaching temporarily as indicated by dashed lines to the transport filament this giving 24 12 0 12 24 36 4!1 60 72 84 96 108 120 132 144 156 166 rise to either fast forward or retrograde movement (though with a slow net forward movement), soluble protein (h) shown as a folded or globular configuration, polypeptides and small Fig. 2 Distrihution <~fradioactii·ity. Activity present in the particulates (c). Simpler molecules are also bound to the trans­ dorsal root ganglia and sciatic nerves of five cats taken 2 to port filaments. Thus, a wide range of components are transported IO hours after injection of 3 H-leucine into the L 7 ganglia (G) at the same fast rate. The cross-bridges between the transport is shown. The activity present in 5 mm segments of roots, filament and the microtubules presumably act in similar fashion ganglia, and nerves is given on the ordinate in logarithmic to the sliding filament theory of muscle and the Mg Ca A TPase divisions. The ordinate scale for the nerve taken 2 hours after found in nerve utilizes ATP as the source of energy. injection is shown at the bottom left with divisions in CPM. At the top left a scale is given for the nerve taken IO hours after injection. Only partial scales are shown at the right for the nerves corresponding fall of ~ P occurred at those later taken 4, 6, and 8 hours after injection. Abscissa in mm from 43 the ganglion taken as zero. times. The dependence of transport on oxidative metabolism was shown by the block of transport nerve fibers exposed to colchicine and vinblastine produced either hy stripping the blood vessels or in amounts which blocked transport showed, how­ by the use of cuff compressions at pressures above 1 ever, that the microtubules still remain intact in 300 mm. Hg. to block circulation: :ia A damming of some of those fibers. 37 ,as This leaves open the activity was seen above the block and no transport possibility that these agents may act on the surface found within the region made anoxic. This was of the microtubules or at the cross-bridges to block demonstrated in vitro by covering the nerve with transport.:rn petrolatum jelly and parafilm strips so that O'.! In analogy with the sliding-filament theory of cannot diffuse into that region. A block of transport muscle, the cross-bridges invoked in the transport was seen starting just at the edge of the anoxic filament hypothesis require energy, which is likely region by the damming of activity above that site 46 to be supplied by ATP. A close dependence of fast (figure 4). Such studies indicate that ATP is pro­ axoplasmic transport on oxidative metabolism was duced all along the length of the nerve fibers. 40 4 shown in in vitro studies. - a When N2 anoxia was The utilization of ATP is likely to be accom­ initiated or azide. CN or DN Padded to the nerve plished by the MgCa ATPase found present in in vitro, fast axoplasmic transport was blocked myelinated nerve, 44 the enzyme having many of the within approximately 15 minutes. At that time, the actomysin-like properties previous1y shown in level of - P (the combined concentration of ATP brain preparations: 15 The ATP is apparently sup­ and phosphocreatine). fell by about 0.6 µ,M/g.-1:i plied and is required all along the length of the Axoplasmic transport failed at a later time when nerve as was indicated when a short region of the the citric acid cycle was blocked with flouroacetate, nerve was made anoxic and block of transport or when glycolysis was blocked with I AA ·11 and a occurred .1ust at the anoxic region. 46 I 91 106

105

..i E-- 'Fi ::> z 0 ::E 104 ~ ..i p,. en E-- z ::> 103 0 u

G ROOT -+- :::::::::::::: -NERVE

30 15 0 15 30 45 60 75 90 105 120 135

mm

Fig. 4. Local anoxia and block. Local anoxia produced by covering part of the nerve with petrolatum and plastic strips at the site indicated by the cross-hatched bar. Downflow occurred in the animal for 3 hours and then 3 hours of in vitro transport took place with the local anoxia block present. Arrow 2 indicates downflow at crest of control nerve.

The anoxic block of fast transport in vitro due level of protein synthesis or the amount of protein to N 2 is reversible after approximately 1-1.5 present in the nerve cell body.:! hours.47 After longer times of anoxia produced A retrograde transport of material was first in vivo by cuff compression of the upper limb, a shown for AChE by Lubinska and her colleagues partial return of fast axoplasmic transport occurred, by the accumulation of AChE just distal to nerve though full recovery was found to require more ligations. 5 More recent studies from her laboratory time. This might take several days after a 4- to showed the retrograde AChE movement to have a 5-hour compression. Irreversible block occurs rate of about I IO millimeters per day. 54 Our after 6 hours of anoxia at 3 7° C. A similar time of studies showed a somewhat higher rate for its 7 hours for reversibility was seen using Wallerian retrograde transport, 220 millimeters per day. at degeneration and electrical conduction as criteria. 48 about half that of the forward rate of close to 410 The effect of cuff compression is not due to millimeters per day."5 A retrograde transport was mechanical changes per se as seen by comparing also shown for foreign materials, e.g. for horse­ the effect of compression at much higher radish peroxidase after its uptake by the nerve 4 1 56 57 pressures. ! terminals, • the substance apparently carried at a fast rate. 58 In the older literature, toxins and Retrograde Transport and Chromatolysis viruses have been reported as moving upward in Various hypotheses have been advanced to nerve fibers and no doubt will be further investi­ account for the phenomenon of chromatolysis. 50 gated in the light of what is now known of axo­ Most likely chromatolysis is triggered because of plasmic transport. s!I, ,rn the failure of some "signal" substance, which During chromatolysis the rate of axoplasmic normally ascends the fibers, and as a result of transport has been reported as increased. decreased interruption fails to reach the cell bodies.:;1 The or unchanged, though in our studies no difference 52 5 increased accumulation of protein in the cells • :i in the rate was found. w This is the case throughout seen after nerve section could thus represent the the whole of the period of chromatolysis lasting failure of a normal negative feedback control due from 4 to 90 days. This result may be stated as a to the signal substance which acts to regulate the principle, namely that fast axoplasmic transport 192 is an "all-or-none" process in the nerve fiber sets of microtubules passing down individually independent of the level of synthesis of materials into the two branches of the same neuron. The cell in the cell body. body exerts a control over the amount and type of "Routing'" Phenomenon materials destined for routing elements to its several terminals. The various materials carried In a study of fast axoplasmic transport in the are likely to be related to some degree to the differ­ monkey where lengths of dorsal roots up to ent functions of the branch terminals, one ending 1 1 centimeters long occur, the crests of outflow as a receptor peripherally, the other as a pre synaptic of labeled materials seen in the root after L 7 terminal centrally.Ii' dorsal ganglion injection with :i H-leucine showed In accord with the transport filament hypothesis, the same fast rate: however, a threefold to fivefold the microtubules are seen to be separately chan­ greater amount of labeled material was found in the neled down each of the two branches with no crests in the peripheral nerve as compared to the branching or other division of the organelles.Ii'.! cr_estsin the dorsal root 10 (figure 5). This asymmetry in the amount of transported activity could not be Transport in CNS Nerve Fibers accounted for by a greater diameter of the fiber The dorsal root fibers entering the cord branch branches of the T-shaped ganglion cell neurons in the with a local collateral in the segment and another nerve branch as compared to the root branch." 1 branch ascending in the dorsal columns of the Furthermore, the numbers of microtubules ( and spinal cord. After ganglion injection with :-iH­ neurofilaments) counted in electron micrograms of leucine, a crest of activity was seen in the dorsal nerve fibers in the two branches were not dissimilar. columns at a distance from the ganglion depending The disparity in the amount of labeled components on the usual rate as is the case in the sciatic carried down the two branches of the L 7 neurons nerves. 10 When the fibers in the dorsal column were depends therefore on a separate routing of com­ interrupted by applied pressure or by freezing at ponents by an internal system in the fibers. On the temperatures below -20° C, a failure of fast axo­ transport filament mechanism we consider two plasmic transport occurred with a damming of

4 HH MONKEY 6 10

p., 104 CJ

G 2 10 DORSAL ROOT-::::::::: -NERVE \

260

110 100 90 80 70 60 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100 110

Fig. 5. Transport of dorsal root and sciatic nerve. L 7 dorsal root ganglion was injected with a H-leucine; 4 hours later the monkey was sacrificed and the distribution of activity in dorsal root and comparable length of sciatic nerve compared. Arrow l shows the furthest extent of the crest of activity of fast axoplasmic transport in the dorsal roots, arrow 2, the crest showing transport into the sciatic nerve. The larger height of the crest in the nerve branches represents some 3-5X more material than in the root branches.

193 activity seen, a result similar to that earlier found REFERENCES in peripheral nerve as expected from an axoplasmic I. Lajtha, A. ( 1964). Protein metabolism of the nervous transport in the fibers. system. Int. Rev. Neurobiol. 6:J-98. Studies of dorsal column transport make it appear 2. Ochs, S. (1974). Systems of material transport in nerve likely that the same fast axoplasmic transport fibers (axoplasmic transport) related to nerve function and trophic control. In: Trophic Function of the Neuron. system is also present in other CNS fibers. Trans­ Ann. N.Y. Acad. Sci. 228:202-223. port in the brain and cord was shown for various 3. Guth. L. ( I 969). Degeneration and regeneration of taste amine fiber systems by making transections along buds. In: Handbook of Sensory Physiology, Vol. 4: their course and finding an increased accumulation Chemical Senses. Berlin, Springer-Verlag. of the amines in the fibers proximal to the lesion 4. Weiss, P., and Hiscoe, H. B. ( I 948). Experiments on the facing the cell bodies with their depletion in the mechanism of nerve growth. J. Exp. Zoo/. 107:315- 395. fibers distal to the lesion. 63 • fi., This technique was 5. Lubinska, L. ( 1964). Axoplasmic streaming in regenerating used to show dopamine containing fibers passing and in normal nerve fibers. In: Mechanisms of Neural from the substantia nigra to the striatum and Regeneration. (Progress in Brain Research. Vol. /3). noradrenaline and serotonin containing fibers pass­ Singer, M. and Schade,J. P. (Eds.) Amsterdam, Elsevier, ing from identified brain stem nuclear groups into pp. 1-66. the hypothalamus, thalamus, and cortex. The 6. McEwen, B. S .. and Grafstein. B. ( I 968). Fast and slow components in axonal transport of protein. J. Cell mapping of monoamine pathways can be clearly Rio/. 38:494-508. shown in their entirety in the smaller brain of the 7. Barondes. S. H. ( 1969). Axoplasmic transport. In: Hand­ rat by the use of combined lesions and fluorescent book of Neurochemistry, Vol. 2: Structural Neuro­ techniques. ,;s chemistry. Lajtha, A. (Ed.) New York, Plenum Press, Such information has already found clinical pp. 435-446. application. The nigrostriatal system has been 8. Ochs, S .. Johnson, J .. and Ng, M. -H. ( I 967). Protein incorporation and axoplasmic flow in motoneuron fibers related to neural motor control mechanisms: de­ following intracord injection of leucine . ./. Neurochem. creased dopamine levels in parkinsonism led to 14:317-331. the introduction of L-DOPA, a precursor of 9. Karlsson, J. 0., and Sjostrand, J. ( I 971 ). Synthesis, dopamine, as a successful therapeutic agent for the migration and turnover of protein in retinal ganglion disease. 66 Changes in the amount and types of cells. J. Neurochem. 18:749-767. neurotransmitter-related materials at the terminals I 0. Ochs, S. ( 1972). Rate of fast axoplasmic transport in mammalian nerve fibers. J. Ph_vsiol. 227:627-645. of the dopamine, noradrenaline, and possibly sero­ I I. Ochs, S. (1972). Fast transport of materials in mammalian tonin fiber systems or their postsynaptic receptors nerve fibers. Science 176:252-260. have been correlated with changes in alertness and 12. Byers, M. R., Fink, B. R., Kennedy, R. D. Middaugh, M. emotional state and thus serve as a rationale for the E., and Hendrickson, A. E. ( 1973). Effects of lidocaine on axonal morphology, microtubules, and rapid transport use of psychotrophic agents. i;5-6u in rabbit vagus nerve in vitro. J. Neurohiol. 4: I 25- The axoplasmic transport of other materials is 143. likely to be important for clinical medicine in a 13. Ochs, S., and .lersild, R. A., Jr. (1974). Fast axoplasmic general sense. Alterations of the amount or types transport in nonmyelinated nerve fibers shown by of materials synthesized by the nerve cell bodies electron microscopic radioautography. J. N eurohiol. as a result of disease can lead to long-term altera­ 5:373-377. 14. Gross, G. W., and Beidler, L. M. (1973). Fast axonal tions. These may come about through a changed transport in the C-fibers of the garfish olfactory nerve. level of trophic substances supplied by the nerve .I. Neurohiol. 4:413-428. fiber to other cells. Some indication that such a 15. Gross, G. W. ( I 973). The effect of temperature on the trophic supply may be directly invested has been rapid axoplasmic transport in C-fibers. Brain Res. 56:359-363. suggested by labeling studies. io, ii Just what the trophic materials may be and how they act on the 16. Edstrom, A., and Hanson, M. ( 1973). Temperature cffech on fast axonal transport of proteins in vitro in frog cells receiving them is at present an important sciatic nerves. Brain Res. 58:345-354. field for study. i:? It is most reasonable to expect 17. Ochs, S .. Sahri. M. I., andJohnson.J. (1969). Fast trans­ that further knowledge of this protean system will port system of materials in mammalian nerve fibers. lead to a better understanding of what are now Science I 63 :686-68 7. obscure neuropathological entities and in turn lead 18. Sabri, M. I., and Ochs, S. (1973). Characterization of fast and slow transported proteins in dorsal root and sciatic to a new and better means of treating diseases of nerve of cat. J. Neurohiol. 4: 145-165. nerve. muscle, cord. and brain. I 9. Grafstein, B. ( I 969). Axonal transport: communication 194 between soma and synapse. In: Advances in /Jiochemirnl ( 1970). Studies on the mechanism of axoplasmic trans­ Psychoplumnacology, Vol. I: 11-25. port in the crayfish cord. J. Neurobiol. I :395-409. 20. McEwen, B. S., Forman, D. S., and Grafstein, B. ( 1971 ). 38. Samson, F. E. ( 1971 ). Mechanism of axoplasmic transport. Components of fast and slow axonal transport in the J. Neurobiol. 2: 347-360. goldfish optic nerve . ./. Neurohiol.2:361-377. 39.Ochs, S. ( 1975). Axoplasmic transport. In: The Nervous 2 I. Elam, J. S., and Agranoff, B. W. (I 97 I). Transport of System, Tower, D.B. (Ed.), Vol. I: The Basic Neuro­ proteins and sulfated mucopolysaccharides in the gold­ sciences, Raven Press. N.Y., pp. 137-146. fish visual system . ./. Neurohiol. 2:379-390. 40. Ochs, S .. and Hollingsworth, D. ( 1971 ). Dependence of 22. Abe, T.. Haga, T., and Kukokawa, M. ( 1973). Rapid fast axoplasmic transport in nerve on oxidative metab­ transport of phosphatidylcholine occurring simul­ olism. J. N eurochem. I 8: I 07- I I 4. taneously with protein transport in the frog sciatic nerve. 41. Ochs, S., and Smith, C. ( I 971 ). Fast axoplasmic transport Biochem . .I. 136:73 1-740. in mammalian nerve in vitro after block of glycolysis 23a. Dahlstrom, A. ( 1971 ). Axoplasmic transport with par­ with iodoacetic acid . .I. Neurochem. I 8: 833-844. ticular respect to adrcncrgic neurons. Phil. Trans. 42. Ochs. S. ( 1974). Energy metabolism and supply of nerve Roy Soc. B. 261 :325-358. by axoplasmic transport. In: Symposium on Metabolism 23b. Geffen, L. B., and Livett, B. G. ( 1971). Synaptic vesicles in Relation to Function in Ganglia and Peripheral Nerves in sympathetic neurons. Physiol. Rev. 51 :98-157. of Vertebrates. Larrabee, M. ( Ed.) Fed. Proc. 33: I 049- 24. Lubinska, L., and Niemierko, S. (I 970). Velocity and 1057. intensity of bidirectional migration of acetylcholin­ 43. Sabri, M. I.. and Ochs, S. ( I 972 ). Relation of ATP and esterase in transected nerves. Brain Res. 27:329- crcatine phosphate to fast axoplasmic transport in 342. mammalian nerve. J. Neurochem. 19: 2821-2828. 25. Ranish, N., and Ochs, S. (I 972). Fast axoplasmic trans­ 44. Khan, M. A., and Ochs, S. ( I 974). Magnesium or calcium port of acetylcholinesterase in mammalian nerve fibers. activated A TPase in mammalian nerve. Brain Res. 81: .I. Neurochem. 19:2641-2649. 413-426. 26. Ochs, S. ( 1971 ). Characteristics and a model for fast 2 2 axoplasmic transport in nerve . ./. Neurohiol. 2:331- 45. Berl. S., and Puszkin, S. (1970). Mg ·-Ca • -activated adenosine triphosphatase system isolated from mam­ 345. 27. Ochs, S. ( 1974). Systems of material transport in nerve malian brain. Biochemistry 9: 2058-2067. fibers (axoplasmic transport) related to nerve function 46. Ochs, S., ( I 971 b ). Local supply of energy to the fast and trophic control. In: Trophic Function of the Neuron, axoplasmic transport mechanism. Proc. Nat. Acad. Sci. Drachman, D. B. (Ed.), A1111.N.Y. Acad. Sci. 228:202- (U.S.A.) 68: 1279-1282. 223. 47. Leoni, J., and Ochs, S. ( 1973). Reversibility of fast axo­ 28. Ochs, S., and Burger, E. (I 958). Movement of substance plasmic transport following differing durations of anoxic proximo-distally in nerve axons as studied with spinal block in vitro and in vivo. Abst. Soc. Neurosci. 3: 147. cord injections of radioactive phosphorus. A mer . .I. 48. Lundborg, G. 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N.Y. Acad. Sci. 228, pp. 1-423.

196 Nerve Root Compression: Effects on Neural Chemistry and Metabolism

DAVID PLEASURE Associate Professor. Neurology University of Pennsylvania, and Children's Hospital of Philadelphia

INTRODUCTION tion will be reviewed, as will recent biochemical Nerve compression results in two distinct studies of nontraumatic segmental demyelination. pathological processes. Trauma of relatively low WALLERIAN DEGENERATION intensity (pressures of 150 to l ,000 millimeters 1 of mercury) causes segmental demyelination. -:1 A. Axonal changes. Most axonal structural pro­ Electrophysiological studies demonstrate slowing teins and enzymes are synthesized in the neuronal 10 11 of conduction velocity in the injured segment, perikaryon. • The major axonal structural pro­ or conduction block. '.',4 Distal to the compressed teins include tubulin, the monomeric form of micro­ segment, conduction velocity and neuromuscular tubules; t'.', 1afiJarin, the subunit of neurofilaments; 14 junction function are preserved. To restore and the growth-cone microfilamentary subunit, an 15 16 normal function, all that is required is new myelin actin-like protein. • Chemical properties of these synthesis in the injured segment~ this is ordinarily proteins have recently been reviewed. 17 Axons also a rapid, successful process. contain a variety of enzymes, including those asso­ When trauma is more severe, Wallerian degen­ ciated with transmitter vesicles and mitochondria. eration occurs. The distal nerve segment becomes Within 24 hours after nerve transection, disin­ electrically inexcitable, and neuromuscular junc­ tegration of microtubules and neurofilaments, tions and sensory end-organs degenerate. 5 ·n· 7 mitochondrial swelling, and rupture of the axo­ 7 18 To restore function, the neurons must synthesize lemma occur distal to the injury."· • Prior to large quantities of axonal structural proteins, the axonal fragmentation, there is a transitory accumu­ axons must sprout through the distal nerve seg­ lation of transmitter vesicles and other axonal ment to reestablish synaptic contact with muscle, organelles in the distal nerve stump, probably a con­ 7 8 18 and finally these axons must be remyelinated. • sequence of residual reverse axoplasmic flow. • rn This complex regenerative process is usually Miniature end-plate potentials continue for several incomplete and unsatisfactory, especially in hours after the transection, longer when the injury adults.H is far from muscle, suggesting continued forward This paper will outline the biochemical altera­ axoplasmic flow.'.!0 Similarly, forward and -reverse tions in peripheral nerves and nerve roots during axoplasmic flow continue for several hours in Wallerian degeneration. Unfortunately, traumatic vitro in isolated nerve segments, indicating that segmental demyelination has not yet been studied such flow is not dependent upon continuity with biochemically, though it is probably more frequent the neuronal perikaryon. 21 • '.''.' than Wallerian degeneration as a cause of neuro­ N eurofilaments, mitochondria and transmitter logical disability after nerve compression. Morpho­ vesicles accumulate in the proximal nerve stump 3 4 logical and electrophysiological investigations of during the first days after axonal transection.:? , :? the pathogenesis of traumatic segmental demyelina- The concentration of cyclic 3' ,5' -adenosine-5' -

' 197 monophosphate in the proximal stump also in­ proteins, ~ glycoprotein ("Po," molecular weight creases; 25 this cyclic nucleotide stimulates the about 30,000 daltons) and two basic proteins 2 polymerization of tubulin into microtubules '; and ("P 1" nearly identical to CNS myelin basic protein accelerates axonal sprouting. :n Axoplasmic trans­ in molecular weight, amino acid sequence, and port of tubulin and the actin-like microfilamentary antigenic properties, and "P2," molecular weight monomer is accelerated, whereas axoplasmic flow about I 2,000 daltons). In addition, a variable of transmitter vesicles is reduced. 10 Axonal sprout­ number of higher molecular weight proteins are ing begins within a few days: each sprout is tipped present in trace amounts; it is uncertain whether by a bulbous growth cone, containing contractile these are intrinsic to the myelin sheath, are non­ microfilaments that are inserted into the plasma myelin Schwann cell plasma membrane proteins. membrane. 15 Axonal microtubules extend into the or contaminants. 4-t--tu sprouts, serving as rigid structural members, and During the first week after axonal transection, perhaps functioning in axoplasmic transport. 28 -:io the amount of myelin that can be isolated from the Retrograde axoplasmic flow, from axonal ter­ distal nerve segment by sucrose density gradient minals toward the perikaryon, is probably also ultracentrifugation falls, and essentially no myelin important during nerve regeneration. In autonomic can be isolated after 2 weeks.47 There are corre­ axons, nerve growth factor is translocated prox­ sponding reductions in distal nerve segment con­ imally and may serve to enhance axonal sprouting. 31 tent of the lipids and proteins characteristic of There is a transitory increase in reverse axoplasmic myelin, and increases in myelin degradation flow of proteins at the time regenernting axons products, including cholesterol ester and lysophos­ 32 reach denervated muscle. phatidylcholine. 48 , 4 9 During this period, the rate B. Anterior horn changes. Neurons actively of incorporation of radioactive lipid and protein synthesize proteins under normal circumstances, precursors into myelin by the distal nerve seg­ and this synthesis is further accelerated after axonal ment falls far below normal.47 Electron microscopy transect ion. 28• 33-35 Uptake of RN A and protein suggests that the Schwann cells themselves are re­ precursors by the perikaryon accelerates within sponsible for myelin catabolism during Wallerian a day after transection, and there is increased pro­ degeneration." 0 duction of the axonal structural proteins. 10, :14, 36 During the first days after axonal transection, Other normal neuronal functions are neglected the rate of mitosis of Schwann cells in the distal during the period of axonal sprouting; synthesis nerve segment increases markedly; 51subsequently. of transmitter vesicles declines, 10and the number of the Schwann cells line up to form bands of Bunger. perikaryal boutons and the extent of dendritic When axonal sprouts have penetrated these arborization are reduced.: 35 Schwann cell bands and reached a size suitable Anterior horn glial cells also participate in the as a framework for new myelin formation, there is response to axonal transection. During the first a dramatic increase in myelin protein and lipid few days after trauma, perineuronal microglia synthesis.47 The amount of myelin in the re­ pro Iif erate and astrocytes increase in cell mass. generated nerve. however. never fully returns to 8 2 Oligodendrocytes do not respond early, but enlarge normal. • " at the time of end-organ reinnervation.:is, 37 D. Changes in collagen metabolism. Collagen C. Changes in Schwann cells. Schwann cells is present in larger quantity than any other protein make up 90 percent of the endoneurial cell popula­ in peripheral nerves. 5:i The relative amount of tion.38•39 All Schwann cells have the capacity to collagen is greatest in small, superficial sensory form myelin when in contact with an appropriate nerves, intermediate in large nerve trunks. and axon! 0 and myelinating Schwann cells are highly lowest in the nerve roots. 54· 55 Two forms of specialized plasma-membrane synthetic cells. collagen are present: interstitial collagen micro­ The function of those Schwann cells surrounding fibrils; and collagen covalently bound to glyco­ unmyelinated axons is unclear, though they may proteins in basement membrane. The chemistry synthesize proteins for export into the axons. 41 of these two forms has recently been reviewed. 56, 57 Myelin is particularly rich in lipids, especially Endoneurial interstitial collagen microfibrils are unesterified cholesterol and the galactolipids. 42· 43 synthesized, at least in part, by endoneurial fibro­ Peripheral nerve myelin contains three principal blasts. Recent tissue culture studies indicate that 198 cloned malignant Schwann cells, like most ecto­ SEGMENTAL DEMYELINATION dermal derivatives, are able to synthesize base­ With trauma of relatively low intensity, there is ment membrane collagen. 58 It seems likely, initial distortion of internodal myelin, followed therefore, that the basement membrane that by paranodal and then segmental demyelination. 1-:1 surrounds all Schwann cell processes in the endo­ Conduction time along demyelinated internodes neurium is synthesized by the Schwann cells is prolonged, though saltatory conduction is not themselves. lost, and the "safety factor" of demyelinated inter­ After nerve crush or transection, collagen accum­ nodes is reduced, so that small increases in temper­ ulates at the site of trauma, and continues to ature or in intracellular sodium content result in increase in concentration for a year or more. 52 • 5:1, :;9 conduction block. 7:1-15 Collagen deposition is restricted to the traumatic With each episode of demyelination, Schwann zone, and there is no increase in this protein in the cells divide and there is deposition of interstitial distal nerve segment, remote from injury." 2 Dense and basement membrane collagen in the endoneur­ collagen scar in the injured zone may be a major ium. 76 Recurrent segmental demyelination may impediment to entry of axonal sprouts into appro­ lead to excessive concentric proliferation of priate fascicles of the distal nerve segment, 60 and Schwann cells and collagen around central denuded the progressive increase in scar with time after 76 axons. • 77 trauma may explain the poor functional return Under normal circumstances, each of the lipids achieved with late secondary repair of transected 6 1 and proteins in myelin has a discrete half-life, nerves. 61 - : Specific pharmacologic inhibition of and steady-state levels of myelin are maintained collagen scar formation in experimental animals by synthesis of each lipid and protein by Schwann subjected to sciatic nerve transection results in an cells at a rate adequate to match losses. Segmental increase in the rate of myelination of the distal demyelination occurs if Schwann cell synthesis 12 nerve segment.' of a myelin constitutent falls below the normal E. Changes in metabolism of muscle. Motor catabolic rate, as occurs in diphtheritic neu­ axons have a trophic effect on muscle, controlling ropathy / 8 or if destruction of myelin increases the mechanical and metabolic properties of the to beyond the capacity of Schwann cells to provide muscle fibers. 64 The nature of this influence of replacements, as occurs when the myelin is de­ nerve on muscle is controversial: some evidence stroyed by a surface-active agent. w points to acetylcholine as the trophic substance, These two possibilities, depressed Schwann while other investigations suggest the existence cell synthetic capacity or accelerated destruction 67 of an as yet uncharacterized trophic protein. 65- of preformed myelin, have both been invoked to After nerve transection, there are early changes explain traumatic segmental demyelination. When in muscle membrane composition and metabolism, a segment of nerve is compressed, blood flow is including increases in sialic acid content and in reduced, and Schwann cell ischaemia occurs: 68 69 phosphatidyl inositol turnover, • and spread of if sufficiently severe, this might depress synthesis the distribution of the acetylcholine receptor pro­ of myelin lipids and proteins. If ischaemia alone tein from the subneural apparatus to larger areas were responsible for pressure-induced demyelina­ of the plasma membrane. 70 The denervated muscle tion, however, then demyelination should be becomes atrophic, and later, there are ·'myopathic'' present throughout the segment of nerve beneath degenerative changes as well. Though the dener­ an occluding tourniquet. In fact, demyelination vated muscle appears fibrotic, whole muscle con­ after acute compression occurs only at the upper tent of collagen does not increase ( Pleasure, un­ and lower borders of the tourniquet, with sparing published data). of the central zone. 3 •4 This suggests that mechanical Muscle has a trophic effect on regenerating deformation induced by a pressure gradient, nerve as well. Reverse axoplasmic flow increases rather than ischaemia, is responsible for acute after restoration of contact between axonal sprouts compression-induced segmental demyelination. and muscle: 2 and sprouts that reach muscle in­ The relative contributions of ischaemia and of crease rapidly in diameter, whereas unsuccessful mechanical deformation to segmental demyelina­ sprouts do not. 71 • 72 Axonal enlargement is less tion induced by chronic compression remain pronounced if the muscle tendon is cut. 72 unknown. 199 CONCLUSIONS 14. Shelanski, M. L., Albert, S .• DeVries. G. H .• and Norton, W. 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Z.: The role of the peri­ Isolation and characterization of a protein from sciatic pheral stump in the control of fibre diameter in regenerat­ nerve myelin responsible for experimental allergic neuritis. ing nerves. J. Physiol. I 03: I 19-136, 1944. Nature (New Biol.) 235:210-212, 1972. 64. Guth, L.: "Trophic" influences of nerve on muscle. Physio/. 45. London, Y.: Preparation of purified myelin from ox intra­ Rev. 48:645-687, 1968. dural spinal roots by rate-isopycnic zonal centrifugation. 65. Drachman, D. B.: ls acetylcholine the trophic neuro­ Biochem. Biophys. Acta 282: 195-204, J 972. muscular transmitter'? Arch. Neurol. 17:206-2 I 8, 46. Singh, H., and Spritz, N.: Polypeptide components of myelin 1967. from rat peripheral nerve. Bioclzem. Biophys. Acta 66. Korr, I. M., and Appcltauer, G. S. L.: The time-course of 351 :379-386, J 974. axonal transport of neuronal proteins to muscle. Exp. 47. Rawlins, F. A., and Smith, M. E.: Metabolism of sciatic Neuro/.43:452-463, 1974. nerve myelin in Wallerian degeneration. Neurobiology 67. Giacobini, G., Filogamo, G., Weber, M., Boquet, P., I :225-231, 1971. and Changeux, .I. P.: Effects of a snake alpha-neurotoxin 48. Berry, J. F., Cevallos, W. H., and Wade, R. R., Jr.: Lipid on the development of innervated skeletal muscles in class and fatty acid composition of intact peripheral chick embryo. Proc. Nat. A cad. Sci. USA 70: I 708- nerve and during Wallerian degeneration. J. Amer. Oil 1712. 1973. Chem. Soc. 42: 492-500, I 965. 68. Andrew, C. G., and Appel, S. H.: Macromolecular char­ 49. Mezei, C.: Cholesterol esters and hydrolytic cholesterol acterization of muscle membranes. I. Proteins and sialic csterase during Wallerian degeneration. J. Neurochem. acid of normal and denervated muscle. J. Biol. Chem. 17:1163-1170, 1970. 248:5 I 56-5 I 63, I 973. 50. Morris, J. H., Hudson, A. R., and Weddell, G.: A study 69. Appel, S. H., Andrew, C. G., and Almon, R. R.: Phos­ of degeneration and regeneration in the divided rat sciatic phatidyl inositol turnover in muscle membranes following nerve based on electron microscopy. I. The traumatic denervation . ./. Neurochem. 23:1077-1080, 1974. degeneration of myelin in the proximal stump of the 70. Chiu, T. H., Dolly, J. 0., and Barnard, E. A.: Solubiliza­ divided nerve. Z. Zellforsch 124: 76- I 02, I 972. tion from skeletal muscle of two components that 51. Bradley, W. G., and Asbury, A. K.: Duration of synthesis specifically bind alpha-bungarotoxin. Biochem. Biophys. phase in neurilemma cells in mouse sciatic nerve during Res. Comm. 51 :205-213, 1973. degeneration. Exp. Neurol. 26: 275-282, 1970. 71. Aitken . .I. T., Sharman, M., and Young, J. Z.: Maturation 52. Pleasure, D. E .. Bora, F. W., .Ir., Lane, J., and Prockop, of regenerating nerve fibres with various peripheral D. J.: Regeneration after nerve transection: effect of connexions . ./. 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597-036 0 - 76 - 14 fiber diameters of intact and regenerating nerves . ./. 77. Pleasure, D. E., and Towfighi,J.: Onion bulb neuropathies. Neurol. Sci.20:451-469. 1973. Arch. Neuro/.26:289-301, 1972. 73. Rasminsky, M., and Sears, T. A.: lntemodal conduction in 78. Pleasure, D. E., Feldmann, B., and Prockop, D. J.: Diph­ undissected demyelinated nerve fibres. J. Physiol. theria toxin inhibits the synthesis of myelin proteolipid 227:323-350, I 972. and basic proteins by peripheral nerve in vitro. J. Neuro­ 74. Koles, Z. J., and Rasminsky. M.: A computer simulation chem. 20:8 J-90. I 973. of conduction in demyelinated nerve fibres. J. Physiol. 79. Hall, S. M.. and Gregson, N. A.: The in vivo and ultra­ 227:351-364, 1972. structural effects of injection of lysophosphatidyl choline 75. Rasminsky, M.: The effects of temperature on conduction into myelinated peripheral nerve fibres of the adult in demyelinated single nerve fibers. Arch. Neurol. mouse . .I. Cell Sci. 9:769-789, I 97 I. 28:287-292, I 973. 80. Pichichero, M., Beer, B., and Clody, D. E.: Effect of 76. Dyck, P. J.: Experimental hypertrophic neuropathy. dibutyryl cyclic AMP on restoration of damaged sciatic Arch. Neurol. 21 :73-95, 1969. nerves in rats. Science 182:724-725, 1973.

202 Discussion: Papers of Sidney Ochs and David E. Pleasure

IRVIN M. KORR Professor, Dept. of Biomechanics College of Osteopathic Medicine Michigan State University

We have just heard two splendid papers on I do not need to remind this group that a nerve axonal transport, trophic functions and neural or nerve root is far more complex than a mere chemistry and metabolism. They are comprehen­ aggregate of axons and their myelin sheaths. sive. though concise summaries of current knowl­ A nerve may even be viewed as an integrated edge and hypotheses and require no detailed com­ organ consisting of many different kinds of cells, ment from this discussant. As a physiologist who tissues and their products. Nevertheless, and for has had the long-time advantage of working in an obvious reasons, the prevailing emphasis of studies osteopathic environment, I believe that my best on neural mechanisms and their impairment has contribution would be to relate this material to been on the axons. the subject of the conference, spinal manipulation. I propose, therefore, to identify and, where pos­ Axonology, however, does not offer enough of an answer to the questions I have just asked sible, characterize the ways in which the functions, about the neurochemical and neurotrophic con­ processes and mechanisms discussed by Ors. Ochs sequences of neural deformation - central questions and Pleasure might be affected by nerve-trunk before this conference. What else do we need deformations of musculoskeletal origins which in to know? We need to know how the nonaxonal turn are amenable to manipulative therapy. To components of nerve trunks. especially those avoid duplication. I shall limit the discussion to which serve nutritive functions and which provide those circumstances in which axons survive, dis­ or control the environment of the axons. are af­ abled though they may be. We shall not, therefore, fected by deformation and how these in turn af­ be concerned with degeneration and regeneration, fect neuronal chemistry, metabolism. synthesis. but only with first degree injury, in Sunderland's axonal transport and trophic relations. These classification. 1 I hope this may be a useful effort include the Schwann cells and myelin; the vascular even if. other than a few clues, the only products elements; the various mesenchymal components; are more unsolved questions. Certainly. I have few the endoneurial fluids and their flow channels. answers. These are my questions: How may compression, Unfortunately, little is yet known about how stretching, angulation, or other deformations of some of these various components contribute nerves and nerve roots by surrounding structures to neural economy under normal circumstances. influence neural chemistry and metabolism and the much less under those engendered by mechanical synthesis and axonal transport of macromolecules insult. I shall try to suggest how these various and subcellular structures'? And how do these components of the nerve may be affected by defor­ neural effects in turn influence the tissues, organs mation. I shall start with axons, about which one and processes under neural control and regulation? feels a little more sectre. 203 AXONS thinner, remains capable of excitation and con­ duction. Whether or not the neuron as a whole is Axoplasmic Transport functional, i.e., can conduct impulses from one end Proximodistal (Cellulifugal) Transport to the other, depends on the state of the injured segment. At that site the axon may transmit Attenuation of the axon by compression or other impulses normally: or conduction may be blocked: deformation, as has been described. impedes axo­ or it may be hyperexcitable: and. in the living. plasmic transport beyond the compression. The breathing, moving animal or human, it may oscillate axon becomes swollen with dammed-up axoplasm back and forth from one state to the other. Con­ immediately proximal to the compressed segment. duction block may. however. be persistent. and while distally the axon may become reduced in recovery delayed for hours, days or months, even diameter. A smaller swelling on the distal side of the compression reflects dammed-up axoplasmic after a momentary deformation. as in concussion. components moving tm-vard the cell. As long as The affected fibers suddenly reawaken to activity. sufficient axoplasmic passage through the stenotic as Dr. Sunderland describes it. The chemical and segment is permitted, axoplasmic continuity is structural basis for the functional states - normal. preserved and the trophic relations between the conduction block. hyperexcitability-is unknown. perikaryon and its long cytoplasmic process con­ We can only assume that they are somehow related tinue. though probably with some impairment. The to the degree of polarization of the resting mem­ axon distal to the lesion survives and Wallerian brane, although Dr. Pleasure has also drawn our degeneration is forestalled. attention to the state of para-nodal myelin. Moreover, trophic maintenance of the axon Hence, excitatory function and trophic function ensures continued trophic support of innervated are completely dissociated in this sublethal degree structures. As long as connectedness is maintained of axonal deformation. Similar dissociation may be between nerve cell and. for example, muscle cells, produced experimentally ( or therapeutically) by whether or not impulses are being or even can be chemical or physical agents applied to the nerve transmitted, the muscle cells remain intact and which block conduction even for long periods of functional. Acetylcholine sensitivity remains, as time (e.g. local anesthetics, cold. pressure) without 7 in the completely normal motor unit, limited to the interrupting the axon. It is of historic interest that junctional area and no fasciculation is seen. only recently was it possible to produce, experi­ We do not as yet know, however, the effects mentally, the reverse dissociation. in which a either on the axon ( other than attenuation) or on trophic influence was blocked, by pharmacological the innervated tissues of the slowing of the axo­ interference with fast axoplasmic transport. while plasmic supplies or whether indeed the change in the nerve remained functional as a transmitter of axoplasmic transport is purely quantitative. The impulses. 8 Of course, when axoplasmic transport is motoneuron, for example, is essential not only for reduced to the point that it is no longer adequate the maintenance of muscle, but also because it for axonal maintenance, conduction soon fails and exerts a variety of trophic influences on the Wallerian degeneration ensues. Up to this point. structure. excitability, contractile properties, en­ removal of the compressing force permits redis­ zyme activity, metabolism, etc .. indeed on its genie tribution of dammed-up axoplasm and the recovery expression.:.!, :i These influences, as Dr. Ochs has of the neuron. indicated. seem to be based on axoplasmic trans­ Retrograde (Cellulipetal) Transport port and, I believe, on the actual trans synaptic delivery of neuronal proteins and other substances As reviewed by Dr. Ochs, at this and other to the muscle cells.H How does the slowing, and symposia,3 axonal transport toward the cell body possible qualitative alteration, of this delivery has also been demonstrated and studied. It has affect the functions and properties of the muscle been shown that proteins in muscle may enter the ( or other innervated structure)? Such questions nerve and be conveyed to the cell body. This are of immense clinical as well as theoretical transport, too, may be expected to be retarded by interest. axonal compression. Insofar as this serves a feed­ We do know that under such conditions of axonal back function which chemically "informs" the continuity, the axon distal to the lesion. though neuron about circumstances in the periphery and 204 thereby regulates perikaryal morphology, metabo­ over even a considerable stretch of nerve does not lism, protein synthesis, synaptogenesis and pos­ necessarily result in ischemia, much less anoxia, sibly even gene expression, this retardation may be because of the rich anastamosis and diffusion of expected to have deleterious effects. This is another oxygen from surrounding tissues and adjacent important area for investigation, not only for nerve segments. The effects of experimental obvious theoretical reasons, but because it relates ischemia, with the use of blood-pressure cuffs to the clinical impact of axonal impingement and or tourniquets, on neural function in humans and the value of spinal manipulation. animals, as reflected in sensation and in motor and autonomic function, have been studied by SCHW ANN CELLS AND MYELIN SHEATHS many investigators, with varying, and even con­ Aside from the role of the Schwann cells in flicting results.• Interpretations of the results are the formation of myelin sheaths, which are so even more ambiguous because, with these methods, important in impulse conduction, there is evidence it is not possible to distinguish between the effects of a role in axonal nutrition and energy exchange of ischemia and those of neural compression. also. Though not yet well understood, it appears However, studies of the effects of local deformation that these cells may supply essential substances. or of anoxia on exposed or isolated nerves, clearly possibly through the Schmidt-Lantermann clefts, indicate that the respective mechanisms leading that are not supplied by the neuron or via blood to conduction block are quite different, as re­ and tissue fluids. 9 Deformation of a nerve almost flected, for example, in different orders of sus­ invariably involves deformation, and even disrup­ ceptibility among fiber types, and in very different tion of Schwann cell and myelin layers. As the dynamics of induction and recovery from block. 10 11 work of Denny-Brown and Brenner • and Of course, ischemia of sufficient intensity and others cited by Dr. Pleasure has shown, these duration does cause degeneration of the ischemic structures, especially in the vicinity of the nodes and distal portions. Less severe or briefer ischemia of Ranvier, may undergo considerable disruption produces conduction block without degeneration. in injured segments of nerve. The axons, though Hyperexcitability occurs during the induction and they remain intact, undergo conspicuous chemical post-ischemic periods. When the perfusion rate is changes, reflected in altered staining properties chronically reduced, but not to the point of com­ at the affected nodes. However, little is known plete ischemia, different fibers in the same nerve about the effects of such changes on axonal chem­ may at the same time be in various functional istry, metabolism, transport or trophic function, states ranging from normal conduction. to hyper­ in contrast with the more substantial understand­ excitability (ectopic, supernumerary impulses) to ing of the role of myelin in excitation and conduc­ conduction block, to degeneration; and the degree tion. In view, however, of the demonstration by of ischemia and neural dysfunction may flucruate Ochs and his coworkers that fast axoplasmic with motion. blood pressure and other variables. transport is energized by metabolic processes The functional state - normal, nonconducting or 1 within the axon, '.! reduced access of Schwann­ hyperexcitable -of the hypoxic (ischemic) nerve supplied metabolites may be expected to impede fibers is related to the resting membrane potential, or even block such transport. Since the sub­ which is also energized by oxidations in the stances, such as glycoproteins, which are rapidly axon. i:i. t4 transported seem to be especially important to the Mechanical insults or relatively moderate pres­ axonal endings and synaptic and myoneural trans­ sures which selectively occlude the veins draining mission, even local disorganization of the Schwann the nerve introduce disturbances other than. or cell and myelin layers may have serious in addition to, ischemia. As in other tissues, consequences. venous obstruction produces hyperemia, increased transudation and edema. Accumulation of inter­ BLOOD VESSELS fibrillar fluids almost certainly retards the exchange Deformation of a nerve or spinal root almost of substances between the axons and other ele­ inevitably produces deformation and even occlu­ ments in the nerve, with detriment to axonal sion of the vessels supplying the nerve. Occlu­ metabolism and to the processes that depend on sion of the vasa nervorum of a peripheral nerve axonal metabolism for energy and for specific 205 substances. Alterations in spatial relationships INTERSTITIAL FLUIDS IN THE NERVE within the edematous nerve and in osmotic rela­ The foregoing discussion of edema draws atten­ tions may also have effects on excitation and con­ tion to the existence of fluid spaces within the duction. Another factor to be considered as a nerve, provided by. or enclosed by, endoneurium complication of the increased transudation is the (and possibly perineurium) and to the evidence for accumulation of protein in the extra-axonal fluids, circulation of the endoneurial fluids in both and the resultant tendency toward fibrosis. This directions. 16- 21 occurs also in chronically ischemic nerves. Little or nothing is known of the origins or fate The consequences of circulatory embarrassment of the endoneurial fluid, the channels of flow or the in the spinal roots may be expected to be the same propulsive mechanisms. Indeed. if the observations as for peripheral nerves. There are several factors, of Weiss et al. 16 are correct that proximo-distal however, which render the roots much more flow continues in the living nerve after arrest of vulnerable in this regard: circulation and even in completely excised nerves. then we are presented with still another mystery I. Their location within the intervertebral foramen regarding the source and site of the motor power. is in itself a great hazard. As to connections of endoneurial spaces with 2. Spinal roots lack the protection of epineurium other fluid compartments there is good evidence, and perineurium. I think, for connections, direct or indirect or across 3. Since each root is dependent on a single radicu­ selectively permeable membranes. with subarach­ lar artery entering via the foramen. the margin noid space 17 , and subdural space 22 centrally, and of safety provided by collateral pathways is with lymphatics distally 23 and in the epineurium. minimal. Brierly, 17 for example, proposes that the periradicu­ 4. Venous congestion may be more common in the lar cul-de-sac of the subarachnoid space is a sub­ roots because the radicular veins would probably sidiary site for the excretion of cerebrospinal fluid be immediately compressed by any reduction (in whi_ch the roots are bathed) which may pass of foraminal diameter. There is also the possi­ into the spinal nerve as well as into segmental bility of reflux from the segmental veins through lymph channels. pressure-damaged valves: and venous conges­ What is the role of the endoneurial fluid in the tion would have additional consequences be­ nutrition, ionic and osmotic balance and metabo­ cause the swelling, being within the foramen, lism of the neuron. and in the processes which would contribute to compression of the other depend upon them, including excitation, conduc­ intraforaminal structures. tion, axonal transport and trophic functions? Un­ 5. Circulation to the dorsal root ganglion is es­ fortunately. we know as little about the function pecially vulnerable for anatomic reasons shown of the endoneurial flow as we do about its mec9a­ by Bergmann and Alexander. 15 nisms. We can assume that at the very least it serves the same function as interstitial fluids in It is interesting to speculate to what degree other tissues, i.e., as medium of exchange between ischemia (or venous congestion) of the dorsal root the tissue cells and the blood. We can also assume, ganglion affects its protein metabolism or the however. that the longitudinal arrangement, the ··routing'' mechanism discussed by Dr. Ochs which apparently channelized flow· and the interchange apparently controls the relative rates of exporta­ with fluid compartments of the central nervous tion of neuronal proteins toward the spinal cord as system underlie some additional functions specific compared to that toward the periphery. It is to nerve. Whatever they are, they may also be important to remember in this connection that expected to be highly vulnerable to mechanical sensory neurons are no less potent trophically insult to the nerve. than motor neurons. One should remember, also, that because the radicular arteries contribute THE CONNECTIVE TISSUES substantially to the blood flow of the spinal cord, The structure and relatively obvious functions reduced radicular flow over several segments of the epineurium, perineurium and endoneurium could also affect central neurons and intraspinal are reasonably well understood. and have been axon~. concisely summarized by Sunderland. 1 The fa- 206 miliar functions include that, especially of the vertebral and other musculoskeletal strains, desig­ epineurium, of imparting compactness and co­ nated as osteopathic lesions and responsive to hesiveness to the nerve; that of support; that of manipulative therapy, are associated with facilitated compartmentalization, the perineurium binding segments of the spinal cord. In those segments, together and encompassing the funiculi, the endo­ motoneurons and neurons of the sympathetic neurium ensheathing the individual fibers with their nervous system are maintained in a hyperirritable Schwann and myelin layers; that of guiding re­ state, presumably by disturbed patterns of afferent generating axons back to their appropriate termi­ input from proprioceptors and other endings in the nals; that of providing and supporting channels for stressed tissues. ~5 In this state, and under condi­ flow of interstitial fluids. blood and lymph; that of tions of daily life, the affected neurons tend to be diffusion barriers; that of defense against mechani­ in constant or relatively high activity when corre­ cal, chemical and microbial insult. sponding neurons in neighboring and contralateral In connection with neural chemistry, metabolism segments are quiescent or only mildly active. The and axoplasmic transport, I think we need to effects of such chronic activity, provoked and sus­ examine the likelihood that in the nerve, the tained by musculoskeletal disturbances, on neural mesenchymal components may play an unusual. chemistry, metabolism. axonal transport and perhaps unique role in the regulation of fluid volume trophic influence and on the retrograde influences and composition and of osmotic equilibrium. In from the target tissues have hardly been explored, the normal nerve the dynamic balance between yet are of great importance to the subject of this hydrostatic and oncotic pressures seems to be conference. between the radial pressure exerted by the epi­ Finally, it is important to re-emphasize the evi­ neurium and water absorption by endoneurial and dence that peripheral nerves not only conduct interstitial collagen, so abundant in nerve, as Dr. impulses to or from the cells, tissues and organs Pleasure has emphasized. As Lorente de Nd that they supply, hut also deliver to them sub­ showed, when the epineurium is mechanically stances synthesized in the cell body, most notably breached or weakened, the nerve swells enor­ proteins. that are essential for their development, mously, with progressive thickening of the endo­ maintenance and self-repair, that influence their deurium and enlargement of the intertibrillar various characteristics and functional capacities, spaces. 24 Under these conditions, one may expect and that condition their responses to various fac­ disturbances in exchange between blood and axons, tors, both physiologic and noxious. in neural chemistry, metabolism, transport, and Any factor which for a protracted period alters electrical properties. This is another area for study the quality or quantity of the axonally transported with modern methods, for its neurophysiological substances, might not only affect impulse trans­ interest, and in relation to the subject of this mission, but could cause the trophic influences to conference. become adverse and detrimental. thereby contribut­ ing to disease. In considering the neurologic impact THE NEURON on human health of postural and biomechanical defects in the body framework that are amenable Having called the roll of axonal and nonaxonal to manipulative therapy. we can no longer limit components of nerves and roots with a view to ourselves to disturbances in impulse traffic. Con­ their involvement in the effects of deformation, it spicuous and distressing as are the resultant pain is now time to return to the neuron. It is important and the motor, sensory and autonomic dysfunction, to remember that neural chemistry, metabolism the more subtle and insidious trophic consequences and axonal transport are subject to alteration not of disturbances in axoplasmic composition and only by neural and radicular deformation but by transport are no less important. It seems likely the activity of the corresponding nerve-cell bodies. that much of the efficacy of manipulative therapy Almost any factor which more or less enduringly is related to the amelioration of those trophic exaggerates the rate of impulse-discharge by factors. ~r,.:27 neurons also affects the energy requirements, metabolism and, almost inevitably, protein syn­ REFERENCES thesis and turnover. I. Sunderland, S. Nen'l',\ and Nerve l1{iurit!s. Williams and As Dr. Denslow will discuss tomorrow. inter- Wilkins, Baltimore, pp. 35-43, pp. 127-137. 1968. 207 2. Guth, L. "Trophic" influences of nerve on muscle. Physiol. 15. Bergmann, L., and Alexander, L. Vascular supply of spinal Re,•. 48(4):645-687, 1968. ganglia. Arch. Neurol. Psychiat. 46:761-782, 1941. 3. Drachman, D. B., Editor. Trophic Functions of the Neuron. 16. Weiss, P., Wang, H., Taylor, A. C., and Edds, M. V .• Jr. N. Y. A cad. Sci. 228: 1-423, I 974. Proximo-distal fluid convection in the endoneurial spaces 4. Korr, I. M., Wilkinson, P. N., and Chornock, F. W. Axonal of peripheral nerves, demonstrated by colored and radio­ delivery of neuroplasmic components to muscle cells. active (isotope) tracers. Am. J. Physiol. 143(4):521-540. Science 155:342-345, 1967. 1945. 5. Korr, I. M., and Appeltauer, G. S. L. The time-course of I 7. Brierly, J. B. The sensory ganglia: recent anatomical, axonal transport of neuronal proteins to muscle. Exp. physiological and pathological contributions. Acta Psy­ Neurol. 43(2):452-463, 1974. chiat. et Neurol. Scand. 30(4):553-576, 1955. 6. Appeltauer, G. S. L., and Korr, I. M. Axonal delivery of I 8. Appeltauer, G. S. L., and Eduardo, E. A. Saa. Incorpora­ soluble, insoluble and electrophoretic fractions of neuronal tion of C-14 Lysine into spinal roots, spinal ganglia and proteins to muscle. Exp. N eurol. 46: 132- I 46, 197 5. peripheral nerves of the rat. Exp. Neurol. 14:484-495. 7. Robert, E. D., and Oester, Y. T., Electrodiagnosis of nerve­ 1966. impulse deprived skeletal muscle. J. Appl. Physiol. I 9. Brierly, J. B .• and Field, J. The fate of an intraneural 28(4):439-443, I 970. injection as demonstrated by the use of radio-active 8. Albuquerque, E. X., Warnick, J. E., Tasse, J. R., and San­ phosphorus.J. Neurol., Neurosurg. Psychiatry. 12(2):86- sone, F. M. Effects of Vinblastine and colchicine on 99, I 949. neural regulation of the fast and slow skeletal muscles of 20. Bodian, D. Some physiologic aspects of poliovirus infec­ the rat. Exp. N eurol. 3 7: 607-634, I 972. tions. Han'ey Leet. 52 :23-56, 1958. 9. Singer, M .. and Salpeter, M. M. The transport of 3 H-L­ 21. Bakin, Ye. I., Dolgachev, I. P., and Kiselev, P. N. Possi­ Histidine through the Schwann and myelin sheath into bility of movement of substances along a nerve. Herald the axon, including a reevaluation of myelin function. of Roe11tgenology and Radiology (Transl.) No. I, pp. J. Morph.120(3):281-316, 1966. 3-6, 1953. I 0. Denny-Brown, D .• and Brenner, C. Paralysis of nerve 22. Dorang, L., and Matzke, H. A. The fate of radio-opaque induced by direct pressure and by tourniquet. Arch. medium injected into the sciatic nerve. J. Neuropathol. Neurol. Psychiat. 5 l: 1-26, I 944. Exp. Neurol. 19:25-32, 1960. 11. Denny-Brown, D., and Brenner, C. Lesions in peripheral 23. Kurdyumov, N. A. Structure of the perineural spaces and nerve resulting from compression by spring clip. Arch. efferent lymphatic routes from cerebrospinal nerves. Neurol. Psychiat. 52: 1-19, I 944. Arkhiv Anatomii, Gistologii i Embriologii ( USSR) 12. Ochs, S. 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208 Chairman's Summary: Neuroscience Studies

HORACE W. MAGOUN Pr<~f'essorEmeritus Department of Psychiatry University of California at Los Angeles

Seth Sharpless: Susceptibility (~( Spinal Roots to rocal innervation, from motor to somatic afferent Compression Block systems, holds that maintained high activity in In 1797, Felice Fontana observed that pressure epicritic afferents reduces or inhibits the central on a nerve blocks its capacity for conduction, transmission of pain signals, leading to analgesia. without causing stimulation. Sharpless has recently 1n the absence of such inhibition from blockade of confirmed this observation with sophisticated epicritic signals, activity in the central pain systems graded-pressure on the sciatic nerve and lumbar may gain an exaggerated intensity leading, by dorsal spinal roots of animals, leading to blockage analogy to motor syndromes of disinhibition, to a of the A components of evoked afferent potentials. sort of spasticity of pain. In addition, he has discovered that dorsal spinal Akio Sato: The Somatosympathetic Reflexes: Their roots display a differential sensitivity to such Physiological and Clinical Sign(ficance pressure as compared with the sciatic nerve. More­ Sato has employed current electro-physiologi­ over, within the _dorsal root. fibers conducting fast cal techniques to analyze reflex discharge in the components of the A potential are considerably white rami and lumbar sympathetic trunk evoked more susceptible to pressure than are those con­ by stimulation of the somatic afferent fibers in the ducting slower components. sciatic nerve in experimental animals. Reflexes Hopefully, the preoccupation of spinal manipula­ evoked by stimulation of myelinated somatic tive therapy with back pain will lead Sharpless to afferents had central pathways traversing spinal, extend his experiments to study the effect of such medullary and supramedullary levels; those evoked pressure upon slowly conducting, intermediate by stimulation of unmyelinated somatic afferents and fine-diametered afferent fibers in dorsal roots~ involved only spinal and medullary levels. The these are more directly concerned with mediating amplitude of spinal reflex discharge was largest pain signals than are the large, rapidly conducting when afferent volleys entered the same or adjacent A component fibers. segments of the cord corresponding to the white Extrapolation of Sharpless' observations that ramus under study. large, fast-conducting fibers are blocked before By contrast, the amplitude of reflex discharge slower components suggests the possibility that involving medullary or higher centers was inde­ still smaller and slower pain fibers may be exceed­ pendent of the segmental level of spinal input. In ingly resistant to pressure blockade, as witness generalization, somatic afferent stimulation has a the ubiquitous complaint of pain during compression twofold action on the sympathetic system: a gener­ of spinal nerve roots in man. It is conceivable that, alized action via supraspinal centers and a more during pressure block of epicritic signals (tactile circumscribed segmental action on preganglionic pressure and position-sense) in dorsal roots, pain neurons. signals that continue to be conveyed centrally may In further experiments, Sato has interrelated gain unusual intensity and unpleasantness. Recent electro-physiological data on somatic-visceral re­ transposition of Sherrington 's concepts of recip- flexes with analysis of recorded changes in the 209 affected visceral organs: Increase in heart rate, pear to form integral elements and the transport inhibition of gastric peristalsis, and increase in filaments involved require energy. presumably bladder pressure. on nociceptive stimulation of supplied by ATP, and are dependent upon local thoracic, abdominal and perineal skin. oxidative metabolism along the length of the fiber. These studies are establishing the physiological Reciprocally. a centripetal transport mechanism bases for determination in man of the visceral enables some signal substances to ascend the consequences of spinal syndromes for which manip­ fibers and provide feedback control regulating the ulative therapy is advocated. level of protein and other synthesis in the cell body. This retrograde transport proceeds at a rate Edward R. Perl: Pain: Spinal and Peripheral Nerve of 220 millimeters per day, about half that of the Factors outward transport system. In addition, some Perl ·s el~gant survey of the peripheral and mechanism exists for the internal routing of trans­ spinal substrates of pain points out that every tissue ported material among different types of neuronal likely to be exposed to unusual stress and noxious branches. For example. after injecting tagged ma­ circumstances in ordinary life, has been found to terial into a dorsal root ganglion, the peripheral contain sense organs with features of nociceptors. branches ending in receptors display a 3-5 fold Although pain is ordinarily initiated by activation greater amount of labeled activity than do the of these specific receptors. whose major charac­ branches proceeding into the spinal cord and teristic is their high threshold to all kinds of stimuli. ending centrally in presynaptic terminals. Perl calls attention to the pronounced functional Major current attention is directed also to CNS lability both of these receptors and their central axoplasmic transport mechanisms influencing the projections, which display remarkable sensitization amounts and types of neuro-transmitter related and hyperalgesia in the presence of inflammation materials delivered to the presynaptic terminals after tissue damage, as well as during pain-induced of dopamine, noradrenaline. and serotonin fiber reflex contraction of muscles following musculo­ systems: as well as to their postsynaptic receptor skeletal injury. sites. Advances in this area have already found Given this situation, Perl concludes. one should clinical application in the introduction of L-Dopa expect that the sensation of pain can be a variable as a therapeutic agent for Parkinson's disease. reaction and that many forms of physical and Further knowledge will doubtless lead to under­ psychological manipulation may alter it. standing of other, now obscure disorders and. in turn, to the development of means of treating addi­ Sidney Ochs: A Brief Review of Material Trans­ tional diseases of nerve, muscle, spinal cord, and port in Nerve Fibers brain. Ochs. who has himself contributed much of the current information in this field, points out that the David Pleasure: Nerve Root Compression: Ejjects nerve cell body is presently regarded as the major on Neural Chemistry and Metabolism site of synthesis of neural proteins and other In his introduction, Dr. Pleasure points out that metabolites, which are conveyed centrifugally nerve compression of relatively low intensity through the axonal and dendritic branches of neu­ causes segmental demyelinization, characterized rons to their receptor, presynaptic and post­ by slowing or blocking of conduction in the in­ synaptic, or neuro-effector terminals. jured segment. To restore normalcy. all that is Ochs' studies of this internal transport system required is new myelin synthesis in the segment have recorded the advancing patterns of labeled involved and this is. ordinarily. a rapid and success­ activity along the sciatic nerves of animals. after ful process. Although this situation is probably injection of3 H-leucine or :i H-lysine into the dorsal much more frequent than Wallerian degeneration. root ganglia or anterior horns of the lumbar spinal as a cause of neural disability after nerve compres­ cord. The characteristic rate of transport, between sion, such segmental demyelination has not yet 410 and 450 millimeters per day, is independent been studied biochemically. of molecular weights of materials. diameters of Dr. Pleasure goes on to point out that, with each nerve fibers. types or lengths of nerve. or species episode of demyelination. Schwann cells divide of animals: indicating a common carrier or con­ and there is deposition of interstitial, basement­ veyor-belt type of mechanism. Microtubules ap- membrane collagen in the endoneurium. With

210 excessive recurrence. this may lead to an exagger­ gradients, of a mechanical, rather than an ischemic ated concentric proliferation of Schwann cells and nature may be responsible for acute, compression­ collagen around central denuded axons. induced. segmental demyelination. Considered more generally, overall viability of Under normal circumstances. each of the lipids Schwann cells and the myelin sheaths they have and proteins in myelin has a discrete half-life and generated around nerve fibers, both in and outside steady states are maintained by the synthesis by the central nervous system, may be significantly Schwann cells at a rate adequate to match natural contributed to, or trophically influenced by, or losses. Segmental demyelination occurs if this syn­ under the control of, their parent cell bodies. Corre­ thesis of myelin constituents falls below the normal spondingly, the sheath cells and their products catabolic rate; or if destruction of myelin exceeds may be dependent upon axoplasmic transport of the capacity of Schwann cells to provide rapid re­ substances moving out of the neuronal perikaryon, placement, as in traumatic injury or even nerve in much the same way that activities at nerve fiber compression. terminals have been shown to be so influenced by When a segment of nerve is compressed, blood Sidney Ochs. Further studies of segmental de­ flow is reduced and, if sufficiently severe, Schwann myelination following nerve or nerve-root com­ cell ischemia may depress synthesis of myelin pression may lead to measures that would reduce lipids and proteins. In fact, however, demyelina­ the incidence of long-term disability following tion after acute compression occurs only at the such trauma. Such studies may even provide more upper and lower borders of the compressive force, fundamental insights that. hopefully, would con­ with sparing of the central zone. This suggests tribute to a therapy for such major demyelinating that some feature of local deformation of pressure diseases of the nervous system as multiple sclerosis.

211 Summary of General Discussion: What Do the Basic Sciences Tell Us About Manipulative Therapy?

HARRY D. PATTON Professor and Chairman Department of Physiology and Biophysics School of Medicine, University of Washington

The discussion focused mainly on the effect of viz., that vascular pulsations cause repeated mechanical forces on nerve trunks, with some dis­ transient mechanical stimuli to compressed or cussion of the mechanisms of mechanoreceptors. stretched roots, that receptors in dura, ligaments It was pointed out that in controlled experiments or other integuments may be the source of pain sustained mechanical forces on axons or nerve impulses, or that inflammation rather than mechani­ trunks block rather than excite; this is true whether cal forces per se may be responsible for sustained the force is directed transversely (compression) or neural discharge. It was pointed out that hypocal­ longitudinally (stretch). An exception is that tran­ cemia renders axons sufficiently excitable to re­ sient rapid mechanical distortions (either longi­ spond repetitively to mechanical stimuli, an tudinal or transverse) depolarize both nerve trunks observation which, though true, is of questionable and mechanoreceptors and generate bursts of relevance to the problem of low back pain. There impulses usually of short duration. The blocking was general agreement that further investigation action of mechanical forces is inconsistent with the of the response of nerve roots to chronic stretches basic theory of spinal manipulation, which is aimed or compression is needed and that such studies at relieving chronic compression or stretching of should attempt to create experimental conditions nerve roots, believed to be the underlying cause of mimicking those believed to be present in spinal pain. Several suggested explanations were offered, subluxations.

213 Chapter V.

What Do the Clinical Sciences Tell Us About Manipulative Therapy? (Subluxation: Pathophysiology and Diagnosis)

Henry G. West, Chairman The Pathophysiology of the Spinal Subluxation

SCOTT HALDEMAN Vancouver, B.C., Canada

The term "subluxation" has been used by mem­ CLASSIFICATION bers of the healing arts since the time of The spinal subluxation, as it is currently used, Hippocrates. 1 It has been referred to extensively is not considered a single entity. The complex by classical'.! and modern:i, 4 medical practitioners, 7 8 biomechanics of the spine allows for numerous chiropractors:;• 6 and osteopaths. • However, despite its common usage, the varying concepts of what constitutes a subluxation and the clinical TABLE I significance ascribed to it by the different pro­ The classification of spinal subluxations as determined by x-ray (from Basic Chiropractic Procedural Manual.) 10 fessions has been a major source of controversy which has hindered interprofessional discussions. The earliest English definition of a subluxation A. STATIC INTERSEGMENTAL SUBLUXATIONS appears to be that of Randle Holme in 1688 9 who l. Flexion malposition described it as "a dislocation or putting out of 2. Extension malposition joynt." In the literature both gross dislocations 3. Lateral tlexion malposition 4. Rotational malposition with separation of joint surfaces and very minor 5. Anterolisthesis (spondylolistheses) misalignments of adjacent articulations have been 6. Retrolisthesis referred to by this term. 7. Laterolisthesis In this paper the definition of the subluxation 8. Altered interosseous spacing (decreased or increased) proposed by the American Chiropractic Associa­ 9. Osseous foraminal encroachments tion will be used: "A subluxation is the alteration B. KINETIC INTERSEGMENTAL SUBLUXATIONS of the normal dynamics, anatomical or physiological I. Hypomobility (fixation subluxation) relationships of contiguous articular structures. " 10 2. Hypermobility (loosened vertebral motor unit) This definition has the advantage of including 3. Aberrant motion most of the concepts used by the various health C. SECTIONAL SUBLUXATION professions and subspecialities involved in the I. Scoliosis and/or alterations of curves secondary to treatment of skeletal disorders. ln addition it makes muscular imbalance no reference to specific symptomatology and gives 2. Scoliosis and/or alterations of curves secondary to no pathophysiological significance to the subluxa­ structural asymmetries 3. Decompensation of adaptational curvatures tion, which may therefore be considered a clinical 4. Abnormalities of motion finding rather than a pathological entity. The sig­ nificance of this finding is dependent upon the D. PARAVERTEBRAL SUBLUXATIONS degree and type of joint dysfunction, its etiology l. Costovertebral and costotransverse disrelationships and more especially its symptomatology and im­ 2. Sacroiliac subluxations portance in initiating further pathology.

217

597-036 0 - 76 - 15 A u

C D

Fig. I. Examp les of s 1a1ic spinal sub luxa tion. 2 18 subclassifications of intersegmental disrelation­ TABLE 2 ships. Table I lists one system of classification Procedures U sec.I in the Diagnosis of the Spinal Subluxation based on X-ray findings. This system includes descriptive terms for minor and major misalign­ I. HISTORY ments, kinetic, sectional, and paravertebral (a) Trauma or inflammatory disease disrelationships. (b) Symptoms In addition to the above-mentioned mechanical classifications a number of adjectives have been 2. GENERAL EXAMINATION used to differentiate subluxations on clinical 3. OBSERVATION grounds. These descriptive terms may be divided (a) Deformity into the following categories: (b) Posture I. According to Etiology - Traumatic (c) Motion

- Inflammatory 4. PALPATION -Postural (a) Static deformity - Psychosomatic (b) Abnormal mobility -Congenital (c) Tenderness and muscle spasm -Reflex 2. Primary, secondary 5. X-RAYS (a) Static or compensatory (b) Motion 3. According to Symptoms-Asymptomatic -Compressional 6. SPECIFIC INSTRUMENTATION -Painful (a) Postural analysis -Fixated (b) Autonomic nervous system monitoring - H ypermobile -Irritable (suggesting abnormal visceral re­ of joint disrelationships, and has increased the flexes) 4 11 number of classifications of the subluxation. • Figures I and 2 present several examples of sub­ Static and motion palpation in conjunction with luxations which may be demonstrated on X-ray. the other procedures in table 2 has been and re­ I -A shows a flexion misalignment of traumatic mains, the primary tool for day-to-day assessment origin of C-4 on C-5: 1-8 a lateral flexion mis­ of joint relationships and the determination of the 12 13 alignment associated with a disc lesion of L-4 on clinical significance of the subluxation. • L-5. This film also shows an abnormal Hadley's S This entity has additional importance in the line on the left~ 1-C demonstrates a spondylolis­ practice of spinal manipulation in that the specific thesis with decreased interosseous spacing and a adjustive thrust and the general techniques of spinal defect in the pars interarticularis, and 1-D a hyper­ manipulation are attempts to reduce positional mobile subluxation of the atlanto-axial articulation abnormalities, 5 increase movement at a "locked 14 15 16 found commonly in rheumatoid arthritis. Figure 2 joint" or the .. reduction" of disc lesions. • shows a normal cervical spine in the upright po~i­ Each of these procedures requires movement be­ tion (2-A) but with aberrant movement of the tween vertebral segments to achieve their goal. atlanto-occipital region on neck flexion (2-8). Therefore, the ease with which an adjustment is given is dependent upon a complete understanding DIAGNOSIS AND IMPORTANCE IN of normal spinal anatomy and mechanics, as well SPINAL ADJUSTING AND as a thorough examination for anomalies and sub­ MANIPULATION luxations in the spine being adjusted. Certain sub­ The existence and clinical significance of the luxation (e.g. the hypermobile segment in rheuma­ spinal subluxation is determined by the procedures toid arthritis) are considered contraindications for listed in table 2. X-ray examinations have been manipulation. Failure to perform an adequate the primary tool for confirmation of the subluxa­ examination and to take this type of spinal sub­ tion and the introduction of motion X-ray studies luxations into account could lead to serious 15 16 has led to a tremendous expansion in the knowledge complications. •

219 A n

Fig. 2. An example of an abe rrant movement sublux ation of th e atlanto-o cc ipital articulation.

CLINICAL SIGNIFI C AN CE normality which is assoc iated with all form s of bac k pain. The determin at ion of the clinical significance of c. The prese nce of an ab normalit y doe s not mean the spinal sublux ation has been clouded by the that the patient is at prese nt suffering from back large number of widely varying , and in many case s, pain. diametric ally oppo sed opinions on this subject To date no conclusive studie s have been don e which have often been dogmatically adhered to to det ermin e the significance of minor misa lign­ without adequate inves tigation. Th e exact clinical ment s in an y sy mptom of spinal or igin. significanc e remains difficult to det ermine because Th e inciden ce and cost of the se back problem s of the great diver sity in its etiology , the complex in the popul ation s of Wes tern Nations is so high natur e of the sublu xation and the co mpar ative lack th at further re sea rch is imper ative . N agi et al.~\ of re sea rch . in an investigation of the general population , found To date the only relevant research has been in th at 18 percent of peopl e que stioned in a surv ey the field of pre employment examinati on and work­ had persistent sy mptom s of backache while Hir sch men 's compen sation studie s on back injurie s. A et al. ia found that 30- 50 percent of women in a few pertinent statist ics from the se studi es are listed Swe dish study suffered from back pain. It is well in table 3. From the se figures it would appe ar that: known that back injurie s are one of the major 1 a. Ther e is a slightly higher incidence of spinal cause s of indu strial tim e loss . i - abnormalities and sublux at ions in pati ent s with Ap art from back pain, a large number of add i­ back problem s than those without problem s. tion al sym ptom s and patholog y have been attributed b. There is no one type of sublu xation or ab- to spinal der angement s by individuals in each of the 220 TABLE 3 An attempt will be made to discuss the role of the The incidence of structural or subluxogenic spinal abnor­ subluxation in each of these processes. malities in patients with and without symptoms. 1. DISC DEGENERATION Asymptomatic Sy~ptomatic The intervertebral disc has been shown to patients patients Reference Defect function optimally, have the greatest resistance to (percent) (percent) stress and optimum mobility when the nucleus I. Any spinal 59.4 81.0 Barton 17 pulposis is located in the center of the disc, and abnormality the height of the disc is of normal proportions and Diveley and 26 27 2. Congenital 41.1 equal in all dimensions. • The integrity of the 21 anomalies Oglevie disc appears to be dependent on the degree of 3. Scoliosis 14.5 27.2 Barton 17 4. Postural 5.0 Diveley and hydration, the collagen and mucopolysaccharide scoliosis Oglevie 21 content, and the amount of stress to which the disc 27 28 5. Decreased 15.0 43.0 Mensor and is subjected. • mobility Duvall 18 The etiology of disc disease is not yet fully under­ 6. Increased 8.0 13.0 Mensor and stood. A number of factors appear to be involved. mobility Duvall 1H 7. Increased 28.6 Morgan and Postural stress, structural abnormalities, and auto­ mobility King w immune processes have been considered as possi­ 0 2 8 31 8. Instability 47.9 White ~ ble pre disposing factors. • Normal aging has 9. Degenerative 77.3 White 20 been shown to reduce the water and mucopoly­ changes saccharide content while increasing the amount of 10. Negative 39.9 13.8 Diveley and 2 x-ray Oglevie 21 collagen in the disc. n,:io In the presence of these findings changes, and perhaps even in their absence, the end plates and annular fibers can rupture when sufficient compressional or rotational force is 6 8 12 25 2 health professions: • • • Nerve root and spinal applied to the disc. H, 27 The rupture of these fibers cord compression due to spinal dysfunction has then leads to fissures in the annulus, the protrusion 4 15 1 been well documented. • • (i The role of the spinal of the nucleus and the production of symptoms. subluxation in the pathophysiology of visceral dis­ The symptoms of local and referred pain, muscle orders, although not well documented, has been spasm and neurological deficit are due to irritation widely claimed by members of all professions who of pain sensitive soft tissue structures and the com­ practice spinal manipulation. 6 • 8 • 25 The implications pression of the spinal cord or nerve roots by the 4 15 of these claims in the understanding of health and bulging nucleus. • disease warrants the properly controlled physio­ The investigation of spinal subluxations has been logic, clinical, and statistical research necessary to used to determine the degree and stage of disc determine their significance. degeneration. 4 Although there is a great deal of doubt as to the value of static X-rays in the pre­ PATHOPHYSIOLOGY diction of symptoms attributable to disc lesions, 15 It is impossible to list and discuss each of the an analysis of spinal position and movement is numerous theories which have been proposed to often included in examinations of spinal disc explain the pathophysiology of the spinal subluxa­ disease to determine the following four types of tion and the results obtained through spinal manipu­ subluxations. lation. However, most of these theories relate to a. The Disc Height one or more of the following pathophysiological The height of the disc is a reflection of the degree processes: of hydration and since the water content decreases I. Intervertebral disc degeneration. with age and degeneration_2H, 3 o it can be used as 2. Posterior joint dysfunction. an indication of these two factors. It is, however, 3. Compression or stretch of vital structures such a late sign of degeneration and normal disc spaces as the nerve roots, spinal cord, perispinal blood may be present in cases of severe disc degenera­ vessels and the sympathetic chain. tion. 27 Macnab'sjoint body line 4 (figure 3), has been 4. Abnormal somato-visceral reflex activity. used as a diagnostic criterion for disc thinning. He 221 It is possible that the displacement of the nucleus found in scolioses 26 is also a result of an abnormal distribution of forces on the disc. Lindblom 34 investigated the effects of this type of stress on the intervertebral discs in rat s' tails. He found that when the tail was fixed in flexion , pro­ ducing a compression on one side of the disc, degenerative changes and annular rupture s could be produced. Clinically there is some correlation between disc wedging and disc disease. Most disc lesions occur in the cervical and lumbar regions of the spine , where the greatest degree of physiological disc wedging occurs. Drum 16 ha s stated that certain spinal configurations such as hyperlordo sis are particularly prone to disc disease , while Wiltse 31 feels that there is a high incidence of disc disease in lumbosacral tilt subluxations. c. Rotational Subluxation In an extensive study, Farfa n~6 found that normal rotation in the lumbar spine , at least in the cadaver, is associated with a forward tilt , which increases the distance between the posterior margins of the vertebral body , thereby stretching the pos te rior lateral annulus. Excessive rotation was found to result in a bulging in one part of the disc with a depression of another part. The maximum degree of Fig. 3. An example of an abnormal Macnab' s joint body line, of the L-4 : L-5 articulation. distortion occurred most commonly at the postero­ lateral angles of the disc, which are the most feels that in the absence of disc degeneration the common sites of disc degeneration. There was also tip of the superior articular facet should not reach separation of the annular filament s which resulted a line extending backward from the undersurface in a disc which had lost its stiffne ss and which of the vertebral body above. lt is pos sible, how­ yielded to touch. On removal of the torsion stre ss ever , to have almost total obliteration of the disc there was an incomplete return of the vertebral space with no symptoms whatsoever. :i 1 segment to the neu tra l position. If similar events occur in vivo , a chronic rotation al unstable subluxa­ h. The Disc Wedge (flexion, extension and lateral tion could be expected to remain following such flexion) an injury. N achemson 32 showed that a compressional d. Th e Hypermobil e Subluxation or Unstable force placed on a normal intervertebral disc is tran smitted via the nucleus evenly throughout the Segment 16 8 5 annulus. It has been suggested · ~ that a wedged Knutsson:i has stated that the first radiolo gical disc or maldistribution of force s can cause a shear­ sign of disc disease is abnormal motion on flexion ing effect, thus increasing the wear and tear force s from the upright position. A number of other ab­ on the disc. Ritchie and Fahrni 33 found that the normal movement s have been desc ribed by number of lamellae in the annulus is the same at Macnab~ who attributes them to degenerative all points around the disc, but that in the lumbar changes such as inspissation of the nucleus pul­ region these fiber s were distorted and compressed posis, tear of the annulus or rupture of the hyaline by the effect of posture on the secondary curve , cartilage plate. Drum 16 in a review of the literature thu s causing a thickening of the anterior portion illustrated a number of the major signs of instab ility of the annulus. (figure 4) which have been described by Had!e y 3G 222 l\lOTION STUDIES

the U -L S disc space a'.oes dot INTERRUPTION o,< HA'DL£Y!S •.s"CURVE close_ oE-, the -rign-t

Fig. 4. Dia gra mmatic illustration s of so me of th e signs of segme ntal instabi lity (by permi ss ion from Drum 16 •

223 Macnab 4 and others. Macnab 4 attributed most of the other hand. restricted movement at one seg­ the pain of disc lesions to repetitive ligamentous mental level may result in an increased strain on strain due to chronic hyperextension of the pos­ joints of adjacent segments. terior joints and the resulting posterior joint arthritis. Farfan 26 feels that the more advanced 3. THE COMPRESSION OF VITAL changes which include the formation of marginal STRUCTURES osteophytes, degenerative facet changes and The significance of the spinal subluxation as a pseudospondylolisthesis found in disc disease are cause of compression or interference with vital also due to abnormal mechanical stresses. Both of organs such as the spinal cord. nerve roots. blood these authors consider these changes to be due to vessels and the sympathetic chain has been the _ instability of the vertebral segment. subject of a great deal of debate. 2. POSTERIOR FACET DYSFUNCTION Nerve root compression has been the major focus of the debate. However, since the anatomy, It has become well accepted that disc disease is physiology, and pathology of the intervertebral not the only cause of back pain. In the search for foramen and nerve root compression have been additional sources of back pain, the posterior facets discussed in the papers presented by Ors. Drum, and their associated ligaments have been repeatedly Sunderland, Schaumberg. and Sharpless, further 1 1 7 implicated, • ,:1 since both of these structures have comment in this paper would be repetitious. been found to have a rich sensory innervation. Because of its anatomical position, the spinal Mennell 14 has stated that these joints can be cord is vulnerable to compression by vertebral injured by active inflammatory disease, or trauma misalignments. However. it would appear that in the same manner as other diarthrodical joints. only gross traumatic, 42 rheumatoid subluxa­ Abnormal joint relationships may be the result of tions 3 or fracture-dislocations 42 which are not such injuries or disc disease, and at the same time amenable to manipulation can cause sufficient may decrease the resistance of the joint to injury. compromise of the vertebral canal to cause com­ Vertebral tilting as seen in disc wedge subluxations pression of the cord. In rare instances posterior changes the relationship of the two articular sur­ disc protrusions may also be so large as to cause 1 faces resulting in a change in the direction of the cord compression. " compressional forces on these joints. Rotation, on The vertebral artery which passes through the the other hand. causes a jamming or compression foramina transversaria, over the atlas and through of the facets on one side, with opening of the joint the foramen magnum may be compressed by 26 space on the other. Experiments by Gritzka et mechanical distortion of the cervical spine. 43 In al. 38 have shown that continuous compression the presence of anomalous arteries or severe which one would expect in these situations, when arteriosclerosis this compression has been known applied to a peripheral joint which is still mobile to cause cerebral ischemia with severe neurological and active, can cause erosion of joint cartilage with deficit. 44 This fact is well recognized and precau­ total destruction of the chondrocytes followed by tions are taken against aggravation of these arthritic changes. symptoms by persons actively engaged in The hypomobile subluxation. fixation or joint manipulation. 12• 44 locking is considered an important cause of spinal Both Palmer 5 and Kunert 25 have suggested that 12 14 37 dysfunction. , • Mensor and Duvall' 8 found the sympathetic chain ganglia which lie immedi­ that 43 percent of persons with back pain have ately adjacent to the costovertebral articulations decreased movement in the lumbar spine, com­ may be irritated mechanically by lesions in the pared with 15 percent of asymptomatic persons. region of the thoracic spine and the heads of the Goldthwaite 39 and Steindler 40 were both of the ribs. Kunert bases this theory on the observation opinion that this type of restricted motion in a that arm movements and body rotation can cause section of the spine made it more susceptible to tension on the sympathetic chain. If this is true, injury. This might be due to the fact that fixation then the costovertebral or rotational subluxations of any diarthrodial joint for a prolonged period of may be capable of interfering with the sympathetic time results in shortening of the ligaments and chain and cause either blockage of impulses or eventually degeneration of the joint cartilage. 41 On irritation of the sympathetic nerves. Unfortu- 224 nately, very little research has been done on this SUMMARY subject. The fact that severe chronic scolioses do not appear to be associated with known sym­ As it is currently used. the term spinal subluxa­ pathetic dysfunction suggests that at least the tion describes a valid clinical finding, .the signifi­ chronic subluxation is not associated with this cance of which is dependent on symptoms and type of interference. signs of local pathology. Since it is used to describe any mechanical or functional derangement between 4. ABNORMAL SOMATO-SYMPATHETIC adjacent vertebrae there are a large number of REFLEXES subclassifications of the subluxation. It has been The physiology and significance of somatosym­ intimately associated with the pathophysiology pathetic reflexes has been discussed by Dr. Sato. of intervertebral disc disease, posterior joint The possibility that abnormal somatosympathetic dysfunction, the compression of vital perispinal reflexes may be initiated by musculoskeletal structures and abnormal somato-visceral reflexes. lesions has been actively researched by Korr and For these reasons an understanding of and the his colleagues 45 who feel that there is significant ability to diagnose the subluxation is important correlation between cutaneous sympathetic activity in the practice of spinal manipulation. and these lesions. 46 • 47 He has postulated that somatic lesions create a "central excitatory state" REFERENCES in the spinal cord by stimulating local receptors and neurones thus causing bombardment of central I. Adams, F.: The Genuine Works of Hippocrates. Trans­ neurones with afferent impulses. lated from the Greek. Vol. 2. Printed for the Sydenham The clinical evidence supporting this theory Society (London) I 849. concerning spinal lesions is primarily indirect 2. Hieronymus, J. H.: De Luxationihus et subluxationihus Ritter. (Jena). 1746. and based on the correlation of physical symptoms 3. Bland. J. H.: Rheumatoid arthriti_s of the cervical spine. 48 with spinal lesions. For example. Ushio et al. .I. Rheumatology I :319-342, 1974. showed that vertigo following a spinal injury 4. Macnab. I.: Pathogenesis of symptoms in discogenic low could be relieved by applying a corset to the back pain. Chapter 6 in American Academy of Ortlw­ lumbar spine and suggested that overactivity of paedic Surgeons Symposium on the Spine. C. V. Mosby Co. (St. Louis) 97-110, 1969. lumbar proprioceptors may be the mechanism 5. Palmer, D. D.: The Science, Art and Philosophy of Chiro­ 12 involved. while Maigne described cases of practic. Portland Printing House Co. (Oregon). 1910. Barre-Lieou syndrome (headache. tinnitis. vertigo, 6. Janse. J.: The vertebral subluxation . ./. National Chiro­ hoarseness, facial flushing, lacrimation etc.) practic College. 20. I :3-7, I 948. which responded to spinal manipulation. A large 7. Laskei, D. L.: Principles <~{ Osteopathy: Third Edition, 1913. number of similar observations have been made by 8. Hoag, M .• Cole, W. V., and Bradford. S. G.: Osteopathic 5 8 other practitioners of spinal manipulation, • but Medicine. McGraw-Hill Book Co. (New York), 1969. unfortunately no controlled studies have been 9. Holme, R.: Academy of Armory. Printed in Chester by the carried out to eliminate placebo effects and to author. I 688. Reprinted by The Scolar Press Limited in determine the frequency with which these results 1972. (Menston, England) 448. 10. Inman, 0. B.: Editor; Basic Chiropractic Procedural occur. Manual. Printed by the American Chiropractic Asso­ The role of the subluxation in the production ciation. 1973. of abnormal somato-sympathetic reflexes has yet 11. Howe, .I. W.: The chiropractic concept of subluxations and to be established. However, by definition. the its roentgenological manifestations . ./. Clinical Chiro­ subluxation is an abnormality in position or move­ practic. 64- 70, September 1973. 12. Maigne, R.: Orthopedic Medicine -A new approach to ment. and in clinically significant situations may be vertebral manipulations. Translated and edited by W. T. associated with ligamentous and discal injury, Liberson. Charles C Thomas (Springfield, Ill.), 1972. joint inflammation and muscle spasm. Since the 13. Johnston, W. L.: Segmental behavior during motion. tissues affected by these processes have a rich .J.A.O.A. 72:352-373, 1972. sensory innervation 4u it seems possible that any 14. Mcnnell, J.: The Science and Art ,~/'Joint Manipulation. acute subluxation would result in an increased Vol. 11: The Spinal Column. J. and A. Churchill Ltd. (London) I 952. sensory input to the spinal cord. which in turn 15. Cyriax . .I.: Textbook of Orthopaedic Medicine. Vol. I: could result in the ··central excitatory state" Diagnosis of soft tissue lesions. Bailliere, Tindall and referred to by Korr. Cassell (London) 1969. 225 16. Drum, D. C.: An introd11ction to the st11dy of posture and 35. Knutsson, F.: The instability associated with disc degenera­ spinal mechanics. Published by the author. (Toronto), tion in the lumbar spine. Acta Radio/. 25: 593-609, 1970. 1944. 17. Barton, P. N.: The si1:n(ficance of anatomical defects of 36. Hadley, L. A.: Apophyseal subluxation; disturbances in lower spine. Ind. Med. 17:37-40, 1948. and about intervertebral foramen causing back pain. 18. Mensor, M. C., and Duvall. G.: Absence of motion at the .I. Bone Jr. Surg. 18:428-433. I 936. fourth and fifth lumbar interspaces in patients with and 37. Wright, J.: Mechanics in relation to derangement of the without low back pain. J. Bone Jr. Surg. 41-A:1047- facet joints of the spine. Arch. Phys. Ther. 25 :20 I -206, 1054, 1959. 1944. I 9. Morgan, F. P., and King, T.: Primary instability of lumbar 38. Gritzka, T. L., Fry, L. R., Cheesman, R. L., and LaVigne, vertebrae as a common cause of low back pain . ./. Bone A.: Deterioration of articular cartilage caused by con­ Jt. Surg. 39-B:6-22. I 957. tinuous compression in a moving rabbit joint../. Bone. Jt. 20. White, A. W. M.: Low back pain in men receiving work­ Surg. 55-A:1698-1720, 1973. men's compensation. Can. Med. Assn. J. 95 :50-56, 39. Goldthwaite, J. E.: The variations in anatomical structure of the lumbar spine. 2:416-434, 1966. Amer. J. Ortlwp. S11rg. 21. Dively, R. L., and Oglevie. R. R.: Preemployment exami­ 1920. 40. Steindler, A.: Mechanics of Normal and Pathological nations of the low back . .I.A .M.A. I 60:856-858, I 956. Locomotion in Man. Charles C Thomas (Springfield, 22. Nagi, S. Z., Riley, L. E., and Newby, L. G.: A social Ill.), 1935. epidemiology of back pain in a general population. J. 41. Hall, M. C.: Cartilage changes after experimental immobili­ Chron. Dis. 26:769-779. I 973. zation of the knee joint in a young rat. J. Bone Jr. Surf?. 23. Hirsch, C.,Jonsson, 8., and Lewin, T.: Low back symptoms 45-A:36-44, 1963. in a Swedish female population. Clin. Orthopaedics and 42. Garber, J. N.: Fracture and fracture-dislocation of the Related Research. 63:171-176, 1969. cervical spine. Chapter 3 in The American Academy of 24. Kosiak, M., Aurelius, J. R., and Hartfiel, W. F.: Backache Orthopaedic S11rgeons Symposium on the Spine. 18-53, in industry . ./. Occup. Med. 8:51-58, 1966. 1967. 25. Kunert, W.: Functional disorders of internal organs due to 43. Jones, R. T.: Vascular changes occurring in the cervical vertebral lesions. Ciba Symposium: I 3-3, I 965. musculoskeletal system. South African Med. J. 40:388- 26. Farfan, H. F.: Mechanical Disorders of the Low Back. 391, 1966. Lea and Febiger (Philadelphia), 1973. 44. Kleynhans, A. M.: Vascular changes occurring in the 27. Armstrong, J. R.: Lumbar Disc Lesions. 3rd Edition. E. cervical musculoskeletal system. Bull. European Chiro­ and S. Livingston Ltd., (Edinburgh), 1965. practic Union. 19-1 :24-30, 1970. 28. DePalma, A. F.: and Rothman, R. H.: The lnten·ertebral 45. Korr, l. M., Buzzell, K. A., Hix, E. L., Northup, G. W., Disc. W. B. Saunders Co. (Philadelphia), 1970. and Kugelmass, I. N.: The physiological basis of osteo­ 29. Naylor, A.: The biophysical and biochemical aspects of pathic medicine. Published by The Postgraduate Institute intervertebral disc herniation and degeneration. Ann . . of Osteopathic Medicine and Surgery (New York), J970. Roy. Coll. S11rg. Eng.31:91-114, 1962. 46. Korr, I. M., Wright, H. M., and Thomas, P. E.: Effects of experimental myofascial insults on cutaneous patterns of 30. Puschel, J.: Der Wasserergehalt normaler und degenerierter sympathetic activity in man. Acta Neuroveg. 23:329- zwischenwirbelscheiben. Beitr. Path. Anat. 84: 123-130, 355, 1962. 1930. 47. Korr, I. M., Wright, H. M., and Chace, J. A.: Cutaneous 31. Wiltse, L. L.: Lumbosacral strain and instability. Chapter patterns of sympathetic activity in clinical abnormal­ 4, in The American Academy of Orthopaedic Sw·1:eons ities of the musculoskeletal system. Acta •Neuroveg. Symposium on the Spine. 54-83, I 967. 25:589-606, 1964. 32. Nachemson, A.: Lumbar lntradiscal Pressure. Acta. 48. Ushio, N., Hinoki. M., Hine, S., Okada, S .• Ishida, Y .. Ort hop. S cand. S 11ppl.43: 1-104, 1960. Koike, S., and Shizuku, S.: Studies on ataxia of lumbar 33. Ritchie, J. H., and Fahrni, W. H.: Age changes in the origin in cases of vertigo due to whiplash injury. Agres­ lumbar intervertebral discs.Can. J. S11rg. I 3:65-71, I 970. sologie 14-D:73-82, 1973. 34. Lindblom, K.: Experimental ruptures of intervertebral 49. Haldeman, S.: Spinal and paraspinal receptors. J. Am. discs in rats tails. J. Bone .It. Surg. 34-A: 123-128, 1952. Chiropractic Assn. 9:5':25-31, 1972.

226 Pathophysiologic Evidence for the Osteopathic Lesion. Data on What is Known, What is Not Known, and What is Controversial

J. S. DENSLOW Vice President Kirksville Col/ef?e of Osteopathic Medicine Kirks ville, Missouri

The term "Osteopathic Lesion·· is generic and temporary therapeutics is judged efficacious on perhaps needs clarification. This term has been subjective evidence alone. used for many years~ its origin is obscure. Ap­ In view of the brief time available, it is necessary parently it came into usage to represent a palpatory to limit these comments to a few examples of experience shared by those who worked with it. "data on what is known, what is not known, and Manipulative Therapy directed to this disturbance what is controversial." The bibliographies of the has often proven beneficial to the patient. papers cited, however, will provide opportunity "Somatic Dysfunction" has recently been for a much broader review in this area than can be offered as a substitute for Osteopathic Lesion for presented at this time. use in the Hospital-International Classification of Disease. Adapted (H-ICDA). This term is de­ fined as ''impaired or altered function of related WHAT IS KNOWN components of the somatic (body framework) sys­ tem: musculoskeletaL arthrodial, and myofascial The clinical evidence for the Osteopathic Lesion, structures, and related vascular. lymphatic, and which leads into a discussion of the Pathophysio­ neural elements.·· logic Evidence is usually obtained by the physical There is persuasive evidence that the Osteo­ examination methods of inspection and palpation, pathic Lesion is similar to, and possibly identical supplemented at times with such procedures as with. such disturbances as trigger points in the X-ray, electromyography. and thermography. body wall and upper extremities in myocardial This clinical evidence includes: disease, splinting and tension of the abdominal wall, a. H yperalgesia ( with or without pain) flank and paravertebral tissues in intra-abdominal b. An abnormality in the texture or tone of soft disease. the muscular aches and pains accompany­ tissues ing systemic infections such as influenza. etc. c. Anatomical Asymmetry* Despite the fact that Osteopathic Lesions have d. Range and ease of joint motion been diagnosed and treated by many thousands of Hyperalgesia is identified clinically by the pres­ health professionals and that millions of patients ence of tenderness to digital palpation in the area have benefited from such diagnosis and treatment, of the Osteopathic Lesion in contrast to the the proof that such disturbances exist, and can be managed effectively. does continue to be on a * It is recognized, of course, and as Maigne I has pointed out, subjective basis with regard to both the health that misshapen bony prominences and the remote location of such prominences, must raise questions as to the validity of professional and the patient. However, it is clear palpation in determining the presence or absence of segmental and is generally acknowledged that much of con- asymmetry. 227 absence of tenderness in response to similar palpa­ weight, one-half on one side and one-half on the tion in a normal area. other side of the center line of gravity. In the Abnormality in the texture or tone of soft coronal plane. the anatomical curves would not tissues is identified by light to moderate digital permit a true bisection but would provide for palpation. The areas of the Osteopathic Lesion may symmetry with half the body weight anterior to be described as being boggy or thickened non­ and half posterior to the center line of gravity. muscle tissue and rigid muscle. It can be identified Thus, balance in the upright position would depend by the palpation methods similar to those described heavily on weight distribution with a minimum by Maigne 1 to identify disturbances in tissue of stress. and subsequent wear and tear, on articu­ texture and in the ease and range of joint motion. lating processes and on nonosseous supporting H yperalgesia and abnormal tissue texture will tissues. be discussed together. H yperalgesia and abnormal Similarly. where there is symmetry in the sagittal tissue texture probably involve all nonosseous plane, and normal anatomical curves in the coronal tissues. including the skin and the periosteum, plane, normality in both the ease and range of and various tissues between the skin and the joint motion would be expected. Conversely. periosteum; namely. muscle, fat, various collagen­ asymmetry in the sagittal plane, and/or a diminu­ ous tissues (e.g. cartilage, fascia, ligaments and tion or exaggeration of the anatomical curves in the tendons) and the vascular, neural and lymphatic coronal plane would produce (i) abnormal stresses networks that are embedded in all of these tissues. and strains on the cushioning and supporting tis­ The heterogeneity of these tissues is probably the sues. and (ii) problems as regards the ease and most important single factor accounting for the range of joint motion. current lack of objective diagnostic methods for Asymmetry in alignment and joint motion ranges differentiating normal from abnormal somatic are detected by inspection and palpation supple­ tissues (in the way that ECG does for cardiac mented at times with radiography, particularly muscle. the X-ray for bone, and the EEG for the brain). Hence. while normal and abnormal somatic when done in the weight-bearing position. Methods tissues can be differentiated by physical examina­ for taking and interpreting such films have been described.a tions. the precise nature of the abnormality still is not yet known. The discussion of Pathophysiologic Evidence The two characteristics of Osteopathic Lesion. will start with our own work. It had been postulated hyperalgesia and abnormality of tissue texture, are that the abnormal tissue texture in Osteopathic of overriding importance. They represent a dis­ Lesion was due, at least in part. to muscle con­ turbance in local homeostasis which might be due traction. Following the early work of Adrian (a) to pathophysiology within these tissues, that and Bronk 4 which used electromyography to might have resulted from trauma, or (b) to changes identify the single motor unit. and the work of induced by visceral, emotional, and other dis­ Jacobson 5 who showed that resting skeletal muscle turbances via the controlling and communicating is electrically silent it was reasoned that, in systems (e.g. neural, vascular, lymphatic, hor­ normal areas, resting muscle would be relaxed monal) which govern, sustain, and determine the and no muscle action potentials would be seen. state of the somatic tissues involved. Conversely, in areas of Osteopathic Lesions the Thus. these two characteristics provide direct finding of action potentials would show the pres­ information concerning the location and severity ence of muscle contraction. The early work did of the Osteopathic Lesion. The cause of this bear out this hypothesis and the first publication disturbance must be determined from the history concerning this work reported no muscle contrac­ and other diagnostic procedures. tion in normal areas (as identified by palpation) Anatomical asymmetry and range and ease of and the presence of muscle contraction in many joint motion will also be considered together. areas of Osteopathic Lesion (also identified by Kendall, Kendall and Boynton:! have pointed out palpation). Ii that, ideally, in the human erect stance, the center However, as more experience was gained with of gravity in the sagittal plane bisects the trunk these methods and after additional studies reported including the pelvis and the vertebrae. Thus. there by other workers, it was recognized that if sufficient would be a symmetrical distribution of the body care was used in bolstering the subject with pillows 228 and sandbags the EMG evidence of muscle con­ to a somewhat similar correlation made by Brend­ traction in some of the abnormal areas disappeared. 7 strup, et al.10 These investigators examined patients In other words, under those conditions, palpable prior to surgery for herniated intervertebral discs. abnormal tissue texture could not be due to muscle Normal areas and areas of "fibrositis" were identi­ contraction. fied by palpation. At the time of surgery, tissues However, another differentiating characteristic from normal and fibrositic areas were taken for between normal areas and areas of Osteopathic microscopic examination and chemical analyses. Lesion was found. In normal areas the irritation Although the series of cases was small ( 12) the produced by placing needle electrodes through findings from the control areas were normal: in fascia and into muscle frequently results in a burst contrast, there were positive findings in IO of the of action potentials called "insertion potentials." 12 specimens from fibrositic areas. The positive This burst lasts for a brief period and subsides findings included a decrease in potassium and an spontaneously: minor movements of the electrodes increase in chloride and hexosamine content ( the do not reinitiate it, and the muscle remains electri­ latter indicated by an excess of acid mucopoly­ cally silent. In contrast, in areas of Osteopathic saccharides). Microscopic examination of the Lesion, the insertion potentials persisted for longer fibrositic tissues showed a widening of the in­ periods of time; and, when they did subside, they terstices, indicating edema, an increased number could be reinitiated by minor electrode move­ of mast cells in the connective tissue and an ment. Further studies revealed that a wide variety increased number of nuclei in muscle fibers. of stimuli, whether applied to the area of Osteo­ As regards fibrositis, in discussing pain thresh­ pathic Lesion or remotely, would initiate action olds, Procacci et al. 11 commented "In the patho­ potentials in that area, unlike the normal area. logical field: in subjects with fibrositis of the upper This observation suggested that the motoneurons limb the cutaneous pain threshold is significantly supplying the areas of Osteopathic Lesion were in lower in the limb itself .... " a state of enduring subliminal excitation, as was Another possibility that might account for ab­ confirmed by the low reflex thresholds demon­ normal tissue texture, which is not due to muscle strated in such areas. 8 contraction, involves the observation that patients Later, methods were developed by Denslow, suffering from migraine (and so-called "tension") Korr, and Krems 11 to (a) quantitate levels of reflex headaches show evidence of Osteopathic Lesion at activity and (b} to correlate reflex thresholds with the atlanto-occipital and upper cervical areas: the various other segmental phenomena. Briefly, the Osteopathic Lesion is severe during acute episodes following was found: and present, but less severe, during interim periods. 11 Normal areas Areas of osteopathic Dalessio in discussing "Vascular Permeability ( by palpation) lesion (by palpation) and Vasoactive Substances: Their Relationship to High reflex threshold Low reflex threshold Migraine" suggested " ... that migraine is a clin­ (facilitation) ical syndrome of self-limited neurogenic inflamma­ Paravertebral tissues Paravertebral tissues tion." He points out that: (a) Normal texture (a) Abnormal texture (b) No hyperalgesia (b) Hyperalgesia ·•... present evidence implicates at (c) No lasting soreness (c) Lasting soreness following following minor trauma minor trauma least five groups of vasoactive substances associated with inflammation: (a) cate­ Probably the most important points to be made cholamines, (b) other bioactive amines here are (a) that there is a direct correlation (histamine and serotonin), (c) the peptide between the palpable tissue texture abnormality kinins, ( d) the prostaglandins, which are in Osteopathic Lesion and a state of chronic facili­ fatty acids, and (e) SRS-A, an acidic tation in the motoneuron pools in the spinal cord lipid. These vasoactive substances all that are segmentally related to the Osteopathic have potent biologic properties which Lesion, and (b} since the abnormal tissue texture differ with their structure and include, may not be due to muscle contraction, some other among others, contraction or relaxation of phenomena must be sought to account for it. smooth muscle, constriction or dilation of The correlation between palpable tissue texture arteries and veins, induction of water and abnormality and other disturbances is comparable sodium diuresis, fever, wheal and flare 229 reactions, and induction of pain, including These segmental disturbances appear headaches." to be physiologic lesions related, by nature It seems possible, even probable, that this in­ and location, to the clinical phenomena flammatory process might account for the abnormal designated as osteopathic lesions." tissue texture that is seen in the absence of muscle This will be discussed further in connection with contraction. The ·•... self-limited neurogenic experimentally produced neuromusculoskeletal dis­ inflammation" could very well be involved in turbances. clinical syndromes, other than migraine headache, Over the years there have been a substantial including Osteopathic Lesion. number of reports of disturbances, or syndromes, Still another possibility that might account for in which somatic and visceral problems concur. abnormal tissue texture in the absence of muscle The somatic problems often show strong resem­ contraction involves the trophic functions of the blance to Osteopathic Lesion. Hence these dis­ neuron, 12 discussed elsewhere in this Workshop. It turbances should be discussed as part of the is known, as regards muscle, that maintenance of "Pathophysiologic Evidence." A few of these axonal and junctional integrity between neuron and reports will be cited as examples. muscle cell is essential for "normal" trophicity. Ruch et al. 17 comment: Axoplasmic flow. rather than impulse traffic, is "Sustained contractions of skeletal mus­ clearly implicated in a variety of neurotrophic cle likely to cause pain may arise from influences, such as those operating in morphogen­ higher centers or from reflexes of somatic esis, regeneration, control of genie expression and or visceral afferents. Such reflexes are the maintenance of structural, functional and bio­ important (i) as diagnostic signs (Kernig's chemical integrity of the innervated tissue. 13 sign, stiff neck of meningeal irritation, ab­ Chamberlain, Rothschild, and Gerard 14 have dominal rigidity of appendicitis), and (ii) " ... shown that a postural asymmetry in the as secondary sources of pain and hind limbs, induced by a unilateral cerebellar or discomfort. vestibular lesion, will persist after mid-thoracic spinal cord transection, providing sufficient time They further comment: is allowed for this asymmetry to 'fixate· in the cord "The muscle contraction may be due to before transection." Patterson 15 has discussed a vicious circle: deep pain -sustained mechanisms involved in conditioning and in the reflex contraction -deep pain - reflex fixation of functional patterns in spinal mammals. contraction - etc. The success of such Surely such patterns of functional activity have single procedures as osteopathic treat­ some bearing on integrity, or lack of it, of the axonal ments, ethyl chloride sprays and procaine transport mechanisms. hydrochloride injection of trigger zones Related to the demonstration of facilitation in may depend on the breaking of the circle.'' motoneuron pools of the voluntary side of the It is well known by those who have studied nervous system, Korr and his colleagues 16 have the neuromusculoskeletal system carefully in shown that similar phenomena occur in the sym­ patients with acute infectious diseases, for example pathetic system. They studied regional and seg­ in various types of pneumonia, that Osteopathic mental variations of sympathetic activity by deter­ Lesions are present in the spinal area that is seg­ mining sudomotor and vasomotor activity. They mentally related to the affected organ or viscus; found that in certain spinal cord e.g. there is hyperalgesia, abnormality in tissue " ... segments, at least some of the texture, and limitations in the ease of joint motion. neurons mediating sensory, motor, and In addition to relieving the hyperalgesia, abnormal­ autonomic function are maintained in a ity in tissue texture and restrictions in the ease state of hyperexcitability, which they of joint movement. spinal manipulation often has manifest in their easier, augmented, and been followed by concurrent improvement in the prolonged responses to impulses reaching remote infection. them from many sources, and are therefore Speransky et al. 18 carried out well-controlled susceptible to sustained and exaggerated experiments, in patients with pneumonia, by re­ activity under conditions of daily life. ducing the related neuromusculoskeletal system 230 abnormality with a different form of therapy (soma­ so acute that when it was palpated a motor re­ tic blockade by local anesthesia). Following a long sponse followed, such as wincing or withdrawal. series of studies on experimental animals, they The trigger area was treated by infiltration of pro­ suggested that treatment of pneumonia in man caine or by spraying the overlying skin with ethyl be directed at the cord segments involved. In chloride, with the result that in a large majority patients suffering from lobar pneumonia, they of cases the pain and disability occasioned by the injected the rhomboid area with procaine. They disease, were eliminated or greatly lessened. observed that this treatment, when given early, Judovich and Bates 22 in the monograph, "Pain is usually followed by a drop in body temperature, Syndromes" direct attention to the large number of resolution of the pneumonic consolidation, and patients who suffer pain and disability due to improvement in the patient's general condition. unrecognized disturbances in the somatic system. One might speculate (a) that the muscular dis­ They comment, ". . . segmental pain and tender­ turbance was the result of spinal cord hyperir­ ness may simulate the pain of visceral disease, ritability initiated and sustained by afferents from and many patients who have submitted to medical the affected viscera. and (b) that when the feed­ treatment for visceral disease are not relieved back from the rigid musculature was moderated, of pain until treatment is directed to the somatic the patient's ability to combat the original infection origin of pain and its cause." was improved. presumably by a breaking of the The diagnostic methods they describe have much positive feedback circle suggested by Ruch et al. 17 in common with the diagnostic methods used in Speransky suggests that "The rationale of this the search for, and evaluation of, Osteopathic treatment is based on the presumed changes in the Lesion. They place considerable stress on struc­ lung following restoration of normal nerve func­ tural asymmetry and imbalance (and related soft tion. " 18 tissue stresses and strains) that are due to an Many years ago, MacKenzie 19 called attention inequality of leg length and that are responsive to to a relationship between cardiac disease and the appropriate use of heel lift. They state, for somatic tissues via what he termed an "irritable example, focus" in the spinal cord. Since then numerous •· A slight shortening of one lower ex­ reports concerning this relationship have been tremity will produce a lateral tilt of the published. Of these, two will be cited. Lindgren 20 pelvis. The lumbar spine swings to the studied patients with angina pectoris and other short side and develops a compensatory cardiac problems by inducing precordial pain with scoliosis with strain at the dorsolumbar hypoxemia or exercise. She mapped the areas of spine. This may be mild and is many referred pain and infiltrated them with local an­ times ignored, yet we have observed and esthetic. It was observed that this procedure corrected these mild postural changes by lessened both the pain and the accompanying using a heel lift, and have often seen electrocardiographic abnormalities. chronic pain disappear without using any Rinzler and Travell 2 1 used somatic blockade other form of therapy." in the management of angina pectoris, related cardiac problems and hyperalgesia in the chest Siehl 23 studied a series of patients who had wall~ the latter may simulate cardiac problems, sciatic pain. All of these patients had lumbar and but may be due to somatic factors. They studied lumbosacral Osteopathic Lesion and were sus­ cardiac and somatic chest pain through the pected of having a herniated intervertebral disc. presence of what they called a trigger mech­ All were studied with electromyography for evi­ anism in. the somatic structures. The trigger dence of nerve root pressure. All received spinal area is an abnormal zone of hypersensitivity manipulation. Subsequently, it was found that a which, when stimulated by digital pressure or high percentage of patients with normal electro­ needling, gives rise to a brief reference pattern of myograms responded favorably to manipulation, pain. They suggested that the essential part while those with positive EMG evidence of nerve of the examination for trigger areas was the root pressure did not respond favorably, and discovery, by careful palpation, of topograph­ required surgical intervention. ically discrete areas of exquiste somatic ten­ Another aspect of Pathophysiologic Evidence of derness. At times the spot of hyperalgesia was Osteopathic Lesion is seen in disturbances that 231 have been produced experimentally. Lewis and visceral problems. But how these reflexes Kellgren 24 point out that (a) stimulation of an interrelate in matters of health and disease is interspinous ligament produces segmentally related not known. For example, a patient might be pain, superficial and deep hyperalgesia and muscle ill from a disturbance involving a psycho­ contraction. (b) stimulating appropriate somatic somatic reflex. structures produces pain similar to that of angina Currently it is not known how to evaluate of effort or intestinal colic, ( c) stimulating either either the higher center or the somatic ele­ spinal muscles or a viscus, such as the pancreas. ment; hence, it is impossible to determine produces contraction of the muscles of the ab­ on the basis of objective evidence which, dominal wall and ( d) visceral disease. and the in any given case, should receive major stimulation of deep somatic structures, both pro­ attention, or if both should be addressed duce segmentally related cutaneous hyperalgesia. simultaneously. Related to this, it is not Likewise, Korr, Wright, and Thomas 25 also known whether one disturbance precedes clearly demonstrated that certain characteristics of the other, or, if two or more occur as primary Osteopathic Lesion can be produced experimen­ pathophysiologic disturbances, what, if any, tally. These investigators irritated musculoskeletal influence each exerts on the other. tissues by hypertonic saline injections and produced This is not to say that the experienced postural stresses by the use of heel lifts and tilt clinician, with competence in the evaluation chairs. They found that ( a) when saline injection of, for example, psychiatric and somatic produced referred pain, there was the appearance problems, cannot successfully treat patients of segmentally related areas of lowered electrical who present such a combination of problems; skin resistance, and (b) experimentally induced he certainly can do so, on an empirical basis. postural changes produced both an exaggeration However, objective evidence, to support his of existing patterns and additional areas of lowered empirical observations, is not available. electrical skin resistance. They concluded that 3. Finally, and again related to 2 above, it is their observations suggest a relationship between not known how to objectively assess the patterned differences in sympathetic activity, as usefulness and effectiveness of therapy, shown by lowered electrical skin resistance, and particularly manipulative therapy, directed painful myofascial and visceral conditions. at Osteopathic Lesion.

WHAT IS NOT KNOWN THE MOST CONTROVERSIAL The identification of what is not known regarding There are two major and one minor controversial Pathophysiologic Evidence of the Osteopathic issues. Lesion represents a very extensive work in itself. First, there is the question as to whether or not However, three of the most critical areas will be Osteopathic Lesion contributes to pathophysiologic identified. disturbances in organs and systems outside of the 1. Objective evidence concerning such things as somatic system itself. Strong evidence has been the etiology, type (acute or chronic), location, presented above that a pathophysiologic disturb­ severity, etc. of Osteopathic Lesion is almost ance in the neuromusculoskeletal system (Osteo­ totally lacking. It is appropriate to recognize pathic Lesion) at least contributes to the total at this point that the heterogeneity of the clinical picture that the patient presents. Since tissues involved, skin, muscle, fat, many kinds emotional, visceral, and other disturbances are of collagens, and the vascular, neural, lym­ generally acknowledged to cause certain somatic phatic, hormonal systems that are embedded disturbances, it is reasonable to assume that the in the tissues, make objective determinations reverse might also occur (e.g. that somatic dis­ extraordinarily difficult. turbances might have comparable deleterious 2. It is known that there are such phenomena as influences on higher center, visceral, and other somatic and visceral reflexes and reflexes functions). The fact that the latter possibility is initiated by impulses from the higher centers. almost totally ignored in texts and treatises in It is also generally accepted that there are medicine and surgery has given rise to major combinations of these, which are involved in controversy. It might be said here that it is the lack psychosomatic, viscerosomatic, and somatico- of appropriate research, particularly involving 232 experimental animal research, rather than negative Here again, this controversy can only be resolved results of research, that has given rise to this through appropriate and well-controlled research. controversy. REFERENCES Second, controversy exists as to whether or I. Maigne. R.: Orthopedic Medicine: a New Approach to not the manipulative and other management of the Vertebral Manipulations. Springfield. Charles C Thomas. Osteopathic Lesion contributes to the ameliora­ 1972. tion or elimination of emotional, visceral, and other 2. Kendall, H. 0., Kendall, F. P., and Boynton, D. A.: disturbances. Here again, this controversy is Posture and Pain. Baltimore. Williams and Wilkins Co. not due to negative observations from carefully 1952. 3. Denslow, J. S., Chace, .I. A., Gutensohn, 0. R., and Kumm, controlled studies, but rather to a lack of ap­ M. G.: Methods of taking and interpreting weight-bearing propriate research. X-ray films . ./. Am. Osteop. A. 54:663-670, July, 1955. A third controversy of lesser significance, 4. Adrian, E. D., and Bronk, D. W.: The discharge of impulses particularly among those health professionals in motor nerve fibres, part I I../.Physiol.6:81-10 I, I 928. who use, and are skilled in manipulation, involves 5. Jacobson, E.: Electrical Measurement ofActivities in Nerve and Muscle. New York. McGraw-Hill Book Co. 1934. the breaking of the synovial seal in arthrodial 6. Denslow, .I. S., and Clough, G. H.: Reflex activity in the joints, which sometimes occurs in the course of spinal extensors . ./. Nurophysiol. 4:430-437, I 941. manipulation. This procedure is frequently accom­ 7. Buchthal, F., and Clemmeson, S.: On the differentiation of accompanied by a noise often ref erred to as a palpable muscle affections by electromyography. Acta "pop" or a "snap." Roston and Haines, 26 and Med. Srnnd. 105:48-66, 1940. 8. Denslow, .I. S., and Hassett, C. C.: The central excitatory later Unsworth, Dowson, and Wright,27 have state associated with postural abnormalities. J. Neuro­ conclusively shown that the breaking of the joint physiol. 5: 393-402, I 942. seal permits an increase in motion (particularly 9. Denslow, .I. S .• Korr. I. M., and Krems, A. D.: Quantitative motion not under voluntary control) for a period studies of chronic facilitation in human motoneuron pools. of time reported as being 15 to 20 minutes. There Am. J. Physiol. I 05: 229-238, August, 1947. 10. Brendstrup, P., Jespersen, K., and Asboe-Hansen, G.: are those that hold that this is an unimportant Morphological and chemical connective tissue changes phenomenon and is not involved in the beneficial in fibrositic muscles. An11. Rhe11m. Dis. I 6: 438, l 957. effects of properly applied joint manipulation. 11. Bonica, .I . .I., Editor: Adl'Clnces in Ne11rology (Vol. 4 ): Livingston 28 disagrees. On the basis of personal lntematio11al Symposi11m 011 Pain. New York. Raven experiences with attacks of low back pain he Press. 1974. 12. Drachman, D. B., Editor: Symposium: trophic functions of comments: the neuron. A11n. N.Y. Academy Science. 228: 1-423, "An unsuccessful manipulation of the 1974. back seems to aggravate the pain, but a 13. Korr, I. M.: The trophic functions of nerves and their mechanisms. Louisa Burns Memorial Symposium. J. Am. successful one causes a snap that may be Osteop. A. 72: 163-171, October 1972. audible. When this occurs, there is an 14. Chamberlain, T . .I., Rothschild, G. H., and Gerard, R. W.: immediate sense of relief, even though Drugs affecting RNA and learning. Pr~c. N A.S. 49: much of the pain and the muscle spasm 918-925, 1963. are still present. The residual muscle 15. Patterson, M. M.: Mechanisms of classical conditioning and fixation in spinal mammals. (In Press). stiffness and soreness gradually disappear 16. Korr, I. M.: Clinical significance of the facilitated state. once the underlying source of irritation Symposium on the functional implications of segmental has been corrected, and within three or facilitation. J. Am. Osteop. A. 54: 265-282, January 1955. four days I am back playing badminton 17. Ruch, T. C., Patton, H. D., Woodbury, J. W., and Towe, without the slightest back disability. A. L.: Neurophysio/of.:y. 2nd Ed. Philadelphia. W. B. This speaker, like many of his colleagues, agrees Saunders Co. 1966. 18. Speransky, A. D.: Experimental and Clinical Lobar Pne11- with Livingston since in many situations, breaking monia. Dolevni Pneuvmonii. 3-17, 1942. the joint seal in the course of manipulation of Osteo­ 19. MacKenzie, .I.: Symptoms and Their Interpretation. Lon­ pathic Lesion is followed by an immediate sense of don. Shaw and Sons. 1912. relief on the part of the patient, an immediate 20. Lindgren, l.: Cutaneous precordial anaesthesia in angina reduction in the palpable abnormality in the texture pectoris and coronary occlusion (an experimental study). Cardio/01:ia. 11: 207-2 I 8, I 946-47. of the tissue, and an improvement in joint motion 21. Rinzler, S. H., and Travel!, .I.: Therapy directed at the that is evident to the individual administering the somatic component of cardiac pain. A. Heart J. 35 :248- manipulation. 268, February 1948. 233

597-036 0 - 76 - 16 22. Judovich, B., and Bates, W.: Pain syndromes. 4th ed. 25. Korr. I. M., Wright, H. 'M., and Thomas, P. E.: Effects of Philadelphia. F. A. Davis Co. 1953. experimental myofascial insults on cutaneous patterns of sympathetic activity in man. Acta Neurovegetatim. Bd. 23. Siehl, D., Olson, D. R .. Ross, H. E .• Rockwood, E. E., XX/I/, Heft 3. Manipulation of the lumbar spine with the patient under 26. Roston, J. B.• and Haines, R. W.: Cracking in the meta­ general anesthesia: evaluation hy electromyography and carpophalangeal joint. J. Anat. 81: I 65-173, I 947. clinical-neurologic examination of its use for lumbar nerve 27. Unsworth, A .• Dowson, D., and Wright, V.: "Cracking root compression syndrome. J. Am. Osteop. A. 70:433- joints" a bioengineering study of cavitation in the meta­ 440, January I 971. carpophalangeal joint. Ann. Rheum. Dis. 30: 348-358, 24. Lewis, T., and Kellgren, J. H.: Observations relating to July 1971. referred pain, visceromotor reflexes and other associated 28. Livingston. W. K.: Pain Mechanisms. New York. Mac­ phenomena. Clinical Science. 4: 47-71, I 939. millan Co. 1947.

234 Discussion: Papers of J. S. Denslow and Scott Haldeman

LYLE A. FRENCH Vice President for Health Sciences Affairs University of Minnesota

Mr. Chairman, ladies, and gentlemen: I ap­ by Dr. Denslow. Traction, however, if correctly preciate very much the privilege of the invitation applied, relieves the pain and the spasm promptly to this workshop and the privilege of discussing in some instances and the "osteopathic lesion" the reports of Dr. Denslow and Dr. Haldeman. disappears since there is neither pain nor palpable In some ways the reports are complementary residual evidence for it. Thus the so-called "osteo­ and in other ways the opposite is true. pathic lesion'' may not be a true structural ab­ The term "osteopathic lesion" as described by normality but rather. simply local muscle contrac­ Dr. Denslow, based on terminology commonly tion brought on by nociceptive input. Further­ used by osteopathic physicians, implies an ab­ more it has been well established experimentally normal structural change in a tissue. He describes that Group 11l afferents (nociceptive) activate the lesion as tenderness to digital palpation with motor neurons via interneurons in the cord so that abnormal texture and tone of the soft tissues which lowered firing thresholds of the motor neurons "may be described as being boggy or thickened visualized in the electromyogram is an expected nonmuscle tissue and rigid muscle." Part of the consequence. In fact. failure to find increased evidence presented for the existence of a structural firing would be more surprising than its presence. change is one report by Brendstrupp et. al., 1 The .. osteopathic lesion" is also said to be similar published in 1957, in which, in IO or I 2 areas of to and possibly identical with "the trigger points fibrositis identified by palpation, there were in the body wall and upper extremities in myo­ positive findings as opposed to negative findings cardial disease, with splinting and tension of the in tissue removed from control sites. The positive abdominal wall, flank and paravertebral tissue in findings were very minor and are of doubtful intraabdominal disease, and the muscular aches significance unless confirmed by independent and pains accompanying systemic infection such observers. There is no additional bibliography as influenza, etc." I doubt if there is really any to support this claim of positive findings. acceptable evidence in the literature for any of There is nothing really novel about the presence these symptoms of disease being associated with of localized or focal tenderness associated with a a lesion, as defined earlier. When the pain is variety of disorders and these are well known to diffuse as in myocardial ischemia, in which the all physicians who treat patients with painful whole of the medial aspect of the upper extremity conditions. A classical example is a patient with a is hyperalgesic and hyperesthetic, with extension cervical intervertebral disc protrusion. Many of into the chest wall, and when there is also muscle these people have typical paravertebral foci of spasm, using the criteria for "osteopathic lesion", pain or point tenderness which are often associated one would be led to the conclusion that most of with muscle spasm and on palpation an increase the limb now had this lesion. The same would in bulk or firmness can readily be detected. This be true of the entire abdominal wall in cases of l believe would qualify as an "osteopathic lesion" peritonitis. Furthermore, as in the case of the 235 protruded intervertebral disc, when the cause blocking of the so-called trigger point. however, or primary disease is removed, the "osteopathi<; even though it may partially relieve symptoma­ lesion" disappears either immediately or leaves tology, is seldom if ever an adequate method of only a mild residual tenderness. I question if we relieving the basic problem. are really talking about a true structural To sum up, it seems to me that Dr. Denslow has abnormality. gathered data in support of the existence of an In fact, what has been described is simply" the "osteopathic lesion" by recourse to work by others. observation that nociceptive input leads to motor some of whom are well-known scientists. and cor­ neuron excitation and thus to muscular contrac­ related these data with clinical observations made tion. It does not lead to the development of a by himself and many others over the past century. structural lesion. but rather to palpably increased I believe the attempted correlation is still incon­ muscle tension. The so-called nodules of myo­ clusive since the data submitted are inadequate to sitis and fibrositis are elusive in most instances establish the existence of a true tissue abnormality. and, when palpated. are most probably only lo­ The sum total of the paper, in fact. repeats a well calized areas of muscle contraction. The micro­ established principle that input of stimuli from a scopic findings in the one report referred to in disease process can be followed by the development which pathological examinations were done of secondary hyperalgesic, painful areas associated (Brendstrupp et. al., 1957) are stated to have been with muscle spasm of more or less discrete extent. "widening of the interstices. indicating edema, and The clinical and neurophysiological literature is in increased number of mast cells in the connective accord with this concept. If good evidence that a tissue. and an increased number of nuclei in the structural tissue abnormality is present could be muscle fibers." It seems highly improbable that provided by biopsy. or other means, this would be such histologically observed findings could be most interesting. It would also be necessary to palpated with any degree of assurance. establish in precisely what condition the lesion A report that pneumonia could be rationally appeared. Furthermore, it would be appropriate to treated by local blockade of the input to the verify that the tissue had returned to normalcy by appropriate segments of the spinal cord comes osteopathic therapy. In essence the report appears from the Russian literature of I 940 (Speransky et. to me to be a good example of taking those pieces al. ).4 The investigator. Speransky, suggested that of information which support one's hypothesis and "the rationale of this treatment is based on the then using them to give scientific stature to a theory presumed changes in the lung following restoration that is lacking in substance. that is, that there ac­ of normal nerve functioning." But there is no evi­ tually is such a thing as an "osteopathic lesion." dence given that there was anything but normal Yes. there is muscle spasm and you can feel it, nerve functioning. Rather than bolstering the case and I can feel it. we all know this, but so far as I'm for an "osteopathic lesion", inclusion of such a concerned, the case for a structural lesion has not bizarre and obsolete and unverified claim tends to been fully made. Whether one calls point tender­ make the reader question the judgment of accepting ness with muscle spasm just that. or uses another it. The literature can be used uncritically to support term such as somatic dysfunction or "osteopathic virtually any thesis. It seems to me that the words lesion," is a matter of semantics as I see it. The of Karl Popper~ exemplify this when he stated semantics become tendentious when they are that "it is easy to obtain confirmation. or verifica­ used to give validity to a thesis. tion. for nearly every theory if we look for con­ The report by Dr. Haldeman is a straight­ firmation.·· It is important that we do not see only forward presentation of some of the ways of what we do not want to see. Observations must be investigating spinal abnormalities. It does begin selective. with a definition of subluxation that is all inclusive The relief of pain which results from local anes­ so that most any variance from the normalcy of thetic block of the so-called trigger points is well a newborn could be considered pathological. known to most observers and, when successful, The result is that many of the consequences of may well be due to interruption of a vicious cycle the subluxation, as so defined, are vague, ill de­ as proposed by Ruch 3 and others. Again this is an fined and most difficult to relate scientifically to old observation dating from the beginning of the specific clinical entities. With such a broad defini­ century. It does not need confirmation. The tion it is really difficult to differentiate cause and 236 effect. The statement is made that subluxation is tures," an attempt is made to implicate problems "important in initiating further pathology." The with the sympathetic nervous system, on the concept promoted is that there is a potential in premise that there is a lack of understanding of subluxation for positive feedback, that spinal the function and anatomy of this system. It is joint dysfunction, produced by minor mechanical my impression that a great deal is known about stresses, may not be self-correcting because the the sympathetic nervous system. It is unclear reflex and tissue abnormalities that develop may to me what Dr. Haldeman really means by costo­ exacerbate the joint dysfunction, tending to main­ vertebral rotational subluxations as a source of tain it. Thus it is presumed, even in the absence sympathetic irritation, particularly in view of the of gross pathology, that in susceptible individuals rather significant rotatory deformities one sees in nerve compression does occur as a result of forces scoliosis as well as the fact that compression to which all of us are exposed every day. It is fractures and fracture dislocations of the thoracic concluded that this feedback then will lead to spine are rarely associated with visceral symptoms. further development of subluxation and eventually even when the sympathetic chain itself has been to various visceromotor alterations. I think every­ severely damaged. I do believe that the quoted one will accept the notion that nerve roots are work of U shio fi makes good sense and confirms always being subjected to mechanical forces the observations of many others that applying of some degree throughout their course and a lumbosacral corset will decrease vertigo follow­ that they are especially vulnerable at the inter­ ing spinal injury. However it is believed that this vertebral foramina, especially in the presence is not accomplished by decreasing activity of the of abnormal conditions. There is reason to believe lumbar proprioceptors, as suggested by Dr. that nerve roots are more susceptible to compres­ Haldeman, but rather that a lumbosacral support sion damage than peripheral nerves, in part be­ will decrease visceral pooling of blood by increas­ cause of their surrounding tissues and in part ing intra-abuominal pressure. This diminishes because of their anatomical structure, i.e., lacking the recurrent hypotensive episodes observed in a perineurium, etcetera. This was shown by these patients. I believe that the conclusions Sunderland and Bradley 5 in 1961. There is no obtained in regard to the review of the literature unchallengeable evidence, however. that symp­ concerning somatosympathetic reflexes leads toms supposedly alleviated by chiropractic to a conclusion totally speculative and really manipulation are, in fact, due to spinal nerve detracts rather than adds to the report. compression. In fact it is believed that such In summary, I have enjoyed reading and hearing evidence will be hard, if not impossible, to obtain. the report of Dr. Haldeman. The paper certainly This is because of the extremely minor variations has virtue if listed simply as a summary of spinal from normal, or even abnormal situations, in which alignment abnormalities, but it really has limited manipulation is applied. This is in contradiction significance in terms of advocating manipulation to the nerve root compressions that are observed of the spine. by neurosurgeons and orthopedists in which spe­ cific neurological evidence of such compression REFERENCES is usually present preoperatively. I think one of I. Brendstrupp P., Jespersen K., and Asboe-Hansen, G. Mor­ the points that Dr. Haldeman is attempting to phological and Chemical Connective Tissue Changes in Fibrositic Muscles. Am. Rheum. Dis. 16:438, I 957. make is that a very minimal compression over 2. Popper, K. R. Conjectures and Rejiltations: The Growth of a period of time may well cause somatovisceral Scientific KnowledJ,:e. Routledge and Kegan Paul, London symptoms which can be alleviated by manipulation. 1969. I would conclude from his discussion that symp­ 3. Ruch, T. C., Patton, H. D., Woodbury, J. W., and Towe, toms which may be alleviated by chiropractic A. L. Neurophysiology. Second edition, W. B. Saunders Co., Philadelphia 1966. manipulation are due to pathological changes so 4. Speransky, A. D. Experimental and Clinical Lobar Pneumo­ minor that neurological and roentgenological nia. Dolevni Pneuvmonii, I 942. (Cited by Denslow, diagnostic procedures will not offer help in obtain­ J. S.) ing definitive evidence of spinal nerve compres­ 5. Sunderland, S., and Bradley, K. C. Stress-Strain Phenomena sion. Certainly many of the X-rays presented in Human Spinal Nerve Roots. Brain 84: 120-124, 196 J. 6. Ushio. N., Hinoki, M., Hine, S., Okada, S., Ishida, Y., today would be considered by the medical profes­ Koike, S., and Shizuku, S. Studies on Ataxia of Lumbar sion as being within the range of normal. Origin in Cases of Vertigo Due to Whiplash Injury. In the section on "Compression of Vital Struc- Agressologie 14-D:73-82, 1973. (Cited by Haldeman, S.)

237 The Role of X-Ray Findings in Structural Diagnosis

JOSEPH W. HOWE Professor and Chairman Department of Roentgenology The National College of Chiropractic Lombard, Illinois

Roentgenology plays an important role in diag­ pain. A study presently under way at the National nosis in all phases of the healing arts. It has College of Chiropractic has found approximately special importance in structural diagnosis as related equal incidence of several lumbosacral anomalies to a manipulative approach to therapy due to its among 72 patients with no history of low back pain unique ability to depict anatomy, pathology, and compared to 284 patients with low back symptoms. certain aspects of articular mechanics or function Cox 11 has observed that facet tropism in the pres­ that are otherwise not obtainable. ence of posteromedial disc protrusion is a poor Although there is considerable overlap and inter­ prognostic sign relative to response to the manipu­ relationship among the following arbitrary cate­ lative treatment he propounds. Farfan 12 • 13 notes gories, this paper will discuss the role of X-ray in that not every person with tropism develops back­ structural diagnosis relative to: (I) Anatomical ache, but that there is a higher incidence of tropism depiction, (2) functional assessment, (3) patho­ in people with backache. He also notes a high logical considerations, with comments regarding correlation between tropism and disc pathology. the present levels of knowledge in each of these Books by Ferguson,3 Schmorl, and Junghanns, 14 areas and some ideas for further investigation. The Hadley ,15 and Epstein 16 have become classic important consideration of the ionizing radiation references relating to the radiological appearances incidental to X-ray examination will also be of the myriad variations of spinal morphology and discussed. other aspects of spinal roentgenology, but their ideas regarding the significance of some of these findings vary. The presence of anatomical variation ANATOMICAL DEPICTION as related to present or previous symptoms has not The ability to depict certain aspects of anatomy, been documented. Further, knowledge about the especially to allow visualization of anomaly and presence of variants is important to manipulative anatomical variation. has made the use of diag­ efforts since such procedures must be planned with nostic X-ray an invaluable tool in structural diag­ knowledge about the structure and function affected nosis. This anatomical information must be placed by these variants. in clinical perspective if it is to be used beneficially. The American College of Radiology recently Differences of opinion regarding the importance of published the proceedings of a conference on low anomaly and anatomical variation are widespread. back X-rays as part of preemployment physical Janse, 1 Calliet, 2 Ferguson, 3 and others 4 • 5 , 6 have examinations. 17 In addition to papers by Epstein, 18 attached clinical significance to spinal anomaly Moreton, 19 and others 20 , 21 dealing specifically with and anatomical variation, while Higley,7 Splithoff, 8 X-ray findings, and Trout 22 who spoke on radiation Fullenlove, 9 and DePalma 10 claim that they find safety, the publication contained an I I -page bib­ no correlation between such variants_ and low back liography of papers dealing with low back X-ray 239 studies. Conference participants included radiolo­ the alteration of the normal dynamics, anatomical gists, orthopedists, epidemiologists, and other or physiological relationships of contiguous artic­ interested people. A 583-page annotated bibli­ ular structures." 24 This definition along with ography on the spine, much of which is radiological manifestations, significance, and a classification of in nature, was published by the Ontario Labour radiological manifestations is presented in the fol­ Ministry in 1972.23 Both publications concluded lowing table. These concepts are currently taught that spinal X-ray findings must be evaluated in in the chiropractic colleges. light of the clinical situation, not as screening pro­ The chiropractic concept of subluxation is largely cedures, because of the ambiguity of the signif­ one of functional derangement. The import of icance of many X-ray findings. subluxation, though anatomical disrelationship Additional studies with reference to specific may be the most recognizable aspect radiograph­ spinal variants as well as to the general category ically, depends upon the articular dysfunction and of spinal anomaly and anatomical variation are the resultant pathophysiological alterations. Sub­ necessary in light of the varying opinions of experts. luxation frequently accompanies articular Such investigations might well consider response pathology. to treatment in people with anomaly and incidence X-ray manifestations, classified as "static inter­ of degeneration in such people as well as the segmental subluxations," have functional import relationship of symptoms to the abnormality. since they may affect spinal dynamics and either cause or be caused by pathophysiological altera­ FUNCTIONAL ASSESSMENT tion. If a radiographically demonstrable subluxa­ The most widely accepted definition of spinal tion causes no presently demonstrable clinical subluxation in chiropractic is: "A subluxation 1s problems, its significance may be questionable

TABLE

Definition Classification of Radiologic Manifestations:

A subluxation is the alteration of the normal dynamics, ana­ A. Static intersegmental subluxations. tomical or physiological relationships of contiguous articular I. Flexion malposition. structures. 2. Extension malposition. Manifestations 3. Lateral flexion malposition (right or left). 4. Rotational malposition (right or left). In evaluation of this complex phenomenon, we find that it 5. Anterolisthesis (Spondylolisthesis). has-or may have-biomechanical, pathophysiological, clinical, 6. Retrolisthesis. radiologic, and other manifestations. 7. Lateralisthesis. 8. Altered interosseous spacing (decreased or in­ Significance creased). 9. Osseous foraminal encroachments. Subluxations are of clinical significance as they are affected by- or evoke- abnormal physiological responses in neuro­ B. Kinetic intersegmental subluxations. musculoskeletal structures and/or other body systems. I. Hypomobility (fixation subluxation). 2. Hypermobility (loosened vertebral- motor-unit). Radiological Manifestations 3. Aberrant motion.

In considering the possible radiological manifestations of C. Sectional subluxations. subluxations, it is important to emphasize that clinical judge­ I. Scoliosis and/or alteration of curves secondary to ment is necessary to determine the advisability of exposing a musculature imbalance. patient to the potential hazards of ionizing radiation. An im­ 2. Scoliosis and/or alteration of curves secondary to portant purpose of exposure, besides the evaluation of sub­ structural asymmetries. luxations, is the determination of the evidence of other 3. Decompensation of adaptational curvatures. pathologies. 4. Abnormalities of motion. The radiographic procedures necessary to determine possi­ ble fractures, malignancies, etc., may not be the specific views D. Paravertebral subluxations. needed to evaluate the possible radiological manifestations of I. Costovertebral and costotransverse disrelation­ subluxation. When subluxation can be evaluated by other ships. clinical m·eans, it may be prudent to avoid radiation exposure. 2. Sacroiliac subluxations.

240 but, as with anomaly, the possibility of later de­ Hildebrandt 33 and others have devised systems of generative or other problems resultant from measurement from such full spine radiographs to such disrelationship has not been sufficiently assess intra-pelvic, vertebro-pelvic, and inter­ investigated. vertebral relationships. 40 41 28 17, 38 9 Hadley ,15 • 25 McNab, 26 Shapiro,27 Williams, Vladeff,: Gregory,:i Messer, Pettibon, and many others refer to radiologically demon­ and Blair 42 among others have advocated methods strable subluxations, ascribing to them the ability of precise patient alignment and stressed exacting to cause pain both locally and peripherally. Their alignment of X-ray tube to film plane as part -descriptions of subluxations correspond with some of their systems of spinographic analysis. of the chiropractic classifications. Mears, 43 , 44 , 45 in addition to his spinographic sys­ Attempts to demonstrate spinal disrelationship tem, has reported a high incidence of certain ab­ by chiropractors and adjustive procedures designed normal cervical spine configurations in patients to correct or improve such disrelationships have with mental illness and certain other syndromes. led to some special approaches to spinal roent­ Vladeffs turntable is applicable to either full genology. Spinography, the term traditionally ap­ spine radiography or to radiography of smaller plied to describe upright spinal radiography, done spinal areas. The others cited advocate the use of particularly for mensuration, comprises by far the smaller films of specific spinal areas to decrease most frequent X-ray procedure done by or at the distortion. direction of doctors of chiropractic. The method­ Radiographic distortion is a constant factor in ology used to produce such radiographs and the any geometric evaluation of spinal relationships. interpretation thereof differs widely among those This is especially true with full spine radiography. from different schools of thought in chiropractic. The use of long target-film-distances (72-inch or One approach to spinography is the use of "full 84-inch) for upright spinographs has therefore been spine" radiography (14 x 36-inch single exposure almost universally employed to reduce such dis­ radiographs of the entire spinal column). Though tortion as much as possible. Figures 1 , 2, 3, and this procedure was developed by a chiropractor 29 4 show mathematical representations of distortion and is used mainly in chiropractic, its acceptance incidental to radiography. One result of such dis­ by at least two 3o,31 noted medical scientists is tortion is that significant deviations from horizontal noteworthy. Winterstein 32 and Hildebrandt :ia have can be made to appear on the film through slight indicated that this procedure allows a conceptual rotations of the patient's body relative to film analysis of postural and intersegmental relation­ plane and central ray. A major difficulty in attempt­ ships that cannot be gained from any other radio­ ing to solve the complicated problem of defining graphic method. Logan, 34 Gonstead, 35 Winterstein, 36 intervertebral relationships via radiography is that

Fig. I. Distortion due to distance between object Y·I and film. The problem is defined on Figure I where (xo, Yo) is a point of the object, (X;, y;) is its image.

Let:

a=CF, h=OF, d=CO

Then: X· I

-=-=----=-X; V; a Xu Yo b

and if all points were in the Xo)b plane, the image would be simply a magnification of the object, in the ratio alb. However, the image is three dimensional and there will be distortions due to the varying of the perpendicular distance between points of the object and film. F

241 Y·I

(xj,Yj) Q I I Fig. 2. Distortion due to rotation of I I plane of object. Even though certain I I structures may lie approximately in I a plane, the object has been so posi­ I tioned that the plane of interest is not I exactly parallel to the film, but ro­ I I tated at an angle a, as shown in I ---- Figure 2. The image Q of a point I P(xo, Yo- will be at: I I I ·= axo cos a x, b-xo sin a X· I I I ayo )'i I b-xo sin a I I I I

F Fig. 3. Consider now an object point P' (- Xo, Yo) sym­ metrical to P with respect to the Yo-axis. Its image Y·I Q' will be at (-x;+ax;, y; -ay;) as shown on Figure 3. Ax; and Ay are most conveniently expressed in IMAGE OF (x ,Y ) 1 0 0 terms of X1, Yi instead of Xo. )'o since coordinates of ~y- film points are the more readily available ones. _1 ___ O(xi,yi) 7 2x; sin a (a+ Xi tan a) Xi=------I b (a+ 2x; tan a) 1x;y; tan a I y; I a+2x1 tan a I If 2.t; tan a <

with better than i O percent accuracy for all standard film sizes and distances a, and angles a less than 15 °.

.05 8

7 Fig. 4. The approximatons shown in Figure 3 are most .04 useful in that, for a given distance, a family of hyper­ 6 w bolas drawn in the x;y; plane will give a quick estimate w a= 40" a: of the amount of vertical deviation to be expected, 14'" x 17" FILM 5 .03 ~ per degree of rotation a, between the two image points Q Qand Q'. Y, z ~Y=~(a·o) I 46 4 >- .02 3 The straight horizontal line PP' will project on the film as the sloping line QQ ': actually QQ' is slightly .01 curved, concave up, but for practical purposes this curvature can be ignored . .005 .002

2 3 4 5 6 Xi

242 the body does not present either parallel planes or have discussed the efficacy of flexion-extension symmetry of its structures. Offcentering of patient lateral films of the spine of side-bending frontal to central-ray and film center is nearly unavoidable spinal films to demonstrate intersegmental mobility to at least some degree in either the vertical or hor­ and integrity of spinal retaining structures. These izontal planes. This makes it nearly impossible to methods are frequently used in chiropractic, osteo­ duplicate patient positioning from one radiograph pathy, and orthopedics for such purposes. Field­ to another. ing,s1 Jones,ss,s9,60,61 ,62,63 Bard and Jones,64,65 The use of full spine radiography has drawn Woesner," 6 Rich, 67· liH and Howe 6!1, 70 have shown criticism from some sources, both as to the diag­ the efficacy of cineradiography in detailing normal nostic film quality obtainable and the irradiation and abnormal intervertebral movements. These of the entire trunk. Use of varying screen speeds studies have allowed somewhat better understand­ in the 14 x 36-inch cassette has been one method ing of spinal mechanics which should have practical used to improve radiographic quality. This method, application. Some of these observations have cast however, exposes the thinner body areas to as doubt upon a few traditional concepts of inter­ much radiation as the heavier areas. Use of com­ vertebral movement. pensating filters reduces radiation to thin body Penning 71 illustrated flexion and extension in the parts and also results in a balance of radiographic mid-cervical region as producing a rocking-gliding densities which produces radiographs of accepta­ movement of a vertebral body over the disc below ble quality. 32 with the fulcrum of. motion approximately in the Levine, Howe, and Rolofson 46used thermolumi­ center of the vertebral body below. Rich 68 and nescent dosimetry and an- Alderson phantom while Jones 5!1 both noted altered intervertebral mobility simulating chiropractic radiographic techniques to associated with spinal degenerative disease. measure the surface exposure and organ doses Howe 70 in confirming this has postulated that the incidental to such radiographic procedures. Their earliest sign of disc degeneration would be altera­ data showed that good quality radiographs using tion of the usual rocking-gliding movement noted full spine techniques did not cause higher organ by Penning. 71 With degeneration the motion be­ doses than were produced by X-rays of the several comes more identifiable with some anterior and spinal regions. Data collected by the Nationwide posterior slippage replacing some of the rocking. Evaluation of X-ray Trends Survey System 47 also This also results in changes in the usual gliding shows that exposure from full spine radiographs facetal movements. This abnormal motion has been is not excessive as compared to radiography of demonstrated in the cervical spine with degenera­ smaller spinal areas. tion; some observations in the lumbar spine also The spinographic systems previously cited suggest such applicability. and others in use, while giving adequate ability to Rich 68 reported that on lateral flexion of the low evaluate spinal structure and relationships for back the L-5/S- I functional unit showed little clinical purposes, do not allow exacting determi­ mobility and that L-4/L-5 was the lowest truly nations. Suh 48 has devised a computer graphics mobile unit. Sandoz 72 aptly likened this to the method to allow very exacting measurements semirigid portion of an electric or telephone cord needed to better assess manipulative effectiveness. which distributes stress over a distance so that Frigerio, Stowe, and Howe 4!) have taken a some­ early breakdown will not ensue where a highly what different approach and by orthogonal radiog­ flexible area functions in close proximity to a more raphy and photogrammetry have demonstrated rigid unit. Recent observations in the cineradio­ movement in the sacroiliac joints, a subject long logical laboratory of the National College of disputed by clinicians and anatomists. Further in­ Chiropractic have shown, however, that when the vestigations in these areas should yield helpful spine is held relatively immobile and the pelvis information relating to spinal function and the moved freely thereunder (as in a hula dance) that effects of spinal manipulation. the L-5/S-1 junction is more freely movable than Functional spinal radiography has been used via the functional units above it. static stress studies and cineradiography to en­ Janse and Illi73 observed that side-bending and hance knowledge of spinal integrity and functional rotation of the spine are concomitant motions. ability. Hviid, 50 Davis, 51Jackson, 52 Cobb, 53 Krau­ Janse 74 then proposed the hypothesis that in scoli­ sova and Lewit, 54 Mehta, 55 Jirout 56 and others osis or subluxation the spine will deviate more 243 easily into distortion (increase the distortion) than elusive approaches to X-ray diagnosis significant it will deviate out of distortion (correct or reverse impetus in the last 15 years. The radiological the distortion). Yochum 75 and Taylor 76 by some­ approach to spinal diagnosis must include all what different methods verified this on a few pa­ aspects- anatomical, biomechanical, and patho­ tients. Further studies under direction of this author logical. have also shown it to be true as related to scoliosis or lateral distortion, but in hyper- or hypo-lordoses EXPOSURE TO IONIZING RADIATION of the lumbar or cervical spine, the principle has FROM SPINAL ROENTGENOLOGY not held true except in those cases where the dis­ One of the great concerns among all who deal tortion was due to antalgic muscle contraction. with X-rays is the exposure to ionizing radiation 11 77 78 Cox , , has suggested a method of assessing incidental to radiological examination. Although disc protrusion or prolapse from plain-film radiog­ patient doses from diagnostic X-ray are low and raphy, along with a manipulative technique for unlikely to cause demonstrable damage if proper treatment of this common problem. His diagnostic radiological safety measures are used, it must be 79 procedures were derived from the work of Herlin recognized that, except for background radiation, with radiographic concepts adapted from cineradio­ diagnostic procedures comprise the greatest amount 68 graphic observations by Rich relating to abnormal of radiation exposure to the general public. In intervertebral movements in patients with disc spinal radiography this is of special concern since 36 hernia, and from Winterstein 's method of diagnos­ all critical organs: Gonads, bone marrow, thyroid, ing disc protrusion from upright radiographs. This eye lens, and much of the body's epithelium are work is being continued. either within or very close to the primary beam dur­ PATHOLOGICAL CONSIDERATIONS ing at least some of the studies. This concern has led to a 7-year major effort within the chiropractic Depiction of spinal pathology is one of the very profession to promulgate proper measures of important aspects of spinal roentgenology. Patho­ patient and operator radiation safety through pub­ 80 81 82 83 logical changes may be present that are not readily lications , , • and continuing education discernible except by radiography. Some of these courses. 84 • 85 could be contraindications for manipulative The chiropractic profession has accepted the therapy. Other pathologies, while not being con­ recommendation of the BEIR Report 86 that "'No traindications to adjustive procedures may have exposure to ionizing radiation should be permitted profound effects upon spinal function and therefore without the expectation of a commensurate must be carefully considered in manipulative ef­ benefit." Through its colleges and radiological or­ forts. Still other pathological changes may point ganizations, the chiropractic profession has pro­ toward dysfunctions which are not readily apparent mulgated the notion that spinal X-ray examination in static radiographs and therefore lead to better should be done only to fulfill clinical needs as understanding of subluxation of dysfunction pat­ shown from other examination procedures and his­ terns that can be found clinically but are poorly tory, and that repeat radiographic examinations appreciated radiographically. Some types of should be avoided unless they are clinically neces­ pathologies may be entirely incidental to the bio­ sary. The profession has also gone on record with mechanical approaches of manipulative treatment, the Bureau of Radiological Health. U.S. Depart­ but the approach of any doctor must encompass ment of Health, Education, and Welfare, as advo­ the totality of the patient's being so that no infor­ cating the use of gonad shielding where such use mation is unimportant. X-ray detection of "silent" will not interfere with the clinical objective of the gall stones, abnormal intestinal patterns, changes X-ray examination. in kidney contours. and other abnormalities fre­ In light of the seriousness of the problem of ex­ quently found may be incidental relative to the posure to ionizing radiation incidental to spinal primary reason for the spinal X-ray examination, X-ray examination, the action of the U.S. Congress but differential diagnosis and consideration of a11 which requires X-ray demonstration of spinal sub­ aspects of health are not incidental to any physician luxation in order to qualify a patient for reimburse­ The emergence of diagnostic roentgenology as a ment of chiropractic services under Medicare and specialty in chiropractic has given this aspect of the Federal Workmen's Compensation Act seems roentgenology and the development of more in- inequitable. capricious, and detrimental to the pub- 244 lie interest. This is especially true since radio­ 3. Ferguson, A. B.: The spine. Chap. 6 in Roentgen Diagnosis logical depiction is only one method of detection of of the Extremities and Spine. 2nd edition. (New York) Harper and Brothers, 1949. subluxation and not as reliable as other clinical 4. Chiak, R.: Variations of lumbosacral joints and their methods in some cases because of the functional morphogenesis. A eta Univ. Carol. Med. 16: No. 12: 145- nature of subluxation and the static nature of 165, 1970. most X-ray examinations. The use of X-ray in 5. Ryan, M. J.: Low back pain-the role of radiology. Jr. J. spinal diagnosis is significant, as this paper has Med. Sci. 351-361, August 1964. 6. Stinchfield, F. E.: Sinton, W. A.: Clinical significance of tried to demonstrate, but the use of X-ray in any the transitional lumbosacral vertebra.J.A.M.A.157:1107- diagnosis should be at the discretion of the clinician 9, 1955. and dictated by other clinical findings. 7. Higley, H. G.: Lumbosacral Spine Facet Facings. Pub­ lished by the Foundation for Chiropractic Education and SUMMARY Research, (Glendale, Calif.), 1967. Spinal X-ray examination gives significant in­ 8. Splithoff, C. A.: Lumbosacral junction- roentgenolographic formation in the diagnosis of spinal normalcy, comparison of patients with and without backache. J.A.M.A 152:1610, 1953. abnormality, and disease. Its benefits also extend 9. Fullenlove, T. M.: Williams, A. J.: Comparative roentgen to giving guidance for therapeutic procedures, findings in symptomatic and asymptomatic backs. especially in manipulative or adjustive approaches Radiolo,:y 68:572, 1957. where intraspinal disrelationship, distortion, 10. DePalma, A. F.: Rothman, R. H.: The lntervertebral Disc. deformity, or disease may necessitate special con­ Saunders (Philadelphia) 262, 265-7, 1970. 11. Cox, J. M.: Lumbar disc herniation: statistics on an innova­ sideration or even contraindicate such ministra­ tive diagnostic and therapeutic approach. J. Clin. Chiro­ tions. Of special importance to chiropractors and practic, Radiographic Edition 20-44, I 973. others whose therapeutic thrust is biomechanical 12. Farfan, H. F.: Sullivan, J. D.: The relation of facet orienta­ is the fact that some radiological procedures give tion to intervertebral disc failure. Can. J. Surg. 10:179, information that is helpful in understanding spinal 1967. 13. Farfan, H. F.: Mechanical Disorders of the Low Back. Lea function. Such use must be dictated by clinical and Febiger (Philadelphia) 1973. needs in light of possible patient benefit. X-ray 14. Schmorl, G. and Junghanns, H.: The Human Spine in examinations sho.uld be designed to give the in­ H ea/th and Disease. 2nd American Edition, translated formation of greatest benefit to the clinician in his by E. F. Beseman; Grune and Stratton (New York) 1971. diagnostic and therapeutic efforts and therefore 15. Hadley, L. A.: Anatomico-roentgenowaphic Studies of the Spine. (Springfield, Ill.) Thomas, 1973. routine use of or stereotyped methods of X-ray 16. Epstein, B. S.: The Spine: Radiographic Text and Atlas. examination may not serve the best interests of 3rd Edition, Lea and Febiger (Philadelphia) 1969. patient or doctor. 17. Conference on Lmv Back X-rays in Preemployment Phys­ In order that the common complaints of man ical Examinations. Published by the American College associated with musculoskeletal function may be of Radiology (Tuscon, Ariz.) 1973. better understood and more effectively managed I 8. Epstein, B. S.: Radiological anatomy of the lower spine. Conference on Low Back X-rays in Preemployment additional investigations in the following areas Physical Examinations, 21-3 I. Published by the Ameri­ are needed: can College of Radiology (Tucson, Ariz.). 1973. I. the significance of anatomical variation, 19. Moreton, R. D.: A radiologists's viewpoint. Conference on anomaly, spinal distortion, and subluxation Low Back X-Rays in Preemployment Physical Examina­ tions, 141- 7. Published by the American College of or dysfunction: Radiology (Tucson, Ariz.). I 973. 2. the effects of various disease processes on the 20. Erickson, G. E.: Morphological perspectives of the back. biomechanics of the body; and Conference on Low Back X-rays in Preemployment 3. the ranges of normal functioning of the spinal Physical Examinations, 2-7. Published by the American column and other supporting body structures. College of Radiology (Tucson, Ariz.). 1973. 21. Ford, L. T.: Orthopedic considerations. Conference on Radiological investigation is indispensable in Low Back X-rays in Preemployment Physical Examina­ such studies. tions, 33-45. Published by the American College of REFERENCES Radiology (Tucson, Ariz.). 1973. 22. Trout, E. D.: Radiation Safety. Conference on Low Back I. Janse, J.: The mechanical pathologies involved in the low X-rays in Preemployment PhysiCChiropractic Economics 14: No. I: I 0-2, 197 I. graphic and conventional roentgenographic methods. Am. 43. Mears, D. B.: Analysis of lateral-cervical X-ray. Digest J. Roentgenol. Radium Ther. Nuc. Med. I 15:148-54, of Chiropractic Economics 14: No. 3:32-3, 1971. 1972. 44. Mears, D. B.: Analysis of AP-cervical X-ray. Digest of 67. Rich, E. A.: Observations noted in 11,000 feet of experi­ Chiropractic Economics. 14: No. I :44-5, 1971. mental cineroentgenographic film. J. Am. Chiropractic 45. Mears, D. B.: Analysis of lateral-cervical X-ray. Digest Assn. I: No. 3:11-12, 1964. of Chiropractic Economics 14: No. 4:36-7, 1972. 68. Rich, E. A.: Cineroentgenographic observations of the 46. Levine, J. I., Howe, J. W., Rolofson, J. W.: Radiation ex­ human systems. Scientific Yearly of the Lincoln Chiro­ posure to a phantom patient during simulated chiropractic practic College I: 1-9, 1966. 246 69. Howe, J. W.: Observations from cineroentgenographic disc protrusion and prolapse, part 2. J. Am. Chiropractic studies of the spinal column. J. Am. Chiropractic Ass11. Ass11. 7: No. 10:65-70, 1970. 79. Herlin, L: Sciatic and Pelvic Pain Due to Lumbosacral 70. Howe, .I. W.: Cineradiographic evaluation of normal and Nen•e Root Compressio11. Thomas (Springfield, Ill.) abnormal cervical spine function . ./. Cli11. Chiropractic 1966. Archil•es. Ed. 2:76-88, 1972. 80. Howe, J. W.: Reduction of patient radiation exposure 71. Penning, L: Nonpathological and pathological relationships through higher kilovoltage-lower milliamperage tech­ between the lower cervical vertebrae. Am . .I. Roentgenol. niques. J. Am. Chiropractic Assn. 5: No. 9, 1968. Radium Ther. Nuc. Med. 91:1036-50, 1964. 81. Howe, J. W.: Buehler, M. T.: Diagnostic roentgenology 72. Sandoz, R.: Newer trends in the pathogenesis of spinal with reduced exposure factors . .I. Am. Chiropractic Assn. disorders. An11als Swiss Chiropractic Ass11. 5:93-179, 4:S l 7-22, I 970. 1971. 82. Howe, J. W.: Roentgenology in chiropractic, state of the 73. Janse, J.: Dr. Illi does research at National College . .I. art-1974 . ./.Am. Chiropractic Assn. 8:S66-72, 1974. Natio11al College of Chiropractic 22: No. l :9, I 950. 83. Hildebrandt, R. W.: Synopsis of Chiropractic Roentgeno­ 74. Janse, J.: Basic Clinical Phe11omena as they Relate to the logic Technology. 2nd Ed. published by the National­ Art of Specific Reduction of Spi11al Segmental Dys­ Lincoln School of Post-Graduate Chiropractic Educa­ arthrias. published by the National College of Chiro­ tion {Lombard, Ill.) I 974. practic (Lombard, Ill.) 1973. 84. Continuing Educatio11 Bulletin l 97 4-75. published by the 75. Yochum, T. R.: Stress studies of thoracolumbar scoliosis. National-Lincoln School of Post-Graduate Chiropractic J. Cli11.Chiropractic Radiographic Ed. 9-19, 1973. Education (Lombard, Ill.) 1974. 76. Taylor, D. B.: Biomechanics of the spine under stress. 85. College Seminar Calendar. A monthly listing of post­ J. Cli11.Chiropractic Education Ed. 61-73, 1973. graduate courses . ./. Am. Chiropractic Assn. 1969-74. 77. Cox, J. M.: Diagnosis, mechanism, and treatment of lumbar 86. The Effects 011Population of Exposures to Low Le\'els of disc protrusion and prolapse, part 1. J. Am. Chiropractic Ionizing Radiation {the BEIR report). Published by the Assn. National Academy of Sciences and the National Re­ 78. Cox,J. M.: Diagnosis, mechanism, and treatment of lumbar search Council (Washington, D.C.) 1972.

247 The Role of Static and Motion Palpation in Structural Diagnosis

WILLIAM L. JOHNSTON Professor, Department of Biomechanics College of Osteopathic Medicine Michigan State University

I have felt definitely challenged by the fact that apparently static, the perception of tissues in their there is only one topic in this conference dealing response to a demand for movement and what they expressly with the term "palpation." Since "hands­ reflect during that movement- specifically what on" is the setting of our subject matter, I will try they reflect to the palpating hand. and report in this short period what stand out as In communicating about palpatory findings, the simple overriding principles, with the broadest clinician's first obligation is to accurately locate application, in the palpatory diagnosis of somatic where his palpating hand is sensing. 3 • 4 Is it overly­ dysfunction. ing a particular spinal segmental level? Is it located Briefly, palpation offers the clinician the oppor­ centrally, laterally, bilaterally, specifically where? tunity for a personal and directed, on-the-spot In this manner, the site of contact is accurately evaluation of the neuromusculoskeletal system. It localized, and the size. That is, does it involve the is·the source of those fingertip cues which provide contact of just the fingertips, fingerpads, or larger him significant diagnostic information about the to include the whole hand? patient. These, in tum, guide him during his thera­ Such designations may seem simple, but they peutic approach. are primary in recording the facts; my initial First of all, what will I not be considering? premise is that careful observation is scientific. 1. I am not going to be analyzing any single kind It is scientific whether you are in a laboratory look­ of anatomical structure- not muscle alone, ing through a microscope, whether you are at the not just bony structure, not ligament or fascia bedside auscultating on the smface of a chest or per se. whether you are in the office palpating on the 2. I will not be commenting on intervertebral surlace of the back. Palpation has not yet been discs, which are not palpable. widely recognized as a careful form of observation 3. I will not be dealing with slackening of liga­ that can have a scientific validity. What it demands ments or pinched nerves. to be scientific is the factual reporting of what is 4. I will not be handling terms like ·•minor inter­ actually observed, and how it is observed. vertebral derangements of discal hernia­ This brings me to my second premise, which is tions," 1 "posterior intervertebral articula­ closely allied to the palpating and the recording. tions of interspinal ligaments," nor reviewing The observing-the situation of the observer and the axes of intervertebral movements. 2 the observed- bears heavily on the implications 5. I will not be talking about facet-joint processes of what is to be recorded as fact. I can't emphasize nor joint surlaces. this too strongly because we have all observed in I will be talking about somatic tissues in toto, the history of our professions that physicians have tissues in movement. tissues in action, the percep­ observed the same neuromusculoskeletal phe­ tion of what it is the tissues reflect when they are nomenon with their fingertips, have climbed onto 249

597-036 0 - 76 - 17 an interpretive framework and then ridden off in all depressions and asymmetries. The perceptions are directions. There is a need to carefully delineate recordable on my right. as to location, size, dis­ what is perceived at the hand of the observer and tribution, (facts): the interpretation would be here what is conceived in the mind of the observer. Often on my left, that is, bony malposition, 7 subluxation, the relation between the two becomes a tenuous sprain (concepts). one. Where deep pressure palpation ends and joint It will be helpful at this point if you will presume probing begins. there may be a point for con­ that I am standing in front of a huge blackboard troversy. The situation is still one of static palpa­ (see page 252), picture my left side of the black- tion with the subject resting. The technique of board as listing items of theory and my right side as pressure probing may involve one thumb or one listing items of fact. What can the palpating physi­ reinforced by the other. 8 The actual scene of this cian (observer) report on the right side of the black­ kind of palpation might involve the subject in a board as a first level record of careful observation? prone position with pressure probing by the oper­ First. the rigors of static palpation. The subject is ator downward over the paraspinal musculature at seated and the operator runs two fingers lightly a given segmental level, comparing one side with down the paraspinal areas overlying the thoracic the opposite, right with left. Encountering a sense spine. He can report encountering differences at of resistance at one side (as compared to a sense different levels. He can report that this area differs of yield at the other side) could be recorded here from that area. (Experience with braille can verify on my right, locating the point of resistance to this fact.) So at the top of our board on my right we pressure probe. On my left side you might have the 3 4 have differences, areas of tissue texture changed • interpretation of a zygapophyseal lock, 9 or of the from their immediate surroundings as reportable vertebra positioned with the transverse process palpatory fact that should be able to be confirmed posterior on the side expressing resistance. by a second observer. If one observer describes that difference as congestive or tense or ischemic One variation of this kind of joint probing in­ or fibrotic, the statement emerges as a level of volves pressure with one thumb over a bony interpretation that may, or may not. be confirmable. prominence at a joint area (spinous or transverse Second, he can factually report the location of process). often with the second thumb creating a this finding. An example would be T2-T4 on the counter pressure on an adjacent bone.1° Each still right or even bilaterally at the level of T6. The senses resistance to pressure probe recorded here size and extent of the difference can be carefully on my right. If a resistance is elicited by pressure observed and measured. Example: a unilateral against the side of the vertebral spinous process, it patch on the right extending vertically 4 centi­ is often interpreted as restricted rotation. If it is meters and horizontally 1.5 centimeters or a bi­ elicited by pressure in a medial direction against lateral strip extending vertically I centimeter and the articular process. it is often interpreted as horizontally 7 centimeters. Even with approximate restricted sidebending: if bilaterally in an anterior numerics, the basic picture emerges reasonably direction (patient still prone) it may be interpreted factually. as restricted extension. These interpretations are By an appreciation of the amount of pressure in all recordable as theory. Other terms like .. hyper­ palpation. we may gauge the approximate depth of mobility," ..joint lock." ··stretched ligaments,'' our finding and begin to interpret the tissue we're "roughened articular cartilages," "irregular joint palpating. The gradation of pressure can be re­ surfaces.'' and "adhesions," 11 are also recordable corded on the right, the interpretation on the left. under theoretical data. Pain and sensitivity 1, 5 • 6 represent significant On my left side of the backboard, a number of criteria and are recordable as fa_ct. However. concepts are accumulating that have given rise in they rely specifically on the subjective nature of the past to much heated discussion. On the right the patient's response. As such, they are of a lesser side, items of skilled perception that need more reliability than the objective palpatory cues of a careful recording are noted. skilled observer. So far we have been talking about local asym­ One of the tissues we are beginning to palpate metry and tissue change. I am proposing that these here is bony. We can sense irregularities of the represent two cues of a triad that is equally as underlying soft and bony tissue, prominences, reflective of problems in the neuromusculoskeletal 250 system as the triad of rate rhythm and murmur in the ator registering the same sense of either compliance cardiovascular system. The third cue is motion or resistance, but this time during movement. These change. In dealing with the issue of motion palpa­ are picked up by a light palpatory technique 14 that tion, let me begin by suggesting that this is not has been described as "nonperturbational"; it necessarily a familiar methodology. does not intrude in the action and therefore offers Most joint motion testing procedures have an increased validity in a scientific setting. separated the joint as an isolate from the rest of Findings during motion palpation add further the body. 2 • ii, 12 With the body static and resting, a specific descriptors to our phenomenon here on joint structure has been evaluated with some type my right under perceived facts. Up until now, dur­ of pressure probe or testing procedure for the joint ing static palpation, we've localized an area of itself and its motion range. Such methods have tissue texture, say overlying T2 bilaterally (changed led to a concept and a terminology of motion from its surrounding areas above and below), and that relates the position of one bone to another, noted its subjective sensitivity and the asymmetry and implies a restriction of motion as a locking of of its relationships and the resistances to pressure a joint in a given position. The facts have emerged probe. Now in motion palpation we can record at as a snapshot photograph. T2 an immediate increasing resistance (active Consider for a moment the commonly used move­ binding) during the initiation of gross rotation of ment patterns of the subject's musculoskeletal the shoulders to the left as compared to its increas­ system. These are not movements of one bone ing compliance, (active easing) when the shoulders alone, nor just at a single joint. They are move­ are rotated to the right. Range is not measured ment patterns involving many segments, with each here. This is not a resistance to all movements. segmental part organized and contributing to the Rather, it is a constantly changing response of local total patterned performance, whether the pattern segmental tissues during movement-bind acceler­ involves primarily segments of a spine or segments ating during some movements, bind decelerating of a limb. during others. With a subject seated, the operator can introduce The conceptual framework is behavioral. The a gross movement passively, palpating first of all for relationship is of a segmental part, not to the one the sense of total range, the extent of the total below but to the whole, that is to the whole move­ performance, and record limitation and asymmetry. ment of which its behavior is being evaluated as it Rotational, lateral, forward and back ward bending contributes its individual segmental part. Here elements are all appropriate for gross motion the phenomenon is viewed as one of lesioned testing. segmental behavior within the dynamics of move­ We are talking about the dynamics of total body ment; this time the picture is a motion picture not movement, or at least the movement of a region a photograph. We are not asking the question: "A of the body, involving a pattern that is segmented, lesion of what?" with a conceptual answer of a the summation of many parts. Does each part bone, joint, ligament, a muscle, and so on. Rather, easily go along with and contribute to the gross we are asking the question: "Lesioned in response movement pattern - or does it express resistance to what?'' with a factual answer: "In response to to the particular demand for movement? the particular gross demand for movement that Motion palpation deals with the behavior of these initiates the response." This is a definable, report­ segmental parts during motion. 13 Once identifying able fact. It is a careful observation that is scien­ a local segmental area of tissue texture change, the tific, one that can be confirmed by a second operator palpates for the motion of that segmental observer. part by monitoring it individually while intro­ Let's consider for a moment what Sherrington ducing·a variety of gross movement patterns (gross had to say about motion and position. His statement rotation of the shoulders, gross forward bending was that position follows motion like a shadow. 15 The of the head and neck, and so on). corollary to this statement is that motion is position It is a light palpation, during motion, with the on the run. The fact to be considered is that motion fingerpads overlying the defined segmental level and position are integral stages of the same process. as it participates in a particular gross movement Realizing that we had already identified a lesioned being introduced. The procedure utilizes the same phenomenon of t.t.a. (tissue texture abnormality) sensations for cues at the fingertips with the oper- during a so-called static palpation in the resting 251 position, we might now consider asking our same facts perceived in palpation. It allows us to inte­ question in this static situation: ··Lesioned in grate all of the diagnostic findings, in both static response to what?" and suggest as a plausible and motion palpation on the right side, put them answer that it may be lesioned in response to the together and organize a single common conceptual demand to assume a position. Actually this is a framework on the left side that will deal with all particular postural positioning, the one that the descriptors of the phenomenon of somatic dys­ subject has been asked to take during the examina­ function- deal with palpatory findings in direct tion: each segment is being asked to contribute to relation to the dynamics of demand and response­ that positioning so that each segment is in the right and deal with the commonality of demands for both place in the sequence. If this is so, we can easily position and movement and their existence together probe this assumption by monitoring the already as a single continuum of demand. With proper atten­ tense tissue texture at T2, as we alter the sub­ tion to the methodology of palpation ( how the ject's position. When we do, the tissue texture -im­ facts are observed) and the clinical diagnostic find­ mediately changes,7 gets more resistant or more ings of palpation ( what is factually observed). we compliant depending on the new position being have procedures that can be reproduced and find­ demanded. But from one position to another posi­ ings that can serve as specific descriptors within tion is movement, bearing out the direct relation­ a laboratory setting. ship of our phenomenon to position and/or motion. Binding has existence only as a response to the Palpation is a careful form of observation that demand being currently placed on it- be it motion can be scientific. I have tried to address a verbal or position. logic, and suggest a kind of physiologic. as the There is an impact to this kind of observation, basis for a theoretical model which will be an attentive to the methodology of palpation and the appropriate guide for clinical research.

Somatic Dysfunction*

Fact Theory (caused by)

Static Palpation Subject seated: Tissue texture abnormality-paraspinal Level T2 bilateral 1 cm. vertical, 7 cm. horizontal Sprain (subjective pain) Subluxation Irregularity, asymmetry bony prominences Bony malposition, zygapophyseal lock

Subject prone: Resistance to pressure probe at rt. T2 on T3, transverse process posterior on right Resistance to pressure in a medial direction from rt. T2 on T3, sidebent to left Resistance to pressure in an anterior direction, bilaterally T2 on T3. restricted in extension, positioned in flexion T2 joint lock on T3 (roughened articular cartilages, irregular joint surfaces, adhesions) T.T.A. at T6-increased compliance to pressure T6-hypermobile joint probe from posterior, bilaterally stretched ligaments Motion Palpation** Subject seated: - t.t.a. at T2 Binding in relation to postural demands (of the seated position) Head rotation to rt.+-+ t.t.a increases Head rotation to left+-+ t.t.a. decreases Head side bending rt. - t.t.a. increases Active bind, accelerating or decelerating in Head side bending 1ft.++ t.t.a. decreases relation to the particular demand for movement. Head forward bending++ t.t.a. increases Head backward bending++ t.t.a. decreases *Three kinds of palpatory facts about somatic dysfunction: asymmetry, tissue change, motion change. **The tissues about a moving part constantly reflect its compliance or resistance (behavior) in response to specific movement patterns (position and changing position).

252 REFERENCES 9. Northup, G. W., Osteopathic Lesions, .I.A.O.A. 71 :854- 865, June 1972. I. Maigne, R., Orthopedic Medicine, translated and edited by 10. Wilson, P. T., Principles and Techniques of Individual Liberson, W. T., Springfield, 1972, Charles C Thomas. Lesion Diagnosis, Yearbook AAO, pp. 193-194. 1955. 2. Ho, R., Testing Interveitebral Joint Movement, J.A.O.A. 61:635-639, April 1962. 11. Stoddard. A., Manual of Osteopathic Practice, New York. 3. Denslow, J. S., Pearson, J., and Gutensohn, 0., An Ap­ Harper & Row, 1969. proac~ to Skeletal Components in Health and Disease, 12. Strachan, W. F.,Joint Motion Testing and Forces Involved .I.A.O.A., 50:399-403, April 1951. In Passive Motion. J.A.O.A. 66:271-277, November 4 . .Johnston, W. L., Manipulative Specifics, .I.A.O.A. 6 I :535- 1966. 539 March 1962. 13. Johnston, W. L., Segmental Behavior During Motion, Part 5. Denslow, J. S. Palpation of the Musculoskeletal System, I: A Palpatory Study of Somatic Relations, ./ .A .0 .A. J.A.O.A.63:1107-1115, August 1964. 72:352-361,Dec.1972. 6. Mennell, .I. McM. Joint Pain, Hoston, Little Brown & Co., 1964. 14. Bowles, C. H., Functional Orientation for Technic, Part 7. Downing, C. H., Principles and Practice of Osteopathy, Ill: Yearbook AAO, 53-57, 1957. Kansas City, Mo., Williams, 1923. 15. Swinyard, C.A., ed.: Role of the Gamma System in Move­ 8. Beal, M. C., Motion Sense, .I.A.O.A. Vol. 53, No. 3, 151- ment and Posture. Association for the Aid of Crippled 153, 1953. Children, New York, 1964, p. 45.

253 The Role of Thermography and Postural Measurement in Structural Diagnosis

MARTIN E. JENNESS Director of Research Palmer Co llege of Chiropractic Davenport , Iowa

INTRODU CT ION cording or " map" of the temperature pattern over the area scanned. Typic al thermographic pattern s The purpose of this paper is twofold : (I) To of the back follow (figures 1-4 ). dete rmine how thermography an d post ure have been used in structural diagnosis and (2) to det er­ mine in what way the analytical tools employed in thermographi c and post ural assessment may be applied or modified to extend our knowledge in the analysis and/or diagno sis of hum an structure. As the se tool s are quite di sparate with respec , to mater ials, methods, and ap plicat ion in eva luatin g or diagnosing st ructur e, they will be co nside red separa te ly. The use of thermography will be con­ sidered first. THERMOGRAPHY Hippocrate s (400 8 .C.) was the first to recogni ze the significan ce of body temper ature regulation relative to pathologic al changes in man. Over 2,000 years later , Claude Bernard ( 1879) discove red that the mainten ance of body temperature was und er the control of the nervous system. Since the introduction of the neurocalometer in 1924 by Evins, 1 skin temperature mea surement s have played a significant role in the clinical practice of chiropractic. Correlation of roentgen and other clinical findings with skin temperatur e pattern s have ass isted doctors of chiropractic in determining the prese nce of vertebral subluxations. He at loss through the skin surface may occur by four different physical mech an isms: Rad iation , convection, conduction, and eva poration. In the Fig. I. On this male subjec t, warm areas arc represe nted basal state , most body heat is lost throu gh as light areas and co ld areas appear dark. Note the warm radiatio n.2 • 3 , •1, 5 streak along the ve rtica l media n line of the back, the warm Thermography is a technique that record s areas be tween the shoulders, and the co ld areas on the infrared radiations and produces a pictorial re- latera l margins of the torso. 255 Fig. 2. T his is the same subject as in Figure I. Co ld areas are Fig. 3. Th ermograp h of the same subject with the warm outli ned in brilliant white. No te that thes e arc found on the areas highlighted in white. N ote the warm area bet ween the latera l mar gins of the lowe r thorac ic and lumba r regions shoulders and the lower tho racic -upp er lumbar area. of the tor so. due to a d isparit y of opini on as to what co nstitutes Th e clinica l appli ca tion of infr ared scannin g a normal ther mogram. Al so , beca use of anatom­ syste ms to map skin temp eratur e distributi o ns ica lly reflec ted radiatio n, the normal patient often stems from th e obse rv ation by Laws on 6 that the ex hibit s increase d hea t in th e lumb osac ral area , skin ove r a ma lignant tum or of th e br eas t is fre­ the most co mm on site for clinica lly significa nt O 14 qu entl y betw ee n I to 3° hott er than surroundin g disc disease .I 1• • 15 Some inves tigators are avo id­ skin. ing thi s prob lem b y bas ing th eir diagnos is on Th e role of th er mog raph y in clini ca l practic e is the rmogra ms of the butt ocks , thigh, and ca lf.16 • 17 still to be es tablished. It is a young diagnos tic too l A numb er of ph ys iolog ic mec hanisms are in­ in which experience is ra pidly accumul ating. In vo lved in form ing sk in temp eratur e pattern s. ca nce r, vasc ular disease , neurol ogy , and ortho­ Mu sc ular co ntr acti on plays a significa nt rol e in pedics , enou gh data are avail ab le to mer it attention . determinin g th e natur e of th erm ographi c pattern s. 18 In orth ope dics , therm ograp hic tec hniqu es have In mu scle , hea t ap pea rs as a byprodu ct of mu sc ular bee n found useful in evaluating mu sc uloliga mento us con tract ion and recovery. 7 • 19 injuri es to the s pine. 7 In most instances , the T he ro le of the nervo us s ystem in skin temp era­ th.erm ogra m loca lizes the hype remia inciden t to ture reg ulation is of para moun t imp ortance , particu­ the loca l insult. 8 , 9 larly in the prac tice of chirop rac tic. Th ere are two In eva luatin g herniated disc s and nerve root sys tem s which regulate th e effec tor sys tem s of co mpr ession in th e lumb ar reg ion of the spin e, tempera tu re co ntro l: the s kin rec ept or mec hanism inves tigator s have reac hed co nflictin g co nclu­ and the centr al reg ulatin g me chanism.20 , 2 1 • 22 sions rega rdin g th e diagnost ic merit s of thermog­ Th e amount of bloo d pa ssing to the s kin is ra ph y. 10 • 11 , 12 , 1:i, 14 T he dichoto mies are apparentl y gove rned by loca l va sculariti es, which in turn are 256 of nerve impul se tra nsmiss ion produces wa rm­ ing.~8• ~!I. :w. :n The th ermog ra m, therefor e, may be a va luab le too l in th e differe ntial diagno sis of neuro pathie s. Bes ide s determining w hether nerve injur y is partial or co mpl ete, thermography may he lp determine whether a ne uropath y is toxic , 1 1 tr'aum atic, or comp ress ive in natur e. · Injur y to the sp inal co rd also results in mark ed chan ges in skin temperature patt ern s. A numb er of orthopedic condition s which may or may not involv e neuron al dy sfunct ion have exhibit etj therm ograp hic manife sta tio ns. In cases of spondyloli sthe sis , co nsistently warm area s were demo nstr ated ove r the are a of sublu xa tion.'' In add ition , inflamm ation from within, suc h as osteoarthriti s ar isin g from inflammation of sy nov ial memb ra nes or rheum atoid arthriti s with infla m­ nation arou nd joints, may be displ ayed by thermography. 32,33, :i1, 35 It is c lea r that the role of th e nerv ous sys tem in pe riph era l va sc ular co ntrol is of primary imp or ­ tanc e. Th e th er mogr a ph is a valuable indic ator of the blood vascular system 's response to neura l contr ol sys tems. In chiropr ac tic , the greatest pot ential of thermogr aphy would appea r to be its use as an adjunct in determining th e relationship betwe en structural disrelation ship s and neurop athic Fig. 4. Both wa rm and coo l areas have bee n highlighted on proc esses . this different subject. No te warm areas in the upper bac k and cool areas at the lateral inferior margins of the torso. POSTURE Th e term posture genera lly impli es a charac ­ 1 co ntroll ed by the s ympathetic nervou s sys tem. 2: , teri stic stance or po sition of the body. In the 2·1, 25 , 26, 27 litera ture , mo st definition s are coupl ed with the Ce ntral temp era tur e regu lation is med iated by adje ctive "good " ; howeve r , ther e is littl e agreement the hyp ot halam us in respon se to changes in blood amo ng auth orities as to what con stitutes good temperature. 20, 22• 25 • 26 ln addition , se nso ry im­ po sture or how it should be defin ed. Thi s was pulse s from the skin on coo ling ca n ac t via the made clear in a re view by Massey 36 in which he hypot halamic mec hanism to incr ease body hea t. stated: Th is is acc ompli shed through shivering , piloe rec­ tion, and vasoco nstrict ion. In the literat ur e related to stand ards of St imul ation o f sy mp athet ic fibers suppl ying the "good" posture , there were many defini­ skin ca uses co nstrict ion o f the cut aneou s vesse ls tions de sc ribin g the co rrec t upright in the area suppli ed by the stimul ated fiber s. Yaso­ position. Au th or ities empha size d segmen­ co nstriction ca uses the skin to blanch , and eve n­ ta l alignment , pelvic inclination, carriage tually coo l. Co nve rse ly, if sy mp athetic pathway s of the head and ne ck, the distribution are interrupt ed throu gh surger y, small art erie s of weight on the feet , the curv es of the and arteriol es dilate , ca using an increase in blo od spine, abdo min al protuberance , the posi ­ flow and ·a rise in s kin temp era tur e. Efferent tion of the che st , and the center of grav ity sympathet ic fiber s ca rr y per sistent elec trica l dis­ in the trunk . When considered coll ec tively , charges , which are chiefly concerned with th ere see med to be general agree ment in vas oco nstrict io n. the choice of cr iteri a used to describe Nerve irrit ation , such as partial nerve inju ry , th e conditions for "goo d" post ure. produces coo ling; where as a complet e int erru ption Thus , "goo d" po stur e shou ld perhap s be tr eated 257 as a general abstraction, implying an idealized drawing pens attached to the head or shoulders relationship between structural form and function, of postural subjects. 45 , 46 with specific attributes tied operationally to the The dynamic and static aspects of erect posture particular touchstone used in its assessment. have been demonstrated by electromyographic In a limited paper of this nature, it is not pos­ measurements of postural muscles by Joseph and sible to consider all aspects of posture. In keeping Nightingale, 47 Floyd and Silver, 48 Nachemson, 49 with the title of this review and the purpose of and Klausen and Rasmussen. 50 this workshop, the following topical delimitation In 1906, Fitz 51 devised a celluloid grid to meas­ expressed in. question form seemed appropriate: ure spinal curves, scolioses, body contour, and (1) How can posture be assessed? (2) Is there a scapular and pelvic levels. A modification of this relationship between posture and health? and (3) type of apparatus capable of measuring rotation How can poor posture be prevented and/or of body parts was developed by Johnston 52 and corrected? used by Vilholm 53 in an extensive postural study Assessment of Posture of Danish children. Finally, a method of describing irregular sur­ Man's unique erect posture has attracted study faces by the use of moire topography was devel­ by physical educators and various members of the oped by Takasaki 54 and used by Terada and healing arts. These investigations have ranged Kanazawa 55 to depict the huinan skull in three from the highly subjective visual grading of posture dimensions. Application of moire topography to more objective methods utilizing photographs, to the erect human posture, as described by Free X-rays, silhouettes, center of foot pressure ap­ (paper presented at the Symposium on Biomedical paratus, electromyography, and moire topography. Photogrammetry, September 13, 1974, Washing­ This review is limited to a brief description of ton, D.C.), shows promise as a new tool for the more objective methods. postural analysis. In 1909, Reynolds and Lovett 37 determined the line of gravity of the body and related it to the Posture and H ea/th A-P spinal profile as determined by a spinal The literature provides a rich and varied assort­ "conformateur." This approach to postural meas­ ment of specific symptoms, conditions, and urement was later modified and employed by diseases that have been associated with poor Cureton and Wickens 38 and Jenness, Speijers, and posture. In addition, a number of general state­ Silverstein.:m However, many of the early postural ments relating posture and health have been for­ investigations utilized objective refinements of warded by various investigators. Hansson 56 stated: previous subjective work. The silhouettograph The medical profession was slow in ac­ 40 described by Fradd was used in the thirties to cepting poor posture and poor health as describe various body contours, landmarks, and one of cause and effect. In 1740, Nicholas angles of intersection of body parts. In 1943, Audry (Andry) taught that many illnesses 36 Massey in addition to his own criteria, took in children had their origin in imperfect measurements utilizing landmarks previously body mechanics. A generation ago the described by Goldthwait and Kellogg and correlated foundation for our present conception them with subjective postural ratings. Similarly, of body mechanics and health was brought MacEwan and Howe, 41 in 1932, correlated sub­ out by Goldthwait and continued by jective ratings with various body measurements Osgood. All surveys of posture in our taken from photographs. primary schools show less illness, as In I 938, Hellebrandt and Braun 42 measured proved by absences among children taught shifts of the line of gravity, or more correctly, the good body mechanics. Similar surveys center of foot pressure in the A-P and lateral in our colleges indicate a definite correla­ planes. Thomas and Whitney 43 in 1959, utilized tion between good functional health and a force analysis platform and accelerometer to good body mechanics. relate center of gravity deviations with center of foot pressure shifts. In 1971 , Stevens and This position was not shared by Keeve 57 who Tomlinson 44 described a method using displace­ contended: ment transducers to record movements of the Unfortunately, much of physical educa­ center of gravity, an improvement over earlier tion and training has (unknowingly) 258 incorporated the tenets of cult medicine A review on posture would be remiss without with its emphasis on "body mechanics" reference to structure and low back pain (LB P). and posture. That LBP is a common malady deserving con­ Other generalized statements were made by tinued research attention has been recently Hallock 58 who asserted that poor posture has an demonstrated by a number of investigators. 71 adverse effect on the general health and, more Magora found that 12.9 percent of a large sample recently, by Kuhns 59 who stated that poor posture of men and women (n = 3316) suffered from LBP. was associated with many pathological conditions With respect to incidence of LBP in industry, 72 and that good posture may prevent serious disease Rowe determined that over a 10-year period, processes. Thompson 60 lists a large number of con­ "35 percent of the sedentary workers and 47 per­ ditions involving every major organ system of the cent of the heavy handlers made visits to the body that may be "cured" through postural cor­ medical department for low back pain." In a radio­ rection. Finally, Garner 61 averred that proper graphic comparison of a primitive "squatting tribe posture a.ids in "minimizing fatigue" and "building in West Central India" with "American and up a resistance to infections." Swedish radiographic studies," Fahrni and 73 As indicated earlier, poor posture has been linked Trueman suggested that lumbar lordosis may be with many specific symptoms, conditions, and implicated in intervertebral disc degeneration. pathologies. Dickson 62 tabulated the following Similar findings had been reported earlier by 74 conditions that he considered to be tied to faulty Jones, who stated that LBP resulted from an posture: Leg, knee, and foot ache; fatigue; nervous­ increased sacral angle, and by Shannon and 75 ness and irritability; failure to gain weight; restless­ Terhune who said that increased lumbar curve ness at night; constipation; and periodic gastroin­ "'is the most common cause of low back pain." Thus, it would appear that LBP is related to ex­ testional attacks. Cochrane 63 said that chronic conditions such as gastrointestinal disturbances and cessive lumbar curvature. This would seem to be particularly significant in that Hagen 76 has shown arthritis yielded to postural correction. Canter 64 , 65 emphasized the prophylactic function of good pos­ that there is a strong tendency toward progressive ture in preventing "footstrain, backache, neuritis, accentuation of the lumbosacral angle during and arthritis." Forrester-Brown 66 stated that maturation and it is known that the incidence of rheumatism and chronic digestive trouble are LB P increases with age. commonly related to faulty body mechanics. In an It would appear that the foregoing melange of article discussing the importance of the quality associations between posture and health or disease of sleep, Mattison 67 said that posture "is generally could quite properly be subsumed and explained admitted to affect circulation, respiration, nutrition, by the basic chiropractic hypothesis, which links and the tonus of the muscles." structural disrelationships to aberrant function of A number of studies have been made to try to the nervous system, with concomitant tissue determine the validity of some of the foregoing dysfunction and/or pathology. claims. In 1917, at the instigation of Brown, 68 Postural M od(fication medical and postural data were collected on There is considerable evidence to support the Harvard freshmen. He found that persons having hypothesis that many disease processes are related poor posture suffered seven times as many back­ to faulty posture. This leads to the third question aches and had one and a half times as many that was posed at the beginning of this review: appendectomies as those having good posture. "How can poor posture be prevented and/or More recently, Fox 69 determined that the incidence corrected?" Time allows but brief mention of of dysmenorrhea amongst college women was techniques that have been suggested or employed significantly greater in those having excessive for effecting postural changes. lumbar curvature than in the controls. Moriarty Some of the most common methods that have and Irwin 70 found that "there is a significant been suggested for the prevention or correction of association between poor posture and certain poor posture are: (1) general and specific postural physical and emotional factors, namely: Disease, exercises; (2) education (inculcation of an aware­ fatigue, self-consciousness, fidgeting, hearing ness of good postural habits); (3) proper structural defects, restlessness, timidity, underweight, heart balance of the spine, legs, and feet; (4) proper defects, and asthma." support of the body when sitting or reclining: (5) 259 good nutntton; and (6) adequate rest. Many ford. 94 Kiernander 95 and Benes , Fiala and authorities consider most or all of the afore­ Krticka !JGreported studie s which seemed to indicate mentioned factor s to be import ant in the postural that exerci se is effective in improving posture equation. 77 , 78 , 7!l, 80 , 8 1 Others have empha sized the and/or correcting faulty posture in schoolchildren . import ance of ( I) correct support while sitting; 82 Finally , because of the nature of this conference, (2) foot or leg imbalance ; 83 , 84 and (3) postural one other postural factor deserves special attention: 85 86 87 88 awareness. • • • However, the greatest atten­ that is, the effectiveness of chiropractic adjust ­ tion has been devoted to the use of exercise as a ments on changing spinal conformation and modifier of posture. balance. That chiropractic adjustments were Stew art 89 described dynamic postural exercises capable of effecting structural changes of the spine designed to appea l to the playful nature of children . has been demonstrated by comparing spinal X-ray s 90 Haller and Gurewitsch have developed postural taken befor e and followin g chiropractic care. 1 • 97 , exercises based on primitive motion patterns. 9s, 99 Refer to figure s 5 and 6. Individualized exercise programs with frequent In addition , from X-r ay mea surements taken on testing have been described by Kraus and Weber. 91 "normalized " (cor rected) spines , Toftness 99 estab­ Other prescriptive postura l exercises have been lished norm al ranges for spinal shape and balance. elaborated by Kendall and Kend all !'2 and Thus , there is objective evidence to support the Phea sant.93 An exercise to reduce lumbar lordo sis value of chiropractic adju 'stments as an effective for eliminating back ache was described by Lank- modifier of posture.

Fig. 5. Male patient , age 41. Suffered low back pain and Fig. 6. Male patient. age 5 1. Medically diagnosed herniat ed sciati ca. Left : A-P spinal X-ray before chiropra ctic adju stment s. disc between 5L and sac rum. Left: A-P sp inal X-ra y before Right: Similar X-ray view taken after 2 month s chiroprac tic chiropractic adju stment s. Right: Similar X-ra y view taken after ca re. Patient returned to work I month after startin g adju st­ 2 'h month s of chirop ract ic ca re. Pati ent returned to farmin g ment s. (Co urtesy Dr. I. N. Toftne ss, C umberl and, Wisc.) · job. (Courte sy Dr. I. N. Toft ness . C um ber land , Wis.) 260 SUMMARY AND CONCLUSIONS medicine. A preliminary study." J. Am. Podiatry Assoc., 63(4), 119-28, April 1973. l t was the purpose of this paper to determine how 10. Edeiken, J., Wallace, J. D., Curley, R. F., and Lee, S. thermography and postural analysis have been and "Thermography and the herniated disc." Am. J. Roellt­ may be used in structural diagnosis. Although ,.:enol., 102, 790- 796, 1968. currently being used for diagnosing a variety of 11. Heinz, R. E., Goldberg, H. I., Taveras, J. M. "Experiences with thermography in neurologic patients." Ann. N. Y. conditions and diseases, thermographic techniques Acad. Sci., 121, 177-189, Oct. 9, 1964. may prove to be of great value for investigating 12. Albert, S. M., Glickman, M., and Kallish, M. Thermography the relationship between structural malposition and in orthopedics. Ann. N.Y. Acad. Sci., 121, 157-170, neuronal dysfunction. Oct. 9, 1964. Posture was discussed with respect to definition, 13. Goldberg, H. I., Heinz, E. R., and Taveras,.!. M. Thermog­ methods of assessment, relationship to health and raphy in neurological patients. Acta. Radio/. DiaR"·· 5, 786-795, 1966. disease, and modification. Considerable evidence 14. Marinacci, A. A. Thermography in the detection of non­ was found to suggest that many symptoms, condi­ neurological imitators of peripheral nerve complexes. tions, and diseases are associated with faulty Bull. Los A11Reles Neural. Soc., 30(1), 1-11, March 1965. posture. Factors thought to be involved in postural 15. Abernathy, M. R., Ronan, J. A., and Winsor, D. T. Diag­ nosis of coarctation of the aorta by inf rared thermogra­ modification included: Exercise; education; proper phy. Am. Heart}., 82(6), 731-41, December 1971. structural balance of the spine, legs, and feet; 16. Duensing, F., Becker, P .. and Rittmeyer, K. Thermographic proper support of the body while sitting or re­ findings in lumbar disk protrusions. Arch. Psychiatr. clining; good nutrition; and adequate rest. Studies Nervenkr., 217(1), 53-70, 1973. dealing with these modifiers of posture were 17. Lebkowski, J., Polocki, B., Borucki, Z., Dudek, H., discussed, including the value of chiropractic Szpakovicz, P., and Tomczyk, H. Determination of the level of prolapsed intervertebral disk in ischalgia by adjustments in normalizing the spine. However, means of an electric thermometer. Pol. Tyg. Lek., 28(24), the need for further research was made evident by 907-908, 1973. the paucity of controlled longitudinal studies in­ 18. Hill, A. V. Thermodynamics of muscle. Nature, 167(4245). volving all of the aforementioned factors that may 377-380, I 95 l. affect posture. 19. Cooper, T., Randall, W. C., and Hertzman, A. B. Vascular convection of heat from active muscle to overlying skin. REFERENCES J. Appl. Physiol., 14, 207-211, 1959. 20. Cranston, W. I. Temperature regulation. Br. Med. J., 5505, 1. Palmer, B. J. Precise posture-constant spinograph compara­ 69-75, 1966. tive graphs (Vol. XX), Davenport, Palmer School of 21. Roberts, T. D. M. Temperature control in fever. Lancet, Chiropractic Press, 1938. 2, 1015-1018, 1970. 2. DuBois, E. F. The mechanisms of heat loss and temperature 22. Benzinger, T. H. Heat regulation: homeostasis of central regulation. Lane Medical Lectures, Stanford, California, temperature in man. Physiol. Rev., 49(4), 67 I- 759, Stanford University Press, 193 7. October 1969. 3. Hardy,J. D.,Soderstrom,G. F. "Heat loss from nude body 23. Pickering, G. W. The vasomotor regulation of heat loss and peripheral blood flow at temperatures of 22C to from the human skin in relation to external temperature. 35C." J. Nutr., 16, 493-510, November 1938. Heart, 16, 115-135,July 1932. 4. Hardy, D. "Radiation of heat from human body." J. Clin. 24. Lewis, T., and Pickering, G. W. Vasodilatation in the Invest., 13, 593-604, July 1934. limbs in response to warming: with evidence for sympa­ 5. Hardy, J. D.; Muschenheim, C. "Radiation of heat from thetic vasodilator nerves in man. Heart, 16, 33-51, human body; emission reflection and transmission of October I 931. infrared radiation by human skin." J. C/in. Invest., 13, 25. Hemingway, A., and Price, W. M. The autonomic nervous 817 -3 l , 1934. system and regulation of body temperature. Anesthesi­ 6. Lawson, R. N. "A new tool in the investigation of breast ology, 29(4), 693- 70 I, 1968. lesions." Canadian Services Medical Journal, 13, 517, 26. Barbour, H. G. Heat-regulating mechanism of body. 1957. Physiol. Rev., l, 295-326, 1921. 7. Karpman, H. L., Knebel, A., Semel, C. J., and Cooper, J. 27. Uprus, V., Gaylor, .I. B., Williams, D. J., and Carmichael, "Clinical studies in thermography, 11. Application of E. A. Yasodilation and vasoconstriction in response to thermography in evaluating musculoligarpentous injuries warming and cooling the body; study in patients with of the spine-a preliminary report." Arch. Environ. hemiplegia. Brain, 58, 448-455, 1935. Health, 20, 412-417, 1970. 28. Winsor, T., and Bendez.u, J. Thermography and the periph­ 8. Connell, J. F., Jr., Morgan, E., Rousselot, L. M. "Thermog­ eral circulation. Ann. N.Y. Acad. Sci., 121, 135-156, raphy in trauma." Ann. N.Y. Acad. Sci., 121, 171-176, Oct. 9, I 964. Oct. 9, 1964. 29. Lippmann, H. I., Winsor, T., and Hume, M. Medical 9. Tai, P. L. "An investigation of clinical applications of instrumentation in peripheral vascular disease; peripheral mesomorphic cholesteric liquid crystals in podiatric vascular disease study group sub-committee on peripheral 261 vascular disease instrumentation. Circulation, XL V, portion of the psoas muscle. Acta Orthop. Scand., 37, A-285-A-291, January 1972. 177-190, 1966. 30. Normell, L. A., and Melander, 0. Thermographic method 50. Klausen, K., and Rasmussen, B. On the location of the for application in clinical neurology. Acta Neurol. Scand. line of gravity in relation to L5 in standing. Acta Physiol. (Suppl),51,471-472, 1972. Sca11d., 72, 45-52, January-February, I 968. 31. Winsor, T. Vascular aspects of thermography. J. Cardio­ 51. Fitz, G. W. A Simple method of measuring and graphically vasc. Surg., 12(5), 379-88, 1971. plotting spinal curvature and other assymmetries by 32. Boas, N. F. Thermography in rheumatoid arthritis. Ann. means of a new direct-reading scoliometer. America11 N.Y. A cad. Sci., 12 I, 223-234, Oct. 9, I 964. Physical Education Review, 11, 18-23, 1906. 33. Agarwal, A. , Lloyd, K. N., Dovey, P. Thermography of 52. Johnston, L. C. Biogravitational Adaptation, Theory the spine and sacro-iliac joints in spondylitis. Rheuma­ Measurement and Interpretation. Toronto, Canada: tology and Physical Medicine, X(7), 349-355, 1967. Posture Research Foundation, I 900 Bayview Ave., 1972. 34. Huskisson, E. C., Berry, H., Browett, J. P., and Balme, 53. Vilholm, F. Statistical evaluation of posture in I 000 H. W. Measurement of inflammation. II. Comparison of schoolchildren. Annals of the Swiss Chiropractors' technetium clearance and thermography with standard Association, 5, 55-79, 1971. methods in a clinical trial. Ann. Rheum. Dis., 32(2), 54. Takasaki, H. Moire topography. Applied Optics, 9(6), 99-102, 1973. 1467-1472, June I 970. 35. Viitanen, S. M., and Laaksonen, A. L. Thermography in 55. Terada, H., and Kanazawa, E. The position of euryon on juvenile rheumatoid arthritis. Acta. Rheum. Scand. 16, the human skull analyzed three-dimensionally by moire 91-98, 1970. contourography. J. of Anthropological Society of Nippon, 36. Massey, W. W. A critical study of objective methods for 82(1), 10-19, March 1974. measuring anterior posterior posture with a simplified 56. Hansson, K. G. Body mechanics and posture. J.A.M.A., technique. Research Quarterly, 14( I), 3-2 I, 1943. 128, 947-953, July 28, 1945. 37. Reynolds, E., and Lovett, R. W. A method of determining 57. Keeve, J. P. Fitness, posture and other selected school the position of the center of gravity in its relation to certain health myths. J. of School Health, 37, 8-15, January bony landmarks in the erect position. Am. J. Physiol., 1967, 24, 286-293, 1909. 58. Hallock, H. The school child's posture. Public Health 38. Cureton, T. K., Jr.. and Wickens, J. S. The center of grav­ Nursing, 32, 533-538, September 1940. ity of the human body in the antero-posterior plane and 59. Kuhns, J. G. Diseases of posture. C/i11. Orthop., 25, its relation to posture, physical fitness, and athletic 64- 71, 1962. ability. Research Quarterly, 6, 93- I 05. 1935. 60. Thompson,J. Knox. Theerectposture.La11cet, 1,107-109, 39. Jenness, M. E., Speijers, F. H., and Silverstein, H. T. Jan. 14, 1922. Use of the conformateur and line of gravity apparatus in 61. Garner, J. R. Posture and fatigue. lnternatio11al Journal of a new technique for assessing posture. The Di~est of Medici11eand Surgery, 45, 27-28,January 1932. Chiropractic Economics, 17(3), 14-18, November­ 62. Dickson, F. D. The effect of posture on the health of the December, 1974. child. J.A.M.A .. 77, 760-764, September 1921. 40. Fradd, N. W. A new method of recording posture. J. Bone 63. Cochrane, W. A. The importance of physique and correct Joi11tSurg., 5, 757-758, October 1923. posture in relation to the art of medicine. Brit. Med. 41. MacEwan, C. G., Powell, E. and Howe, E. C. An objective Jour., 1, 3 I 0-313, February 1924. method of grading posture. The Physiotherapy Review, 64. Canter, B. M. The value of proper body mechanics. /nter­ 15(5), 167-173, September-October, 1935. natio11alJournal of Medicine and Surgery, 45, 134-135, 42. Hellebrandt, F. A., and Braun, G. L. The influence of sex March 1932. and age on the postural sway of man. Am. J. Phys. A11- 65. Canter, B. M. Importance of posture in health. M. J. & thropol., 24, 347-360, January-March, 1939. Rec., 137, 483-484, June I 933. 43. Thomas, D. P., and Whitney, R. J. Postural movements 66. Forrester-Brown, M. Posture and its relation to health. during normal standing in man. J. Anal., 93, 524-39, J. Royal San. Inst., 55, 429-435, February 1935. October 1959. 67. Mattison, N. D. A new estimate of sleep quality. M. Rec., 148, 133-134, August 1938. 44. Stevens, D. L., and Tomlinson, G. E. Measurement of 68. Brown, L. T. A combined medical and postural examina­ human postural sway. Proc. R. Soc. Med., 64, 653-5, tion of 746 young adults. Am. J. Orth. Surg., 15, 774-787, February I 97 I. November 1917. 45. Eichkern, G. C., and Skaggs, E. B. Some studies in body 69. Fox, M. G. The relationship of abdominal strength to sway. Papers of Michigan Academy of Science Arts selected posture faults. Research Quarterly, 22, 141-144, and Letters, IO, 369-379, 1929. May 1951. 46. Sheldon, J. H. The effect of age on the control of sway. 70. Moriarty, M. J., and Irwin, L. W. A study of the relation­ Geront. Clin., 5, 129-138, I 963. ship of certain physical and emotional factors to habitual 47. Joseph, J., and Nightingale, A. Electromyography of poor posture among school children. Research Quarterly, muscles of posture: leg muscles in males. J. Physiol., 23, 221-225, May I 952. I 17, 484-491, 1952. 71. Magora, A. Investigation of the relation between low back 48. Floyd, W. F., and Silver, P. H. S. The function of the pain and occupation. Jndustr. Med. Surg., 39, 465-47 I, erectores spinae muscles in certain movements and 1970. postures in man. J. Physiol., 129, 184-203, July 1955. 72. Rowe, M. L. Low back pain in industry. J. Occup. Med., 49. Nachemson, A. Electromyographic studies on the vertebral 11, 161-169, 1969. 262 73. Fahrni, W. H., and Trueman, G. E. Comparative radiologi­ 87. Metheney, E. The balanced posture. Amer. J. Occup. cal study of the spines of a primitive population with Therapy, 2, I 33-144, June I 948. North Americans and Northern Europeans. Bone Joint 88. Barlow, W. Discussion on postural re-education-a critical Surg., 47, 552-555, August I 965. examination of methods (postural deformity). Proceed­ 74. Jones, L. Nerve tension and inflammation. Postgrad. Medi­ ings Royal Soc. of Med., 49, 667-674, September 1956. cine ( Minneapolis), 7, 441-449, June I 950. 89. Stewart, H. E. Principles underlying modernized corrective 75. Shannon, P. W., and Terhune, S. R. The low back problem. exercises. Arch. Phys. Therapy, 19, 103-106, February American Surgeon, 17, 1106-1112, December 1951. 1938. 76. Hagen, D. P. A continuing roentgenographic study of rural 90. Haller, J. S., and Gurewitsch, A. D. An approach to school children over a 15-year period: the lumbosacral dynamic posture based on primitive motion patterns. angle. J. Am. Osteopath. Assoc., 64, 1163-70,July 1965. Arch. Phys. Med., 31, 632-640, October 1950. 77. Wiggins, R. H. Posture in children. Canad. Med. Assoc. 91. Kraus, H., and Eisenmenger-Weber, S. Fundamental J., 24, 820-825, June 1931. considerations of posture exercises: guided by qualitative 78. Brown, W. D. Some unattained objectives in pediatrics. and quantitative measurements and tests. Physiotherapy Texas State .I. of Medicine, 38, 335-38, September 1942. Review, 27, 361-368, November-December I 947. 79. MacNamara, j_ Posture fundamentals. Med. J. Aust .. 2, 92. Kendall, H. 0., and Kendall, F. P. Developing and main­ 592-595, October 1949. taining good posture. Phys. Ther., 48, 319-36, April 80. Howorth, M. 8. Extremities in young children. N. Y. J. 1968. Med., 5 I, 2868-2874, December I 951. 93. Pheasant, H. C. Practical posture building. Clin. Orth., 25,83-91, 1962. 8 I. Henrichon, M. Posture and the school age child. Canad. 94. Lankford, L. L. Postural backache. Amer. J. Orth., 6(7), Nurse, 55, 826-828, September 1959. 150-153,June-July 1964. 82. Garner, J. R. Posture and woman. International J. Med. & 95. Kiernander, 8. Discussion on postural re-education­ Sun:ery, 45, I 95- I 99, April 1932. a critical examination of methods. Proceedings Royal 83. Krynicki, F. X. The chronic low backache. Jndust. Med., Soc. of Med., 49, 667-674, September l 956. 21, 111-114, March 1952. 96. Benes, V., Fiala, L., and Krticka, Z. Prevention of spinal 84. Pepin, W. A., and Kasch, F. W. Induced postural changes abnormalities in school and preschool children. C esk. resulting from orthopedic programming. American Podi­ Pediat .. 16, 932-4, October I 961. atry Assoc. Journal, 50(10), 805-9, October 1960. 97. Logan, H. B. Textbook of LoRan Basic Methods. Chester­ 85. Ewerhardt, F. H. Bodily mechanics. Arch. Physical Thera­ field, Mo.: Logan Basic Chiropractic College, 1950. py, IO, 216-221, May 1929. 98. LBM, Inc. Chiropractic Corrections. Normandy, Mo.: 86. Denniston, H. D. The value of exercise in the control of LBM, Inc., 1961. posture. J. Health Phys. Educ., 9, 556-557, 581, No­ 99. Toftness, l. N. "Re-Searchin1:" the Chiropractic Adjust­ vember 1938. ment. Cumberland, Wis.: I. N. Toftness, D.C., 1961.

263 Discussion: Comments on Subluxation - Pathophysiology and Diagnosis

ROBERT SHAPIRO Chairman, Department of Radiology Hospital of St. Raphael New Haven, Connecticut

Although spinography furnishes an overview definition of "an alteration of the normal dynamics, of various static spinal conditions, e.g. curvatures, anatomical or physiological relationships of con­ it has serious inherent deficiencies. Moreover, the tiguous articular structures." Subluxation is diag­ limited information it provides can be obtained in nosed erroneously all too freely because of the other ways. The limitations of spinography may be inability to make and reproduce accurate measure­ categorized as follows: (1) technical, (2) interpre­ ments from the spinograms and the misinterpre­ tive, and (3) excessive radiation. tation of the normal wide range of motion. 1. Technical. - Good bone detail requires a Atlanto-axial rotary subluxation is an excellent small focal spot and sharp coning. The substantial example of the existing confusion. 6 This diagnosis scatter produced by radiation of a large volume of is often incorrectly made because the spinous tissue is incompatible with optimal resolution. process of C2 is seen off the midline. This finding Because of poor film quality, focal as well as gen­ per se has no significance in the absence of an eralized bone diseases may be overlooked on increased distance of the dens from the anterior spinography. atlantal arch in the lateral projection. The atlanto­ The inability to visualize important anatomical axial joint has convex opposing lateral articular structures on the anteroposterior spinogram is surfaces which are not exactly reciprocal. Hence, also a distinct disadvantage. Structures such as there is a telescoping effect during rotation as the intervertebral foramina, apophyseal joints, pars each lateral atlantal mass slides forward or back­ interarticularis and the sagittal diameter of the bony ward on the corresponding articular surface of spinal canal can only be seen on oblique or lateral C2. As a consequence of the telescoping, the projections. anteroposterior radiographs show relative widening 2. Interpretive. -The great gamut of normal between the articular surfaces on the side of an­ variations facilitates misinterpretation and erro­ terior gliding and relative narrowing on the side neous diagnosis in the anteroposterior projection - of posterior gliding. This is demonstrable on e.g. asymmetry of the articular facets at the same anteroposterior tomograms which are often misin­ or different levels, asymmetry of the dens and terpreted because the two lateral masses are not lateral masses of the atlas, variations in the shape in the same plane. of the pedicles, spurious unilateral compression of Pseudosubluxation. - Because the ligaments in a cervical articular process, 7 spurious vertebral infants and children (up to age 10-12 years) are malalignment (subluxation). laxer than in adults, the range of motion in the Subluxation. -Subluxation should be a definite former is greater. Thus, the body of C2 may project objective finding that any trained observer can see several millimeters anterior to C3 in forward and measure. Hence, I prefer to define subluxation flexion of the neck in children. This should not as a partial disruption of the normal articular be misinterpreted as a dislocation since it dis­ alignment instead of the all-inclusive chiropractic appears in the neutral position or in extension. In 265

597-036 0 - 76 - 18 adults, the apex of maximal cervical motion shifts In his measurements with the full spine technique caudad to C5-C6 (sometimes C4-C5). he used high speed screens for the caudal three­ In my experience, vertebral subluxation in the fifths of the cassette. On the other hand, he used normal spine is rare. The popular chiropractic par speed screens in the regional technique. Had practice of diagnosing subluxation on the basis high speed screens also been used for the regional of spinography is inexcusable and should be technique, the radiation dosage to the gonads abandoned. would have been significantly less than in the full There is the additional difficulty of correlating spine technique. 2 various pathologic findings on the roentgenogram In practice, we are all guilty of a somewhat with the patient's clinical problem. McCrae 4 has cavalier attitude toward radiographic examina­ shown that disc protrusions occur in all areas of tion of the spine in females in the child-bearing the spine in almost everyone over 40 years of age. age. Perhaps, we should be asking ourselves Similarly, Pallis, Jones and Spillane 5 reported the whether we would be ordering the examination presence of cervical spondylosis in 50 percent of if the patient were known to be pregnant. non-neurological hospitalized patients over the age of 50 years. It is important, therefore, not to REFERENCES attribute etiologic significance to such findings I. Howe, .I. W. The Role of X-Ray Findings in Structural Diag­ unless there is good neurological segmental nosis. Presented at NINOS Conf. on Spinal Manipulation, correlation. February 4, I 975. 3. Excessive radiation. - l cannot agree with 2. Kennelly, E.: Unpublished data Howe's statement that "good quality radiographs 3. Levine, J. l., Howe, J. W., and Rolofson, J. W. Radiation Exposure to a Phantom Patient During Simulated Chiro­ using full spine technique do not cause higher practic Spinal Radiography. Radio/. Health Data and Re­ organ doses than those produced by well-col­ ports 12 :245-25 I, May I 97 I. limated radiographs of the several spine regions." 4. McCrae, D. L. Asymptomatic lntervertebral Disc Pro­ In the first place, the quality of the radiographs trusions. Acta Radio/. 46 :9-27, I 956. is not comparable. Films produced by the regional 5. Pallis, C., Jones, A. M. and Spillane, J. D. Cervical Spondy­ losis: Incidence and Implications. Brain 77:274-289, technique with sharp collimation are far superior 1954. in quality to spinographic films for reasons previ­ 6. Shapiro, R., Youngberg, A. S. and Rothman, S. L. G.: The ously mentioned. If roentgenograms of the spine Differential Diagnosis of Traumatic Lesions of the Occi­ are indicated, they should be of the best quality. pito-Atlanto-Axial Segment. Rad. Clin. N. Am. 11 :505- Secondly, although Howe states that the radia­ 526, 1974. 7. Vines, F. S. The Significance of "Occult" Fractures of the tion delivered to the gonads in both techniques is Cervical Spine. Am. J. Roentgenol., Rad. Ther. and Nucl. comparable, the data he presents are misleading. 3 Med. 107:493-504, 1969.

266 Chairman's Summary: What Do the Clinical Sciences Tell Us About Manipulative Therapy?

HENRY G. WEST, JR. Pocatello. Idaho

It is acknowledged that manipulative therapy has problems than those without problems. Also, the been utilized universally since antiquity for the presence of abnormality does not mean that the treatment and relief of back pain. Back pain is patient is suffering from back pain. "To date," one of the most common complaints met in prac­ he added. "no conclusive studies have been done tice. It has been stated that back pain affects to determine whether those asymptomatic persons probably 80 percent of the members of the human with subluxations are more likely to suffer from race at some time in their lives. Some have as­ back pain in the future. Also, no research has been cribed their symptoms to mechanical malfunction, done to determine the relationship of spinal sub­ while others may blame the symptoms on psycho­ luxation to symptoms other than back pain." somatic disorders. The symptoms, therefore, lend Dr. Joseph Howe stated that "x-ray examina­ themselves to evaluation and treatment if the tions are widely used by physicians engaged in normal mechanisms are known and deviations manipulative therapy for the detection of under­ from normal are recognized. lying pathology in order to have some understanding Dr. Augustus A. White stated "that many symp­ of the structure which he is going to manipulate toms described by patients suffering from back knowing that structure governs function." Accord­ pain are also found in well established psycho­ ing to Dr. Robert Shapiro, one cannot make a somatic types of disease - that the natural course diagnosis of a vertebral subluxation from a single of pain will go away with no assistance in about radiograph. He also stated that he was "absolutely 99 percent of the cases. Differentiation between convinced that a diagnosis of disc disease cannot natural pain and psychosomatic disease calls for be made from a plain radiograph in the presence careful clinical trials." of the normal intervertebral disc space, regardless Dr. Alf N achemson stated "that epidemiological of the orientation of the pedicles and articular studies show that many people with subluxations pilars, because of great individual variability." do not have pain. He added that additional studies He also pleaded for appreciation of the wide gamut have demonstrated that patients with 2, 3, and even of normalcy. Both Dr. Howe and Dr. Shapiro 5 cm. of leg length discrepancies that can not be agreed that multiple films in various postures are corrected have not suffered· any more back pain necessary before one ventures a diagnosis of an than people with equal leg length." abnormal relationship between two vertebra. Dr. Peter Tilley suggested that further studies on Dr. Peter Tilley added that the question of sacral base unleveling on the erect lumbar spine subluxation or identification of the osteopathic would be productive in resolving the statements lesion is not one which has been productive in about comparative leg length. terms of radiographic criteria. Radiographic exami­ Dr. Scott Haldeman presented a table that nation has not adequately defined the osteopathic demonstrated a higher incidence of spinal abnor­ lesion nor given sufficient corrobroation with malities and subluxations in patients with back postural factors or anomalies, which is an indication 267 that the compensatory mechanisms which the is little understanding about how that pain is caused human body possesses are extremely effective. or transmitted. He added that, in the field of Therefore, our attention is drawn to the soft tissue. manipulative therapy. we cannot cast aside clinical Dr. Martin E. Jenness said .. the lack of quanti­ experience, clinical reporting and clinical observa­ fication of a thermographic picture at the present tion as being merely anecdotal. time has limited the use of thermography as a Dr. John Mennell repeatedly emphasized the universally employed diagnostic tool for physicians importance of manipulation for the extremities as utilizing manipulative therapy. well as the spine. The best summarization for the Much discussion centered around palpation as a discussion was given by Dr. Robert Maigne, "if a diagnostic tool and whether it could be sufficiently patient is in pain and is treated with manipulative quantified with reliable interpretation by more therapy and he has no more pain. what has hap­ than one examiner. Dr. Andries Kleynhans quoted pened? Why?" references that pathological changes do take place The purpose of this workshop was not to prove in soft tissue as a result of disturbances of local or disprove chiropractic, osteopathy or spinal homeostasis such as edema, fibrotic infiltration. manipulative therapy (SMT), but rather to estab­ waxy degeneration. increase in cell nuclei of muscle lish what is known and what is not known about fibers, all contributing to a palpable change- that manipulation, and to suggest areas for further re­ a trained physician can palpate and interpret this search. We can summarize by saying that the tissue change compared to normal tissue. Dis­ exact nature of the lesion which responds to cussion also centered around the ambiguities of the manipulation has never been fully established and role of poor posture and its effect upon health that exactly what is accomplished by manipulation problems. This would appear to be another area of no one has fully explained. The fact that manipu­ research. lation relieves patients is self evident. The follow­ Concepts, theory, philosophy and terminology ing areas of research were suggested during the came into discussion. Terminology has been a discussion period: major source of controversy which has hindered I. What is the nature of the lesion that responds interprofessional discussions. This workshop will to manipulative therapy? probably contribute to alleviating this major 2. What is actually accomplished by manipula­ problem. tion in the terms of anatomical, pathological, Dr. Irvin M. Korr summarized the apparent and physiological changes? differences in philosophy: that chiropractic appears 3. Epidemiological studies of biomechanical back to be concerned with structural and anatomical pain. approach, whereas osteopathy is more concerned 4. Sacral base unleveling and its symptomatic with the interplay of the inputs and outputs via the effect on an erect lumbar spine. central nervous system. 5. Epidemiological studies of patients with symp­ Dr. George Northup adroitly stated that "one toms (e.g. pain) and "normal spines" as com­ of the causes of confusion is that we are not pared to patients with symptoms and "ab­ talking about a single type of lesion, but about a normal spines." variety of lesions with influence on a variety of 6. The relationship of spinal subluxations to mechanisms. Perhaps there is too much emphasis symptoms other than back pain and the role on static mechanisms rather than on dynamic of spinal subluxation in the pathophysiology aberrations of function. He added that there are of visceral disorders. many changing concepts in medicine and in the 7. Biomechanical dynamics of a normal spine. theorization of manipulation and the various 8. Quantification of thermography for structural musculoskeletal lesions that are treated. Manipula­ diagnosis. tive practitioners are faulted for their theories on 9. The effects of abnormal posture on problems manipulation on the premise that we do not know of health. the exact mechanism which is observed clinically 10. Quantification of disturbances of local in the musculoskeletal system. Yet there were six homeostasis. or seven different theories of pain for which there 11. Quantification of palpation for diagnosis. 268 Chapter VI.

What Do The Clinical Sciences Tell Us About Manipulative Therapy? (Thero peutic Studies)

Andrew B. Wymore, Chairman Treatment of Pain by Manipulation

JAMES CYRIAX St. Thomas's Hospital London

So many concepts have been put forward during Here then lies the point where physicians and the last 2 days that I feel I must start by clearing nonmedical manipulators meet. The former main­ the air before putting forward a unifying concept. tain that any theory involving bony subluxations I do not believe that any minor subluxation of a is faulty- correct. The latter maintain that manipu­ lumbar vertebra causes any symptoms at all. This lation stops the pain by correcting a displacement­ view has been confirmed by many radiographic correct again. But the subluxation is of ·a small studies in thousands of people with and without fragment of radio-translucent tissue -cartilage. I backache. They show no difference. hope that this concept will prove acceptable to I do not believe that manipulation has any effect both parties, and enable them to come together (other than momentary) on the position of one at last. vertebra on another. Any lasting alteration results Vertebral manipulation has lain under a cloud from shift of a displaced intra-articular fragment of all this century. Understandably so; for most disc. Normal movement returns when its correct medical men do not manipulate the spinal joints position is restored, whether by the passage of time, at all. By contrast, nonmedical manipulators rest in bed, manipulation, traction. or laminectomy. manipulate nearly all comers. Both these policies I do not believe that disc degeneration causes are mistaken and smack of bigotry. The proper symptoms. We all know that lumbar symptoms attitude lies midway between the two extremes. come and go, yet it is not conceivable that disc Manipulation of the spine is important to physi­ narrowing can cease, nor that an osteophyte gets cians for three reasons: smaller. Statistics from everywhere inform us that 1. It is the only method of treatment required backache is commonest at the age group 40-50, in his daily work that he was taught nothing declines slightly by the age of 60, but has fallen of as a student. by two-thirds by 70. Were backache caused by 2. The lesions that respond, though restricted degeneration of the disc or the facet joint. the in number, occur very commonly and provide frequency of backache would increase as age ad­ the most frequent reason for a fit man being vanced. Again, we have all met with the old man off work. who has lost several inches in height and has no 3. Every time a patient, relievable by spinal disc spaces at all at any lumbar level, with conse­ manipulation, visits his doctor and this is not quent gross incongruence of the facets and their done, a gratuitous advertisement is afforded fixation in the position of full extension; yet he has to nonmedical manipulators. We all know that no backache. some of these men claim to cure disorders If a patient's pain is elicited by a lumbar move­ that no manipulation could possibly affect, ment, it must arise from a joint. Since most lumbar but this justified scepticism should not blind pain starts centrally, this must be the central inter­ us to the fact that some of their patients are vertebral joint. Lumbar pain, in my view, results greatly benefited. It behooves medical doc­ from a minor displacement of a fragment of disc; tors to study not their failures. but their it does not matter if the fragment comes from a successes. We must avoid such patients having thick or a thin disc, supported or not by osteophytes. to look beyond the medical profession for 271 relief either by manipulating them ourselves, tivity to pain must all be taken into account. In or (as has been my policy for the last 30 years) th<; lumbar region, my experience is that two-thirds handing them over to physiotherapists, trained of all cases of backache, but only one-third of all in spinal manipulation. sciaticas, prove reducible. Reduction of a fracture or of a dislocation is PURPOSES OF MANIPULATION ascertainable objectively. By contrast, at a spinal Manipulation of joints has three purposes. (No joint, it is a subjective event. It is only with the mention will be made of reduction of fractures, patient's cooperation that the operator can tell dislocations, hernias, etc., since no controversy when all the spinal movements have become free, exists there.) or straight-leg raising has become painless at full l. To break adhesions. Minor adherent scars range. The patient is examined immediately before may form when a sprained ligament unites, re­ the session starts and after each maneuver. The stricting its mobility. They can be ruptured by immediate result is ascertained: also, which measure a sharp jerk in the direction of the limitation. Major has the best effect. All this knowledge is denied to adhesions severely restrict movement at the joint the manipulator under anesthesia, who cannot even after, say, immobilization in plaster after fracture. tell if he is making the patient better or worse, let These require rupture by a strong stretch under alone when to go on and when to stop. Since so anesthesia. much spinal manipulation is carried out in Britain 2. To stretch out a contracture. Both congenital either under anesthesia or by untrained persons, it and acquired contractures need elongation by occasions little surprise that many medical men gradual increasing .sustained pressure. Congenital regard it as dangerous or useless. torticollis and talipes equinovarus are obvious CERVICAL DISC LESIONS examples: arthritis at shoulder and hip represent acquired capsular contracture. These present themselves in five different ways 3. To reduce an intra-articular displacement. and, to add to the confusion, have been given names Here lies the main object but, curiously enough, that distract attention from the actual lesion. also the most controversial aspect of manipulation. Clinical Examination In general, a physician's first thought when a dis­ This has five purposes. The function is assessed placement is found present is the feasibility of of: reduction. In fracture, dislocation, hernia, or breech 1. The joints. The partial articular pattern presentation or indeed a subluxated meniscus at indicates internal derangement. Of the six move­ the knee or jaw joint, the advisability is considered ments, two, three, or four hurt; four, three, or two at once. But manipulative reduction appears do not. Moreover, the pain is usually unilater~l. scarcely to figure in medical thought when a frag­ 2. The cervical muscles. Movement, attempted ment of disc is found out of position at an inter­ against suc·h resistance that none of the joints move, vertebral joint. Before 1929 ,1 when Dandy first discloses the state of each muscle group in turn. ascribed sciatica to a disc-protrusion, the disorder 3. The cervical nerve roots. Monoradicular was regarded as "sciatic neuritis" for which manip­ palsy indicates a disc protrusion. Neuralgic amyo­ ulation would have been absurd. Until 1945 ,:2 trophy, neuroma, secondary neoplasm, neuritis, when I put forward the concept of a postero-central and pulmonary sulcus tumor each set up weak­ displacement of a fragment of disc as the cause of nesses in wholly different patterns. lumbago, this had been regarded as the result of 4. The spinal cord. Whether the pyramidal spontaneous inflammation of muscle, which deficit is caused by a disc protrusion or not, ob­ manipulation could only aggravate. Now, however, jective signs of spinal cord involvement wholly when the pathological concepts that we advanced contraindicate manipulation. have been accepted everywhere, reason surely 5. The upper liinb. This may well contain a demands logical treatment based on this mechanical separate lesion causing pain in the arm. etiology. By no means will all disc lesions respond to Radiography manipulatio·n. Suitability is based on the size, dura­ None of this vital information is obtainable by tion, position, and consistency of ttie displacement. inspection of radiographs. A displaced fragment of Moreover, the patient's age, occupation, and sensi- disc within an osteoarthrotic joint is often just as 272 reducible by manipulation as one in a radiographi­ physicians must be on the lookout for such cases, cally normal joint. Every time a medical physician for they strengthen the assiduously fostered idea pays excessive attention to a few harmless osteo­ that manipulation by nonmedical men cures phytes, he is creating one more opportunity for visceral disease. nonmedical manipulators to score. The only reliable Manipulation during traction is simple and basis for a decision on whether to manipulate or usually completely successful in one or two ses­ not rests on careful and informed evaluation of sions. The distraction relieves pain, thus enabling clinical data. By contrast, normal radiographic the patient to relax: it doubles the width of the joint 3 appearances must not be allowed to lull the (1954 ), thus giving the fragment room to move. manipulator into a false sense of security: since It also exerts centripetal force on the displacement chordoma, myeloma, neuroma, and early secondary both by suction and by tautening the posterior neoplasm do not show up at first. longitudinal ligament. Manual traction can be used early in cases with basilar ischaemia (but not Clinical Types of Disc Lesions during anticoagulant the~apy). l. A cute torticol/is. This is the analog at a Nonmedical manipulators inexplicably avoid cervical joint of lumbago. The young patient wakes adequate traction: in fact they squeeze the verte­ with his neck fixed in a posture of gross deformity. brae together. Na tu rally, such compression mili­ Marked limitation of one rotation and one side­ tates against a successful result, and this type of flexion movement is present. "adjustment" (locking the facets) may require Reduction is secured in patients under 30 by many sessions or may fail altogether. Also, judging manipulating during strong traction only in the by the literature it tends to be clangerous. direction of full range. When this measure has 3. "Brachia/ neuritis." There are many reasons secured as much improvement as possible, the for pain and paraesthesia in the upper limb, but patient lies down and his head is pushed over more the common cause is a disc protrusion compressing and more in the direction of limited range. It may a cervical nerve root: if so, the lesion is neither weir be 1 or 2 hours before full range is restored brachia] nor a neuritis. by this means. In patients over 30, manipulation If no root palsy is present when the upper limb during traction, first in painless direction, then in is examined and the spinal cord conducts normally, the painful, suffices. reduction is often still possible provided that 2'. "Scapular fibrositis." This is the unfortunate unilateral radiation to the arm has lasted less than name that has been given to cervical disc lesions 2 months. If a root palsy has supervened and causing, as they usually do, pain felt in the muscles muscle weakness is apparent, manipulation always about the scapula. The lesion is neither scapular fails and spontaneous recovery from pain (3 to nor is it caused by inflammation of fibrous tissue. 4 months since the brachia I pain, not the scapular Clinical examination shows that the passive, pain, started), and from the muscle paresis (6 to 8 but not the resisted movements of the cervical months) must be awaited. Manipulation is also apt spine bring on the pain, thus showing its cervical to fail when one or more of the neck movements articular origin, and that the resisted movements provoke the pain down the upper limb, and when of the scapula are neither weak nor painful~ thus the symptoms appear in the reverse of the usual exculpating the structures about the scapula. In order, i.e. paraesthesia in the hand, then aching other words, positive signs at a joint of the neck are in the limb, then scapular pain. corroborated by negative signs from the circum­ In Britain a very annoying situation exists. In scapular tissues. cervical root compression, the pain in the scapula Medical physicians are accustomed to cervical and arm goes on getting worse for 2 to 3 weeks. lesions causing scapular pain and accept this extra­ During this time, the patient's physician pre­ segmental reference. But reference to the pectoral scribes him ever stronger analgesics. By the third area is rare. When it does occur diagnoses like or fourth week the pain is at its worst, and lack of pseudoangina may be reached. When now a non­ progress leads to reference to hospital. There medical manipulator manipulates the neck and examination reveals the root palsy, confirmed by relieves this symptom, both he and the patient electromyography. Physiotherapy, traction or a may well imagine that the manipulation has•cured collar are employed, all in vain. At the end of 2 some obscure form of heart disease. Medical months, just when the symptoms are about to 273 wane. the despairing patient takes himself off to a frontal headache every day on waking. At first it nonmedical manipulator. Since his treatment starts has eased by midday, later by the afternoon: it at the same moment as spontaneous subsidence of never lasts all day. At his age. some elevation of the pain, manipulation twice a week for, say, 6 blood pressure may be found present. The head­ weeks coincides in time with the advent of spon­ ache attributed to that, the more so since the radio­ taneous recovery. Again, both the nonmedical graphs of the upper neck show no more osteo­ manipulator and the patient mistakenly ascribe phytosis that anyone that age often has. One recovery to the manipulations. session of manipulation of the neck during traction 4. A croparaesthesia. Bilateral root pressure nearly always affords full relief lasting at least a may set up pins and needles in both hands together couple of years. The nonmedical manipulator may with a vague aching in the upper limbs. (Differ­ cure this type of headache. If so. again both he entiation between the thoracic outlet syndrome and and the patient understandably, but mistakenly. a bilateral carpal tunnel syndrome may present take for granted that high blood pressure has been difficulty.) relieved. This not uncommon misdiagnosis pro­ Manipulation may help. Often the disorder vides nonmedical manipulators with renewed proves intractable, but the symptoms are never ··evidence" that they can cure visceral disease. severe. 5. Posterolateral ~·clerosis. Evidence of pressure THORACIC DISC LESIONS on the spinal cord contraindicates manipulation. These also present under misleading names e.g. Pins and needles in the hands and feet (or-postural fibrositis of chest wall, muscle strain, pleurodynia vertigo indicating basilar ischaemia) are not an (because a deep breath hurts), intercostal neuritis. absolute bar, provided the methods of nonmedical Diagnosis is not difficult if thoracic disc lesions are manipulators are avoided: these are dangerous kept in mind. The influence of posture and exertion and death has resulted. Strong traction without on the pain is elicited in the history and the spinal rotation may succeed and no lasting harm has re­ movements therefore tested. sulted from such measures. If the apex of the spur The difficult cases are those with a primary compressing the spinal cord consists of a fragment postero-lateral onset, the root pain felt in the an­ of cartilage, manipulation during strong traction terior thorax or abdomen coming on without pre­ can still shift it. If the point is osseous, manipula­ vious backache. Exhaustive examination of visceral tion must fail and the prevention of paraplegia due junction naturally reveals no abnormality, and to compression of the anterior spinal artery is such patients are often dismissed as neurotic, or now laminectomy. Prevention of cord pressure is feasible. The alternatively. some vague label such as gastritis or A. T. Still, osteophyte arises in the first place by traction on chronic cholecystitis is applied. the the posterior longitudinal ligament from a postero­ founder of osteopathy, describes how he had pain central bulging of the disc. The periosteum at the in the region of his own heart. which ceased with a· edge of the vertebral body is elevated and bone click during pressure at his mid-thoracic vertebrae. grows to reach its limiting membrane. The propyl­ In this type of case pain exists that the nonmedical axis of an osteophyte increasingly menacing the manipulator can easily abolish: however it is spinal cord is to have carried out manipulative wrongly ascribed to some vague visceral disorder. Obviously, vertebral manipulation relieves not reduction years ago. visceral disease. but those pains actually of spinal HEADACHE origin that have been mistakenly ascribed to a viscus. Neither patient nor non medical manipu­ There is one type of headache that physicians lator realizes that. nor would it suit the latter's often fail to recognize-that arising from the liga­ book if he did have doubts. ments about the occipito-atlantoid and atlanto­ axial joints. These joints are developed within the Examination first and second cervical segments and therefore This comprises eliciting: refer pain along the relevant dermatomes in the l. Articular signs. The partial articular pattern usual way, i.e., to the back of the head (CI) and indicates internal derangement. Some, but not all, the forehead (C2). The patient is an elderly man of the six movements prove painful. (women are almost immune) who describes occipito- 2. Dural signs. Neck flexion and scapular ap- 274 proximation draw the dura upwards and increase Examination the thoracic pain. Four data are sought: 3. Root signs. Though root pain felt as a rule Articular signs. These comprise: I. visible devia­ along the lower costal margin is common, neuro­ tion; 2. limitation of movement in some directions logical deficit is rare and suggests a neuroma rather but not in others. In early disc lesions a painful than a disc lesion. arc, usually on trunk flexion, is often present. 4. Cord signs. If evidence of pyramidal pressure The partial articular pattern indicates internal exists, manipulation is wholly barred; laminectomy derangement. should be considered. Dural signs. Lumbar pain produced by neck Articular signs accompanied by dural signs flexion and bilateral limitation of straight-leg raising clearly indicate a posterior disc displacement, indicate that the mobility of the dura mater is im­ since the dura mater lies behind the joint. Manipu­ paired on stretching from above or below. When, lative reduction during traction is usually very easy. in sciatica, the straight leg is raised as far as possi­ ble, neck flexion causes added root pain, again as the result of pulling on the tense nerve root via the LUMBAR DISC LESIONS dura mater. Nerve root mobility. At the third root, this is Here, too, the situation is obscured by many tested by prone-lying knee flexion. different names for the same disorder- pulled At the fourth and fifth lumbar levels, the mobility muscle, lumbago, sciatica, sacroiliac strain, sprung of the dural sheath of the roots L4 to S2 is assessed back, lumbar or gluteal fibrositis, spinal arthritis, by straight-leg raising. or spondylosis. The same phenomenon as is so Nerve root conduction. Muscle weakness, im­ conspicuous at the neck- extra segmental reference paired reflex, cutaneous analgesia indicate a degree from the dura mater with a secondary localized of protrusion too great for manipulation or traction tender spot within the painful area-occurs also to help. in lumbar disc lesions. Since a postero-central disc protrusion bulges the posterior ligament out Radiography far enough to compress the dura mater, remarkable Choice of treatment in disc lesions rests on what areas· of reference are reported by sufferers from is found when these four essential elements in acute lumbago, e.g .. to one or both groins, to the clinical evaluation are correlated. None of these lower abdomen, up to the lower posterior thorax. findings emerges from inspection of a straight When the referred pain ·overshadows local pain, radiograph nor is appreciable ..help afforded by it is not unknown for a low lumbar disc lesion to positive or negative myelographic appearances. be mistaken for chronic appendicitis, since the Manipulative reduction should form the physi­ way the dura mater refers pain misleadingly is not cian's first approach, and be performed forthwith recognized by most doctors. Clearly, spinal manipu­ unless clinical examination has disclosed a lation may well relieve such a pain in the iliac fossa, contraindication. and the mistaken notion of nonmedical manipula­ tion curing visceral disease is once more CONTRAINDICATIONS TO strengthened. MANIPULATION Detailed diagnosis is most important for it is by no means enough to know that a lumbar disc The contraindications are: lesion is present. The lesion's duration, size, posi­ l. Danger to the fourth sacral root. Any com­ tion, consistency, and stability have all to be corre­ plaint of weakness of bladder or rectum or of lated with the patient's occupation, age, and perineal, testicular or saddle paraesthesia suggests sensitiveness. A small cartilaginous displacement severe stretching of the posterior longitudinal should be reduced by manipulation; a small nuclear ligament. If this should rupture during manipula­ protrusion should be reduced by daily traction. If tion, massive protrusion of the whole disc may the protru'sion is large neither method is applica­ result, leading to severe bilateral sciatica and ble and the desensitization of the nerve root at the damage, possibly permanent, to the innervation of point of impact by the induction of epidural local the bladder. In such cases laminectomy is urgently anasthesia is the treatment of choice. required. 275 2. Hyperacute lumbago. Most cases of lumbago The patient lies on a low couch ( 15 in. high) and respond very well to manipulation. However, in a pressure on his lumbar spine. accompanied by a few cases the patient is so fixed that the slightest jerk, is applied as he lies prone. or rotation of the movement provokes such sharp stabs of pain that pelvis on the thorax is secured while he lies on his the attempt becomes unthinkable. If so, epidural side or supine. Patients who present with much local anesthesia is induced, whereupon the dis­ lumbar deviation do best on the rotational placement impinges against the now-insensitive maneuvers. dura mater and all pain ceases for the time being. The family doctor should be prepared to carry Spontaneous reduction is aided during this period out these maneuvers as soon as the patient attends: of painless mobility if the patient lies prone for as for he sees the case early and thus offers treatment long as the anesthesia lasts. at the most favorable moment. Alternatively. he 3. Pregnancy. During the last month manipula­ should instruct the physiotherapist of his choice tion is impracticable. During the first 4 months, to carry out these measures at once. This insures prone pressures as well as the rotation manipula­ that the patient remains under medical supervision tions are quite safe. throughout, and is treated by trained personnel. I 4. Neurosis. Very nervous patients. or those found this policy welcomed in England, and who, owing to a legal suit pending, have to main­ wherever my graduates have gone, including the tain disablement are not suited to manipulation. U.S.A. and Canada, they have been esteemed by physicians and patients for their skill (Cyriax. MANIPULATION USELESS BUT NOT 1974).5 HARMFUL SUMMARY l. Too large. Reduction is impossible when the In my experience, the only good reason for spinal protrusion is larger than the aperture whereby manipulation between the third cervical and fifth it emerged. Sciatica with a marked lumbar lateral lumbar vertebrae is an endeavor to reduce a dis­ deviation, or signs in the lower limb of impaired placement of a small fragment of disc. This is what conduction at the nerve root (muscle paresis, loss nonmedical manipulators, without realizing it, of reflex, cutapeous analgesia) show that this is have been doing for the past 100 years and have the situation. gained many kudos thereby. Their successes have 2. Too long. When root pain has lasted 6 months led to untenable hypotheses. An attempt is made or more in a patient under 60 years of age, the at­ to substitute a valid anatomical explanation. tempt is almost sure to fail. 3. Too soft. Nuclear protrusions require I to 3 REFERENCES weeks' daily traction for 30 to 45 minutes, at a distracting force of 80 pounds (minimum for a I. Dandy, W. E. Loose cartilage from intervertebral disc simu­ lating tumor of spinal cord. Arch. Surg. 19 ii, 660, 1929. frail woman) to 200 pounds (for a large strong man). 2. Cyriax, J. Lumbago: The Mechanism of Dural Pain. Lancet The treatment is entirely painless ( I 950 4 ). It should ii,427, 1945. never be used for acute lumbago with twinges, 3. Cyriax, J. Textbook of Orthopaedic Medicine, Vol. I, plates which is made much worse. 5 and 6. London: Bailliere, Tindall, 1954. 4. Cyriax, J. Treatment of Lumbar Disc-Lesions, Brit. Med. J. LUMBAR MANIPULATION ii, 1434, 1950. 5. Cyriax, J. Textbook of Orthopaedic Medicine, Vol. II, Manipulative technique is not difficult to master. Eighth edition. London: Bailliere, Tindall, 1974.

276 The Treatment of Pain by Spinal Manipulation

RONALD GITELMAN Canadian Memorial Chiropractic C allege Toronto, Ontario, Canada

Chiropractic is a discipline of the scientific Henderson 18 in 1954 reported on 500 unselected healing arts concerned with the pathogenesis, patients with low back pain. Of the group treated diagnostics, therapeutics and prophylaxis of func­ by manipulation, more than half were relieved or tional disturbances, pathomechanical states, improved. Another group of 20 patients did not pain syndromes and neurophysiological effects improve with physiotherapy or exercise until related to the statics and dynamics of the locomotor after manipulation was instituted. system, especially of the spine and pelvis.* Fisk 13 (1971) treated 327 unselected patients Man has used manipulation as a means of re­ with manipulation and claimed a 90 percent success lieving pain and disability since his beginnings. rate .. Wilson 19 prepared 18 patients with herniated Hippocrates ( 1) described manipulation and "how intervertebral discs with interspinal pantopaque to press down hard on a gibbus of the spine" in and studied the results of manipulation radiograph­ order to relieve pain. ically. Crude rotational manipulations to both the Sir James Pagett [1866] and Dr. Walton P. right and left side of the spine were employed. Hood [ 1871] wrote "Cases That Bone Setters Surprisingly, three patients experienced relief Cure", and "On Bone Setting," respectively. of the back and leg pain for 48-72 hours and only At that time the medical profession looked upon one case had a slight increase in the discal defect. manipulation with disdain, primarily because of Mensor 2 (1955) using manipulation under gen­ the theoretical explanation of its practice. In eral anesthesia reported good to excellent results spite of being scorned or even ostracized by their with 64 percent of 72 private patients and 45 colleagues, many individuals utilized manipulation percent of 13 3 industrial accident cases with lower for the benefit of their patients. The advent of back pain. Many clinicians feel that manipulation osteopathy and chiropractic helped fill the need under anaesthetic is unsafe, due to the patient's for this form of treatment. The fact that both of protective reflexes being abolished. 6 - 8 , 10 , 11 , 14 these disciplines developed outside the medical The first controlled series was conducted by mainstream did little to soften the attitude of Coyer and Curwen 21 (1955). One hundred and traditior .. ' medicine. Even so, many dedicated thirty-six patients were divided into two groups. medical scientists 2 - 16 urged that manipulation The first group of 76 patients was treated by was a valid procedure and should no longer be manipulation and the second group of 60 with set aside. bed rest and analgesics. In the first group 50 per­ Travell 17 in 1946 applied manipulation in over cent were free of signs and symptoms within 1 400 selected low back patients. No deleterious week as compared to 27 percent in the second effects were observed and many cases secured group. At the end of 6 weeks, 12 percent of the immediate relief of pain. first group and 28 percent of the second group were still afflicted. A number of additional studies *Definition of Chiropractic as taught at The Canadian have been conducted by individuals who have Memorial Chiropractic College, Toronto, Ontario, reported excellent results with manipulation, Canada. often after more traditional methods have 277 14 22 2 failed. 11 • 12 • • - H These studies must be viewed technique or the ability of one practioner to deliver slightly more critically. as a man is reporting the it. results of his own work. We must also bear in mind that while manipula­ A more objective report was made by Poul tion is the mainstay of chiropractic treatment it is Bechgaard 27 in a series of 807 patients. Sixty-four usually preceded by soft tissue massage, passive percent received a primary dramatic improvement stretching and mobilization and/or triggerpoint with one treatment. The subjects were referred therapy. Manipulation is not the end of treatment for manipulation by a second individual and then since the practioner must not only reeducate the he evaluated the results. joint's range of movement, restore normal motor An independent research group did an objective tone. and power, but give the patients advice about review 28 of the Workmen's Compensation Board their lifestyle including work habits and leisure time reports of all cases of spinal sprains and strains in activities, in order to restore full function and at­ the State of Florida for the year 1956. Cases tempt to prevent recurrence. The major problem numbering 19 .666 were reviewed by comparing for the scientific community is still an explanation costs and days lost. Under chiropractic care. the as to the mode of action of manipulation and the average total cost was $60 and days lost were 3. scope of its application. Under medical treatment (nonspecialist, nonhos­ The symptom of pain usually indicates tissue pitalization), the average cost was $ I 02 and days threat. It is the end result of a long process (except lost were 9. in the case of acute trauma). It is not merely the 2 The Lance/ !1 in 1974 published a similar study stimulation of receptors that marks the beginning on 300 compensation cases which showed that the of the painful process: that stimulus enters a physician was somewhat less effective than the nervous system which is already a total of past chiropractor in the treatment of the acute low back. experience, trauma, anxiety. cultural factors, et The Palmer College investigation ( 1950) 30 of 1,000 cetera. These higher processes. these past ex­ low back syndromes, and the National College periences, and the state of the nervous system at investigation ( 1970)=11 of I 00 cases with osteogenic the time of stimulus participate in the selection, changes and vertebrogenic pain reported impres­ abstraction and synthesis of the information from sive results. The effectiveness of the treatment the total sensory input. 60 of headache by manipulation is well established To understand the mode of action of manipula­ in the high percentage which are vertebro­ tion we must have a greater appreciation of the genic. 10 , 11 , 27 • :12 - 5:1, 1:16 Research material from the combinations of functional reflexes which are scientific communities of Czechoslovakia and disturbed, and which, under normal circumstances, Germany shows that they are investigating a wide enable the organism to adapt itself to its internal variety of applications for manipulation.~ 4 - 58 For and external environment. While the removal of example. 72 cases of Meniere's syndrome were pain represents the ultimate test of any therapy, studied with excellent results in 53 patients: also the pathophysiological process and its interruption 52 cases of cervicogenic vertigo (Barre and Lieou at any given stage is also a method of understanding syndrome) were studied with excellent results in and establishing its worth. 3 5 of the 5 2 cases treated. :;o The growth and A great deal of attention has been paid to nerve development of osteopathy and chiropractic with root compression syndromes at the intervertebral its tens of thousands of relieved patients, the foramina, but we must bear in mind that these are growing interest of medicine in manipulation with usually the result of a prolonged process and the formation of the International Federation and represent a small percentage of the subluxations the American Academy of Manipulative Medicine which are manipulated in the everyday experience and the fact that this Conference is being held, of the average practioner. These are primarily the are indications that manipulation is effective. I am conditions which we hope to prevent. We do not confident that any fairminded thinker does not know the precise nature of the cause of subluxa­ doubt the fact that manipulation works, however, tions or the neurophysiological mechanisms by I feel that a meaningful research study could be which they exert their influence. We do know that conducted if for no other reason than to convince trauma is a major cause, whether sudden or slight the remaining skeptics. This study, however, must or the result of false or poorly judged movements. be conducted. in such a way as to not only test one Prolonged or repeated postural or occupational 278 stresses result in muscle tensions, postural im­ nucleus pulposis, 86 breakdown of the annulus of 1 94 4 8 9 85 89 balance and contractions of muscles, >1-H:i which the disc, 9• 10, 86•!io- facet capsular swelling, • • • - produce a low-grade type of traumatic inflammation approximation of pedicules, 13• 86 spinal stenosis 86 and have an effect upon the articular and periarticu­ edema within the foramina, perineural adhesions, lar structures and functions of the involved areas. 64 radiculitis, 98 subluxation of the articular proc­ Activity of the muscle itself causes some degree esses,86• 98 and exostosis. 98• 19:i As a result, a com­ of ischemia, 65,66 which can result in pain, 67• 68 pression of the nerve trunk may occur within the probably through the transfer of "P" substance intervertebral foramina even to the point of affect­ across the muscle membrane into the tissue fluid,trn ing neural conduction.7· sH, 03· mi How can we explain which gains access to pain endings. The pain itself the relief of root compression and pain by manipu­ brings about a tonic reflex muscle contraction lation when we know that pressure on a nerve which intensifies the ischemia leading to a vicious causes paresthesiae, not sustained pain. 88, 100, 1°1 cycle. These contractions and their effects upon The x-ray picture of exostosis and disc thinning capsules, tendons, fascia, ligaments and joints remains the same, but the pain is relieved. How produce postural asymmeteries 70 and limitation do we explain Dr. McNab's observation 101 of of movement, 71·77 and the resultant proprioceptive some cases of instant relief of pain with injection bombardment may be the initiating factor of an­ of chymopapain, when we know the enzymic terior horn facilitation. 78, 79 effect of the drug will not immediately reduce a This in turn leads to the further perpetuation of pulpy protrusion and that myelograms show no the muscular contraction by any additional excita­ such immediate change in the defect. Could it be tion into the same or related neural segments. 80·82 that the enzyme had its dramatic effect by changing The resultant stress on the ligamentous capsules the chemistry in such a way as to neutralize pain­ and articular surfaces can lead to local inflamma­ producing polypeptides which stimulate hitherto tion, adhesions and early breakdown of the facet unknown nociceptors in the disc or perhaps articulations. 8:1, 84 These articulations and liga­ destroy them? ments have a rich nerve supply and local and Studies of asymptomatic and symtomatic radiating pain results. 4, 8 , 9, 85·89 spines 102 at autopsy showed there was no signifi­ Limitation of mobility decreases the efficiency cant difference between the two groups. 103Manipu­ of the hydraulic system of the vertebral motor unit lation can break adhesions and free fixations 10, 1Ii, 109 which is so necessary for the integrity of the inter­ of the facets and even in some cases affect the discal vertebral discs and contributes to its break­ contents, 7•93•104 but surely we cannot explain on down,9• 10,86,110•93•84 hence to the production of this mechanical basis alone the more far-reaching hypermotoricity in the same or adjacent segments. neurological effects. 1o, 34.55, 56, 81, 99,105-1 ,rn Subluxations of the apophyseal joints may If there were no other signs and symptoms, the follow. 86,93,95 We believe that a hypermotoricity placebo effects of the immediate environment, the for example, of the fifth lumbar could be due to white coat, and the laying on of hands could account fixation and aberrant movement of the pelvis and/or for much of the relief our patients receive. How­ hip joints with the resultant disturbances of the ever, there are other parameters which we can dynamics of the postural muscles; for example, measure, not only in determining the stage of the the psoas 96 could produce asymmetrical stresses involvement but in monitoring the results of our at the lumbosacral articulations. This is a matter manipulation objectively. Facilitated anterior horn for future research. cells produce changes which can be detected by We begin to see that subluxation is a process the educated palpating finger 10,180,110-113 and by and not a static condition; a state of living tissue electromyography 58• 114-1 18 in the innervated mus­ undergoing constant change. These pathologic cles of that segment. These muscles are in a state changes are as follows: hyperemia, congestion, of increased tone 114• 119·121even under anesthesia. 122 edema, minute hemorrhage, fibrosis, local ischemia, The appropriate manipulation produces palpable atrophy, and eventually rigidity and adhesions improvement in the muscular tenderness and which form not only within the joint capsule but tension. 88· a!i An increase in mobility of the spinal also within the ligaments and tendons and muscles segments 1°, 1 i:i. t:! 3 • 1:!4 can be demonstrated by themselves. The end result of this is osteogenic x-ray; 64 • 7:! • 110 , l:!:\-l:!!I measurable electromyographic change within the facet, 97 premature aging of changes locally and in the extremities have been 279 122 130 131 reported. • • Improvements in the motor There are other questions, does the lesion irri­ supply to the eye have been recorded by the nystag­ tate the recurrent meningeal nerve to cause vaso­ 125 132 mograph. 59 • • Nystagmographic changes­ constriction to the innervated structures? Does whether accomplished by modifying the proprio­ the lesion give rise to proprioceptive impulses ceptive input into the facilitated segment 1n- 1a5 or which stimulated anterior horn cells to cause by decompression of the vertebral artery to relieve somatic vasoconstriction, ischemia and pain? a temporary relative ischemia of the vestibular Could this vasoconstriction take place within the 122 centers, or by other reflex effects - is a question cord and lower the threshold of excitation to con­ that is open for further investigation. tribute to a '"central excitory state"? There are other symptoms associated with sub­ There are several questions which must be luxation which show evidence that the facilitation answered with regard to the "central excitory takes place segmentally in the lateral horn cells as state" and the spinal mechanism as they relate demonstrated by the changes in the sudomotor, 137 to pain, such as specificity or convergence of 8 141 visceromotor 1:i - and vasomotor 142 - 147 , 181 activi­ impulses transmitted to higher structures and the ties. Pre- and post measurements of manipulative effects of descending controls upon them. procedures have demonstrated the effectiveness of manipulation in restoring more normal tone in SUMMARY 148 150 9 these sympathetic activities. - Audiograms,'., • 125 151 152 , 132 • blood pressures, - 156 and serologic In this paper I have attempted to review the 156 160 profiles - also show an improvement after nature of the painful vertebral lesions. I have manipulation. The question of how pain is relieved presented data which would indicate that manipu­ by manipulation still remains unanswered. In the lation is effective in relieving pain and other case of myalgia, adhesion and facet subluxation, symptom complexes which result from vertebral manipulation could decrease the stimulation of dysfunctions. The exact mode of action of manipu­ nociceptors by passive stretching to relieve the lation is not known. In this regard I have presented muscle spasm, 161 by breaking the adhesions questions, not answers. It would seem to me that and/or by mobilizing the fixated facet. This then one thing is clear~ if we direct all of our efforts decreases the nociceptor stimulus just as Dr. into the investigation of nerve compression at McNab's chymopapain did when he injected it into the intervertebral foramina. we will obtain only the discs of patients with root compression. partial answers to our questions. F oraminal com­ Kibler and Nathan 162 showed that pain could be pression is the end result of a pathological process. abolished in cases of cord and root damage by in­ We must investigate the process itself. I nvestiga­ jecting a local anaesthetic distal to the region of tion must be aimed at the understanding of the damage. This indicates that the lesion was not the normal and abnormal mechanics of the spine and point which generated the pain but impulses from the effects of joint function on the afferent side undamaged tissues were necessary to trigger the of the nervous system. Somato-somatic and pain. The questions then arise: Does the lesion somatovisceral reflexes must be clearly under­ block inhibitory impulses or is there a decrease of stood if we are ever to appreciate the mechanism inhibitory impulses due to a lack of normal motor­ of vertebrogenic pain and other symptomatologies isity? Is the manipulation successful because it and their relief by manipulation. This quote from relieves the nerve root pressure or is the manipula­ the latest edition of Gray's Anatomy :;5 , 168 is tion successful because it increases the amount of instructive: ·The autonomic nervous system is inhibitory stimuli by restoring movement to the intimately responsive to changes in the somatic level that would provide a beneficial propriocep­ activities of the body and while its connections tive bombardment? It is interesting to note that with the somatic elements are not always clear in acupuncturists are routinely relieving pain 16 a and anatomical terms. the physiological evidence of even producing surgical anaesthesias 164 - 166 by visceral reflex activities stimulated by somatic needling of points distal to the site of pain. Kakizaki events is abundant.., 13, m1, 140, 169-11s, 11s, 11!1 and Manaba 167 have performed caesarean section We recognize other etiological factors over and 134 141 176 177 after applying static electricity to the hands and above the vertebrogenic. • • • We are also feet. This demonstrates that sensory bombardment aware of the fact that visceromotor reflexes fre­ does affect pain. quently cause characteristic spinal distortions. 140 , 141 280 It is these phenomena that we must clearly com­ 15. Smart, M., Manipulation. Arch. Phys. Med. pp. 730-734, prehend when we discuss scope of practice. December 1946. One cannot study chiropractic only by investi­ 16. Foreman, E.W., Face It We Can Learn From Chiroprac­ tors. Medical Economics, March 5, I 973, pp. 187-205. gating manipulation as if it were one modality in 17. Travell, J. and Travell, W., Therapy of Low Back Pain a long list of modalities of physical medicine, for By Manipulation and of Referred Pain in the Lower it is a whole system of analysis, diagnosis, thera­ Extremity By Procaine Infiltration. Arch. Phys. Med., peutics and prophylaxis. Chiropractic emphasis September 1946, pp. 537-547. is on the unity of the human body-the individual 18. Henderson, R. S., The Treatment of Lumbar lnterver­ tebral Disk Protrusion. Brit. Med. J., September 1952, patient. This is perhaps the major contribution pp. 597-598. chiropractic can make. 19. Wilson, J. N., Manipulation of The Herniated lnterver­ The main thrust of research should be directed tebral Disc. Am. J. Surg., February 1952. to the functional disturbances, pathomechanical 20. Mensor, M. C., The Nonoperative Treatment of Lumbar states, pain syndromes and neurophysiological Disc Syndrome. J. Bone and Joint Surg., Vol. 37 A, No. 5, October 1958. effects related to the statics and dynamics of the 21. Coyer, M. B. and Curwen, I. H. M., Low Back Pain locomotor system, especially of the spine and Treated by Manipulation. Brit. Med. J., March 1955. pelvis. 22. Leemann, R. A., Pain Syndromes Originating In The This Conference constitutes a threshold which, Vertebral Column and Their Amenability To Manip­ when crossed with an unbiased scientific attitude, ulative Treatment. Schweiz med. Wchnschr, 87: pp. 1289 and 1321, 1957. will result in the development of the full poten­ 23. Fischer, A. G. T., Manipulation in Lumbar lntervertebral tialities of the manipulative sciences. The result, Disc Lesions. The Practitioner. September I 961, Vol. I believe, will be a quantum step in the evolution 187, pp. 3 I 9-327. of the healing arts for the benefit of all mankind. 24. Valentini, E., The Rate of Success of Chiropractic Manip­ ulation in Lumbar Herniated Discs. 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A Survey and Analysis of the Treatment of Sprain and Session of the American Congress of Physical Therapy, Strain Injuries in Industrial Cases. Published by Florida Chicago, 111.,I 943. Chiropractic Association, 1216 Colonial Drive, Or­ 5. Marlin, T., Manipulative Treatment for the Medical lando, Fla., April 1960. Practitioner. Edward Arnold, London, 1934. 29. Kane, R. L., Leymaster, C., Olsen, D., Woolley, F. R., 6. Jostes, F. A., Place of Manipulative Procedures in the Fisher. F. D., Manipulating the Patient. A Comparison Overall Treatment Rationale for Painful Back Con­ of the Effectiveness of Physician and Chiropractor ditions. Arch. of Phys. Therapy, 1944. Care. Lancet, June 29, I 974, pp. 1333-1336. 7. Cyriax, J., Textbook of Orthopaedic Medicine, Vol. I. 30. Research Department International Chiropractors. A Bailliere Tindall and Cassell, London, 1969. Study c~f1,000 Herniated and "Slipped Discs". Daven­ 8. Mennell, J., The Science and Art <~{Joint Manipulation. port, Iowa, I 950. Churchill, 1952. 31. Shelby, R. L., Chiropractic Management of Degenerative 9. Mennell, J., Back Pain. Little, Brown, Boston, I 960. Joint Disease of the Spine -A Study of 100 Patients. 10. Maigne, R., Orthopedic Medicine. Charles C Thomas, National College of Chiropractic, June I 970. Springfield, Ill., 1972. 32. Baoke, H. K., Cervical Headache, Canadian Family 11. Bourdillon, J. F., Spinal Manipulation. William Heine­ Physician, May I 972. mann, London, 1970. 33. Kovacs, A., Subluxation and Deformation of the Cervical 12. Parsons, W. B. and Cumming, J. D. A., Manipulation in Apophyseal Joints-A Contribution to Aetiology of Back Pain. Canadian M.AJ., July 15, 1958, Vol. 79. Headache. Act. Radiocogica, Vol. 43, January 1955, Vertebral Manipulation, Coll. Gen. Pract. J., July I 965. Fasc. I. 13. Fisk, J. W., Manipulation in General Practice. N. S. Med. 34. Travell, J., Mechanical Headache. 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I 964. 44. Jones , R. T. , O steo Arthriti s of the Paravertebral Jo ints 65. Barcroft. H. and Millen, J . L. E., Th e Blood Flow Through of the Seco nd and Third Ce rvica l Vertebrae as a Cause Mu sc le During Sus tained Con tra.ction . ./. Phys .. 97: of Occip ital Heada c hes. S.A . M ed . ./., May 1964. pp. 17-3 1, 1939 . pp. 392-394. 66. Kleynhans , A. M., Vascular C hanges Occurring in the 45 . G utm an n, G., /·lalsll'irbelsifo ce 11ml 11w11uelle therapie. Cervica l Mu sculoskeletal Sys tem . 811/l. Eur opean pp. 3 I 0- 343. C hiroth erapie- manu elle therapie. Ther­ Clriroprac tic U., 194, No. I, pp. 24-30 , J 970. apie iiber da s nervensys tem , Band 7. H ippokmtes. 67. Dorpat , T. L. and H olmes, T. H. Mechanis ms of Skeletal I 96 7. Stuttg art. Muscle Pain and Fa tigue. Ar clr. Neurol & Phy sclriat .. 46. Strohal, R., Ma1111elle Therapie Bei Wirbel siiuce Er­ 74, pp. 628-640, I 955. kra11k1111gen, pp. 70-73. Urban & Sc hwarzenberg 68. 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Lewit , K., Meniere· s Disease and the Cervi cal Spine. in Gro ntal a nd Sagitta l Project ion. S vy. Uni v. Car olinae. Re viell' of Czeclroslovak Medicin e. I 96 I . V ll -2, Suppl. 2 1: 128- 129. 1965. pp. 129-1 39. 72. Jirou t, J. , Th e Effect of Mobilization of the Segment. 5 1. Miller , H. C., Head Pain. /-1.A.O.A., Vol. 72 , pp. 135- 142 , Blockage on the Sagitta l Com pone nt of the Reaction October 1972. on Latero n exio n of the Cerv ica l Spi ne. N eurorad iology . 52. Janda, V. , The C ervicocranial Syndrome in Ch ildren. 3: pp. 2 10- 2 15, 1972. Cs. Pediatri e, 14 , p. 10 18, 1959. 73. Krausov a, L. and Lew it, K. , The Mechanism and Mea s­ 53. Kabatn icova, S. and Kabatn iz, Z. , T he Significance of uring of the Mobility in the Cra niocervica l Joints Dur­ of th e Vertebral Column in Child ren' s He adaches. ing Lateral Inclination. Acta Unii-. Carolinae (Med .) Lek Pln or, p. 361 , I 966. Suppl. 2 1: pp . 123- 126 , 1965. 54. Novot ny, A. and Pvorak, V., Func tional Disturbances 74. Go ldthw aite, J . E., Variations in Anat om ical Stru ctu re of of the Vertebral Column in Gynoco logica l Prac tice . the Lumb ar Spine. A . J. Ortlrop. Sur g. 2:146, 1920 . Manuell e Medi zin 2: I 972. 75. Steind ler , G. A., Kinesiolo gy. p. 145. Charle s C Thomas. 55. Stary, 0. , The Co ncept of Research of Ver teb roge nic Springfield , Ill.. I 955. D isea se in CSSR. Ac ta Universiti e.,· Carolinae Med., 76. Gutman, G. , O pinion on the C hange of Cerv ica l Spine. Suppl. 2 1: pp. 16- 18. 1965. Man.M ed .. 6, pp. 124- 134, 1973. 56. Jir ou t, J., Stu dies in the Dynam ics of the Spine. A cta 77. Jirout , J. , Ma1111elle M edicine and llrrd Wissensclwftli chen. Radi o/, 46:55 , 956 , pp. 55-60 . Gn111dlage11. pp. I 56- I 66 , Verlag Fur Physikau sche 57 . Rettig , H., Observat ion ofan Acute Basedow 's Syndrome Medi zin, Heidelberg, 1970. Afte r C hiroprac tic Treatment of the Cervica l Spine . 78. Korr, I. M., The Co ncep t of Fac ilitation and its Origin. Med. K lin., 36. pp. 1528 -1 530, 1955. J.A.O.A ., January 1955. 58. Pfeiffer, .I.• Nauer. L.. Berkokva. J .. and Sussova. J .. Elec­ 79 . Korr , I. M .. C linical Sign ificance of the Faci litated State. tro myograp hy of th e Ab dom inal and Dor sal Muscles ./.A.O.A .. Januar y 1955 . 282 80. Sherrington, 0. C., The Selected Writings

285 A Critical Look at the Treatment for Low Back Pain

ALF NACHEMSON Professor and Chairman Department of Orthopaedic Surgery V niversity of G oteborg, Sweden

In order to discuss the treatment of back pain by like to mention the lumbosacral fascia in which manipulation, an overview of the whole problem one investigator II has detected an inflammatory along with other types of treatment must be given. reaction and has performed I 0,000 lumbar fasci­ We know this is a field of importance for the ectomies over the years. individual patient as well as for society. In epide­ The muscles, which some treat for nodulus, miological studies petformed in Sweden, 1-3 in Eng­ fibrositis, and contractures, have never been land,4 and in Israel, 5 it has been demonstrated that demonstrated pathoanatomically to show any 70-80 percent of the population in modern indus­ significant changes, nor have any consistent trialized societies some time during active years EM G changes been demonstrated. will suffer back pain - the majority between 20 and The yellow ligament, the ligamentum flavum, 55 years of age. The problem seems to be of the was thought to be responsible for sciatica: that same magnitude in the United States.' 1 structure is still believed by some orthopedic I will limit my discussion to the treatment of surgeons to cause pain when it is thickened. 10 low back pain - by far the most common of the Such an increase in width is, however, always back syndromes and also the most frequently secondary to severe disc degeneration. 11 manipulated. 7 From a theoretical point of view, the inter­ There are two key issues in this conference. vertebral (facet) joints seem to be a likely site of 1. What is pain and exactly how is it elicited? origin for back pain. It must be stressed, however, 2. What is the cause and origin of low back pain? that pathoanatomical changes have always been It seems clear that some anatomical structure found in these joints secondary to degenerative 8 1 must be diseased or at fault in order to elicit pain. changes in the intervertebral disc. '.!, ta Medical Having engaged in research in this field for nearly or paramedical literature does not show facet 25 years and having been clinically engaged in back subluxation or dislocation as being more common problems for nearly the same period of time, and as in normal individuals than in those with back pain. a member and scientific adviser to several inter­ We do not even have knowledge of what is the 14 16 national back associations, I can only state that for normal radiographic picture of these joints. - the majority of our patients, the true cause of low With recently developed techniques of tomo­ back pain is unknown. graphic examination, this seems feasible to ob­ The origin of pain is most likely looked for in tain. Hi, 17 Decreased motion of the facet joints, 14 15 17 the lower lumbar motion segments. Practically all according to some authors, • • is always structures in this region have had their proponents secondary to disc degeneration. In a few older in the etiological discussion, from the skin and patients with severe osteoarthritic changes in subcutaneous tissue down to the disc. their lumbar facet joints, however, it might be Without discussing each one of them, I would possible that this is responsible for back pain. 287 For the maJonty of scientists working in this the low back pain syndrome. Thus, all we can state field, the origin of the pain is most likely in the is it is likely that certain stages in the aging process lumbar disc or its close surrounding, the longi­ are significant in the production of the pain syn­ tudinal ligaments. dromes.36 Evidence in favor of this is that prolapse Unfortunately, we lack direct conclusive evi­ is known to occur only in discs with degenerative dence of the part played by the disc in the etiology, changes. Secondly, in roentgenologically demon­ but a number of indirect indications should be strable disc degeneration, the number of patients mentioned. who had had low back pain is significantly greater I. The disc hernia is usually preceded by one than comparable subjects in whom no roentgeno­ 2 3 or more attacks of low back pain. • 18 logic changes can be found. On the other hand, it 2. Following intradiscal injection either by is wrong to state that a roentgenologically degen­ hypertonic saline or by contrast media, it is often erated disc definitely means that the patient's 9 possible in patients with complaints as well as in troubles are due to that particular inters pace. 18• 37-3 symptom-free subjects to cause pain of the same Thus, it seems that the trouble starts during the 1921 type as experienced earlier. · It is not fully stages of degeneration which occur before the understood if this pain is due to increase in intra­ changes are clearly visible on the roentgenograms. discal pressure or to chemical irritation: either This means that we cannot say to our patients: could act on the outermost layer of the annulus "It is obvious from the X-rays that you have a 22 23 where nerve endings are located. • Inside the bad back." Certainly such a statement will only intervertebral disc proper, however, no nerve create further anxiety and will never increase the endings have been found. cure rate. The roentgenologically degenerated disc 3. Investigations have been performed in which space probably should be looked upon as "burned during surgery for sciatica, thin nylon threads out," and chances are greater that it is not the spe­ were fastened to the fascia lumbosacralis, the cific cause of the patient's present condition. muscles, ligamentum interspinale, the interverte­ Before further discussing different types of bral joints, and ligamentum flavum, and also to the treatment for this disease, it must be clearly stated posterior part of the annulus fibrosus, to the dorsal that, since the cause is unknown, there is only longitudinal ligament, and to the nerve root symptomatic treatement available. proper. 24 These structures were irritated 3 to 4 Dr. Gitelman 40 in his paper quotes a controlled weeks after surgery by pulling the threads, but pain series conducted by Coyer and Curwen 41 where resembling that which the patient had experienced they showed a trend for better results from manipu­ previously could be elicited only from the three lation in the first week but not after 6 weeks. Their last mentioned structures. own statement was: "Statistical analysis has not 4. Pathoanatomically, radiating ruptures are yet been applied because the present preliminary known to occur in the posterior part of the an­ figures are inadequate for this purpose." nulus reaching toward the areas in which nerve endings are located. The presence of such single There are a few more similar trials on manipula­ ruptures in the lumbar discs is first seen around tion in the literature, none of which show statisti­ cally valid results.10, 42,43 the age of 25, i.e. the same age at which the low back pain syndromes start to -be of clinical Beechgaard 44 reports that he personally followed importance. is. 2s, 26,21, 2s 18 patients himself, not 800, and that 64 percent The intervertebral disc has been subjected to a of the 800 patients manipulated- the majority of number of morphological and chemical investiga­ them in the lumbar area- showed good results. tions, but they have shed no light on the origin of The only randomized clinical trial in this field, to pain; these investigations have, however, expanded my knowledge, was recently published by Glover our knowledge of the biological events in that et al. 45 demonstrating no statistically significant largely a vascular structure. 18• 25-35 Eventually all in­ difference between those manipulated and those dividuals will have degenerative changes in the receiving detuned short wave. discs, characterized by increased fibrosis in the In a recent article by Kane and associates 46from nucleus and ruptures in the annulus. Some subjects Utah, no statistical difference between patients show such changes earlier than others, but it has treated by physicians and patients treated by chiro­ been impossible to prove a direct relationship with practors was seen except for the number of visits. 288 The chiropractors saw their patients nearly twice as salicylates, why do most orthopaedic surgeons li6 many times as the physicians. refute manipulative chiropractic or osteopathic In Dr. Gitelman's paper 40 reference is given to types of treatment? Perhaps because these some papers -1;-:;o demonstrating the effect of manip­ latter treatments are based on theories of ulation as measured by electromyography. Careful disease processes that at least for the majority of scrutiny reveals, however, only anecdotal obser­ our patients have never been proven or disproven. vations with no quantitatively documented results Those medical doctors, like Dr. Cyriax, 67who use and no comparison with any normal material. There manipulative treatment are convinced they are is no statistical evaluation of the results. treating a disc lesion. There is evidence that disc Gitelman also said •to that this conference by its morphology is changing from 20 years of age very existence is proof that manipulation is effec­ onward~ this is also the age at which attacks tive and that "any fairminded thinker does not of low back pain become more common in the doubt the fact that it works." May I express my population. 1-3, 3 ; doubts. There is no proof that manipulation for In the medical field, new types of treatment for acute or subacute low back pain patients has been low back pain are introduced with some frequency, demonstrably better in large control series than it tried for some time, and then proven or disproven has with simple bed rest and salicy.lates. by clinical trials in various places around the world. Several epidemiological studies 1-:i. :u; have dem­ No such attempts have been made by chiropractors onstrated that nearly 50 percent of patients improve or osteopaths for nearly 100 years. in a few weeks irrespective of treatment given and The enormous problem of back pain cannot be some 80 percent, even as high as 86 percent in a solved by "armchair pathology." Yet, there is one recent English study .4 are well in 2 months. Dr. St. single pathological entity in this field where scien­ Clair Dixon, 4 in a recent paper given at the annual tific evidence does exist. That is the true disc meeting of the British Association for Rheuma­ hernia, which, when found at operation to be press­ tology and Rehabilitation, said that the placebo ing on a nerve root, on removal gives a 90-95 element of back pain is enormous. Anyone who percent good result. 10. 18, 31, 64,68-10 takes care of the patient will provide help for The true herniated disc can be successfully 70 percent of patients. treated conservatively with bed rest, 10 , 70 with con­ In this context it must be emphasized that a trolled manipulation under anesthesia, 43 or trac­ careful clinical examination is of benefit. Perhaps tion,10,53 with extradural, 10, 71 or intradiscal, 54 • 72 this is the reason for the slight trend to be seen in hydrocortisone injections and intradiscal chymopa­ 55 some series 4'- 42· 45that the first one or two manipu­ pain injections. • 72· n It remains to be demon­ lative sessions seem to help a little more than, for strated that the results are equally good as those example, detuned shortwave or bed rest. I must obtained by surgical removal in patients with a also mention that radiation therapy f I ultrasound. 10 definite disc hernia. These methods are, however. shortwave diathermy, 52 traction, 53 injection of helpful in avoiding operation in some patients. various drugs including hydrocortisone 54 and Unfortunately, this is not much consolation, chymopapain 55 • 56 have not proven to be more since few back patients develop symptoms, signs, effective. This is also true for lumbar fusion opera­ and pathology of a true prolapsed disc. For the tions for low back pain :-,Hoand facet joint denerva­ vast majority of our patients we still have to look tion.61•62 Most of us in our present state of for the origin of the pain as well as for the "right" ignorance get 70-80 percent good results. There is, treatment. however. one important difference. The latter pro­ Why should it be difficult for the lay public and cedures are only performed in patients with more for us who are treating patients to comprehend and chronic back pain. For these, no evidence exists at explain that we do not know the cause of this dis­ all of the percentage helped by manipulations. order? We know and accept that the cause and The psychological aspects of back pain have cure of cancer is still hidden. This is the same recently been emphasized by several authors na-m; with back pain. On the other hand, mankind has a and certainly have to be subjected to further tremendous need for explanation. This demand evaluation. can be met with information of those few facts With actually no treatment program being supe­ that exist. We all agree that patients with low back rior to simple measures such as bed rest and pain experience an increase of their troubles when 289 their backs are mechanically stressed. The results of decreasing the load on the back is stressed at obtained by intravital disc pressure measure­ work, at home, and at rest. ments 36 • H, 75 constitute a base for patient educa­ tion. This has led to what we in Sweden call "'the Pn low back pain school." 76 The purpose of this is to: (1) create confidence for the patient to be able kp/cm 2 35 to cope with his back troubles: (2) avoid excess A therapy; (3) decrease the expenses both for the 30 individual and the society. The back school consists of four group sessions 25 } with six patients led by a physiotherapist. The 20 first and second lessons give information on the A B 15 anatomy and function of the spine and present knowledge on low back pain, its etiology, fre­ 10 ' quency, and therapeutic efforts. The mechanism 5 of the spine is explained, based on low pressure

measurements and movements and positions are 5 10 15 20 sec. analyzed (tables I and 2. figure I). The importance Fig. I. Pressure recorded from the L3 disc in a 25-year-old male lifting 20 kg with bending of back and knees straight. with TABLE I back straight and bending of knees. Approximate Load on L3 Disc in 70 Kilogram Individual in Different Positions. Movements, and Maneuvers The third lesson is a practical application of the previous theoretical lessons. Individual advice Activity Load regarding working and resting positions is given. I so metric abdominal and back muscle exercises kg and leg exercises are taught, the former because Supine 30 Standing 70 measurements ;-1 have demonstrated that they load Upright sitting, no support 100 the lumbar spine less than isotonic exercises. The Walking 85 advantage of such an approach has been clinically Twisting 90 76 77 verified. • Bending sideways 95 The last lesson is mainly a repetition of the Coughing 110 .lumping 110 course including an examination to avoid mis­ Straining 120 understanding and to underline the importance of Laughing 120 self-confidence for the future. Physical activities, Bending forward 20° 120 sports, and plays" are encouraged to improve Lifting of 20 kg, back straight, knees bent 210 psychological and physical tolerance of pain and I .ifting of 20 kg, back bent, knees straight 340 stress. The physiotherapist's primary task is to teach TABLE 2 ergonomics and to help patients to cope with their Approximate Load on L3 Disc in 70 Kilogram Individual in back troubles. The basic therapeutic principle is Different Positions and Exercises rest in the semi-Fowler position combined with Activity Load analgesics, postural, and ergonomic advice. Since most of the patients get well within a couple of kg weeks irrespective of treatment, this seems to be Standing 70 the most logical approach in the absence of knowl­ Bending forward 20° with IO kg. in each hand 185 edge about the specific cause of the back pain. Supine 30 Supine in traction (30 kg) 10 In the therapeutic field today the introduction Bilateral straight-leg raising, supine 120 of a new drug is practically impossible without Sit-up exercise with knees bent 180 clinical and laboratory tests to prove its effective­ Sit-up exercise with knees extended 175 ness: we are sensitive to and critical of pharma­ Isometric abdominal muscle exercise 110 Active back hyperextension, prone 150 cological side effects. The same posture should be taken with regard to the different forms of treat- 290 ment for low back pain. Present methods should 7. Smith. R. L. At Your Own Risk. The Case Against Chiro­ be given a critical look. practic. New York. Pocket hooks. Simon & Schuster. Thus, while awaiting further knowledge about Inc .. 1969. 8. Werle. E., and Zickgraf-Ruedel, G. Intrinsic Pain-Pro­ the back problem, it is in the interest of our pa­ ducing Substances of the Body. Sandorama. Sandoz Ltd .. tients and ourselves to prescribe simple and Basie, Switzerland, 1972. inexpensive methods of treatment in which the 9. Morotomi, T. Affections of spine. Ed. T. Amako. In: known clinical. biological, and mechanical factors Orthopaedics, p. 351. Tokyo, Japan, Kanehara, I 960. can serve as guides. A plea is made for all of us to 10. Hanraets, P. R. M. The Degenerative Back and its Differ­ ential Diagnosis. Amsterdam, the Netherlands, Elsevier evaluate our belief in a statistically sound manner. Publishing Co., 1959. 11. Nachemson, A., and Evans, J. H. Some mechanical proper­ ties of the third human- lumbar interlaminar ligament (ligamentum tlavum). J. Biomechanics I :21 I, J 968. 12. Lewin, T .• Moffett B., and Viidik, A. The morphology of the Betterunderstan9ll)g lumbar synovial intervertebral joints. Acta Morph. and treatmentof Neer/. Scand. 4:299, 1961. 13. Lewin, T. Osteoarthritis in Lumbar Syno1·ial Joints. A lowback pain. morphologic study (thesis). The Department of Anatomy and the Department of Orthopaedics, Goteborg, Sweden, ~4 1964 . 14. Lewin, T. Anatomical variations in lumbosacral synovial joints with particular reference to subluxation. A eta ...\. ~ o16gy\ I \'J.\ Anal. 71 :229, 1968. 1 15. Hirsch, C., and Lewin, T. Lumbosacral synovial joints in tlexion-extension. Acta Orthop. Scand. 39:303, 1968. 16. Reichmann S. The Lumbar lntervertebral Joints. An Ana­ tomical and Roentgeno/01-:ical Study (thesis). The Depart­ ment of Anatomy and the Department of Diagnostic Radiology Ill, Goteborg, Sweden, I 971. I 7. Reichmann, S., Berglund, E. and Lundgren, K. Das Bewegungszentrum in der Lendenwirbelsaule bei Flexion und Extension. Z. Anat Entwicklungsgesch 138:283, 1972. I 8. Friberg S. and Hirsch C. Anatomical and clinical studies Fig. 2. The troika of low back pain. on lumbar disc degeneration. Acta Orthop. Scand. 14:222. I 949. As seen from figure 2, only by investigative efforts I 9. Hirsch C. An attempt to diagnose the level of a disc lesion by clinicians of all kinds, by engineers, by chemists, clinically by disc puncture. Acta Orthop. Scand. 18: 132, and by pathologists is it likely that the etiological 1948. and therapeutic problems of low back pain may be 20. Lindblom K. Technique and results of diagnostic disc punc­ ture and injection (discography) in the lumbar region. solved. Acta Orthop. Scand. 20:315, 1950. 21. Holt E. P. The question of lumbar discography. J. Bone REFERENCES Joint Surg. 50-A:720. 1968. 22. Hirsch, C., lngelmark, B.-E., and Miller, M. The anatomical I. Hult, L. The Munkfors investigation. Acta Orthop. Scall(/., basis for low back pain. Acta Ortlwp. Scancl. 33: I, 1963. Supp. 16. 1954. 23. Jackson, H. C., Winkelmann, R. K., and Bickel, W. H. 2. Hult, L Cervical, dorsal, and lumbar spinal syndromes. Nerve endings in the human lumbar spinal column and A field investigation of a nonselected material of I ,200 related structures. J. Bone Joint Surg. 48-A: 1272, 1967. workers in different occupations with special reference 24. Smyth, M . .I., and Wright. V. Sciatica and the intervertebral to disc degeneration and so-called muscular rheumatism. disc. An experimental study. J. Bone Joint Surg. 40-A: Acta Orthop. Scand., Supp. 17, 1954. 3. Horal J. The clinical appearance of low hack disorders in 1401, I 958. 25. Hirsch. C. and Schajowicz. F. Studies on structural changes the city of Gothenburg, Sweden. Acta Orthop. Scand., in the lumbar annulus fibrosus. Acta Orthop. Scand. Supp. I I 8, I 969. 22: I 84, 1952. 4. Dixon, A. St. C. Progress and problems in back pain re­ search. Rheumatology and Rehabilitation 12: 165. 1973. 26. Coventry. M. B .. Ghormley, R. K., and Kernohan, J. W. The intervertehral disc: its microscopic anatomy and 5. Magora, A. Investigation of relation between low back pathology. Part I. Anatomy, development, and physiol­ pain and occupation. I. Age, sex, community, education. ogy. J. Bone Joint Surg. 27: I 05, I 945. and other factors. Ind. Med. Surg. 39:465, 1970. 6. Chaffin, D. B. Human strength capability and low back pain. 27. Coventry, M. B., Ghormley, R. K., and Kernohan, .I. W. J. Occup. Med., 16:248, 1974. The intervertebral disc: Part 11. Changes in the inter- 291 vertebral disc concomitant with age. J. Bone Joint Surg. nerve root compression syndrome. J. Amer. Osteopath 27:233. 1945. Assn. 70:433, 1971. 28. Coventry, M. B., Ghormley, R. K., and Kernohan, .I. W. 48. Denslow, J. S. and Hassett, C. C. Spontaneous and induced The intervertebral disc: Part 111.Pathological changes in spasm in structural abnormalities. J. Amer. Osteopath. the intervertebral disc. J. Bone Joint Surg. 27:460, I 945. Assn. 42:207, 1943. 29. Bijlsma, F., and Peereboom, .I. W. C. The aging pattern of 49. Denslow, J. S. and Clough, D. 0. Electromyographic stud­ human intervertebral disc. G eronto/ogia l 8: 157, 1972. ies of structural abnormalities. J. Amer. Osteopath Assn. 30. Jayson. M. I. V. and Barks. J. S. Structural changes in the 4 I : I 7 5, l 94 I. intervertebral discs. Ann. Rheum. Dis. 32: 10, 1973. 50. England, R. W. and Deibert, P. W. Electromyographic stud­ 31. Nachemson, A., Lewin. T., Maroudas, A., and Freeman, ies: Part I. Consideration in the evaluation of osteopathic M. A. R. In vitro diffusion of dye through the end plates therapy. J. Amer. Osteopath Assn. 72: 162, 1972. and the annulus fibrosus of human lumbar intervertebral 51. Goldie, I., Rosengren, B., Moberg, E., and Hedelin, E. discs. Acta Orthop. Scand. 41 :589, 1970. Evaluation of radiation treatment of painful conditions 32. Maroudas, A .• Nachemson, A., Stockwell. R., and Urban,J. of the locomotor system. A doubleblind study. Acta In vitro studies of the diffusion of glucose into the Radio/. 9:311, 1970. intervertebral disc. To be published in J. Anat. 52. Lehmann, J. F .• Warren, C. G., and Scham, S. M. Thera­ 33. Naylor, A. The biophysical and biochemical aspects of peutic heat and cold. Clin. Ortlwp., 99:207, 1974. intervertebral disc herniation and degeneration. A 1111. 53. Weber, H. Har traksjonsbehandling noen effekt ved Roy. Coll. Surg. Eng., 31 :9 I, I 962. ischias forarsaket av skiveprolaps? Tidsskrift for Den 34. Peyron, .1.-G. Biologic due disque intervertebral. Sem. norske laeJ?eforening 33:2243, 1972. Hop., Paris, 43:33 l 8, l 967. 54. Feffer. H. L. Therapeutic intradiscal hydrocortisone. A 35. Feffer, H. L. A physiological approach to lumbar inter­ long-term study. C/in. Orthop. 67:100. 1969. vertebral disc derangement. Ed., .I. P. Adams. In: Curr. 55. MacNab, I., McCullouch, .I. A., Weiner, D.S., Hugo, E. P., Pract. Ortlwp. Surg., I, p. 111, St. Louis, C. V. Mosby Galway, R. D., and Dall, D. Chemonucleolysis. Canad. Co .• 1963. J. Surg., 14:280, 1971. 36. Nachemson, A. Low back pain. Its etiology and treatment. 56. Ford, L. T. Clinical use of chymopapain in lumbar and C/in. Med., 78:18, 1971. dorsal disk lesions. An end-result study. Clin. Orthop., 37. Spangfort, E. V. The lumbar disc herniation. A computer­ 67:81, 1969. aided analysis of 2,504 operations. Acta Orthop. Scand. 57. Rolander, S. D. Motion of the lumbar spine with special Supp., 142, 1972. reference to the stabilizing effect of posterior fusion. 38. Inman. V. T., and Saunders, J. B. Anatomicophysiological Acta Orthop. Scand., Supp. 90, 1966. aspects of injuries to the intervertebral disc. J. Bone 58. Stauffer, R. N. and Coventry, M. B. Posterolateral lumbar­ Joint SurJ?., 29:461, 1947. spine fusion. Analysis of Mayo Clinic series . ./. Bone 39. LaRocca, H. and MacNab, I. Value of preemployment Joint Surg. 54-A: 1195, 1972. radiographic assessment of the lumbar spine. Canad. 59. Stauffer, R. N. and Coventry, M. B. Anterior interbody Med. Assn. J., 101:383, 1969. lumbar spine fusion: Analysis of Mayo Clinic series. 40. Gitelman, R. The treatment of pain by spinal manipulation. J. Bone Joint Surg. 54-A:756, 1972. Paper given at the NINOS-NIH workshop on the Re­ 60. Rothman, R. H. and Marvel, J. P., Jr. Pseudarthrosis of the search Status of Spinal Manipulative Therapy, Bethesda, lumbar spine. In: Proc. of the First Meeting of the Md., February 2-4, 1975. International Society for the Study of the Lumbar Spine 41. Coyer, A. B. and Curwen, I. H. M. Low back pain treated in Montreal, Canada, .lune I 9-22, l 974. Also to be by manipulation. A controlled series. Brit. Med. J .. published in the Orthopaedic Clinics of North America. March:705, 1955. 42. Edwards, B. C. Low back pain and pain resulting from 6 I. Wyke, B. The neurology of joints. Ann. Roy. Coll. Surg. £11.1:.41:25, 1967. lumbar spine conditions: A comparison of treatment results. Aust. J. Physiother. 15:104, 1969. 62 Shealy, C. N. The role of the spinal facets in back and sciatic 43. Chrisman, 0. D., Mittnacht, A., and Snook, G. A. A study pain. Headache 14:101, 1974. of the results following rotatory manipulation in the 63. Wolkind, S. N. and Forrest, A. J. Low back pain: a psychi­ lumbar intervertebral-disc syndrome. J. Bone Joint Surg. atric investigation. Postgrad. Med. J. 48:76, 1972. 46-A:5 l 7, 1964. 64. Roslund, J. Indications for Lumbar Disk Surgery. Factors 44. Beehgaard, P. Late post traumatic headache and manipula­ influencing the long-term prognosis (thesis). The Depart­ tion. Corres. Brit. Med. J., June 4:1419, 1966. ment of Orthopaedic Surgery, Karolinska Hospital, 45. Glover, J. R., Morris, J. G., and Khosla, T. Back pain: a Stockholm, Sweden, 1974. randomized clinical trial of rotational manipulation of the 65. Westrin, C.-G. Low back sick-listing. A nosological and trunk. Brit. J. lndustr. Med. 31:59, 1974. medical insurance investigation. Srnnd. J. Soc. Med. 46. Kane, R. L., Leymaster, C., Olsen, D., Woolley, F. R .• and Supp. 7, 1973. Fischer, F. D. Manipulating the patient. A comparison of 66. Scham, S. M. Manipulation of the lumbosacral spine. Clin. the effectiveness of physician and chiropractor care. Ort hop. IO I: 146, I 974. Lancet,June,p. 1333, 1974. 67. Cyriax, J. Textbook of Ortlwpaedic Medicine, Vol. I. Diag­ 47. Siehl, D., Olson, D. R., Ross, H. E., and Rockwood, E. E. nosis of soft tissue lesions. London, England, Bailliere Manipulation of the lumbar spine with the patient under Tindall & Casell, 1969. general anesthesia: Evaluation by electromyography and 68. Sparup, K. H. Late Prognosis in Lumbar Disc Herniation. clinical-neurologic examination of its use for lumbar Copenhagen, Denmark, Munksgaard, 1960. 292 69. Soderberg, L. Prognosis in conservatively treated sciatica. 73. Smith, L. Chemonucleolysis. Clin.'.Orthop. 67:72, 1969. Acta Orthop. Scand. Supp. LI, 1956. 74. Nachemson, A. and Elfstrom, G. lntravital dynamic pres­ 70. Hakelius, A. Prognosis in sciatica. A clinical followup of sure measurements in lumbar discs. A study of common surgical and nonsurgical treatment. Acta Ortlwp. Scand. movements, maneuvers, and exercises. Scand. J. Rehab. Supp. 129, I 970. Med. Supp. I, 1970. 7 I. Dilke, T. F. W., Burry, H. C., and Grahame, R. Extradural 75. Nachemson, A. Physiotherapy for low back pain patients. corticosteroid injection in management of lumbar nerve A critical look. Sca11d. J. Rehab. Med. I :85, 1969. root compression. Brit. Med. J., .lune:635, J 973. 76. Lidstrom, A. and Zachrisson, M. Physical therapy on low 72. Graham, C. E. Chemonucleolysis: A double-blind study back pain and sciatica. An attempt at evaluation. Scand. comparing chemonucleolysis and intradiscal hydro­ .I. Rehab. Med. 2:37, I 970. cortisone in the treatment of backache and sciatica. Ed. 77. Kendall, P. H. and Jenkins, .I. M. Exercises for backache: 0. D. Chrisman. In: Proc. of the 26th Annual Meeti11g in A double-blind controlled trial. Physiotherapy 54: 154, Boston, Massachusetts, June 15-19, 1974. 1968.

293 Treatment of Visceral Disorders by Manipulative Therapy

WILLIAM D. MILLER Acting Dean The Postgraduate Institute of Osteopathic Medicine and Surgery New York City, N.Y.

The relationship of the musculoskeletal system, attributed to reflex spasm of the muscles and liga­ the soma, and the viscera forms an interdependence ments about the shoulder secondary to cardiac recognized by all physicians. Disorders in the pain impulses referred to the same segment of the neuromusculoskeletal system, at times, and in some spinal cord as innervate the affected muscles and instances, may be a factor in visceral disorders and ligaments. 5 • ,; disease. 1 The literature is replete with discussions The Postgraduate Institute of Osteopathic Medi­ on disturbances in the neuromusculoskeletal sys­ cine and Surgery planned as its main objective to tem as possible factors in visceral disease.:! The determine whether individuals in whom these literature describes various somatovisceral and somatic disturbances are modified have a signif­ viscerosomatic reflexes as relating to a specific icant objective or subjective improvement in their disease condition. When an average threshold disease and pulmonary function compared to a stimulus is applied to a somatic receptor such as the control group. It must be realized from the onset, skin, visceral function is influenced by way of the alterations of visceral function by producing central connection in the gray matter of the spinal changes in the somatic musculature represent only cord. If the sympathetic nervous system is one modality for treating visceral disease. ln no involved, the activation occurs in the cells of the way does this supplant other methods and pro­ mediolateral column in the thoracolumbar area. 3 cedures in treatment. Since the sympathetic axones terminate in the con­ This study w.as brought about by the observation tractile mechanism of vascular smooth muscle of those with wide experience in osteopathic medi­ fibers, the end result could be vasoconstriction. cine who had the clear clinical impression that cer­ Other sympathetic nerves affect heart rate, bron­ tain osteopathic methods were valuable in diagnosis chodilation, sphincter contraction, etc. There is not and therapy. The main objective was to determine a direct action and effect relationship between whether individuals in whom neuromusculoskeletal manipulation and a physiologic response. This point disturbances were removed or appreciably modi­ has two parts: (I) Malfunction or disturbances in fied had a significant improvement in their obstruc­ the neuromusculoskeletal system can affect the tive lung disease and pulmonary function. physiology of tissue or organs of the body if the This study was entertained with the idea to body does not compensate adequately; (2) Removal review uniformity of objective data and determine or diminution of disturbances in the neuromusculo­ if patterns of postural stresses and/or faults in the skeletal system may be an aid in overcoming intervertebral and costovertebral mobility, muscu­ visceral disorders. 4 lar contractions or other changes in physical struc­ As an example, the so-called shoulder-hand syn­ tures are coexistent with chronic obstructive lung drome, periarthritis of the shoulder following acute disease and whether they are statistically signifi­ myocardial infarction, is believed by some to be cant. In addition, efforts were made to establish the 295 efficacy of manipulative procedures designed to on the four basic variables - one in the treated eliminate or modify musculoskeletal disturbances group and the other in the control group. It was found in a given subject. expected that this system would produce two Patients admitted to the study were randomly groups approximately equal with respect to assigned to the treated or control group. Medical severity of disease, sex, race, and age distribution, and adjunctive treatment were the same for both while at the same time minimizing the possibility of groups, with the same breathing exercises given to bias arising in the process of assigning any specific each patient. In contrast to the control group, patient to one or the other group. those in the treated group also received stand­ The initial examination included a detailed. ardized manipulative treatments twice weekly. general history and a series of objective measure­ Thus, the design called for comparable therapy ments to be used as a basis for comparison in for the two groups except for the additional subsequent periodic evaluations made during the osteopathic manipulative treatment administered course of treatment. The history examination was to the subjects in the treated group. This report in a modified version of the Questionnaire on Respira­ no way should be considered complete as other tory Symptoms (1966) approved by the Medical factors such as smoking, symptomatology as to Research Council's Committee on Research Into coughing, occupation, etc. were not included so Chronic Bronchitis. In addition a complete blood that the thrust of this report is directed toward the count, serological test for syphilis, sputum culture. musculoskeletal changes and the results observed modified blood chemistry. urinalysis, 12-lead here. electrocardiogram, 2-meter chest X-ray, measure­ ment of gas tensions, and pulmonary function METHODOLOGY studies including lung volumes, diffusion, maximum voluntary ventilation, vital capacity, FEY 1,2 and Patients admitted to the study had to meet the midexpiratory flow rate were done. In addition, a following criteria: special standardized examination of the musculo­ I. Age: 36 years to 65 years. skeletal system was conducted on each patient. 2. Height: 145-185 centimeters for females and Special attention was made to determine if there 157-190 centimeters for males. were evidences of neuromusculoskeletal stress 3. Weight: 41-85 kilos for females and 50-1 I 5 and/or faults in intervertebral and costovertebral kilos for males. as well as costochondral articulations. Methods in 4. A diagnosis of chronic obstructive lung use involved recording hypermobility, costoverte­ disease. bral dysfunction, or alterations in side bending, Patients with concurrent disease were excluded rotation. Skin drag was used to determine sudo­ if the disease was considered to have a sufficient motor changes and red reaction to determine potential for altering their response to treatment. vasomotor changes. Spinal examination recorded The diagnosis of the patient and the evaluation, curvatures whether anterior-posterior or lateral. the class, and severity of obstructive disease were Deviations at segmental levels also were recorded made by an internist. using the criteria of Gaensler both at the right and left sides of the body. In . and Wright 7 before the patient was assigned to one addition, muscle tension was graded both right and of the two groups. A combination of random alloca­ left. These matters were recorded with number tion and matched pairing was used to determine four as arbitrarily accepted as normal. Above the group to which the patient would be assigned. four was considered hyperreactive and below four Patients were paired according to their sex, race, hyporeactive. degree of involvement, and age. The diagnosis and evaluation of the class and Briefly, this was the method used: The first severity of the obstructive disease was then deter­ patient in any given group was assigned at random mined. The individual's number was assigned by to the treated or control group. The random alloca­ random selection and placed in either the A-treated tion was carried out using a standard table of group or B-control group. Patients in both groups A random numbers. The next patient admitted to the and B received the same appropriate chemical, study with the same four characteristics however, medical, and adjunctive therapy including bron­ was automatically assigned to the opposite group. chodilators, aerosol, intermittent positive pressure These two patients now constituted a pair, matched breathin .~. breathing exercises, postural drainage 296 graded exercises, and supplemental oxygen inhala­ 20 tion as indicated. Patients in group A received in 18 addition osteopathic manipulative therapy twice weekly, including specific manipulative proce­ 16 dures. There was uniformity in the application of 14 these procedures in all aspects. The procedures involved methods to hyperextend the dorsal spine 12 using several techniques. Other techniques 10 involved increasing any restrictive motion that could be present within the musculoskeletal system. 8 Another method was to increase lymphatic flow by 6 applying pressure to the muscles of the thoracic 4 cage through anterior compression of the chest. 8 • 9 The methods for osteopathic manipulative pro­ 2 cedures in chronic obstructive lung disease took 0 into consideration the pathophysiology involved. 0 2 4 6 3 5 7 9 11 3 5 In chronic bronchitis, there is believed to be Cervical Dorsal Lumbar increased mucus secretion with decreased ventila­ tory capacity and, as a result, a decrease in dif­ Fig. 1. Subjects and controls with chronic obstructive fusion. This increase in mucus secretion alteration pulmonary disease (COPD): 44 cases. could also result in a decrease in compliance. 20 Osteopathic manipulative therapy was designed to ( 1) modify somatic factors that directly or by 18 abnormal neural reflex activity caused or aggra­ 16 vated the pathophysiology of the disease and (2) to aid the body in reestablishing the normal physio­ 14 logic balance that has been caused to veer beyond 12 optimal homeostatic limits. 10 The neuromusculoskeletal examination was 10 assigned to two physicians for consistency. Neither 8 examiner knew if the subject was A or B. /·,, without COPD 6 / ...... , .,,-..J ' r- .,, '- /" I ' RESULTS 4 / '----' ' I ", ~ ~~ ' 1' ',, / 1 2 / V The first figure shows a compilation on the I ordinate of the neuromusculoskeletal findings in 0~__.__....____...____.__...._____. ___ __.__~___.~__,_ _ _.____. the various spinal areas which are represented by 0 2 4 6 3 5 7 9 11 3 5 the abscissa. The findings on the ordinate were the Cervical Dorsal Lumbar mean of those variations from parameters recorded Fig. 2. Comparison of subjects with and without COPD. at each spinal level. In figure 1, 44 cases, showing findings of chronic obstructive lung disease, dem­ onstrated increased neuromusculoskeletal findings tive lung disease who would receive just the stand­ in the dorsal area. This is significant when com­ ard treatment. Figure 5 shows the curve for subjects pared with subjects without chronic obstructive and controls compared with the entire group of 44 lung disease in which no comparable changes in patients with chronic obstructive lung disease. This the dorsal area were noted (figure 2). In figure 3, demonstrates that the pattern of neuromusculo­ 23 patients with chronic obstructive lung disease, skeletal activity is comparable. Figure 6 shows the type A subjects, to be treated with standard modali­ pairing of subjects and controls with the neuromus­ ties as well as osteopathic manipulation reveal their culoskeletal changes again most evident in the musculoskeletal findings to be similar to that of the dorsal area. Figure 7 reveals the findings of control 44 cases shown in figure I. Figure 4 represents patients with the original examination, and figure 8, 2 l cases of the B patients or controls with obstruc- the final examination, showing an improvement in 297

597-036 0 - 76 - 20 the neuromusculoskeletal findings. This was nificant (p > 0.05). The vital capacity also when repeated on several occasions. expressed as a percent of normal showed similar results. The residual volume increased in the 20 treated group but not in the control group (p >0.05). 18

16 20

14 18

12 16

10 14

8 12

6 10

4 8

2 6 0 4 0 2 4 6 3 5 7 9 11 3 5 2 Cervical Dorsal Lumbar 0 Fig. 3. Twenty-three subjects with COPD: Type A; treated 2 4 6 3 5 7 9 11 3 5 with standard modalities plus osteopathic manipulation. Cervical Dorsal Lumbar

20 Subjects and Controls with COPD ---­

18 Controls with COPD -­

16 Subjects with COPD -·-

14 Fig. 5. Subjects and controls with COPD compared with entire group. 12

10 20

8 18

6 16

4 14

2 12 0 10 0 2 4 6 3 5 7 9 11 3 5 8 Cervical Dorsal Lumbar 6 Fig. 4. Controls with COPD: 21 cases. Type B: standard treatment. 4

The pulmonary function studies revealed the 2 following: (table I) Blood gas tensions both in the 0 treated and control group remained within rela­ 2 4 6 3 5 7 9 11 3 5 tively the same value. The mean vital capacity was Cervical Dorsal Lumbar almost identical at the initial examination: the Subjects -----. treated group, however, showed an increase in Controls o- - -~ 0.5 liters while the control group increased by 0.1 liter. This was not considered statistically sig- Fig. 6. Pairing of subjects and controls. 298 20 the forced expiratory volume both to the control 18 and treated group. (table 4.)

16 However, there was a tendency for the treated subjects to show a greater improvement in their 14 lung function than the control subjects. It was in the 12 area of subjective improvement that the most I\ marked changes occurred in the treated group. " ....,I \ \.. 10 I ', Ninety-two percent of patients in the treated group, v '- 8 ', when responding to the questionnaire, stated that ---' ...... they were able to walk greater distances, had fewer 6 colds, upper respiratory infections, and less dys­ 4 pnea then prior to treatment. They were able to function in their normal capacities far better than 2 they had in the past. The cough, in addition, was 0 far less in all aspects. 0 2 4 6 3 5 7 9 11 3 5 Cervical Dorsal Lumbar CONCLUSIONS

Original Exam-­ Most studies of chronic obstructive pulmonary Final Exam--- disease have emphasized significant chronicity Fig. 7. Controls. 10 11 and poor response to treatment. , Yearly changes have been relatively small. Data would suggest that chronic obstructive pulmonary disease is one that begins many years prior to clinical 20 symptoms. 12 Because of its nature this makes 18 early diagnosis rather difficult. The data herein 16 presented is not complete by any means. Despite the relatively small number of individuals studied, 14 .,,.., the trend noted would indicate a relationship _,_.-J \ 12 , ' between the neuromusculoskeletal findings of / \ patients with chronic obstructive lung disease 10 I \ ,..,_ r, compared to a normal population without this ✓ 'I.,./ ' 8 \, condition. The studies of lung capacity suggest that specific osteopathic therapy might increase 6 various lung capacities. Subjectively, a marked 4 change with fewer deviations in the neuromusculo­ skeletal findings were revealed. This would sug­ 2 gest that there exists a relationship between the 0 neuromusculoskeletal findings and visceral disease 0 2 4 6 3 5 7 9 11 3 5 involving the lung. Lumbar Cervical Dorsal The patients who received osteopathic manipu­ lation in 92 percent of instances, claimed sub­ Original Exam-­ jective improvement in physical work capacity. Final Exam--- This was so consistently observed by the patients that careful observers could not blithely discount Fig. 8. Comparison of original and final examinations. its· importance. As a consequence, we have been looking for a reconciliation of the physical findings The mean total lung capacity increased in both the and the patients' increased physical capacity. treated and control groups. (tables 2 and 3.) The Perhaps the explanation rests in the area of im­ increase in the treated group was larger than the provement of patients' oxygen uptake and other increase in the control group. This same applied to similar measurements of physical work capacity. 299 TABLE I Mean Arterial Blood Gases and pH on Initial Exam and After Treatment, for Treated and Control Subjects

Initial exam After treatment Mean arterial blood gases and pH Treated Control Treated Control (N=13) (N=IO) (N=l3) (N=6)

pH 7.4±1.7 7.4 ± 2.4 7.4 ± 2.8 7.4 ± 0.8 P02(mm Hg) 86.6 ± 1.6 85.8 ± 1.1 83.0 ± 3.5 82.5 ± 3.2 PC02(mm Hg) 39.4 ± 1.5 40.0 ± I.I 34.4 ± 3.0 36.7± I.I

± Standard error.

TABLE 2 Mean Lung Volume Measurements on Initial Exam and After Treatment, for Treated and Control Subjects

Initial exam After treatment Mean lung volume measurements Treated Control Treated Control (N= 13) (N=IO) (N=I3) (N=IO)

VC: Measured 2.3 ± 0.2 2.4 ± 0.2 2.8 ± 0.2 2.5 ± 0.2 Percent of normal 68 ± 6 67 ± 5 77 ± 6 68 ± 5 Functional residual: capacity Measured 2.5 ±0.3 2.7± 0.3 3.2 ± 0.3 2.7 ± 0.3 Percent of normal 80 ± 7 83 ± 7 JOO± 7 85 ± 8 Residual volume: Measured 1.9 ± 0.2 2.0 ± 0.2 2.4 ± 0.2 2.0 ± 0.3 Percent of normal 100 ± 8 106 ± 10 129± 9 106 ± 11 Total lung capactity: Measured 4.1 ± 0.4 4.4 ± 0.4 5.1,± 0.3 4.5 ± 0.4 Percent of normal 77 ± 5 80± 5 94 ± 5 82 ± 5 RV/TLC .43 ± .03 .43 ± .03 .47 ± .03 .39 ± .05

TABLE 3 Mean of Carbon Monoxide Diffusion Studies and Other Respiratory Function Studies, on Initial Exam and After Treatment, for Treated and Control Subjects

Initial Exam After Treatment Means of carbon monoxide diffusion studies and MVV Treated Control Treated Control (N= 13) (N=IO) (N= 13) (N= 10)

D,.COss-measured 10.26 ± 1.04 11.39 ± I.87 11.7 + 1.30 11.58 ± 1.90 Percent of normal 72 ±6 72 ± 7 84± IO 71 ± 10 Tidal volume - measured 4.95 ± 0.39 4.32 ± 0.47 5.93 ± 0.43 5.54 ± 0.57 Minute ventilation- measured 8.108±4.95 6.283 ± 7.59 8.745 ± 4.86 9.410± 1.221 MVV-measured 51.3 ± 6.0 75.3 ± 14.7 65.7 ± 5.5 75.9 ± 11.4 Percent of normal 60 ±7 75± 9 77 ± 7 68 ± IO

300 TABLE 4 Mean of Forced Expiratory Volumes and Forced Expiratory Flow Rate on Initial Exam and After Treatment, for Treated and Control Subjects

Initial Exam After Treatment

Flow Studies Treated Control Treated Control

(N= 13) (N=l0) (N= 13) (N= 10)

FEV1.u 72.4 ± 3.5 77.6 ± 3.3 74.5 ± 2.9 75.2 ± 3.0 FEV2.o 88.9 ± 1.4 90.0 ± 3.1 92.3 ± 1.6 91.6 ± 1.8 FEFR 1.5 ± 0.2 1.8 ± 0.2 1.6 ± 0.2 1.8 ± 0.3

REFERENCES 9. Allen, T. Use of thoracic pump in treatm_ent oflowerrespira­ tory tract disease . .I.A.0.A .. 67:408-411, December I. MacConail, M. Muscles and Movements. Williams & Wil­ 1967. kins, Baltimore, 1969. I 0. Allen, T. Management of acute exacerbation of COPD. 2. Campbell, E. Respiratory Muscles. Second Ed., W. B. .I.A.0.A .. 71 :330-333, December I 971. Saunders Co., Philadelphia, 1970. I I. Emirgil, C. Study of the long-term effect of therapy in 3. Hoag, J. M. Osteopathic Medicine. McGraw-Hill, New chronic obstructive pulmonary disease. Amer. J. Med., York, 1969. 47:3-367-377, 1969. 4. Guyton, A. C. Textbook of Medical Physiology. W. B. 12. Barrow, B. Course and prognosis of COPD. New Eng. Saunders Co., Philadelphia, 1971. .I. Med., 280:397-404, l 969. 5. Friedenberg. Disease of the Heart. Third Edition, W. B. Saunders Co., Philadelphia, 1968. 6. Hurst, J. W., Ed. The Heart. McGraw-Hill, New York, 1970. Grateful acknowledgment is given to the contributions of the 7. Gaensler, E. A., and Wright, G. W. Evaluation of respira­ faculty of Postgraduate Institute of Osteopathic Medicine and tory impairment. Arch. Em•iron. Health 12:173, Fehru­ Surgery: Philip E. Fleisher, 0.0.; Solomon Gerber, D.O.; ary 1, 1966. Mary E. Hitchcock, 0.0.; .I. Marshall Hoag, 0.0.; William 0. 8. Hall, J. Flow of lymph. New Eng . .I. Med .. 28 l :720- 722, Kingsbury, D.O.; Robert G. Thorpe, D.O.; William B. Strong, 1969. 0.0.

301 Design of Clinical Trials

JEROME CORNFIELD Chairman and Professor Department of Statistics The George Washington University

It is appropriate that a consideration of the design of independent investigations are undertaken; the of clinical trials should come at the end of this results are not always in agreement; subclasses of informative and interesting set of meetings. This patients are delineated, in some of whom there order of discussion recapitulates the course of is reason to think the therapy may work: the much modern medical investigation, in which exist­ literature grows; reviews of articles summarizing ing concepts and knowledge do not permit the the strengths and weaknesses of the various trials theoretical determination of the effectiveness get written: and increasing numbers of investiga­ of suggested therapies. They must, therefore, be tors come to realize that the expectation of quick subjected to the ultimate pragmatic test- do they and easy answers was naive and that the issues work? We have had a recent dramatic demonstra­ are more complex than was originally thought. tion of this process in the treatment of diabetes. 1 Lest this picture be thought overdrawn, I point Although the condition is characterized by an to the present status of anticoagulant therapy in impaired glucose tolerance, correction of the acute myocardial infarction, to cholesterol-lower­ impairment by lowering of blood glucose does ing therapies, whether by drugs or by diet. in not appear to inhibit the development of the vascu­ postcoronary patients, and to the oral hypogly­ lar sequelae of diabetes in a large class of patients cemic agents in diabetes. Furthermore, clinical and this could have been discovered only by trying trials are not exactly most people's idea of fun it and seeing what happened. since they demand unremitting attention to detail, It is not as easy as it might seem to answer the and, in collaborative trials, working with other question of whether a therapy works. The con­ investigators whose views must be accorded trolled clinical trial, according to no less a person respectful attention, no matter how doubtful they than the President of Royal College of Surgeons may seem. So, on the assumption that there are ·•was as important and valuable as the discovery pressing questions about manipulative therapy of penicillin" in its effort to provide a systematic for which answers simply must be found, l shall and widely accepted way of evaluating therapy. try to sketch some of the design issues that will Its basic value is that it shifts attention from arise. But be forewarned that they won't be as abstract theorizing and the enumeration of special easy to implement as might be thought. cases to resolvable issues, such as exactly what The first issue is how to allocate patients among therapy is under investigation, exactly what is the therapies to be compared. Control and experi­ it supposed to do to exactly what class of patients, mental patients must be alike in all relevant fac­ and exactly what observations are needed to see tors if differences in the outcome are to be at­ if it does. I wish I could go on to say that once tributed to the therapy under study. But the only this is done it is possible to mount a crucial experi­ safe way now known to achieve this compara­ ment which provides definitive and universally bility is by random allocation. The fundamental accepted answers. This may sometimes happen, difference between the clinical trial and its second but, as the old story goes, it has never happened cousin, the epidemiologic investigation, is that to me. The more usual situation is that a number in one the patients are randomly assigned to therapy 303 and in the other they assign themselves, with control day, so that they could receive what effects on comparability that cannot always be was regarded as the superior therapy- the anti­ readily determined. Numerous examples could coagulant. At least a partial explanation of subse­ be given of the noncomparability of patient groups quent nonconfirmation of their results is the non­ formed by methods other than random allocation, comparability induced by the alternation. so that the burden of proving comparability of Excessive dropout of patients after randomiza­ groups not formed at random rests on the investi­ tion can seriously weaken a study, and has. up gators. As I understood Dr. Gitelman 's interest­ to now, made it impossible to evaluate the effect ing summary of published evaluations of manipu­ of exercise in postcoronary patients. If the drop lation. none of them involved randomization. in Dr. Miller's tables from 44 to 23 patients is Dr. Miller does attempt such an allocation and for due to dropouts, he is in the same boat. this he deserves much credit. Subjective outcomes, and this could include Even with such an allocation it has become performance on pulmonary function tests, present necessary to convince critics that the randomized a serious difficulty. Many of the best things in groups are in fact comparable with regard to a range life are, of course, subjective and therapeutic of characteristics relevant to the outcome vari­ evaluations cannot avoid dealing with them. The ables being investigated. Dr. Miller has presented problem is not in the subjective response per se us with a comparison, particularly in figure 5 but in its interpretation. Even in a randomized and in his tables, of what I take to be baseline clinical trial, subjective improvement in the characteristics of the two groups. The ordinates treated group can be interpreted either as the of the graphs are stated to be '"neuromuscular effect of therapy as compared with the control findings." I do not know what this parameter is or as autosuggestion. There are many examples and consequently am unable to comment further that emphasize that the hypothesis of autosugges­ on the graph. The blood gas and pulmonary vol­ tion is not a fanciful one. An early operation for ume and function measurements provide addi­ the relief of angina] symptoms, the mammary tional information on comparability; but since artery implant, was widely considered as success­ the - number of patients for whom these measure­ ful until it was shown that a sham operation, ments are available is 23 rather than the 44 origi­ consisting of a superficial incision on the chest nally randomized, these results are difficult to wall, which was then sewed up. was equally suc­ interpret. cessful. :i Placebo effects in drug trials are almost Most experts in chronic obstructive lung disease beyond enumeration. I need mention only a re­ would regard equality in baseline smoking status cently reviewed trial in which the nausea and as mandatory to establish the comparability of vomiting of pregnancy was reported by par­ the two groups of patients. Since this information ticipating patients to have been spectacularly is also lacking, I must conclude that the com­ relieved by the placebo. parability of the two groups still remains to be In drug trials the standard procedure for elimi­ demonstrated. nating both patient and physician bias in evaluation Alternation of patients is not the same as random of outcome is blinding; neither the patient nor assignment, even when the first patient in each the physician knows the therapy to which the pair is assigned at random. Such an alternation patient has been assigned. In the nausea and permits anyone to predict the treatment assign­ vomiting of pregnancy example, an even greater ment of half the patients before they are actually relief was reported by patients on the therapy so assigned. Such predictability would have harmful that, while a considerable degree of autosuggestion consequences, as in the initial study of anti­ was present, the therapy had an effect over and coagulant therapy in acute myocardial infarction above that of autosuggestion. by Wright and his associates,2 ·in which patients How could blinding be achieved in the evaluation were allocated to therapy and control groups of spinal manipulation? The answer must eventu­ on alternate days. This was known to admit­ ally be provided by those most familiar with the ting physicians and their reaction to this knowl­ procedure, but the analogy of the sham operation edge, as documented in the final Wright report, is suggestive. Patients in the control group would was to withhold the admission of patients with be subjected to a manipulation which could not be more severe infarcts until after midnight of the distinguished from the standard manipulative 304 therapy, but which would, in the opm1on of the inducing similar changes in concomitant variables osteopathic and chiropractic community, be in­ in treated and control groups, but this must be effective. A similar procedure has been proposed demonstrated by monitoring the concomitant for the evaluation of acupuncture, the insertion of variables. In the National Diet-Heart Study this the needles in positions which acupuncture special­ was done and it was, therefore, possible to demon­ ists would consider without effect. The therapist strate quite similar changes. 4 Whether this is also administering both the sham and the approved true for the study presented by Dr. Miller cannot manipulation, would, of course, not disclose which be decided on the basis of the evidence presented was which to the patient: and the subsequent evalu­ to us. Did the treated patients, for example, reduce ation of the subjective outcomes would be done by the amount of their smoking more than the controls? someone who did not know the treatment assign­ I remark parenthetically, less as a criticism and ment of the patient. Whether such an approach is more in the hope of influencing future studies, that feasible must be decided by those more expert it is customary in controlled clinical trials to pre­ than I. But if it is not, it will not be possible to sent much more detailed information on the study interpret the subjective response that is associated variables than we have seen, or indeed than it was with spinal manipulation as caused by it rather possible to p_resent, today. There are many ques­ than by the autosuggestion it induces. tions that could be raised in addition to issues What about the ethics of a sham manipulation? already discussed. Is the statement that "there was It is, of course, necessary that patients be informed a tendency for the treated subjects to show a greater in advance that they might be assigned to either improvement in their lung function than the control group and that different forms of manipulation subjects" a clinical impression of the overall re­ would be involved. Experience in a wide variety sults, or is it the result of a statistical analysis: and of circumstances, including an ongoing study in if so, what was the analysis and what did it show? which patients with unstable angina, the so-called Ninety-two percent of the patients in the treated impending infarct syndrome, are randomly as­ groups reported symptomatic relief, but, entirely signed to either coronary bypass surgery or to aside from questions of specificity and interpreta­ medical therapy, indicates that most patients will tion of the difference, what did the controls report? agree to participation in such trials. But how can a Similarly, was it really 92 percent for each of the therapist who is convinced of the efficacy of his subjective improvements enumerated, as the manu­ therapy ethically justify withholding it from some script seems to state, or did it vary, as one might patients? The use of a randomized control group, expect, from improvement to improvement? How of course, already commits him to such a course long was the period of treatment and how long was and a sham manipulation, with the patient's prior the followup? How many patients dropped out? consent to a random allocation introduces no new Exactly what do the four specific manipulative ethical issues. In some recent trials the patients techniques used consist of? Were they all used on assigned to the control groups have turned out to each patient? One could go on, but I think it perhaps be the fortunate ones, since the controlled trial sufficient to suggest that those interested in the disclosed that the therapy had unanticipated and clinical evaluation of manipulative therapy, could undesired side effects. It can be argued at least as profitably review the reporting practices in ongoing cogently that subjecting patients to a course of controlled trials, such as that reported in this therapy about whose effects nothing definitive is week's J.A.M.A. by the Coronary Drug Project. known constitutes the really unethical procedure In the absence of such detailed reporting, con­ and that ethics require a controlled evaluation. clusions must be taken on faith, and this is entirely There is another general issue involved in ap­ contrary to the spirit and practice of the modern praising the specificity of whatever effect may be controlled clinical trial. found which is related to the question of blinding, I turn now to a set of issues that can be conven­ but raises additional issues, and that is the question iently grouped about the question of "How many of changes in other variables during the course of patients?" It has been by no means unusual for the investigation. In studies of diet and heart therapeutic trials to find, at the end of a long and disease, for example, related variables, such as difficult investigation, that the sample size used smoking, obesity and blood pressure may change was too small to supply clear-cut answers to the simultaneously. Blinding can control this effect by questions asked. It is advantageous before em- 305 barking on such an investigation to consider in examine enough end points and subgroups and a detail one's objectives and their implications for ·•significant" result is virtually guaranteed, even number of patients. There is a well-worked-out when none exists. body of theory for how one proceeds in this matter, The difficulties experienced by the Coronary and while it is always fun for a statistician to ex­ Drug Project in pinpointing on a post hoc basis the pound this theory to a medical audience, I do not subgroups in whom excess mortality was occurring, think we are quite at the point at which such an even with over a thousand patients on dextrothy­ exposition is required. The issues at this point roxine therapy and over two thousand on control. appear to me to be more elementary -what are is sobering. 5 If the most rigorous form of controlled the hypotheses that are to be tested? What specific clinical observation arrives at unequivocal con­ outcomes in what patient populations is spinal clusions only with difficulty, it is not surprising that manipulative therapy designed to influence and uncontrolled unverified clinical impressions can what are the magnitudes of the effects to be ex­ lead to nothing but continued controversy. pected? Although the required numbers of patients cannot be estimated until answers to these ques­ tions are forthcoming. the answers are required REFERENCES for more than statistical reasons: they are a pre­ I. The University Group Diabetes Program: A study of the requisite to achieving a scientific and generally effects of hypoglycemic agents on vascular complications accepted evaluation of therapy. in patients with adult-onset diabetes. Diabetes, 19 (supple­ ment 2): 747-830, I 970. It might be thought sufficient to adopt a shotgun 2. Wright, L. S., Marple, C. D., Beck. D. F., Report of com­ approach, i.e. to collect a wide variety of data, in mittee for evaluation of anticoagulants in treatment of coronary thrombosis with myocardial infarction (progress a wide variety of patient types, without prespecify­ report on statistical analysis of first 800 cases studied by ing a hypothesis or the patient subgroups to whom the committee). American Heart Journal, 36:801 -8 I 5, 1948. it applies and to search the results for significant 3. Spodick, D. H., Revascularization of the heart-numerators effects. There are dangers in such a course that in search of denominators. American Heart Journal, 81:149, 1971. are best summarized by saying that even if there 4. National Diet-Heart Study Final Report. Circulation. 37 are no effects present one expects to find signifi­ (supplement I): 279-309, I 968. 5. Coronary Drug Research Group: Findings relating to further cance at the P=.01 level in I percent of the end modification of its protocol with respect to dextrothy­ points and subgroups examined. One need only roxine. J .A .M.A., vol. 220, 996-1008, May 15, 1972.

306 Chairman's Summary: Comments on Therapeutic Studies

ANDREW B. WYMORE Osawatomie, Kansas

The general discussion on therapeutic studies United States. In Sweden it was given was initiated by the question: I have not heard up some IO years ago. anything about complications associated with • Complications from manipulation have spinal manipulative therapy. Would some of the been observed; I've certainly had three speakers be willing to briefly describe their com­ instances in my practice. Two were self­ plications? The response included: limiting within a week. There do exist • The most severe complications reported contraindications whereby manipula­ have been associated with upper cervical tion should be avoided. manipulation. Fairly simple clinical meas­ • It is justified to ask for statistics, and ures can be used to determine contra­ the graph by Glover shown by Dr. indications to the manipulative pro­ N achemson is statistically favorable to cedures. manipulative therapy. The study indicated • In 10 years and more than 50,000 manipu­ that manipulations were much more lations, no complications have been re­ successful than the control therapy dur­ ported in my clinic. The absence of sta­ ing the first 3 days, while at the end of tistics in the treatment of low back pain 7 days results were comparable. Is it not by manipulation does not prove that this advisable to attain the results faster form of treatment is poor. At one time sta­ than to wait for 7 days? Medical science tistics indicated that fusion was a good and surgery have advanced without al­ form of treatment for low back pain, and ways applying double blind studies, and this is no longer the case. Sixty percent of manipulative therapy which is not a low back pain did not originate from the standardized therapy, but is in the proc­ low back, but from T 10, T 11, T 12. There ess of ·evolution, would be a difficult is a method for determining which seg­ place to apply a double blind study. In the same light, how about applying double ment was involved. • While some low back pain may be self­ blind studies to surgery? limiting, if means exist of bringing ready relief they should be use_d. There was a detailed discussion of the problems • Statistics and not anecdotal observation associated with controlled clinical trials. Comments advance science. In the medical field - made during the discussion included: in the medicoscientific field- the truth takes a long time to carry through. Studies • Double blind trials for either surgery or from Mayo Clinic, Philadelphia (from manipulation were not being advocated, Rothman), and Seattle, Washington rather single blind trials. have demonstrated that lumbar fusion • It is possible, though difficult and tedi­ is not the operation for low back pain ous, to design valid clinical trials of and that it is being abandoned in the surgical intervention. Lack of prospec- 307 tive randomized controlled trials is not treated every day just what the safest, the sole property of any of the disci­ most efficacious treatment may be. There plines represented here. While we have is need for standardization of diagnostic heard much about drug treatment of hy­ measurement. We need to study reliability pertension, in the majority of hyper­ and validity, sensitivity and specificity in tensives we do not have convincing trial the measurement process, since these evidence of efficacy or safety. We need clinical measurements do relate to the much research in medical, surgical, osteo­ basic treatment given. We need more pathic, and chiropractic areas directed data in every specialty and better de­ toward therapeutic evaluation. We need signed, more scientific, more believable to know in the interest of patients being results.

308 Clinical Research Areas Requiring Further Study

FLETCHER H. McDOWELL Professor of Neurology Cornell University College of Medicine

It is an unusual opportunity to have nearly It is certainly not a new observation that severe the last word at an important conference. There or noxious stimuli from the periphery alter visceral are a few things I would like to mention about function or that major alterations in visceral func­ research that seem to me to be important. tion alter somatic function. What is needed is data First of all, I think it is desirable to organize that chronic less severe peripheral stimulation the discussion of needed investigation into three can change visceral activity. categories: At the bedside it is difficult to think of basic science studies which could be carried out to 1. The evaluation of chiropractic therapy; support chiropractic theory. It is possible that 2. Chiropractic dianostic technique; and the use of cortically evoked responses from 3. The basic science underpinning of peripheral stimulation might be useful in the study chiropractic concepts. of nerve root compression. Altered cortical re­ If these are mixed, we will likely take sides on sponses from stimuli in the neural segment of the issues which will interfere with a sensible dialogue. compressed root might be used to investigate the First, I would like to mention what seem to role of compression in altered neural function. me to be excellent opportunities for firming up A major area of basic science - clinical in­ basic science correlation with chiropractic con­ vestigation that should be undertaken is more cepts. The correlation of basic science data and thorough clinical pathological correlation. I did clinical observation is often difficult and usually not know of the report that Dr. N achemson relies on animal experimentation. You have heard mentioned about the study of ch~nges in vertebral today of some rather elegant experimental tech­ joints, but it seems to be appropriate for neuro­ niques which could be used to investigate chiro­ pathologists and pathologists to look at the ver­ practic theory. The studies of Dr. Sharpless and tebral column for telltale evidence of fibrosis, Dr. Sato could be combined to examine the joint thickening, nerve compression and other effects of afferent barrage caused by nerve root changes that might suggest a connection between compression on the central excitatory state, a pathological process and a history of trouble changes in reflex activity and the effects on au­ with back pain or other disturbances in the past. tonomic function. Using Dr. Sharpless' technique It will take a long time to get the information of nerve root compression, one could sample but it is a worthy task. neural activity in the spinal cord and in higher In the area of diagnostic techniques at the centers in response to varying degrees of pres­ clinical level, careful scrutiny of the accuracy and sure on nerve roots. With this technique, Dr. reliability of chiropractic diagnostic methods Sato has the opportunity to study somatic visceral is needed. As Dr. Remington mentioned, the reflexes and to see whether chronic irritation of accuracy of these methods affects every clinical spinal nerve roots in the experimental animal study. It is clear to any of you who have studied changes visceral function. the reliability of clinical diagnostic techniques, 309 that there is enormous variability between in­ We know it was first practiced by the Egyptians: dividual observers. by the 20th century. we found that there are a few Chiropractic physical diagnostic techniques rather specific conditions which are treated by at the bedside need to be carefully correlated with this therapy and that most others are made worse, what is seen on X-rays, and what is found with or not helped by this treatment. techniques like thermography, and so forth, on a We must evaluate therapy as rapidly as possible, blinded basis. For instance, one could review I 00 because therapies are being suggested with in­ back X-rays of patients who come to chiropractors, creasing frequency and the public is anxious for list the abnormalities found without knowing effective relief from its complaints and its diseases. the patient's history, and then see how good the All of us are concerned with relieving human correlation is with the symptoms and how ac­ suffering. one way or another. curately they have been localized. These studies I'm not bothered by a kind of therapy as long are often tedious and long, but need to be well as it can be shown to be effective and is safe. As designed. They need to be done and if done, will for manipulative therapy, my experience with it enhance the ability to evaluate therapy correctly. certainly is limited at best. It may be effective. I suspect that I wouldn't get too much argument I have the impression that there are obviously going from most of you if I stated that in the overall to be some conditions for which it is effective. totality of human illness, about two-thirds of it is It is mandatory that we take the steps needed to self-resolving. Regardless of what kind of outside prove this. First of all, we must focus on the intervention we choose to use, the patient often elements of chiropractic therapy, if we are going will get well by himself. to talk about effective treatment. If it were more than that figure, that is, if it were Second. we must s~arpen diagnostic techniques over 80 percent, I suspect there'd be no need for and be certain that we are talking about the same our skills. If it were less than 50 percent self­ thing when we make a particular diagnosis, and resolving, we'd either all be out of work or in jail. know exactly what is being studied. This demands that anyone who suggests a therapy Perhaps the most important problem related to for a particular condition must demonstrate to manipulative therapy is that of quantifying treat­ the satisfaction of the best possible scientific ment. That is, how often is therapy administered, scrutiny that he can better the natural history of how vigorously, for how long. and at what stage illness. of the disease. For those of you who have sat here today and heard the controversy about the use of manipu­ I need not tell you who have dealt with patients lative therapy, I would suggest that this is a polite, that the interaction between a sick individual and quiet session compared to some where neurologists his physician is complex. All kinds of things are deal with neurosurgeons about the treatment going on, probably the most important being that of stroke or cerebral aneurysm. Often needed the patient is relieved of the responsibility of his studies have been impeded by the fact that in­ illness when he hands it to his physician. That dividuals choose sides about therapy and refuse simple act may be the important factor, and much to recognize the fact that what must be done is of other therapy may have little to do with the to demonstrate that the natural history of an ill­ relief of symptoms. ness or complaint can be improved. One has to be sure that a therapy is effective at There are two ways to do this. One is by con­ better than chance level. This objective is what the trolled trials which have as their main desira­ statisticians have helped modem evaluators of bility that they offer short and accurate routes therapies and drugs to do. to desired data. I think that the time is ripe for carefully con­ The other way is to gather anecdotal evidence trolled clinical therapeutic trials of manipulative about the efficacy of therapy through careful therapy for a variety of conditions. I also believe clinical observation of patients. This has been that this should be a cooperative venture between the standard means of sorting problems out, but physicians and chiropractors. it sometimes takes a decade or longer to do it As someone pointed out, if we do it separately we and sometimes it takes centuries. It is hard to be may arrive at the same conclusion, but it will take sure how long it took to determine the usefulness a long time. If we do it together, we may get there of skull trepanization as an effective therapy. more quickly.

310 U.S. GOVERNMENT PRINTING OFFICE : 1976 0-597-036