THE EFFECT OF CERVICO-THORACIC ADJUSTMENTS ON THE ACTIVITY OF THE LATTISIMUS DORSI MUSCLE AND ITS TRIGGER POINTS USING ELECTROMYOGRAPHY AND ALGOMETER READINGS RESPECTIVELY.
A dissertation submitted to the Faculty of Health Sciences, University of Johannesburg, in partial fulfilment of the requirements for the Master's Degree in Technology: Chiropractic.
By
Nico Goosen (Student number 802013714)
SUPERVISOR: oS og DR. M. MOODLEY DATE (M. Tech. Chiropractic (Natal))
DECLARATION
I, Nico Goosen, do hereby declare that this dissertation is my own, unaided work except where otherwise indicated in the text. It is being submitted for the Degree of Master of Technology at the University of Johannesburg, Johannesburg. It has not been submitted before for any degree or examination at any other Technikon or University.
Signature of Candidate: Date: °7 i&S—/Ok
Signature of Supervisor: n/■,e■I'■-c•c>U2_s--k Date: S Dr. M. Moodley M.Tech. Chiropractic (Natal)
ii DEDICATION
This work is dedicated to my parents, Braam and Beneta Goosen, two extraordinary people whose love and support made everything possible. I am truly blessed to be your son and love you with all my heart.
And
To my wife, Terina Goosen, an amazing woman whose kindness and love is an example for us all. Thank you for all your support. Thank you for all the sacrifices you have made for me to reach my goals. You are a wonderful wife and friend.
iii ACKNOWLEDGEMENTS
First and foremost, praise and glory to our Lord and Saviour, Jesus Christ, through whom all things are possible.
To Dr. Moodley, my supervisor, for her support and constant enthusiasm throughout this study. Her assistance in this study is greatly appreciated and her ongoing motivation made the world of difference.
To my friends and family for their unwaving love and support, especially my wife and parents, for their constant guidance and prayers.
And finally, a special thanks to all the patients who participated in this study.
iv ABSTRACT
OBJECTIVE: To determine and compare the effect of Spinal Manipulative Therapy (SMT) to the cervico-thoracic junction on the activity of the ipsilateral latissimus dorsi with regards to muscle activity measured by electromyography and activity of the trigger points measured by the algometer.
STUDY DESIGN: Fourty subjects with lower cervical spine pain and dysfunction underwent six spinal manipulative treatments on alternative days over a 3 week period (excluding weekends) to test the changes in activity of the ipsi-lateral Latissimus Dorsi muscle.
SETTING: Chiropractic Day Clinic at the University of Johannesburg, Johannesburg, South Africa.
SUBJECTS: Forty subjects with lower cervical spine pain participated in this study. Each of the subjects was randomly assigned to one of two groups. Group A consisted of 20 subjects receiving SMT to the cervico thoracic junction. Group B consisted of 20 subjects receiving de-tuned ultra-sound to the area of cervical spine pain.
METHODS: Latissimus Dorsi muscle activity and its trigger point activity were tested before and after the first consultation using electromyography and the algometer respectively. After consultations two, four and six readings were taken. For the electromyography readings subjects were asked to lie down in a prone position with their arms next to their sides. They were then instructed to lie as still as possible for three minutes. The mean, peak and minimum values from the surface electromyographic meter were recorded, analysed and compared for reference. For the algometer readings, the researcher grasped the Latissimus Dorsi muscle along the free border at the posterior axillary fold of the midscapular level. The algometer was then pushed into this point and candidates had to indicate when they started to feel pain. This measurement was then recorded. RESULTS: Data was analysed using the T-test for independent samples to compare the two individual groups. Repeated measures ANOVA was useful to investigate changes over time. If one considers Group A as the superior group, no statistical significant difference were noted between Group A and Group B regarding the electromyographic readings. With regards to the algometer readings no statistically significant differences were identified between the two groups except for the last consultation (treatment 4) of Group A where the p-value = 0.035<0.05.
CONCLUSION: In light of these findings, it can be concluded that there were no statistically significant differences between Group A and Group B, regarding the electromyographic readings. Group A showed the most favourable treatment efficacy in terms of the algometer readings. The trends shown in this study should be used and tested in future similar research studies incorporating larger sample groups.
vi TABLE OF CONTENTS
DECLARATION ii
DEDICATION iii
ACKNOLEDGMENTS iv
ABSTRACT
TABLE OF CONTENTS vii
LIST OF APPENDICES xii
LIST OF FIGURES xiii
LIST OF TABLES xiv
CHAPTER ONE — INTRODUCTION
1.1 Introduction 1
1.2 Statement of the problem 2
1.3 Objectives 2
1.4 Benefits of the study 2
vii CHAPTER TWO — LITERATURE REVIEW 4
2.1 Anatomy 4
2.1.1 Anatomy of aTypical Cervical Vertebra 4 2.1.2 Anatomy of the Seventh Cervical Vertebra 4 2.1.3 Anatomy of a Typical Thoracic Vertebra 6 2.1.4 Anatomy of the First Thoracic Vertebra 6 2.1.5 Anatomy of the Sacro-iliac Joint 7 2.1.6 Anatomy of the Latissimus Dorsi Muscle 7 2.1.7 Anatomy of the Gluteus Maximus Muscle 8
2.2 Biomechanics of the Cervico-thoracic Junction 10
2.3 Functional Anatomy 11
2.4 Stability vs. Instability of the Sacro-iliac Joint 13
2.5 The Self-locking Mechanism 14 2.5.1 Form Closure 14 2.5.2 Force Closure 16
2.6 The Vertebral Subluxation Complex (VSC) 17
2.6.1 The Kinesiological Component 19 2.6.2 The Neurological Component 20 2.6.3 The Connective Tissue Component 20 2.6.4 The Myologic Component 21
2.7 Effects of Chiropractic Adjustive Technique 21
2.8 Surface Electromyography 23
2.9 Algometry 24
viii CHAPTER 3 — MATERIALS AND METHODS 25
3.1 Introduction 25
3.2 Study Design 25
3.2.1 Patient Selection 25 3.2.2 Patient Consent 26 3.2.3 Patient Sampling 27
3.3 Interventions 27
3.3.1 Chiropractic Motion Palpation 27 3.3.2 Spinal Manipulative Therapy 28
3.4 Measurements 29
3.4.1 Objective Measurements 29 3.4.1.1 Surface Electromyography 29 3.4.1.2 Algometer 30
3.5 Data Analysis 30
CHAPTER 4 — RESULTS 31
4.1 Introduction 31 4.1.1 Graphical Representation of Data 31
4.2 Demographic Data 32
ix 4.3 Objective Measurements 33
4.3.1 The Mean Surface Electromyographic Readings 33 4.3.1.1 Column statistics for the improvement in the average sEMG readings of the ipsi-lateral Lattissimus Dorsi muscle for group A and group B from data collected on the initial, second, fourth and final consultation 35
4.3.2 The Peak Surface Electromyographic Readings 36 4.3.2.1 Column statistics for the improvement in the peak sEMG readings of the ipsi-lateral Lattissimus Dorsi muscle for group A and group B from data collected on the initial, second, fourth and final consultation 38
4.3.3 The Minimum Surface Electromyographic Readings 39 4.3.3.1 Column statistics for the improvement in the minimum sEMG readings of the ipsi-lateral Lattissimus Dorsi muscle for group A and group B from data collected on the initial, second, fourth and final consultation 41
4.3.4 Algometer Readings 42 4.3.4.1 Column statistics for the improvement in the algometer readings of the ipsi-lateral Lattissimus Dorsi muscle for group A and group B from data collected on the initial second, fourth and final consultation 44
4.4 Non-Parametric Tests 45 CHAPTER 5 — DISCUSSION 47
5.1 Introduction 47
5.2 Demographic Data 47
5.2.1 Mean Age at Onset of Treatment 47 5.2.2 Gender 47
5.3 Objective Data 48
5.3.1 Electromyographic Readings 48 5.3.2 Algometer Readings 50
CHAPTER 6 — CONCLUSION AND RECOMMENDATIONS 52
6.1 Conclusion 52 6.2 Recommendations 53
REFERENCES 55
xi LIST OF APPENDICES
Appendix A: Advertisement 60
Appendix B: Contra-indications to Spinal Manipulative Therapy 61
Appendix C: Consent Form 63
Appendix D: Illustration of Adjustment 64
Appendix E: Case History 65
Appendix F: Physical Examination 70
Appendix G: Cervical Spine Regional Examination 80
xii LIST OF FIGURES
Figure 2.1: A Comparison between a typical cervical vertebrae and an atypical cervical vertebrae 6 Figure 2.2: Location'of the Lattissimus Dorsi muscle and the Gluteus Maximus muscle in relation to the thoracolumbar fascia 9 Figure 2.3: Model of the self-locking mechanism: To illustrate the combination of form and force closure to establish stability in the sacro-iliac joint 13 Figure 2.4: Form closure: decreasing sacroiliac joint shear through the "keystone in a Roman arch" effect, with the sacrum being "trapped" vertically 16 Figure 2.5: The posterior oblique sling 17 Figure 2.6: A Model of the Vertebral Subluxation Complex 18 Figure 4.1: Intra- and inter-group comparison of the mean improvement in the average sEMG readings of the ipsi- lateral Lattissimus Dorsi muscle for both groups using data collected on the initial, second, fourth and final consultations 34 Figure 4.2: Intra- and inter-group comparison of the improvement in the peak sEMG readings of the ipsi-lateral Lattissimus dorsi muscle for both groups using data collected on the initial, second, fourth and final consultations 37 Figure 4.3: Intra- and inter-group comparison of the improvement in the minimum sEMG readings of the ipsi-lateral Lattissimus Dorsi muscle for both groups using data collected on the initial, second, fourth and final consultations 40 Figure 4.4: Intra- and inter-group comparison of the improvement in the algometer readings of the ipsi-lateral Lattissimus Dorsi muscle for both groups using data collected on the initial, second, fourth and final consultations 43 LIST OF TABLES
Table 4.1: Demographic data 32 Table 4.2: Group A column statistics for the improvement in mean surface EMG readings 35 Table 4.3: Group B column statistics for the improvement in mean surface EMG readings 35 Table 4.4: Group A column statistics for the improvement in peak surface EMG readings 38 Table 4.5: Group B column statistics for the improvement in
peak surface EMG readings 38 , Table 4.6: Group A column statistics for the improvement in minimum surface EMG readings 41 Table 4.7: Group B column statistics for the improvement in minimum surface EMG readings 41 Table 4.8: Group A column statistics for the improvement in Algometer readings 44 Table 4.9: Group B column statistics for the improvement in Algometer readings 44
xiv CHAPTER 1— INTRODUCTION
1.1 Introduction
According to Pool-Goudzwaard, Vleeming, Stoeckart, Snijders and Mens (1995), the Latissimus Dorsi muscle, the thoracolumbar fascia and contra-lateral Gluteus Maximus muscle form the functional posterior oblique sling. These muscles function as synergists (Mooney, Pozos, Vleeming, Gulick and Swensky, 2001). Thus contraction of these muscles can directly optimise stabilisation of the sacro-iliac joint (Pool-Goudzwaard, Vleeming, Stoeckart, Snijders and Mens, 1998).
For modern society low back pain (LBP) is an expensive disease. The yearly prevalence varies from 15 — 20 % in the USA to 25 — 40 % in European countries and the lifetime prevalence is as high as 60 — 90 %. The minority of patients who recover within three months account for 75 — 90 % of the total expenses related to this health care problem, exceeding $60 billion per year in the USA (US department of health, 1994) (Pool-Goudzwaard et al., 1998).
Not withstanding the high prevalence, in 70 — 80% of cases, the cause of LBP is not clear. Pool-Goudzwaard et al., 1998 wondered what the reason could be for such a deficiency in our understanding.
The models used to understand and treat low back pain are generally based on descriptive anatomy. This branch of anatomy was developed to determine the structures that comprise the body and to categorise them (Pool-Goudzwaard et al., 1998).
Categories such as the spine, pelvis and lower limbs are primarily based on bony anatomy. Functional anatomy of the locomotor system, which is strongly linked to biomechanics, attempts to explain how bones, ligaments and muscles operate as a system. Could it be that better knowledge of the functional anatomy of the spine, the pelvis and lower limbs could lead to understanding of the aetiology of so called 'a- specific' low back pain? (Pool-Goudzwaard et al., 1998).
1 1.2 Statement of the Problem
The purpose of this study was to determine the effect of spinal manipulative therapy (SMT) to the cervico-thoracic region to determine a change in latissimus dorsi activity via electromyography (EMG) and a change in the trigger point in this muscle via an al gometer.
The hypothesis is that a favorable change in this specific muscle will have an effect on the contra-lateral Gluteus Maximus through the thoraco-lumbar fascia. Thus effectively having an effect on the stability of the Sacro-iliac joint by means of force closure.
1.3 Objectives
The first objective was to determine whether Chiropractic spinal manipulative therapy to the cervico-thoracic junction would affect muscle activity in the ipsi-lateral Latissimus Dorsi muscle. The second objective was to determine the effect of Chiropractic spinal manipulative therapy to the cervico-thoracic junction in terms of the trigger points activity in the ipsi-lateral Latissimus Dorsi muscle.
1.4 Benefits of the Study
If, as a result of this study, it was found that Chiropractic spinal manipulative therapy of the cervico-thoracic junction does indeed have an effect on the ipsi-lateral Latissimus Dorsi muscle with respect to muscle activity and the activity of it's trigger points, it would be beneficial to research this topic further to determine whether SMT to the cervico-thoracic junction might indeed have an effect on the contra-lateral Gluteus Maximus and directly have an effect on the stability of the Sacro-iliac joint.
2 Thus this study will pave the way for further research into this topic. It will help to highlight additional areas that will need further research with regards to muscle activity, myofascial trigger points and Chiropractic manipulative therapy, thereby improving our understanding on this topic and our competency as Chiropractors.
Thus this research should show that it is a necessity to examine the cervico-thoracic junction in a patient that presents with Sacro-iliac dysfunction.
3 CHAPTER 2 - LITERATURE REVIEW
2.1 Anatomy
2.1.1 Anatomy of a Typical Cervical Vertebrae
These are readily distinguishable by the presence of a foramen in each transverse process. The foramina (except that of the seventh vertebra) transmit the vertebral artery, a plexus of veins and autonomic fibers. The cervical nerves as they lie on the transverse processes pass laterally behind the vertebral artery. In a typical cervical vertebra (figure 2.1) the body is transversely oval. The superior articular processes have small flat articular facets, which face obliquely backwards and upwards, while the facets of the inferior articular processes face downwards and forwards. The spinous process commonly bifid and becomes progressively larger from the third vertebra downwards. The transverse processes also become progressively larger, and on them anterior and posterior tubercles can be recognized (Hamilton, 1956).
2.1.2 Anatomy of the Seventh Cervical Vertebra
The seventh cervical vertebra is sometimes called the vertebra prominens, as its long spinous process is visible through the skin at the lower end of the nuchal furrow. The spinous process of the first thoracic vertebra is usually just as prominent and sometimes more so (Moore and Dalley, 1999).
The seventh cervical spinous process is thick, almost horizontal and ends in a single tubercle, to which the lower end of the ligamentum nuchae is attached. Also attached near the tip of the spinous process are Trapezuis, Rhomboidius minor, Serratus posterior superior, Splenius capitis, Spinalis cervicis, Semispinalis thoracis, Multifidus and Interspinales muscles. The transverse processes are large, particurly their prominent posterior parts (Warwick and Williams, 1973).
4 Anteriorly to the transverse foramina, which are relatively small and may be duplicated, the anterior part of the process is slender and shorter. This is the costal element and may be a separate bone-, a cervical rib. The costo-transverse bar anterio- lateral to the foramen, is grooved by the ventral ramus of the seventh cervical nerve and is often partly deficient. The prominent posterior tubercle of the transverse process provides attachment for the Scalenus minimus muscle, when present and also to an aponeurotic layer that covers the cervical dome of the pleura, the suprapleural membrane (Warwick and Williams, 1973).
The seventh cervical vertebra or vertebra prominens, is distinctive because of its long and nearly horizontal spinous process. This process is not bifid, but has a tubercle to which the lower end of the ligamentum nuchae is attached. The transverse foramina of the seventh cervical vertebrae vary sometimes being small, occasionally double, or even absent. The usual arrangement is for the vertebral arteries and veins to pass in front of, rather than through the foramen, though there are many variations (Crouch, 1985).
Also known as the vertebra prominence due to its long knoblike spinous process, the spinous process can project almost as far back as the first thoracic spinous process. It has a small (sometimes absent) foramen transversarium, but the vertebral artery does not pass through it, rather the artery runs through the foramen tansversarium of the sixth vertebra and then courses upwards. It has a small costal process with an anterior tubercle which is sometimes absent. Occasionally the rib element is separate and then it is called a cervical rib (Scheepers, Duminy and Meiring, 1999).
5 Transverse process Anterior Body Body tubercle Groove for Anterior tubercle spinal nerve Posterior Posterior tubercle tubercle T. ransverse foramen
Pedicle
Superior articular facet
Inferior articular process Lamina Vertebral foramen Lamina Spinous process
4th cervical vertebra: superior. view 7th cervical vertebra: superior view
Figure 2.1: A Comparison between a typical cervical vertebrae and an atypical cervical vertebrae (Netter, 1997)
2.1.3 Anatomy of a Typical Thoracic Vertebra
The body is heart-shaped and characteristically has demi facets for the heads of the ribs. Superior and inferior demi facets are present on both sides of the vertebral body. The upper demi facet articulates with the lower facet on the head of the rib of the same number, the lower demi facet articulates with the upper facet of the next rib. The vertebral foramina are the smallest in the series. The pedicles are flattened from side to side and the inferior vertebral notch is much deeper than the superior notch. The laminae are short and broad and overlap each other like roof tiles. The spinous processes are long and slope downward, they end in a knob and overlap each other. The transverse processes have an articular facet anteriorly for the tubercle of it's own rib. The rib is a separate element (Scheepers et al., 1999).
2.1.4 Anatomy of the First Thoracic Vertebra
The first thoracic vertebra is to a large extend similar to a typical thoracic vertebra, except that it displays a full facet on the side of the body for the head of the first rib. Inferiorly there is a demi facet for the head of the second rib (Scheepers et al., 1999).
The first thoracic vertebra is distinguished from the remaining thoracic vertebrae by the upper costal facets on it's body. These are circular, articulating with the facets on the heads of the first pair of ribs. The spine is thick, long and horizontal and is
6 commonly as prominent as that of the seventh cervical vertebra (Warwick and Williams, 1973).
2.1.5 Anatomy of the Sacro-iliac Joint
These articulations are strong weight bearing synovial joints between the ear-shaped auricular surfaces of the sacrum and ilium. These surfaces have irregular elevations and depressions that produce some interlocking of the bones. The sacrum is suspended between the iliac bones and is firmly attached to them by interosseous and sacroiliac ligaments. The sacroiliac joints differ from most synovial joints in that they possess little mobility because of their role in transmitting the weight of most of the body to the hipbones. Movement of the sacroiliac joints is limited because of the interlocking of the articulating bones and the thick interosseous and posterior sacroiliac ligaments. The sacrotuberous and sacrospinous ligaments allow only limited upward movement of the inferior end of the sacrum, thereby providing resilience to the sacroiliac region when the vertebral column sustains sudden weight increases (Moore and Dalley, 1999).
The principal strains to which the ligaments are subjected, however, arise from flexion movements of the vertebral column, which tends to produce a similar movement at the sacro-iliac joints. These strains fall mainly on the ligaments, since there is little musculature so situated as to protect the joint from excessive movement, the musculature is almost entirely comprised in the sacral attachments of the Gluteus Maximus muscle (Hamilton, 1956).
2.1.6 Anatomy of the Latissimus Dorsi Muscle
The Latissimus Dorsi muscle as its name suggests is the widest muscle of the back. It has its origin from the thoracolumbar fascia, the crest of the ilium, the lower three or four ribs and as it passes over the inferior angle of the scapula it receives a few fasciculi from that bone. From this broad origin it passes laterally and superiorly, with the upper fibers nearly horizontal to the axilla of the arm and the fasciculi converge into a flat narrow tendon that spirals almost 180 degrees before inserting
7 into the bottom of the intertubercular groove of the humerus (refer to figure 2.2) (Crouch, 1985).
In spite of its widespread attachment to the trunk, the nerve supply is from a branch of the posterior cord of the brachial plexus (sixth, seventh and eight cervical nerves) (Hamilton, 1956). According to Warwick and Williams (1973), the thoracodorsal nerve innervates the Latissimus Dorsi muscle.
2.1.7 Anatomy of the Gluteus Maximus Muscle
The Gluteus Maximus muscle the most superficial gluteal muscle, is the largest, heaviest and most coarsely fibered muscle in the gluteal region. The Gluteus Maximus muscle covers the other gluteal muscles except the posterior third of the Gluteus Medius muscle, and forms a pad over the ischial tuberosity (refer to figure 2.2) (Moore, 1999).
It arises from the posterior gluteal line of the ilium, the aponeurosis of the Erector Spinae and from the thoracolumbar fascia. The fibers descend obliquely and laterally, the upper larger part of the muscle together with the superficial fibers of the lower part ending in a thick tendinous lamina. This passes laterally to the greater trochanter, and is attached to the iliotibial tact of the fascia lata. The deeper fibers of the lower part of the muscle are attached to the gluteal tuberosity between the Vastus Lateralis and Adductor Magnus muscles (Warwick and Williams, 1973).
8 Superior nuchal line of skull Semispinalis capitis muscle
Spinous process of C2 vertebra el.' • , Splenius capitis muscle
Spinous process of C7 vertebra Sternocleidomastoid muscle '
Posterior triangle of neck Splenius cervicis muscle
Trapezius muscle Levator scapulae muscle
Spine of scapula Rhomboid minor muscle (cut)
Deltoid muscle Supraspinatus muscle Infraspinatus fascia Serratus posterior superior muscle Teres minor muscle \I Rhomboid major muscle Teres major (cut) muscle
Infraspinatus fascia (over infraspinatus LatissiMus muscle) dorsi muscle
Teres minor and major muscles Spinous process of T12 vertebra Latissimus dorsi muscle (cut) Thoracolumbar fascia Serratus anterior muscle
External Serratus posterior inferior oblique muscle muscle
Internal oblique 12th rib muscle in lumbar triangle (Petit) Erector spinae muscle
Iliac crest External oblique muscle
Gluteal aponeurosis Internal (over gluteus medius muscle) oblique muscle
Gluteus maximus muscle
*Novella
Figure 2.2: Location of the Latissimus Dorsi Muscle and the Gluteus Maximus muscle in relation to the Thoracolumbar fascia (Netter, 1998)
9 2.2 Biomechanics of the Cervico-thoracic Junction
The head can be regarded as the platform that houses the sensory apparatus for hearing, vision, taste and smell. In order to function optimally, these sensory organs must be able to scan the environment. It is the cervical spine that sub serves this facility (Bogduk and Mercer, 2000).
Muscles of the neck execute head movements. The specific type of movement possible depends on the shape and structure of the cervical vertebrae and interplay between them. The kinematics of the cervical spine is, therefore, dictated by the anatomy of the bones that make up the neck and the joints that they form (Bogduk and Mercer, 2000).
Commonly regarded as the commencement of the typical cervical spine is the C2/C3 junction. Here all segments share the same morphological and kinematic features (Bogduk and Mercer, 2000).
The cervical intervertebral joints are saddle joints: they consist of two concavities facing one another and set at right angles to one another. Across the sagittal plane the inferior surface of the vertebral body is concave downwards, while across the plane of the zygapophyseal joints the uncinate region of the lower vertebral body is concave upwards. This means that the vertebral body is free to rock forwards in the sagittal plane around a transverse axis, and is free to rock side-to-side in the place of the facets around an axis perpendicular to the facets. Motion in the third plane that is side-to-side around an oblique axis, is precluded by the orientation of the facets. Therefore, it allows for flexion/extension but stipulates that the only other pure movement is rotation around an axis perpendicular to the facets (Bogduk and Mercer, 2000).
The planes of motion of a cervical motion segment include flexion and extension, and axial rotation. Axial rotation occurs around a modified axis, that passes perpendicular to the plane of the zygapophysial joint and this motion is cradled by the uncinate processes. Furthermore, was stipulated that horizontal rotation is inescapably coupled with lateral flexion, and vice-versa. If horizontal rotation is attempted, the inferior
10 articular process must ride up this slope. As a result, the vertebra must tilt to the side of rotation (Bogduk and Mercer, 2000).
Cardinal movements of the cervico-thoracic junction are the flexion-extension movements and shows with the numerous research addressing these movements at these segments (Bogduk and Mercer, 2000).
2.3 Functional Anatomy
A theoretical rationale for sacro-iliac joint stabilisation via muscle activity was presented by Vleeming et al., (1995). In this study, anatomic dissections revealed a strong connection between the Gluteus Maximus muscle on one side and the Latissimus Dorsi muscle on the other side by means of the thoracolumbar fascia. In cadaver studies, loads were directly transferred from one muscle group to the other. This is a reciprocal relationship that has been suggested in the past but not documented in living patients (Mooney, Pozos, Vleeming, Gulick and Swenski, 2001).
The Latissimus Dorsi muscle is supplied by the thoracodorsal (long subscapular) nerve through the posterior cord and spinal nerves C6, C7 and C8 (Simons, Travell and Simons, 1999).
Latissimus Dorsi muscle is an interesting muscle. From a relatively short, linear attachment on the humerus, this muscle covers the back of the thorax and assumes widespread distant attachment on the thoracic, lumbar, sacral spinous processes and to the ilium.
Furthermore, some authorities Vleeming et al, 1995 have ventured to say it's aponeurosis crosses the midline to reach the contra-lateral posterior superior iliac spine and that it is thereafter continuous with the aponeurosis of the contra-lateral Gluteus Maximus muscle (Bogduk, Johson and Spalding, 1998).
It is important to note that muscles, especially those like the Latissimus Dorsi muscle and Gluteus Maximus muscle, are able to exert a contra-lateral effect. This implies
11 that both the Gluteus Maximus muscle and contra-lateral Latissimus Dorsi muscles tense the posterior layer of the posterior oblique sling. Hence, parts of these muscles provide a pathway for un-interrupted mechanical transmission between the pelvis and trunk (Vleeming, Pool-Goudzwaard, Stoeckart, Van Wingerden and Snijders, 1995).
Mechanically, the Latissimus Dorsi muscle is a powerful adductor and extensor of the shoulder, when the trunk is fixed but it has also been ascribed an action in the lumbar spine and of reference more recently on the Sacro-iliac Joint (Guzik, 1996). When the pelvis is fixed it has been described as an extensor and lateral flexor of the back, and is reported to have a bracing effect on the Sacro-iliac Joint together with the Gluteus Maximus muscle, through it's action on the posterior layer of thoracolumbar fascia (Bogduk et al., 1998).
The thoracolumbar fascia plays an important role in load transfer between the trunk and legs. It is part of a "corset" that surrounds the trunk. The erector spinae muscles lie within its layers. Contraction of the Latissimus Dorsi muscle, Gluteus Maximus _ muscle and abdominal wall muscles tense the fascia, which effectively links the actions of these muscles (Waddel, 2004).
The Gluteus Maximus muscle is a major dynamic stabilizer of the sacroiliac joint. It has the greatest capacity to provide increased compressive forces at the sacroiliac joint secondary to its anatomical attachment at the sacrotuberous ligament (Prentice, 2000).
Gluteus Maximus muscle, because it runs perpendicular to the Sacro-iliac Joint, could also compress the joint and hence increase its stability directly and through it's attachment to the sacrotuberous ligament it could also stabilize the joint indirectly (Oldreive, 1996).
The Latissimus Dorsi muscle on the contralateral side could also compress the Sacro- iliac Joint via the thoracolumbar fascia in conjunction with the ipsi-lateral Gluteus Maximus muscle, as in the single support phase of gait (Oldreive, 1996).
12
For many decades, it was thought that the sacro-iliac joint was immobile due to the close fitting nature of the articular surfaces. However research in the last two decades has shown that mobility of the sacro-iliac joint is not only possible, but essential for shock absorption during weight bearing activities (Lee, 2001).
FOAM F-C,44CE CLCISUkE SI/Y.12111_1 Y Figure 2.3: Model of the self-locking mechanism: To illustrate the combination of form and force closure to establish stability in the sacroiliac joint (Schamberger, 2002)
2.4 Stability vs Instability of the Sacro-iliac Joint
Shear in the sacro-iliac joints (figure 2.3) is prevented by the combination of specific anatomical features (form closure) and the compression generated by muscles and ligaments that can be accommodated to the specific loading situation (force closure) (Harrison, 1997).
If the sacrum would fit the pelvis with perfect form closure, no lateral forces would be needed. However, such a construction would make mobility practically impossible (Schamberger, 2002).
Instability can be defined as a loss of the functional integrity of a system that provides stability (Lee, 1996). In the pelvic girdle there are two systems that contribute to stability — the osteoarticularligamentous system (form closure) and the myofascial system (force closure). Together they form the self-locking mechanism (Lee, 1996).
13 Stability (both for sustained and intermittent loading) can only occur when the passive, active and control systems work together to transfer load safely and efficiently (Panjabi, 1992).
Adequate approximation of the joint surfaces must be the result of all forces acting across the joint if stability is to be ensured. Adequate means not too much, not too little, but just enough. Consequently, the ability to effectively transfer load through joints is dynamic and requires: Intact bones, joints and ligaments, thus form closure. Optimal function of the muscles which includes the ability of muscles to contract tonically in a sustained manner as well as the ability of the muscles to perform in a co-ordinated manner such that the resultant force is adequate compression through the articular structures at an optimal point, thus force closure. Appropriate neural control, which ultimately orchestrates the pattern of motor control.
This requires constant accurate afferent input from the mechanoreceptors in the joint and surrounding soft tissues, appropriate interpretation of the afferent input and a suitable motor response (Lee, 2001).
2.5 The Self-Locking Mechanism
Some authors term this shear prevention Pool-Goudzwaard et al., (1998) system the "selfbracing or the selflocking mechanism" of the sacro-iliac joint. The shear prevention system is characterized by the combination of form and force closure.
2.5.1 Form Closure
According to Lee (1996) form closure refers to a stable situation with closely fitting joint surfaces, where no extra forces are needed to maintain the state of the system (refer to figure 2.4).
14 Since the Sacro-iliac Joints have to transfer large loads, it can be assumed that the shape of the joints are adapted to this task. The joint surfaces are relatively flat which is favorable for the transfer of compressive forces and bending movements (Snijders, 1993).
The Sacro-iliac Joints are protected from these forces in three ways. Firstly, due to its wedged-shape the sacrum is stabilized by the innominates. Secondly, unlike a normal synovial joint the articular cartilage is not smooth. Thirdly, by studying the frontal slides of intact joints of embalmed specimens we can show the presence of cartilage covered bone extensions protruding into the joint (Pool-Goudzwaard et aL, 1998).
Vleeming et al., (1995) who found that the coarse cartilage texture contributed to the ability of the joint to resist translation. The complimentary ridges and grooves in the mature Sacro-iliac Joint also increases friction and contributes to form closure or stability of the joint (Lee, 1996).
The Sacro-iliac Joint is surrounded by some of the strongest ligaments in the body. The dorsal sacro-iliac ligament system tightens when the sacrum extends relative to the innominate and it is thought to control this motion. The sacrotuberous and interosseus ligaments tighten during sacrum flexion and thus controls this motion (Lee, 1996).
The ventral Sacro-iliac ligaments are the weakest of the group, and are supported anteriorly by the integrity of the pubic symphysis. These ligaments contribute to form closure (Lee, 1996).
15 Figure 2.4: Form closure: decreasing Sacro-iliac Joint shear through the "keystone in a Roman arch" effect, with the sacrum being "trapped" vertically (Schamberger, 2002)
2.5.2 Force Closure
If the sacrum could fit in the pelvis with perfect form closure, mobility would be practically impossible. However, during walking, mobility as well as stability in the pelvis must be optimal. Extra forces may be needed for equilibrium of the sacrum and the ilium during loading situations (Pool-Godzwaard et al., 1998).
In the case of force closure, extra forces are needed to keep the joint in place. Here friction must be present. Compression of the Sacro-iliac Joint occurs when the Gluteus Maximus muscle and the contra-lateral Latissimus Dorsi muscle contracts (Lee, 1996).
The posterior oblique sling (refer to figure 2.5) can be energised by the coupled function of the Latissimus Dorsi muscle and the Gluteus Maximus muscle. These muscles function as synergists. Contraction can directly optimise stabilisation of the Sacro-iliac Joint (Lee, 1996).
Pool-Goudzwaard et al., (1998) assume that an increase in tension in the thoracolumbar fascia can lead to more compression on the Sacro-iliac Joint, increasing force closure.
16 (.31trttaz;.
Figure 2.5: The posterior oblique sling (Schamberger, 2002)
2.6 The Vertebral Subluxation Complex (VSC)
A subluxation is defined as a motion segment in which alignment, movement integrity, and/or physiologic function are altered although contact between the joint surfaces remains intact. This is in contrast to the medical definition of subluxation, which involves an incomplete or partial dislocation (Gatterman, 1995).
The vertebral subluxation complex is defined as a theoretical model of motion segment dysfunction (subluxation) that incorporates the complex interaction of pathologic changes in nerve, muscle, ligamentous, vascular and connective tissue (Gatterman, 1995).
The current model of the VSC appreciates that when a spine is dysfunctional, all tissues are involved in such an interconnected way that it is impossible to discern where one tissue involvement ends and another begins (Gatterman, 1995).
Immobilization degeneration is a term that refers to consistent patterns of degeneration in all tissues associated with an immobilized joint. There is considerable discussion as to whether partial immobilization can lead to significant degenerative changes. Trauma, both severe and moderate, can contribute to subluxation degeneration. The VSC model presented here will deal exclusively with
17 the neuromusculoskeletal components of spinal degeneration and dysfunction as they relate to the Chiropractic concept of subluxation (Gatterman, 1995).
Figure 2.6 illustrates the hierarchical organization of the VSC in which the components are seen in relation to one another. The kinesiological component is represented as the apex of the model because restoration of motion is the central goal in the clinical practice of Chiropractic. This is the functional end point of the combined efforts of the tissue components. Movement is affected by the muscles (myologic component); guided, limited and stabilized by connective tissue; and controlled largely by the nervous system (neurological component). The vascular system serves the essential nutritive and cleansing role for all tissues and is the means for the immediate stages of the inflammatory response (Gatterman, 1995).
"Sc
Myop^.; ho
pthology „oc hoh
Corirtez.:i,e tissve
re54..lonst
Figure 2.6: A Model of the Vertebral Subluxation Complex
18 These constitute the tissue-level components of the VSC, and each works in co- ordination with the others to permit and sustain proper movement. Interference with any single component affects all others. Each tissue component has a role to play in spinal pathomechanics and the pathological processes associated with subluxation degeneration (Gatterman, 1995).
2.6.1 The Kinesiologic Component
The basic unit of spinal mobility is the motion segment, a three-joint complex. Functionally, it may be considered to be a single, compound joint with three articulations. A typical motion segment consists of two adjacent vertebrae joined by an intervertebral disc, two posterior articulations with their capsules and several ligaments. The muscles and segmental contents of the spinal canal and the intervertebral canal are also included (Gatterman, 1995).
Atypical spinal motion segments include the occiput-atlas and the atlas-axis articulations. The pelvic ring with the two posterior Sacro-iliac Joints and the disc- like symphysis pubis also has been considered an atypical three-joint motion segment (Gatterman, 1995).
No disorders of a single motion segment can exist without affecting first the functions of the other components of the same unit and then the functions of other levels of the spine (Gatterman, 1995).
One of the most central tenets in Chiropractic is the notion that restricted motion of the manipulable subluxation is central to spinal degeneration. All situations that lead to immobilization cause some degree of degenerative change in the musculoskeletal system. Restoring motion to a previously immobilized joint leads to normal joint function and physiology. Although the degenerative effects of immobilization may be completely reversed on re-mobilization, the extent of and time for maximal recovery are dependent on the duration of immobilization (Gatterman, 1995).
19 2.6.2 The Neurological Component
Spinal nerves may be impinged by herniated discs or by osteophytosis around the joints of Luschka. Nerve impingement from facet joint hypertrophy can also occur. The dorsal root ganglia lie with in the intervertebral canal in close proximity to the articular capsule, except for the first and second cervical segments. Dorsal root ganglions contain all the cell bodies of all sensory neurons (Gatterman, 1995).
Articular neurology is central to the theory of chiropractic. Wyke (1985) classified - the spinal joint receptors into four types: three types of mechanoreceptors and one nociceptor. The spinal joints can produce patterns of pain referral but the neurological mechanisms are not well understood (Gatterman, 1995).
The afferent discharges derived from articular mechanoreceptors have a three-fold impact when they enter the neuraxis: reflexogenic and perceptual effects, and pain suppression. Joint inflammation sensitizes articular receptors to fire at rest and during normally non-noxious joint movements (Gatterman, 1995).
2.6.3 The Connective Tissue Component
The major impact of connective tissue changes in the vertebral subluxation complex model is seen with joint immobilization. All connective tissue elements are affected by immobilization, each with its own unique pattern of change (Gatterman, 1995).
When joints are immobilized, adhesions form between the adjacent connective tissue structures. Adhesions may also form between the nerve root sleeves and the adjacent osseous and capsular structures in the intervertebral canal, or between tendons and articular capsules, or between any two connective tissue structures that come into contact and do not move relative to one another (Gatterman, 1995).
20 2.6.4 The Myologic Component
With immobilised joints the associated muscles will undergo a degenerative process known as disuse atrophy. This process is complicated by the fact that different muscle types respond differently to immobilization. These muscle changes are secondary to joint changes in some cases, but in turn, also contribute to joint degeneration (Gatterman, 1995).
Muscle spindles are adversely affected by immobilisation showing significant morphologic, physiologic and biomechanical changes, including shortening and thickening, degeneration of the primary muscle spindle endings, swollen capsules, and loss of cross-striations. Physiological alterations of immobilisation include increased sensitivity to stretch and elevation of resting rate. This results in an excessive feed of stimuli into the central reflex pathways, resulting in altered efferent activity. This could lead to the over-stimulation of muscle groups that respond to the stretch reflex leading to muscle spasm as well as tender and active myofascial trigger points. Alternatively, such input could lead to reflex inhibition or failure of joint musculature on challenge (Gatterman, 1995).
2.7 Effects of Chiropractic Adjustive Technique
Wyke (1999) mentions the reflexogenic effect of the joint capsules due to nociceptive and mechanoreceptor influence that affect the muscle tone of muscle both segmentally and intersegmentally (Hammer, 1999).
The characteristics of uncomplicated joint dysfunction include mechanical alteration and/or restriction of range of motion. The impact this has on reflex stimulation and/or inhibition on the articular neuroreceptors is the basis for several models for the effectiveness of spinal manipulation (Vernon and Mootz, 1999).
21 The reflex mechanism involved in muscle spasm may be interrupted by the adjustment, leading to an instantaneous restoration of motion. Muscle changes from fixation dysfunction are often completely reversible depending on the type of muscle and the duration of the immobilization (Plaugher and Lopes, 1993).
Spinal treatments have been associated with measurable electromyographic responses in muscles close to the target areas that were associated with -- reflex pathways (Gatterman, 1995).
Manipulation and mobilization are two manual techniques that are commonly used by osteopaths, Chiropractors and physiotherapists to treat spinal pain and dysfunction. Spinal manipulation and mobilization have been proposed to have a number of therapeutic benefits, including the stretching of shortened and thickened peri-articular soft tissues to improve range of motion, improved drainage of fluid within and surrounding the joint, and changes in pain modulation, motor activity and proprioception (Fryer, Carub and McIver, 2004).
According to Bolton (2000) studies clearly identified that slow —conducting (group3 and 4) afferents with receptive fields in the zygapophyseal joints and paravertebral tissues can be activated by mechanical forces applied to the zygopophyseal joints, para-articular tissues, or both. Some of these high (mechanical) threshold afferents (group 4) may be responsible for relaying signals that result in the sensation of pain known to arise from the vertebral joints. There is good evidence that displacement of vertebrae modulate nerve activity in afferent nerves innervating muscle spindles and other low (mechanical) threshold receptors, such as Golgi tendon organs in the intervertebral muscles.
22 2.8 Surface Electromyography
Surface electromyography is a technique used to measure muscle activity. It is non- invasive, using surface electrodes that are placed on the skin overlying the muscle. In addition surface electromyography can record both voluntary and involuntary muscle activity (Pullmann, Goodin, Marquinez and Tabbal, 2000).
One sign of segmental dysfunction is the presence of muscle hypertonicity. Localized increased muscle tone can be detected with palpation and by electromyography (Peterson and Bergman, 2002).
Surface EMG provides objective quantitative data concerning the changes in muscle function that accompany vertebral subluxation (Masarsky and Todres Masarsky, 2001).
As muscles generate, action generates currency that flows through the resistive medium of the tissues, and these voltage gradients produced may be recorded as the myolectrical signal (Loeb and Gans, 1997).
Clinical and anecdotal observations of electromyographic responses associated with spinal manipulative therapy have been made for a long time. It has been hypothesized that these electromyographic responses have a beneficial treatment effect by inhibiting hypertonic muscles. Reduction in hypertonicity might be supported if SMT caused an electromyographic response in the hypertonic musculature followed by a decrease in hypertonicity, evaluated by electromyeolography (Herzog, Scheele and Conway, 1998).
23 2.9 Algometry
Instruments measuring pain have been introduced since the beginning of physical therapy or even earlier. Instruments most frequently used to measure pain, include questionnaires and applying pressure by palpation, which are probably the oldest and simplest methods. However, there is a need for reproducibility and quantification of manual pressure. The algometer is an instrument that can quantitate local tenderness on pressure (Hogeweg, Langereis, Bernhards, Faber and Helders, 1992).
Both in clinical practice and experimentally it would be of great value to have a reliable yet simple method to quantify trigger point sensitivities once they have been manually located. The pressure algometer may be suited for this purpose (Reeves, Jaeger and Graff-Radford, 1986).
Pressure threshold is the minimal pressure which induces pain. The algometer has been proven to be useful for quantification of deep muscle tenderness and trigger points. Pressure algometry has been used for evaluation of sensitivity to pain and the assessment of pressure perception (Fischer, 1987).
24 CHAPTER 3 - MATERIALS AND METHODS
3.1 Introduction
This chapter serves to explain and describe the way in which this study was constructed and carried out.
3.2 Study Design
The purpose of this study was to assess the effect of SMT to the cervico-thoracic junction and to determine the changes in activity of the ipsi-lateral Latissimus Dorsi muscle and it's trigger points.
3.2.1 Patient Selection
Forty subjects with lower cervical spine pain were required to participate in this study. Advertisements were placed in and around the Doornfontein Campus of the University of Johannesburg to attract possible participants (Appendix A). The study was conducted at the University of Johannesburg Chiropractic Day Clinic.
Prior to inclusion in the study, each subject had to undergo a thorough examination conducted by the researcher. This included a case history (Appendix E), physical examination (Appendix F) and an orthopedic examination of the cervical spine (Appendix G). Subjects were included and excluded from the study on the following criteria.
25 Inclusion Criteria
The following are inclusion criteria: Positive results for cervico-thoracic joint dysfunction as determined by motion palpation of the cervico-thoracic junction. Aged between 18-30 years. Candidates must present with lower cervical spine pain. Good general health.
Exclusion Criteria
The following are exclusion criteria: Patients outside the age group. Patients with structured deformities of the spine (for example: scoliosis, ankylosing spondylosis, fused vertebrae). Any muscular pathology.
Subjects were excluded if they presented with any contra-indication to spinal manipulative therapy (Appendix B), as determined by case history, physical examination findings, and cervical spine regional examination.
3.2.2 Patient Consent
After a participant met all the inclusion criteria, he/she received all the information relevant to the study. Each subject was then required to give written informed consent acknowledging his/her participation in this study (Appendix C).
26 3.2.3 Patient Sampling
Subjects that met the inclusion criteria were assigned randomly to one of two groups of 20 participants each. Group A: 20 subjects receiving spinal manipulative therapy of the cervico- thoracic junction; Group B: 20 subjects receiving de-tuned ultrasound to the cervico-thoracic junction.
3.3 Interventions
Subjects were treated six times over a three-week period. This involved two consultations during the first week, two during the second week and two during the third week.
3.3.1 Chiropractic Motion Palpation
Motion palpation of the cervical spine was used to assess the zygopophyseal joints for Chiropractic manipulation. All assessments were done prior to each treatment with the subject in a seated position. The following motions were assessed: C2 — C7.
i. Flexion /extension of C2-C7 Bilateral contact was established over each one of the articulations. The index and middle fingers were placed on one side, and a thumb contact on the other side. After assessing each level, the hand was moved down to the next level. The indifferent hand supported the top of the head, inducing flexion and extension. During extension, the articular pillars should glide postero-inferiorly resulting in approximation of the joints. During flexion the articular pillars should glide antero-superiorly with separation of joint surfaces (Peterson and Bergmann, 2002).
27 ii. Rotation of C2-C7
The palmar surfaces of the middle and index fingers contacted the posterior surfaces of the articular pillars of adjacent vertebrae. The hand was moved down the cervical spine after assessing each level. The indifferent hand passively rotated the head away from the contact hand. The superior pillar should move forward relative to the inferior pillar during cervical rotation to the opposite site (Peterson and Bergmann, 2002).
iii. Lateral Flexion of C2-C7
The contact is as per the contact hand for rotation above. The palmar surfaces of the middle and index fingers contacted the posterior surfaces of the articular pillars of adjacent vertebrae. The hand was moved down the cervical spine after assessing each level. The indifferent hand passively laterally flexed the head towards the contact hand, and then away. Articular pillars should approximate on the side of lateral flexion, and separate on the opposite side (Peterson and Bergmann, 2002).
3.3.2 Spinal Manipulative Therapy
Once a cervico-thoracic restriction in joint motion was analyzed, SMT was performed using the following diversified technique (Appendix D).
Thumb Movement: Bench TM Indications: Rotary or lateral flexion restrictions of C5-T3. Patient Position: Patient lies prone with the headpiece lowered and the head is turned away from the researcher. Researcher's position: Fencer stance facing cephalad, standing on homolateral side of the lesion. Cephalad foot in line with patient's shoulder.
28 Contact hand: Cephalad hand is the contact hand, using the pad of thumb contacting on the lateral aspect of the spinous process of the listed vertebra, and the forearm must be parallel to the floor. Indifferent Hand: Caudad hand and the palm cups the ear. Thrust: Indifferent hand indicates to patient to rotate head and traction is applied in a cephalad direction and into further rotation. The contact hand then thrusts straight across.
3.4 Measurements
3.4.1 Objective Measurements
The two objective measurements utilized were surface electromyography and algometry.
3.4.1.1 Surface Electromyography
On the first consultation the electromyographic readings were recorded prior to any interventions, be it spinal manipulative therapy for Group A candidates or de-tuned ultrasound for Group B candidates. This served to determine each individual's th th baseline reading. For the 2nd, 4t hand 6 visit readings were recorded after the treatment interventions. Electromyographic readings were recorded by the candidate was placed in the prone position on a horizontal plinth with their arms next to their sides. Two pre-gelled electrodes were placed on the Latissimus Dorsi muscle, more specifically one electrode was placed 1 cm medial and inferior to the inferior lateral angle of the scapula and the second pre-gelled electrode was placed directly lateral to the first. A third electrode was used to function as a reference electrode, and was placed on the ipsilateral paraspinal musculature.
Electromyographic readings were recorded for 3 minutes. Candidates were instructed that no talking was allowed in this 3-minute period and that they had to be as still as possible. The subjects were instructed that he or she was to begin with the recordings after hearing the words "Ready, Begin" and at which time the above rules applied.
29 3.4.1.2 Algometer
Algometer readings were obtained prior to any interventions on the first consultations. For the 2nd, 4th and 6th consultation readings were recorded after interventions be it SMT for Group A or de-tuned ultrasound for Group B. Algometer readings were recorded with the patient lying supine. The researches grasped the Latissimus Dorsi muscle along the free border of the posterior axillary fold of the mid-scapular level. The algometer was then pushed into this point and candidates had to indicate when they started to feel pain. This measurement was then recorded.
3.5 Data Analysis
Data was analyzed using the T-test for independent samples to compare the two individual groups. Repeated measures ANOVA was useful to investigate changes over time.
30 CHAPTER 4 - RESULTS
4.1 Introduction
This chapter will present the results obtained during this clinical study. As the sample size was only thirty subjects, statistical results will not be representative of the general population and therefore no generalizations can be made to the -population.
The probability level for the statistical analysis to be significant was set at 0.05. There was a statistical significant difference between the groups and/or treatments compared if P<0.05. Thus if P>0.05, then no statistically significant difference existed between the means of the groups and/or treatments compared.
The analysis included: Surface electromyographic (EMG) readings in mV and algometer readings in kg.
4.1.1 Graphical Representation of Data
Throughout this chapter, pertaining to the graphs, the variable being tested is represented on the y-axis. The data collected on the initial (first), second, fourth and sixth consultations, is represented on the x-axis. The blue bars represent the initial readings (t1), including algometer and electromyographic readings. The green bars represent the second readings (t2), including algometer and electromyographic readings. The brown bars represent the third readings (t3), including algometer and electromyographic readings. The purple bars represent the fourth (t4) and final readings, including algometer and electromyographic readings. With regards to the objective data collected, Group A is illustrated on the left hand side of the graph and Group B is illustrated on the right hand side of the graph.
31 • The black "T" extending from the top of each bar is an error bar, and represents the standard error of mean, that is the corrected form of the standard deviation for the sample size. The larger the sample size, the smaller the standard error.
4.2 Demographic Data
Table 4.1 Demographic data
Data Group A Group B Combined Total S.M.T to the De-tuned for both groups Cervico-Thoracic ultra-sound Junction Age Distribution 18-30 years 18-30 years 18-30 years
Mean Age 24.6 24.5 24.55
Gender 10 Male 10 Male 20 Male Distribution 10 Female 10 Female 20 Female
Race distribution 15 Whites 19 Whites 34 Whites 4 Blacks 1 Black 5 Blacks 1 Indian 1 Indian
The above table indicates the Age Distribution, Mean Age, Gender Distribution and Race Distribution of the Chiropractic Manipulative Therapy and the de-tuned ultra sound groups respectively, as well as giving a summary of these factors for a combination of both groups.
32 4.3 Objective Measurements.
4.3.1 The Mean Surface Electromyographic readings
Figure 4.1 reveals the intra- and inter-group analysis of both groups with regards to the changes in EMG average of the ipsi-lateral Latissimus Dorsi muscle due to S.M.T. for group A and de-tuned ultra-sound for group B respectively. Data for the initial, second, fourth, and sixth consultations were demonstrated. Data was analyzed using the one way repeated measures analysis of variance (ANOVA) and it's non- parametric equivalents (Mann-Whitney Test and Wilcoxon Signed Ranks Test) where needed or indicated.
As displayed by figure 4.1 and the column statistics (see table 4.2 and 4.3), group A and group B demonstrated a consistent increase in muscle electrical activity.
33
EMG AVG EMG_AVG_1 EMG_AVG_2 ❑ EMG_AVG_3 20- EMG_AVG_4
15-
5-
T
0-
A B GROUP
Figure 4.1: Infra- and inter group comparison of the mean improvement in the average sEMG readings of the ipsi-lateral Lattissimus dorsi muscle for both groups using data collected on the initial, second, fourth and final consultations.
34 4.3.1.1 Column statistics for the improvement in the average sEMG readings of the ipsi-lateral Lattissimus dorsi muscle for Group A and Group B from data collected on the initial, second, fourth and final consultations.
Table 4.2: Group A column statistics for the improvement in mean surface EMG readings Group A Column statistics for the improvement in Mean Surface EMG readings Consultation Min Max Mean Std Std Deviation Error Initial 0.70 08.90 3.42 2.36 1.19 Second 1.00 10.10 3.59 2.47 1.17 Fourth 1.00 07.40 3.80 2.05 0.20 Sixth 0.80 12.10 4.00 2.67 1.54
Table 4.3: Group B column statistics for the improvement in mean surface EMG readings Group B Column statistics for the improvement in Mean Surface EMG readings Consultation Min Max Mean Std Std Deviation Error Initial 0.40 07.00 2.40 1.78 1.49 Second 0.50 07.10 3.42 1.99 0.37 Fourth 1.30 19.60 4.68 4.47 2.5 Sixth 0.80 06.00 3.01 1.41 0.41
Inter-group comparison revealed no statistical significant changes between group A and group B, however with regards to intra-group analysis group B demonstrated statistically significant changes: Consultation 1-2: P=0.006<0.05 Consultation 1-3: P=0.049<0.05 Consultation 1-4: P=0.077>0.05
35 4.3.2 The Peak Surface Electromyographic readings
Figure 4.2 reveals the intra- and inter-group analysis of both groups with regards to the changes in peak EMG readings of the ipsi-lateral Latissimus Dorsi muscle due to S.M.T. for group A and de-tuned ultra-sound for group B respectively. Data for the initial, second, fourth, and sixth consultations were demonstrated. Data was analyzed using the one way repeated measures analysis of variance (ANOVA) and it's non- parametric equivalents (Mann-Whitney Test and Wilcoxon Signed Ranks Test) where needed or indicated.
As displayed by figure 4.2 and the column statistics (see table 4.4 and 4.5), group A demonstrated an initial increase in muscle electrical activity, but decreased during the last consultation. Group B demonstrated a slight increase in muscle electrical activity over the entire treatment protocol.
36 PEAK PEAK_1 PEAK_2 PEAK_3 80- PEAK_4
60-
) V.
ity (m ity 40- iv t Ac G EM s 20- I
o-
A GROUP
Figure 4.2: Infra- and inter-group comparison of the improvement in the peak sEMG readings of the ipsi-lateral Lattissimus dorsi muscle for both groups using data collected on the initial, second, fourth and final consultations.
37 4.3.2.1 Column statistics for the improvement in the peak sEMG readings of the ipsi-lateral Lattissimus dorsi muscle for Group A and Group B from data collected on the initial, second, fourth and final consultations.
Table 4.4: Group A column statistics for the improvement in peak surface EMG readings Group A Column statistics for the improvement in Peak Surface EMG readings Consultation Min Max Mean Std Std Deviation Error Initial 3.00 37.00 8.51 7.68 2.95 Second 2.10 35.30 9.53 8.74 2.23 Fourth 2.20 18.90 8.36 4.40 0.49 Sixth 2.90 31.60 9.88 6.24 2.30
Table 4.5: Group B column statistics for the improvement in peak surface EMG readings Group B Column statistics for the improvement in Peak Surface EMG readings Consultation Min Max Mean Std Std Deviation Error Initial 2.30 14.10 06.23 03.87 0.93 Second 1.20 14.00 06.50 03.95 0.53 Fourth 2.10 77.00 11.96 17.28 3.29 Sixth 2.10 34.00 09.75 07.27 2.07
Inter-group comparison revealed no statistical significant changes between group A and group B, however with regards to intra-group analysis group B demonstrated statistically significant changes:
Consultation 1-2: P=0.501>0.05 Consultation 1-3: P=0.151>0.05 Consultation 1-4: P=0.030<0.05
38 4.3.3 The Minimum Surface Electromyelographic readings
Figure 4.3 reveals the intra- and inter-group analysis of both groups with regards to the changes in minimum EMG readings of the ipsi-lateral Latissimus Dorsi muscle due to S.M.T. for group A and de-tuned ultra-sound for group B respectively. Data for the initial, second, fourth, and sixth consultations were demonstrated. Data was analyzed using the one way repeated measures analysis of variance (ANOVA) and it's non-parametric equivalents (Mann-Whitney Test and Wilcoxon Signed Ranks Test) where needed or indicated.
As displayed by figure 4.3 and the column statistics (see table 4.6 and 4.7), group A demonstrated an initial increase from consultation one to two, but an overall decrease in muscle electrical activity. Group B demonstrated a consistent increase in muscle electrical activity.
39
MIN MIN _1 MIN_2 El MIN _3
10 - MIN_4
8-
2-
INN
0- T
A GROUP
Figure 4.3: Infra- and inter-group comparison of the improvement in the minimum sEMG readings of the ipsi-lateral Lattissimus dorsi muscle for both groups using data collected on the initial, second, fourth and final consultations.
40 4.3.3.1 Column statistics for the improvement in the minimum sEMG readings of the ipsi-lateral Lattissimus dorsi muscle for Group A and Group B from data collected on the initial, second, fourth and final consultations.
Table 4.6: Group A column statistics for the improvement in minimum surface EMG readings Group A Column statistics for the improvement in Minimum Surface EMG readings Consultation Min Max Mean Std Std Deviation Error Initial 0.10 6.40 2.04 1.99 1.36 Second 0.30 7.80 2.05 1.77 1.96 Fourth 0.10 5.20 1.87 1.50 0.57 Sixth 0.10 8.40 1.91 2.15 1.82
Table 4.7: Group B column statistics for the improvement in minimum surface EMG readings Group B Column statistics for the improvement in Minimum Surface EMG readings Consultation Min Max Mean Std Std Deviation Error Initial 0.10 5.30 1.26 1.29 1.75 Second 0.20 5.80 2.23 1.59 0.80 Fourth 0.70 8.80 2.52 1.95 1.84 Sixth 0.10 3.90 1.88 1.28 0.14
Inter-group comparison revealed no statistical significant changes between group A and group B, however with regards to intra-group analysis group B demonstrated statistically significant changes:
Consultation 1-2: P=0.008<0.05 Consultation 1-3: P=0.016<0.05 Consultation 1-4: P=0.061>0.05
41 4.3.4 The Algometer readings
Figure 4.4 reveals the intra- and inter-group analysis of both groups with regards to the changes in algometer readings of the ipsi-lateral Latissimus Dorsi muscle due to S.M.T. for group A and de-tuned ultra-sound for group B respectively. Data for the initial, second, fourth, and sixth consultations were demonstrated. Data was analyzed using the one way repeated measures analysis of variance (ANOVA) and it's non- parametric equivalents (Mann-Whitney Test and Wilcoxon Signed Ranks Test) where needed or indicated.
As displayed by figure 4.4 and the column statistics (see table 4.8 and 4.9), group A demonstrated a pronounced increase in pressure (kg/cm 2) that is able to be applied. Group B demonstrated minimal change to pressure being applied.
42 ALGOMETER ALGOMETER_1 MI ALGOMETER_2 ALGOMETER_3 111ALGOMETER_4
A B GROUP
Figure 4.4: Infra- and inter-group comparison of the improvement in the Algometer readings of the ipsi-lateral Lattissimus dorsi muscle for both groups using data collected on the initial, second, fourth and final consultations.
43 4.3.4.1 Column statistics for the improvement in the Algometer readings of the ipsi-lateral Lattissimus dorsi muscle for Group A and Group B from data collected on the initial, second, fourth and final consultations.
Table 4.8: Group A column statistics for the improvement in Algometer readings Group A Column statistics for the improvement in Algometer readings Consultation Min Max Mean Std Std Deviation Error Initial 2.00 5.90 3.85 1.06 0.03 Second 3.00 5.70 4.47 0.94 -.49 Fourth 3.10 6.00 4.79 0.87 -.46 Sixth 3.60 6.20 5.03 0.76 -.31
Table 4.9: Group B column statistics for the improvement in Algometer readings Group B Column statistics for the improvement in Algometer readings Consultation Min Max Mean Std Std Deviation Error Initial 3.40 7.00 4.49 1.04 1.58 Second 3.00 7.00 4.57 1.05 0.93 Fourth 3.00 6.50 4.53 0.95 0.87 Sixth 3.20 6.80 4.53 1.01 1.22
Inter-group comparison revealed statistically significant changes between group A and group B (P=0.035). With regards to intra-group analysis group A demonstrated statistically significant changes:
Consultation 1-2: P=0.000<0.05 Consultation 1-3: P=0.000<0.05 Consultation 1-4: P=0.000<0.05
44 4.4 Non-Parametric Tests
At each time interval (initial, time 2, time 3 and time 4) and for each of EMG average, peak, minimum and algometer the following hypothesis is tested.
HO: groups A and B have the same mean rank. HI : the mean rank of group A and B differ.
To test these hypotheses the Mann Whitney Rank Test was used each time. The utilization of this test (non-parametric) is necessitated by the fact that the sample sizes in the two groups are small and due to the fact that normality (bell curve shape) cannot be assumed.
For initial time the P-values pertaining to these tests are as follows: EMG Average — P=0.091 EMG Peak — P=0.265 EMG Minimum — P=0.192 Algometer — P=0.192
For time two the P-values pertaining to these tests are as follows: EMG Average — P=0.947 EMG Peak — P=0.398 EMG Minimum — P=0.620 Algometer — P=0.883
For time three the P-values pertaining to these tests are as follows: EMG Average — P=1.000 EMG Peak — P=0.678 EMG Minimum — P=0.192 Algometer — P=0.253
For time four the P-values pertaining to these tests are as follows: EMG Average — P= 0.314 EMG Peak — P=0.602
45 EMG Minimum — P= 0.478 Algometer — P=0.035
Hence in all four cases i.e. initial, t2, t3 and t4 the null hypothesis cannot be rejected, i.e. the two groups can be assumed to have the same mean rank, indicating they are similar.
Hence we conclude that the two groups do not differ except at time four where group A had a higher mean than group B with respect to the algometer readings.
Furthermore, to test whether each of groups A and B changed significantly over time in terms of EMG average, EMG peak, EMG minimum, and Algometer, Wilcoxon Signed Rank Test was used. The null and alternative hypotheses are:
HO: Mean rank time 2 equal mean rank time 1. Hl: Mean rank time 2 is not equal to mean rank time 1.
The same hypothesis was tested for time 3 and time 4.
No significant changes were observed for group A. However for group B the mean rank at time 2 was significantly different than the mean rank at time 1 (P=0.006< 0.05) and the mean rank at time 3 was significantly different from the mean rank at time 1 (P=0.049<0.05).
46 CHAPTER 5 - DISCUSSION
5.1 Introduction
This chapter discusses the results described in chapter four and focused on those results that were statistically significant. Possible explanations were given and the outcomes from previous clinical studies presented to explain the results and implications of this study.
5.2 Demographic Data
5.2.1 Mean age at onset of treatment
For inclusion into the study an age limit of 18-30 years was set. Both groups fell within their limits.
The average age of patients presenting in the experimental group showed an average of 24.6 years. The average age of patients presenting in the control group showed an average of 24.5 years.
There was no significant difference between the two groups (P>0.05), which made the results between the groups more valid and reliable since age is an important variable that can alter statistical results (Lehman, 2002).
5.2.2 Gender
In this study there was an equal number of males and females in both groups, thus there was no significant difference in gender (P>0.05), which made the results more valid and reliable.
47 5.3 Objective data.
5.3.1 Electromyographic readings
The study was designed to look at the effects of S.M.T. to the cervico-thoracic junction and its effect on the ipsi-lateral Lattisimus Dorsi muscle using surface elctromyogrpahy.
The first hypothesis presented by the study was that S.M.T. to a restricted cervico- thoracic junction would stimulate the capsule and mechanoreceptor afferent neurons of the zygopophyseal joint. Thus this will effect the ipsi-lateral Latissimus Dorsi muscle directly because of its nerve innervation. The Lattisimus Dorsi muscle is supplied by the thoracodorsal nerve, spinal nerves C6-C8 (Travell & Simons, 1999).
The results obtained from the statistical analysis of this study showed that the electrical activity over the ipsi-lateral Latisimus Dorsi muscle did not reveal any statistically significant differences between the readings obtained from the experimental group receiving S.M.T to the cervico-thoracic junction and the control group receiving de-tuned ultra sound to the restricted cervico-thoracic junction.
The above findings are in contrast with those obtained by Herzog, Scheele and Conway (1998), where segments in cervical spine and thoracic spine was adjusted. EMG recordings were taken over muscles of the spine including the Latissimus Dorsi. EMG readings were taken 2-4 seconds before the spinal manipulation, during the manipulation and then 2-4 seconds after the manipulation. A positive electromyographic response occurred when the signal increased to 3 times the baseline valve within 500 milliseconds (m/sec) of the onset of the spinal manipulative thrust. Muscles of the back including Latissimus Dorsi showed a generalized response after S.M.T. According to the described study, the response was short acting, beginning between 50-200 m/sec after the onset of the manipulative thrust and lasting between 100-400m/sec.
48 Thus, a possible explanation for the similarities in the experimental group may have been that the immediate effect of the manipulation on the muscle activity was extremely brief and may have therefore not been accounted for on the sEMG used in the study.
Other possible explanations for the relatively ineffective results may include a reduced speed at the time of the manipulative thrust. In a study, based on that of Herzog, Scheele and Conway (1998), using the same methods and treatment protocol, but applied at a much slower rate, it was found that spinal manipulation using similar force magnitudes and direction did not produce the same reflex responses as deserved in their original study. Thus it appears that the magnitude of the reflex response directly depended on the rate of change of force and deformation produced by the manipulation rather than the force or stretch of the magnitude itself (Herzog, 1998).
Michaeli and Vosloo (2001) stated that once the pre-gelled surface is interrupted, one may find a disturbance to the conducting pathway between the muscle and electrode because of artifacts, this might alter the desired readings.
EMG findings obtained from this study do not support the hypothesis that spinal manipulative therapy produces a change in muscular electrical activity, as there was no statistically significant difference between the first and last EMG readings.
Regarding group B (control group), an intra-group analysis reveal statistically significant differences between treatment one and treatment two (P=0.006), treatment one to treatment three (P=0.049).
Regardless of the effects of the de-tuned ultrasound apparatus, it definitively produces expectations of improvement and expectancy is the foundation of the placebo effect (Lewith, 2002).
There is growing evidence to suggest that even light touch of the skin can stimulate mechanoreceptors coupled to slow conducting afferents, which causes activity in the insular region and subsequent increased feelings of well-being and decreased feelings of unpleasantness (Dommerholt, 2006).
49 5.3.2 Algometer Readings
Regarding the algometer readings, the study was designed to look at the immediate and prolonged effect of SMT to the restricted cervico-thoracic junction and changes in the pain threshold of the ipsi-lateral Latissimus Dorsi trigger point.
The second hypothesis presented by this study was that S.M.T to the restricted cervico-thoracic junction would affect the trigger points of the ipsi-lateral Latissimus Dorsi. Haldeman (1992) stated that the nervous system plays an important role in the amount of tension within a muscle. This is based on the fact that the muscle spindle reflex, which determines the sarcomere length, is controlled by the nervous system with this being the case and the fact that the segmental nerve supply to the Latissimus Dorsi muscle originates from C8-T1 and is postulated, that the effect of the chiropractic adjustment is due, at least in part, to its direct effect on their nerve roots during manipulation of the respective cervical vertebral segments.
The results obtained from the statistical analysis of this study revealed statistically significant differences (P=0.035) in the trigger point activity of the ipsi-lateral Latisssimus Dorsi muscle when compared to that of the control group.
Three studies were done by Reeves et al., (1986) to demonstrate the reliability of the pressure algometer. In study one, five specifically marked myofascial trigger point locations and one none-myofascial bony point was allocated. The two experimenters independently applied the pressure algometer to these six locations and both within — and between —experimenter correlations were computed. For study two, the same two experimenters independently applied the pressure algometer to the same six points used in study one. The procedures were identical to the previous study with two exceptions, firstly the experimenters took only one measurement each and the measurement points were not marked. This was done to test the between — experimenter reliability of locating and measuring the same unmarked points. In study three that was identical to study one, the following exceptions were included. Firstly, each experimenter obtained only one reading from each point and secondly in addition to measuring the trigger points the experimenters also measured an adjacent muscular area located within a 2 cm diameter from the trigger point and away from
50 neighbouring myofascial trigger points. Trigger points and adjacent non-trigger point locations were taken immediately following that of the corresponding adjacent trigger point.
These three studies above demonstrated the reliability of the pressure algometer as an index of myofascial trigger point sensitivity. The first study showed high reliability between and within experimenters when measuring marked trigger point locations. In study two, significance between experimenter reliability in locating and measuring the same unmarked trigger point locations was shown, while study three supported the idea that trigger points are discreet points of focal tenderness within the muscle. The ability to quantify and reliably measure trigger point sensitivity opens the door to a range of clinical and research possibilities for myofascial and related musculoskeletal pain problems.
When comparing the results of the study discussed above with the findings of this study. There is a strong correlation between the findings of the study discussed above and this study as a statistically significant difference was noted between the first reading and the last reading. These findings do support the hypothesis that spinal manipulative therapy produces a significant change in pain threshold and activity of the trigger points of a muscle, as it was observed over a three week period.
51 CHAPTER 6 - CONCLUSION AND RECOMMENDATIONS
6.1 Conclusion
The purpose of this study was to determine whether S.M.T to the cervico-thoracic junction could affect the ipsi-lateral Latissimus Dorsi muscle in terms of muscle electrical activity as well as with pain tolerance readings. The changes in muscular activity were measured with an Electromyelographic machine and alterations in pain tolerance were measured with an algometer. These measurements were taken over the ipsi-lateral Latissimus Dorsi muscle in patients with cervico-thoracic junction restrictions.
No statically significant differences were found when the values for muscle electrical activity was compared in both the experimental and control groups, using intra-group and inter-group analyses.
Once the study was performed, statistically significant changes were found when comparing all four readings from the algometer findings from the experimental group. Comparing the algometer values for the experimental group to those of the control group, it was found that the fourth or final consultation was found to be statistically significant.
The results obtained from this study were inconclusive and widely varied for muscle electrical activity. There was no statistically significant changes identified when the pre- and post-manipulation values of each session were compared between both the experimental and control groups. Also, there were no significant changes between each treatment session and between the first and the last treatment sessions of the experimental group. Therefore it cannot be stated with certainty that S.M.T. to the cervico-thoracic junction affects muscle electrical activity in the ipsi-lateral Latissimus Dorsi muscle. The treatment given did however, seem to have a notable effect on the patients' perception of their pain and trigger point activity as most showed an increased pain threshold.
52 6.2 Recommendations
A control group without de-tuned ultrasound should be used, as this seem to have an effect on muscle activity and thus is not a proper control group.
A study could be performed to determine the immediate effects of S.M.T. to the cervico-thoracic junction, thus surface electrodes should be placed prior to the adjustments and measured during the adjustment as well as the period directly after the adjustment.
A different pair of electrodes should be used on each session for each patient to avoid interference that is caused by the disruption of the conducting gel, as this might have led to EMG signal interference and therefore altered the readings.
A once off study could be performed to determine the immediate effect of S.M.T to the restricted cervico-thoracic junction to determine changes in Algometer- and EMG-readings.
Researchers must be proficient in the application and use of the EMG; so that more accurate readings might be obtained.
S.M.T. to the entire cervical spine and thoracic spine could be included to determine the effects of spinal manipulation on muscular activity and pain tolerance of the ipsi- lateral Latissimus Dorsi muscle.
Future studies might include another treatment group for example, ischaemic compression, dry needling and interferential current therapy, used in conjunction with spinal manipulative therapy to determine the superior treatment protocol.
A single blind' study can be performed where an external individual can motion palpate for a cervico-thoracic restriction and the researcher only adjusts and takes the objective readings.
53 A double blind study can be performed where motion palpation and a therapy of choice is left for external individual and researcher only records the findings.
A larger number of participants in the research study could be undertaken, to obtain results with narrower confidence intervals.
A study could be performed to compare symptomatic and asymptomatic subjects, for more information on the effects of S.M.T.
Re-evaluating subjects one month after the last session may determine the long term effects of S.M.T. on muscle activity of the ipsi-lateral Latissimus Dorsi muscle.
A study could be performed to include recording subjective data for example the Oswestry Questionnaire and visual analogue pain scale to determine whether pain and discomfort decreased/increased during the treatment protocol.
54 REFERENCES
Bogduk, N., Johnson, G., Spalding, P. (1998). The morphology and biomechanics of latissimus dorsi. Clinical Biomechanics 13. pp377-385
Bogduk, N. and Mercer, S. (2000). Biomechanics of the Cervical Spine. 1: Normal Kinematics. Clinical Biomechanics, Elsevier 15. pp648-663
Bolton, P.S. (2000). Reflex Effects of Vertebral Subluxations: The Peripheral Nervous System. An Update. The Journal of Manual and Manipulative therapy. Vol. 23 No. 2, pp103
Crouch, J.E. (1985). Functional Human Anatomy 4 th edition. Lea and Febigir Philadelphia. pp130, 225
Dommerholt, J., Mayoral, 0., Grobli, C. (2006). Trigger point dry needling. The Journal of Manual and Manipulative therapy. Vol. 14 No.4, pp70-87
Fischer, A.A. (1987). Pressure Algometry over Normal Muscles. Standard Values, Vaidity ad Reproducibility of Pressure Threshold. Pain 30, pp115-126
Fryer, G., Carub, J., McIver, S. (2004). The effect of Manipulation and Mobilisation on Pressure Pain Thresholds in the Thoracic Spine. Journal of Osteopathic Medicine. Vol. 7 No. 1, pp8
Gatterman, M.I. (1990). Chiropractic management of spine related disorders, 1st edition. Williams and Wilkins. pp67-68
Gatterman, M.I. (1995). Foundations of chiropractic subluxation, 1st edition. Lippincot, Wilkins and Williams. Colorado. pp109-111,150-168, 180-183
Grieve, G.P. (1988). Common vertebral joint problems rd edition. Churchill Livingstone. pp104
55 Haldeman, S. (1992). Principles and practice of Chiropractic, 2nd ed. Appleton and Lang. East Norwalk Connecticut. pp3, 304-318
Hamilton, W.J. (1956). Textbook of Human Anatomy. St. Martin's Press, London. pp64, 82, 91, 198, 534
Hammer, N.I. (1999). Functional soft tissue examination and treatment by manual methods 2"d edition. Aspen publication. pp416
Harrison, P. (1997). The Sacro-Iliac Joint Review. The Journal of Manipulative and Physiological Therapeutics. Vol. 20 No. 9, pp610
Herzog, W., Scheele, D., Conway, P.J. (1998). Electromyographic Responses of Back and Limb Muscles Associated with Spinal Manipulative Therapy. Spine Vol. 24 No. 2, pp146-153
Hogeweg, J.A., Langereis, M.J., Bernards, A.T.M., Faber J.A.J., Helders, P.J.M. (1992). Algometry. Scand J Rehab Med. 24, pp99-103
Kirk, C.R., Lawrence, D.J., Valvo, N. (1985). State's manual of spinal, pelvic and extravertebral technic 2"d edition. pp79
Lee, D. (1996). Instability of the Sacroiliac joint and the consequences to gait. The Journal of Manual and Manipulative Therapy. Vol. 4 No. 1, pp313-317
Lee, D. (2001). 4th Interdisciplinary World Congress on Low Back and Pelvic Pain. Moving from Structure to Function. pp2
Lehman, G.J. (2002). Clinical consideration in the use of surface electromyography: Three experimental studies, Journal of Manipulative and Physiological Therapeutics, vol. 25 no. 5, pp.294
56 Lewith, G., Jonas, W.B., Walach, H. (2002). Clinical Research in Complementary Therapies. 1 edition Churchill Livingstone. London. pp129
Loeb, G.E. , Gans, C. (1997). Electromyelography for experimentalist. University of Chicago Press. Chicago and London ppl7
Masarsky, C.S., Todres-Masarsky, M. (2001). Somatoviceral Aspects of Chiropractic. An evidence-based approach. Churchill Livingstone. pp91
Michaeli, A. and Vosloo, G., (2001). Clinical Surface EMG: Module 1, pp 4, 6
Mooney, V., Pozos, R., Vleeming, A., Gulick, J., Swenski, D. (2001). Exercise Treatment for sacroiliac Pain orthopedics; Jan 2001; 24:1 Proquest Nursing Journals pp29
Moore, K.L., Dalley, A.F. (1999). Clinically Orientated Anatomy 4 th edition. Lippincot Williams and Wilkins. pp340, 550
Mootz, R.D., Vernon, H.T. (1999). Best practices in clinical chiropractic. Aspen publishers. pp107-109
Netter, F.H. (1998). Atlas of Human Anatomy 2 nd edition. Novartis. pp13, 143, 160
Oldreive, W.L. (1996). A Critical Review of the Literature on the Anatomy and Biomechanics of the Sacro-Iliac Joint. The Journal of Manual and Manipulative Therapy. Vol. 4 No. 4, pp160
Peterson, D.H., Bergmann, T.F. (2002). Chiropractic Technique. 2nd edition Mosby. pp28,203-207
Plaugher, G. (1993). Textbook of clinical chiropractic — a specific biomechanical approach. Lippincot, Wilkins and Williams. pp57, 66
57 Pool — Goudzwaard, A.L., Vleeming, A., Stoeckart, R., Snijders, C.J., Mens, J.M.A. (1998). Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to 'a-specific' low back pain. Manual therapy (3)1, pp12-20
Prentice, W.E. (2000). Rehabilitation techniques for sport's medicine and athletic training. 6th edition. McGaw Hill Editors. pp202-206
Pullmann, S.L., Goodin, D.S., Marquinez, A.I., Tabbal, S. (2000). Clinical Utility of Surface EMG. American Academy of Neurology. Vol. 55 no. 2, ppl
Reeves, J.L., Jaeger B., Graff-Radford, S.B. (1986). Reliability of the Pressure Algometer as a Measure of Myofascial Trigger Point Sensitivity. Pain no 24, pp13-321
Schamberger, W. (2002). The malalignment syndrome: Implication for medicine and sport. Churchill Livingstone. Edinburgh. pp21-25
Scheepers, M.D., Duminy, J., Meiring, J.H. (1999). Practical Osteology. Faculty of Medicine. University of Pretoria. pp69-71
Schleip, R. (2000). Report from the 3 rd Interdisciplinary World Congress of Low Back and Pelvic Pain. pp4
Simons, D.G., Travell, J.G., Simons, L.S. (1999). Myofascial Pain and dysfunction. The trigger point manual. Volume 1. Upper half of body, 2" d edition. pp573,575,580
Vleeming, A., Pool-Goudzwaard, A.L., Stoeckart, R., Van Wingerden, J.P., Snijders, C.J. (1995). The Posterior layer of the thoracollumbar fascia its function in load transfer from spine to legs. Spine Vol. 20 No. 7, pp753-758
Waddel, G. (2004). The back pain revolution. Churchill Livingstone. pp133
58 Warwick, R., Williams, P.L. (1973). GRAY'S Anatomy 35 th edition. Langman. pp236-238, 566
59
BC= 12==libr CZEM:=3. ===== Emu MIM iss=1 SALARY ADVICE amm=rAr mmommommm r=3 f=231 Eta TIErit'OME E=33 t It1 MEM IBM CONFIDENTIAL r ( INESEM PERSONAL IBM South ilea
PERSONAmikA, MEWLSAmmer EMP. CODE 007262 IBM South Africa PERIOD END DATE: 31/03/2008 EMP. NAME VAN ROOYEN J 70 Rivonia Road KNOWN AS: JOSEPH Sandhurst DATE ENGAGED: 15/08/2006 Johannesburg ID. NUMBER: 7605275105087 2196
BRANCH CODE AL NR 632005 19086326843
EARNINGS EDLICTIONS 117TA!- Salary 10648.52 Tax 2882.64 Travel Allow 2433.33 U.I.F. 124.78 EssCarUser All 2800.00 IBM Provident 227.36 KM Reimb 60%Tx 736.80 IBM Pension Fix 363.77 Bonus 2700.00 IBM Club Member 15.00 IBM Club Deduct 206.00 KM Reimb 736.80
TOTAL EARNINGS 19318.65 TOTAL DEDUCTIONS 4556.35
ADDITIO. AL FORMA NET : SALARY 14/62 30 TOTA COS ( "Ij*I0P6\*N-7 Total Perks 0 . 00 Total Company Contributions 3606.66
Taxable Earnings 17608.51 Total Comp TCC 13991.28 Tax 2882.64 Additional Tax 0.00 PER Ratio % 65.00 Total Perks 0.00 Pens Earn Ratio 9094.33
Annual Lve Days Due 20.00 Backlog Days Due 12.00
Guarnt Min Earn 13991.28
- Travel All 2433.33
- Provident CC 877.60 - Group Life CC 31.83
Cash Component 10648.52
007262 APPENDIX A DO YOU SUFFER FROM NECK PAIN?
You might qualify for FREE treatment! At the University of Johannesburg 3 Chiropractic Day Clinic Gate 7, Sherwell Road, Doornfontein
Participants must be between the ages of 18-30.
For more information contact: Nico Goosen 082 455 3441
60 APPENDIX B: Contra Indications to Manipulative Therapy if the case history or regional examination of the Cervicothoracic area reveals any one of the following contraindications the patient will be excluded fro the study
I. Vascular Complications 1.1 Atherosclerosis of major blood vessels
Tumours 2.1 Lung 2.2 Thyroid 2.3 Prostate 2.4 Breast 2.5 Bone .
Bone Infections 3.1 Tuberculosis 3,2 Osteomyelitis
4, Traumatic 4.1 Fractures 4.2 Joint instability or hyper mobility 4.3 Severe sprains or strains 4.4 Unstable Spondylolisthesis
5. Arthritic Conditions 5.1 Rheumatoid Arthritis 5.2 Ankolosing Spondylitis 5.3 Psoriatic Arthritis 5.4 Unstable or late stage Osteoarthritis 5.5 Uncoarthritis
61 Metabolic Disorders 6.1 Clotting disorders 6.2 Osteopenia
Psychological Considerations 7.1 Malingering 7.2 Hysteria 7.3 Hypochrondriasis 7.4 Pain intolerance
Neurological Complications 8.1 Disc lesions 8.2 Space occupying lesions
• t
62 APPENDIX C: Consent. Form
Participation in the study is voluntary and you are free to refuse treatment or withdraw your consent at any time. Such refusal or discontinuance will not affect your regular treatments or medical care in any manner.
I have fully explained the procedure, identifying those, which are investigated and have explained their purpose. I have asked whether any questions have arisen regarding the procedure and answer these questions to the best of my ability.
Date: Researcher:
I have been fully informed as to the procedures to be followed and have been given a description of the risks and benefits to be expected and the appropriate alternate procedures. In signing this consent form I agree to this method of treatment and I. understand that I am free to withdraw my consent and discontinue participation in this study at any time. I understand also that if I have any questions at any time, they will be answered.
Date: Patient:
The procedures that will be followed in this study will be in accordance with the ethical standards of The Responsible Committee on .Human Experimentation. You the patient have signed a consent form prior to treatment with the full understanding of the research purposes and conditions. If any aspects are unclear to you the patient please contact Nice Goosen.: 082 455 3441.
63 Appendix D PART ONE: Spinal Technics 79
Fig. 73. Thumb movement (bench TM).
THUMB MOVEMENT: BENCH TM L: RP-LP; RI-LI: RL-LL: C5-T3. Laterality is opposite to the side of poste- riority. PP: Prone antigravity; headpiece lowered; head turned to side homolateral to posteriority (away from doctor). DP: Fencer's stance facing cephalad; contralateral to posteriority, (homolateral to laterality). Cephalad foot even with patient's shoulder. CH: Cephalad hand; pad of thumb on lateral aspect of SP of listed vertebra; forearm parallel to floor. IH: Caudad hand; palm cups ear. T: CH takes contact; [H indicates to patient to rotate head. [H tractions cephalad and into further rotation, CH thrusts straight across. NOTE: If patient cannot rotate head full 90 degrees, modify technic by using IH to traction head slightly out of headpiece.
64
APPENDIX E UNIVERSiTY JOHANNESBURG UNIVERSITY OF JOHANNESBURG CHIROPRACTIC DAY CLINIC
CASE HISTORY
Date:
Patient: File No:
Age: Sex: Occupation:
Student: Signature:
FOR CLINICIAN'S USE ONLY
Initial visit clinician: Signature:
Case History:
Examination: Previous: TWR Current: TWR Other . Other
X-ray Studies: Previous: TWR Current: TWR Other Other
Clinical Path. Lab: Previous: TWR Current: T1NR Other Other
Case status: PTT: Conditional: Signed off: Final sign out:
Recommendations:
65 Students case history
Source of history: Chief complaint: (patient's own words)
Present illness:
Location
Onset
Duration
Frequency
Pain (character)
Progression
Aggravating factors
Relieving factors
Associated Sx's and So's
Previous occurrences
Past treatment and outcome
2
66 Other complaints:
Past history
General health status
Childhood illnesses
Adult illnesses
Psychiatric illnesses
Accidentsfinjuries
Surgery
Hospitalisation
C. Current health status and lifestyle
Allergies
Immunizations
Screening tests
Environmental hazards
Safety measures
Exercise and leisure
Sleep patterns
Diet
Current medication
Tobacco
Alcohol
Social drugs
7. Family history: Immediate family:
Cause of death
3
67 DM
Heart disease
TB
HBP
Stroke
Kidney disease
CA
Arthritis
Anaemia
Headaches
Thyroid-disease
Epilepsy
Mental illness
Alcoholism
Drug addiction
Other
Psychosocial history:
Home situation Daily life Important experiences Religious beliefs
Review pf systems:
General
Skin
Head
Eyes
Ears
Nose/sinuses
4
68 Mouthithroat
Neck
Breasts
Respiratory
Cardiac
Gastro-intestinal
Urinary
Genital
Vascular
Musculoskeletal
Neurologic
Haernatologic
Endocrine
Psychiatric
69
APPENDIX F UNIVERSITY JOHANNESBURG UNIVERSITY OF JOHANNESBURG CHIROPRACTIC DAY CLINIC
PHYSICAL EXAMINATION
Underline abnormal findings in RED. Date:
Patient: File No:
Clinician: Signature:
Student: Signature:
Height: Weight Temp:
Rates: Heart: Pulse: Respiration:
Blood pressure: I Arms: I L _ R I • - I Legs: IL R I ' I I .
General Appearance:
1
70 STANDING EXAMINATION
Minor's sign Skin changes Posture:Erect Adam's Ranges of motion (Thoracolumbar Spine) T/L spine: Flexion: 90° (fingers to floor) Extension: 50° R. lat. flex: 30° (fingers down leg) L. lat flex: 30° (fingers down leg) Rot. to R: 35° Rot. to L: 35°
L. Rot R. Rot
L Lat Flex R. Lat Flex
Ext.
/ = pain-free limitation // = painful limitation
Romberg's sign F ronator drift Trendelenburg's sign Gait - rhythm - balance - pendulousness - on toes - on heels - tandem Half squat Scapular winging Muscle tone Spasticity/Rigidity
Shoulder: skin symmetry ROM - glenohumeral - scapulo-thoracic - acromioclavicular - elbow - wrist 2
71 L R 14. Chest measurement: - inspiration cm cm - expiration cm cm 15. Visual acuity
16. Breast examination: Inspection: - skin - size - contour - nipples - arms overhead - hands against hips - leaning forward Palpation - axillary lymph nodes - breast incl. tail
SEATED EXAMINATION
Spinal posture Head - hair - scalp - skull - face - skin Eyes: Observation - conjunctiva - sclera - eyebrows - eyelids - lacrimal glands - nasolacrimal duct - position and alignment - corneas and lenses
corneal reflex
ocular movement R HI VI III IV VI
visual fields accommodation Opthalmoscopic Examination - iris - pupils - red reflex - optic disc - vessels - general background 3
72 - auricle ear canal drum auditory acuity Weber test Rinne test
Noce:
External Internal
Mouth and pharynx:
- inspection - movement - taste - palpation'
inspection
posture size swelling scars discolouration hair line Ranges of motion (cervical spine)
The following are normal ranges of motion
Forward flexion = 45 ° chin to larynx or sternum Extension = 55 ° forehead parallel to ground l/R Rotation = 70 ° IJR Lat Flexion = 40 °
Flex. L. Rot R. Rot
L. Lat Flex R. Lat Flex
Ext.
lymph nodes trachea thyroid carotid arteries (thrills, bruit) Cranial Nerves - CN V - CN VII - CN VIII (nystagmus) -CN IX - CN XI - CN X11
9. NEUROLOGICAL EXAMINATION (CERVICAL SPINE)
( DERMATO Left Right MYOTOMES Left Rig REFLEXES Left Right MES ht C2 Neck Flexion Biceps C1/2 C5 C3 Lat. Neck Flexion Brachio — C3 radial's C6 C4 Shoulder Elevation Triceps C4 C7 C5 Shoulder Abduction CS C6 Elbow Flexion C5 C7 Elbow Extension C7 5
74 C8 Elbow Flexion at 90 O
C6 T1 Forearm Pronation C6 Forearm Supination C6 Wrist Extension C6 Wrist Flexion C7 Finger Flexion C8 Finger Abduction T1 Finger Adduction T1
9. Peripheral vasculature: Inspection - skin - nail beds - pigmentation hair loss
Palpation pulses: - femoral - dorsalis pedis - popliteal - radial - post. Tibial - brachial
- lymph nodes - epitrochlear - femoral (horizontal & vertical) - temperature (feet and legs)
Manual compression test Retrograde filling (Tredelenburg) test Arterial insufficiency test
10. Musculoskeletal: (i) ROM hip
L R flex. 90/120 ext. 15 abd. 45 add. 30 int rot 40 ext rot 45 I L i R flex. 130 ext. 0/15
6
75 L R plantar Flex 45 dorsiflex 20 inversion 30 i eversion 20 L R Apparent Actual
• knee
• ankle
(ii) leg length
• Co-ordination - point to point - dysdiachokinesia
TMJ • Inspection - ROM - deviation • Palpation - crepitus - tenderness
Thorax • Inspection - skin - shape - respiratory distress - rhythm (respiratory) - depth (respiratory) - effort (respiratory) - intercostals/supraclavicular retraction
Palpation - tenderness - masses
- respiratory expansion - tactile fremitus
• Percussion - lungs (posterior) - diaphgragmatic excursion - kidney punch
• Auscultation breath sounds - vesicular - bronchial adventitious sounds - crackles (rates) - wheezes (rhonchi) - rubs voice sounds - broncophony - whispered pectoriloquey
76 egophony
Cardiovascular - auscultation (aortic murmurs) - Allen's test
SUPINE EXAMINATION
JVP PM1 Auscultation heart (L. lat. Recumbent) respiratory excursion percussion chest (anterior) breast palpation Abdominal Examination Inspection 'akin 'umbilicus - contour 'peristalsis 'pulsations - hernias (umbilical/incisional)
• Auscultation - bowel sound - bruit
• Percussion -genera - liver - spleen
• Palpation - superficial reflexes - cough - light - rebound tenderness - deep 'liver -spleen 'kidneys -aorta - intra-Iretro-abdominal wall mass - shifting dullness - fluid wave
• Acute abdomen - where pain began and now - cough _tenderness -guarding/rigidity - rebound tenderness - rovsing's sign - owes sign - obturator sign - cutaneous hyperaesthesia
77 - rectal exam - Murphy's sign
MENTAL STATUS
Appearance and behaviour - level of consciousness - posture and motor behaviour - dress, grooming, personal hygiene - facial expression - affect
Speed and language - quantity - rate - volume - fluency - aphasia (pm)
(ii) Mood
(v) Memory and attention orientation (time, place, person) remote memory recent memory new learning ability
(vi) Higher cognitive functions information and vocabulary (general and specialised knowledge) abstract thinking
NEUROLOGICAL EXAMINATION (LUMBAR SPINE)
DERMATO I Left Right MYOTOMES Left Rig REFLEXES Left I Right MES ht 112 Hip Flexion Patellar (L'UL2) 0-3. 4) Ll Knee Extension Medial (12, 3, 4) Hamstring (L5) L.2 Knee Flexion Lateral (L5/S1) Hamstring (Si) L3 Hip Int Rot (L411.5) L4 Hip Ext. Rot (L5/S1) L5 Hip Adduction (L2, 3, 4) S1 Hip Abduction iL4/5) S2 Ankle Dorsifiexion
78 1 (L4/L5) S3 i Hallux Extension (L5) Ankle Plantar Flexion (S1/S2) Eversion (S1) Inversion (L4) Hip Extension (L5/S1)
10
79
t'
UNIVERSIIY cF APPENDIX C JOHANNESBURG
UNIVERSITY OF JOHANNESBURG CHIROPRACTIC DAY CLINIC'
REGIONAL EXAMINATION CERVICAL SPINE
Date:
Patient File No:
Clinician: Signature:
Student: Signature:
OBSERVATION
Posture Size Swellings Scars Discolou ration Hairline Bony and soft tissue contours Shoulder level Muscle spasm Facial expression
5. RANGE OF MOTION
Flexion = 45° - 90° Extension = 55° - 70° ' UR Rotation = 700 - 90° UR Lat Flexion = 20° - 45°
80
Flexion Left RI otation • Right Ro ation
Left Lateral Flexion Right Lateral Flexion
Extension 1= Pain free limitation 11= Painful limitation
PALPATION
Lymph nodes Trachea Thyroid gland Pulses/thrills Tenderness Muscle Tone Active MF Trigger Points SCM - Trapezius - Scaleni Levator Scapulae - Posterior Cervical musculature
ORTHOPAEDIC EXAMINATION
Doorbell Sign
Max. Cervical Compression
Spurling's manoeuvre
Lateral Compression (Jackson's test)
Kemp's Test
Cervical Distraction
Shoulder abduction Test
2
81 Shoulder depression Test
Dizziness rotation Test
Lhermitte's Sign
0' Donoghue Manoeuvre
12, Brachial Plexus Tension
13. Carpal tunnel syndrome: Tinel's sign Phalen's Test
14. TOS:
Haistead's test . Adson's test Eden's (traction) test Hyperabduction (Wright's) test — Pec minor Costoclavicular test
Remarks:
VASCULAR I LEFT j RIGHT BLOOD PRESSURE I CAROTIDS SUBCLAVIAN ARTERIES I WALLENBERG'S TEST
COMMENTS:
3
82 MOTION PALPATION
JL Play Left Right Jt. Fla PIA Lat Fle Ext LF I AR PR Fle Ext LF I AR PR PIA Let Ma= Cl C2 IMINIIIM Mil
lummosimmi. - - nimor.- I T3 WWII= Td MIMEO
NEUROLOGICAL EXAMINATION
DERMATOMES 1 Left Right MYOTOMES Left Right REFLEXES i Left Right C2 Neck Flexion C1/2 C3 Lat. Neck Flexion C3 C4 Shoulder Elevation C4 C5 Shoulder Abduction CS C6 Elbow Flexion C5 l C7 Elbow Extension C7 C8 Elbow Flexion at 900 C6 T1 Forearm Pronation C6 Forearm Supination CS Wrist Extension Cs Wrist Flexion C7 Finger Flexion C8 OF Finger Abduction • .1 T1 ,., Finger Adduction NY T1 * AnAii •
4
83
. Hs, 53q- Goo