TheChiroprac,cTheories:HowdoesSpinalManipula,onExertit’s

ClinicalEffect?Dr.J.KimRoss

TheTheories1.  OvercomeMuscleSpasmbyreseHngmuscle

spindles2.  S,mula,onofMechanoreceptors3.  BreakingScarTissueinjoints4.  Removalofacutejointlocking(Trapped

Meniscoid)5.  Restora,onofmovementimprovesjoint

nutri6onandlubrica6on6.   ReleaseofendorphinsfromtheCNS7.   ADIO(boneoutofplace,blockingnerveflow)

1.MuscleSpindle/GolgiTendonTheory

GolgiTendonOrgan

1bafferent

αmotorneuron

Inhibi6on

MuscleSpindles

HowcantheGaingoAwryineverydaylife?

•  CNSordersacontrac,onandtheintraandextrafusalfibrescontractsospindles,llprovidinginfoaboutlength

•  Thenaposturalfaultoccurssuddenlyandtheintrafusalfibresgoslackbuttherewasnoorderfromγtofollowthemovement(so1aafferentsgosilent).Nowγincreaseac,vitytosothat1acangiveinforma,onaboutlengthagain.

•  Sogainisincreasedtoac,vatethespindle•  Nowbodypartsgobacktooriginalposi,onbutγgainwon’tletithappen

•  Sonowinnormalposturethemuscleisinspasm

HowdoesManipula,onHelp?

•  StretchtheintrafusalfibresagainstaspindlemaintainedresistancewouldproduceabarrageofafferentimpulseintenseenoughtosignaltheCNStoreducetheγdischarge

•  GTO’swouldbes,mulated(becausethemusclewass,fffromtheγac,vity)andthatwillresultinαandγinhibi,onwhichwillcausethemuscletorelax

HowdoesManipula,onHelp?

Notethebarrageofafferentac,vityimmediatelyontheonsetoftheimpulse.Doesthisallowthegaininthegammasystemtobeturneddown?Thentheafferentac,vitybecomessilent.Aretheysilentbecausethemuscleisnowrelaxed?

Lehmanetal,(2001)

2.MechanoreceptorS,mula,on•  InthespinewehaveTypeI,TypeIIandTypeIVmechanoreceptorsassociatedwiththejointcapsule

•  TypeIhaveaconstantdischarge(slowadap,ng)eveninanon-movingjoint(becausethereisalwayssometensioninthecapsule

•  TypeIIarerapidlyadap,ngandhencearesilentinnon-movingjoints.Howeverwouldrespondquicklytomovement(physiologicaloranadjustment)andthengosilentagainevenifthemovementiss,lloccurring.

MechanoreceptorS,mula,on

•  TypeIcanindicatethedirec,onofmovement(bycomparingdifferentpartsofthecapsule)

•  Duringtrac,onallpartsofthecapsulewouldbestretchedwhileothermovementswouldslackensomepor,onofthecapsuleandstretchothers

•  TypeIIindicateonlythatmo,onhasoccurred.

HowDoesManipula,onHelp?

•  Throughs,mula,onofmechanoreceptors,manipula,onwouldtrigger3possiblemechanisms:

1.  ReflexogenicEffects

2.  PerceptualEffects

3.  PainSuppression

ReflexogenicEffects

•  Mechanoreceptorafferentsprojecttofusimotorneurons(γneurons)oftheassociatedwithmusclespindles

•  Hencetheyinfluencemuscletonebyaffec,ngthegainofthespindles

•  Theyalsosynapseintersegmentallysomusclesfromjointsremotetothejointcausingthedischarge,alsoexperienceatonealtera,on

Manipula,on&ReflexogenicEffects

•  Manipula,onthenwoulds,mulatethemechanoreceptorswhichwouldalterγoutput,whichwouldaltermuscletone.

•  Soitcoulddecreasemusclespasmatajointandadjacentjoints,oritcouldincreasemuscletonedependingonthesitua,on

Manipula,on&PerceptualEffects•  TypeImechanoreceptorscontributetotheperceptualexperiencesofposturalsensa,onandkinesthesis.

•  Inflamma,oninadamagedjointmayalterthiscontribu,on

•  Manipula,oncouldreduceinflamma,onandhencereduceinappropriatefiringofthesereceptors

•  And/ormanipula,onmaydirectlyaltertheoutputofthesereceptorsandnormalizethemsothatkinesthe,csenseisreturnedtonormal

Fig2Thearrangementofpa,ent,helmetwithpointer,andrecordsheetwithcoordinatesystemfortheHRAprocedure.

ImprovementaBerchiroprac6ccareincervicocephalickinesthe6csensibilityandsubjec6vepainintensityinpa6entswithnontrauma6c

chronicneckpain.PalmgrenPJ,SandströmPJ,LundqvistFJ,HeikkiläH.JManipula,vePhysiolTher.2006Feb;29(2):100-6.

ImprovementaBerchiroprac6ccareincervicocephalickinesthe6csensibilityandsubjec6vepainintensityinpa6entswithnontrauma6c

chronicneckpain.PalmgrenPJ,SandströmPJ,LundqvistFJ,HeikkiläH.JManipula,vePhysiolTher.2006Feb;29(2):100-6.

ImprovementaBerchiroprac6ccareincervicocephalickinesthe6csensibilityandsubjec6vepainintensityinpa6entswithnontrauma6c

chronicneckpain.PalmgrenPJ,SandströmPJ,LundqvistFJ,HeikkiläH.JManipula,vePhysiolTher.2006Feb;29(2):100-6.

PainSuppression(GateControlTheory)

•  UnmyelinatedCfibresarepainsensors•  TheyalsoinhibitaninhibitoryinterneuronhenceintensifyingthepainsignaltotheCNSviaaprojec,onneuron

C-fibre

- -+ +

+InhibitoryNeuron

Projec,onNeuron

MechanoreceptorNeuron

Manipula,on&PainSuppression

•  Ifthejointisnotmoving,themechanoreceptorsarenots,mulated.Ifthemechanoreceptorsarenots,mulated,thereisnothingtoinhibitthesignalfromtheCfibres.

•  Manipula,onrestoresthemo,on,s,mula,ngthemechanoreceptorswhichinturninhibitsthepainfromtheCfibresbys,mula,ngtheInhibitoryInterneuron.

3.BreakingJointAdhesions

•  Iffacetjointadhesionsexisttheycouldtakeplaceatthecapsule/synoviumorthecar,lage

•  Car,lageunlikelybecauseyouneedexudatetoformadhesionsandyouneedcapillariestoproduceexudate.Car,lagedoesnothavecapillaries

•  Goodexampleofcapsularadhesionsis“frozenshoulder”alsoknownasadhesivecapsuli,s.

HowDoesManipula,onHelp?

•  Thesuddengappingbreakstheadhesionsandthejointnowreturnstoitsnormalmovementpaperns.

Crameretal(2000)

Lumbarside-postureSMTproducesgappingoftheZjoints.Side-postureposi,oning(alone)producesgapping,butlessthanabove.Thus,sidepostureSMTwouldappeartobeabletobreakupadhesionswithinhypomobilejoints.SidePostureLumbarManipula,ongapstheupsidejoints

IfadhesionsbreakthenROMshouldincrease!

Whipenham&Nilsson(2001)

4.TheTrappedMeniscoid

•  Synovial,ssuewithacertainamountofadiposepackinginthebase.

•  Roleistoincreasecongruenceofthejointsurfaces.

•  Ideathatthemeniscoidendsupinan“awkward”posi,onthatdoesnotallowthejointsurfacestoapproacheachotherhencelimi,ngmo,onofthejoint.

AnIdealMeniscus

Looseconnec,veandadipose,ssue

Synovial,ssueandbloodvessels

Denseconnec,veTissue

AFibro-AdiposeMeniscoid

LumbarFacetJoint LumbarFacetJoint(car,lagesurfacesseparated)

TheMeniscusEntrapmentTheory

Normalposi,on Apextrappedanddeformscar,lagecrea,ngarecesswhichtrapsit

Manipula,onseparatesthesurfacesallowingtheapexto“escape”

Notetensionincapsulewhichwouldleadtopain

HowDoesManipula,onHelp

•  Theadjustmentthenwould“free”themeniscoidfromthatimpedingposi,onandthejointreturnstonormal

•  Howevernotlikelythatthebaseofthemeniscoidcouldwithstandthetensiontocreatecapsulartension

•  Itwouldmorelikelytearfromitsbaseleavingaloosebodyofapexinthejoint.

•  Thatloosebodycouldbereleasedbymanipula,on

5.Restora,onofMovementImprovesJointNutri,onandLubrica,on

•  Rabbitswithfullthicknesscar,lagedefectsweredividedintothree

•  treatmentgroupswiththerapyins,tutedimmediatelypostopera,velyasfollows:

1.  •Immobilisa,onwithacast2.  •Intermipentac,vemo,on(cageac,vity)3.  •Con,nuouspassivemo,on

Restora,onofMovementImprovesJointNutri,onandLubrica,on

•  Conclusions1.  Theimmobilizedgroupshowedhealingcharacterized

bytheforma,onoffibrous,ssueandmanyadhesions.

2.  Thecageac,vitygroupshowedimperfecthealingcharacterizedbyacombina,onoffibrous,ssueandpoorlydifferen,atedcar,lage.

3.  TheCPMgroupshowedhealingthroughforma,onofnewhyaline-likecar,lageoccurringinonehalfofthedefectswithinfourweeks.CPMdidnotharmintact,normallivingar,cularcar,lageinrabbits.

Restora,onofMovementImprovesJointNutri,onandLubrica,on

•  ThebenefitsofCPMforhealingcar6lage:1.  •Enhancednutri,onandmetabolicac,vity2.  •Acceleratedhealingofar,cular,ssues3.  •Regenera,on

HowDoesManipula,onHelp?•  Intheorymanipula,onwouldrestoremovementandthemovementwouldensureproperlubrica,onandremovalofinflammatoryproducts

•  WhenCPMisdoneauercompletekneereplacementhowever,pa,entsdonotexperienceanadvantageovernothavingCPM

•  Butthatfinding(regardingCPM)cannotbegeneralizedtotheeffectsofnormaljointmovement.Itiss,llverypossiblethatrestora,onofmovementisbeneficialtojoints.

6.ReleaseofEndorphins

•  Althoughtheevidenceiscontradictory,ithasbeensuggestedthatadjustmentscausethereleaseofendorphinsfromthebrain,henceinducingpaininhibi,on.

•  Theevidencemaybecontradictorybecauseineachstudythe“dose”ofmanipula,onmaybedifferent.

•  Perhapsthereisathreshold“dose”neededtoproducearelease.

SummaryofPoten,alEffectsofSpinalManipula,on

ReleaseofEndorphins

MuscleSpindle/GolgiTendonOrgan

BreakingJointAdhesions

MechanoreceptorS,mula,on

TrappedMeniscoid VertebralMo,on

Pain

Lubrica,on

7.ADIO

•  Above,Down,Inside,Out•  BoneoutofplaceblocksnervousflowwhichnormallytravelsfromAboveDownandInsideOut.

•  Boneoutofplacehasnotbeendocumented.•  Thatbeingsaid,manypa,entswithvisceralsymptomshavebeenhelpedbyadjus,ngvertebra.

SomeClaimsarealiple“OvertheTop”•  Avertebralsubluxa,onisaspinalabnormalitythatinterfereswithyour

nerves.Itcancreatedis-ease,loweredresistancetodisease,pain,imbalance,fa,gueandcanpavethewayforillhealth.Itissome,mescalledthe"silentkiller"becauseitcanslowlyeatawayatyourhealthandvitalitywithoutyourhavingtheslightestawarenessofit....

•  Subluxa,onsaresoverycommontheycanbeconsideredanepidemic—nearlyeveryonehasthem.

•  Subluxa,onscanundermineyourhealthjustastermitescanunderminethefounda,onofyourhome....Bythe,mesymptomsappearacertainamountofthedamagecausedbylongstandingsubluxa,onsmaybeirreversible.

•  Forthatreasonperiodicspinalexamina,onstolocateandcorrectvertebralsubluxa,onsshouldbepartofeveryfamily'shealthrou,ne.Correc,ngsilentsubluxa,onstodaycouldsaveyouandyourfamilyfromdiseasesthat,laterinlife,couldnotpossiblybeignored.