Muscle Testing in Applied Kinesiology

Muscle Testing Muscle Testing in in

Applied KinesiologyApplied Kinesiology

Research has indicated that the AK Research has indicated that the AK muscle test is dependent upon the muscle test is dependent upon the integrity of the entire neuromuscular integrity of the entire neuromuscular complex.complex.

In theory, then, it should be possible with the In theory, then, it should be possible with the muscle test to evaluate local and more central muscle test to evaluate local and more central control mechanisms.control mechanisms.

Muscle Testing Muscle Testing in in

Applied KinesiologyApplied Kinesiology

The dependence of the muscle test on the The dependence of the muscle test on the integrity of the nervous system does not integrity of the nervous system does not necessarily imply that the act of testing a necessarily imply that the act of testing a muscle will immediately evidence muscle will immediately evidence abnormalities within that complex.abnormalities within that complex.

AK Muscle Testing Designed to Uncover the AK Muscle Testing Designed to Uncover the Cause of the ProblemCause of the Problem

This is accomplished by a combination of: This is accomplished by a combination of: Specific muscle testing.Specific muscle testing.

– The muscle(s) chosen must be as closely associated The muscle(s) chosen must be as closely associated with the problem being examined as is possible.with the problem being examined as is possible.

– Ideally, the muscles tested will already be weak or over-Ideally, the muscles tested will already be weak or over-facilitated in response to the problem. facilitated in response to the problem.

A specific ‘challenge’ coupled with the muscle test A specific ‘challenge’ coupled with the muscle test in an attempt to change the muscle response in an attempt to change the muscle response pattern which will evidence the disturbance.pattern which will evidence the disturbance.

It has been estimated that almost It has been estimated that almost 90% of all individuals will suffer 90% of all individuals will suffer from low back pain at least once in from low back pain at least once in their lives.their lives.40-50% - Will have pain at least once 40-50% - Will have pain at least once per year.per year.20-30% - Will frequently experience 20-30% - Will frequently experience chronic pain.chronic pain.2-5% - Will have continual pain.2-5% - Will have continual pain.

Wiesel SW (1984) A Study of Computer-Assisted Tomography: The Incidence of Positive CAT Scans Wiesel SW (1984) A Study of Computer-Assisted Tomography: The Incidence of Positive CAT Scans in an Asymptomatic Group of Patients, Spine 9(6):549-551.in an Asymptomatic Group of Patients, Spine 9(6):549-551.

Often disc herniation is not the origin of Often disc herniation is not the origin of pain.pain.

About 40% of adults with an age greater About 40% of adults with an age greater than 40 and the presence of a herniated than 40 and the presence of a herniated disc do not have pain.disc do not have pain.

Kirkaldy-Willis, William MD Kirkaldy-Willis, William MD

The lumbar area consists of three components:The lumbar area consists of three components:The intervertebral discThe intervertebral disc

The two zygoapophyseal jointsThe two zygoapophyseal joints

Any loss of disc height can alter the function of Any loss of disc height can alter the function of the zygoapophyseal joints.the zygoapophyseal joints.

The posterior joints are extremely rich in nociceptorsThe posterior joints are extremely rich in nociceptors

Pain can originate from any one or all three of the Pain can originate from any one or all three of the componentscomponents

The Evolution of Disc HerniationThe Evolution of Disc Herniation

Two classic theories for the herniation.Two classic theories for the herniation.– Spontaneous prolapsSpontaneous prolaps

With the spine in flexion, the individual attempts to lift a With the spine in flexion, the individual attempts to lift a weight which is too heavy and the intradiscal pressure weight which is too heavy and the intradiscal pressure becomes too great and suffers damage.becomes too great and suffers damage.

– A gradual prolapsA gradual prolapsRepetitive, prolonged stress to the disc fatigues the annulus Repetitive, prolonged stress to the disc fatigues the annulus fibrosis and predisposes it to further damage.fibrosis and predisposes it to further damage.

Natural History of the DiscNatural History of the Disc

In most patients, the disc during a period In most patients, the disc during a period of several months will spontaneously of several months will spontaneously reduce in size.reduce in size.

The reason for this reduction in size is:The reason for this reduction in size is:A drying out of the discal material.A drying out of the discal material.

Why this occurs, at this moment not known.Why this occurs, at this moment not known.

Theories for the spontaneous Theories for the spontaneous reduction of the discreduction of the disc

Reabsorption:Reabsorption:A deficiency in nutrition within the disc caused by a A deficiency in nutrition within the disc caused by a severe loss of bioavailability of nutrients to the severe loss of bioavailability of nutrients to the disc. disc.

Desiccation (dehydration) – Caused by a Desiccation (dehydration) – Caused by a deficiency of hydrophilic proteoglycans.deficiency of hydrophilic proteoglycans.

Phagocytosis – Secondary to the Phagocytosis – Secondary to the inflammatory response during the acute inflammatory response during the acute phase of disc herniation.phase of disc herniation.

Low Back Society Low Back Society (2004)(2004)

Has concluded that the options available Has concluded that the options available to the patient should include specific to the patient should include specific manual therapy by a skilled specialist.manual therapy by a skilled specialist.

Also recommended that manual therapy is Also recommended that manual therapy is made more effectively if combined with made more effectively if combined with other adjunctive methods of treatment:other adjunctive methods of treatment:

These would include: TENS, Massage, UltrasoundThese would include: TENS, Massage, Ultrasound

Yet is it necessary to consider other alternatives?Yet is it necessary to consider other alternatives?

Professor Karel Lewitt - NeurologistProfessor Karel Lewitt - Neurologist(Medical University - Prague)(Medical University - Prague)

Vertebral “blocks” found together with the Vertebral “blocks” found together with the herniated disc can stimulate a noted herniated disc can stimulate a noted worsening of the condition.worsening of the condition.

More importantly, research has More importantly, research has demonstrated that following a manual demonstrated that following a manual therapy to “unblock” the vertebrae involed therapy to “unblock” the vertebrae involed in the condition, a major portion of patients in the condition, a major portion of patients improve in a significant manner.improve in a significant manner.

Professor Karel Lewitt - NeurologistProfessor Karel Lewitt - Neurologist(Medical University - Prague)(Medical University - Prague)

One should almost always attempt a series of One should almost always attempt a series of manual treatments on patients who suffer from manual treatments on patients who suffer from lumbosciatica because it always has value. lumbosciatica because it always has value.

But he has also said: This recommendation is But he has also said: This recommendation is dependent upon the application of the correct dependent upon the application of the correct therapy. therapy.

Is There More?Is There More?

Pain caused by muscle?Pain caused by muscle?Strains (Often a diagnosis used)Strains (Often a diagnosis used)Weakness from a deficiency in capacity.Weakness from a deficiency in capacity.

As with ‘Back School’.As with ‘Back School’.

Pelvic floor musculature post-partum. Pelvic floor musculature post-partum.

Viscero-somatic reflexes?Viscero-somatic reflexes?For example – the prostate in the male and uterus in the female.For example – the prostate in the male and uterus in the female.Kidneys – stones and infection.Kidneys – stones and infection.The intestine – colitis, irritable bowel, dysbiosis.The intestine – colitis, irritable bowel, dysbiosis.

Postural reflexes caused by mechanical problems far Postural reflexes caused by mechanical problems far removed from the source of pain.removed from the source of pain.

Cervical lesionsCervical lesions

Our Dilemma?Our Dilemma?

How is it possible in a clinical How is it possible in a clinical setting to make an accurate setting to make an accurate diagnosis between the various diagnosis between the various elements causing pain?elements causing pain?

Our Normal InstrumentsOur Normal Instruments

Static and motion palpationStatic and motion palpation

Examination specific to manual medicineExamination specific to manual medicine

Orthopedic examsOrthopedic exams

Neurologic examsNeurologic examsEx. - Deep tendon reflexesEx. - Deep tendon reflexes

Range of motionRange of motion

ExperienceExperience

Subjective symptoms of the patientSubjective symptoms of the patient

X-ray and other scanning methodsX-ray and other scanning methods

More Often Than Not – More Often Than Not – With too little time and too many patients we With too little time and too many patients we

fall back on habitual methodsfall back on habitual methods..

We refer the patient to x-ray and scanning in order We refer the patient to x-ray and scanning in order to arrive at a diagnosis.to arrive at a diagnosis.

If we don’t have these possibilities? If we don’t have these possibilities? – Deep tendon reflexes (not always significant)Deep tendon reflexes (not always significant)– A few orthopedic tests – if time permitsA few orthopedic tests – if time permits– Sensory examination (Can be very subjective)Sensory examination (Can be very subjective)– Manual medicine techniques like motion palpation.Manual medicine techniques like motion palpation.

In manual medicine, more often than not, In manual medicine, more often than not, the conclusion is to manipulate the spinethe conclusion is to manipulate the spine

How do we confirm our decision to manipulate?How do we confirm our decision to manipulate?

The number of treatments is dependent upon – The number of treatments is dependent upon – what?what?

BJ Palmer, DCBJ Palmer, DC

The son of David Daniel Palmer, the man who The son of David Daniel Palmer, the man who founded the profession of Chiropractic.founded the profession of Chiropractic.

““One can have 50 people with back pain One can have 50 people with back pain walk past you and each one is hit on walk past you and each one is hit on the backside with a shovel. Twenty-the backside with a shovel. Twenty-five will probably feel better. This is five will probably feel better. This is

not an indication of good …not an indication of good …manipulative therapy”manipulative therapy”

How do we measure the effectiveness How do we measure the effectiveness of our treatment regime?of our treatment regime?

If we are fortunate, the patient may feel a positive change If we are fortunate, the patient may feel a positive change immediately – but this is not always the case.immediately – but this is not always the case.

More often than not we take the More often than not we take the ‘wait and see’ ‘wait and see’ attitude.attitude.

We fill the patient with platitudes of when the We fill the patient with platitudes of when the pain will ease and how many treatments they will pain will ease and how many treatments they will need, but…need, but…

We are too often dependent upon the patient’s We are too often dependent upon the patient’s response as to pain relief in concluding the response as to pain relief in concluding the validity of the treatment rather than having other, validity of the treatment rather than having other, less subjective, methods at hand to use in less subjective, methods at hand to use in further evaluation.further evaluation.

How May We Increase Our Diagnostic Ability How May We Increase Our Diagnostic Ability and and

Therapeutic Conclusions?Therapeutic Conclusions?

Study neurology.Study neurology.

Learn more orthopedic exam procedures.Learn more orthopedic exam procedures.

Continue to follow every course available Continue to follow every course available in manual medicine.in manual medicine.

Work with more experienced colleagues.Work with more experienced colleagues.

Is manipulation alone enough?Is manipulation alone enough?

Research shows that many patients suffer Research shows that many patients suffer from musculoskeletal pain due to from musculoskeletal pain due to dysfunction in areas far removed from the dysfunction in areas far removed from the source of pain. source of pain.

Cassidy , Thiel e Kirkaldy-Willis Cassidy , Thiel e Kirkaldy-Willis ConcludeConclude

Pain from the herniated disc is primarily Pain from the herniated disc is primarily caused by inflammation.caused by inflammation.

When other neurologic signs are present When other neurologic signs are present they say that these are directly associated they say that these are directly associated with the compressive forces caused by the with the compressive forces caused by the disc. disc.

Sensory loss (paresthesia).Sensory loss (paresthesia).

Motor inhibition.Motor inhibition.– Loss of muscle strength easily determined using AK Loss of muscle strength easily determined using AK

methods.methods.

Reduced or loss of deep tendon reflexes.Reduced or loss of deep tendon reflexes.

The basis of all healing arts is to attempt The basis of all healing arts is to attempt to eliminate the suffering of our patientsto eliminate the suffering of our patients

Statistically the results do not always Statistically the results do not always speak well for our efforts.speak well for our efforts.

The numbers of the suffering are on a steady The numbers of the suffering are on a steady increase as is the number of those attempting increase as is the number of those attempting to offer a therapeutic answer.to offer a therapeutic answer.

George Goodheart DCGeorge Goodheart DCResults are based on….Results are based on….

DiagnosisDiagnosis

DiagnosisDiagnosis

DiagnosisDiagnosis

Low Back Pain Patient Protocol

Patient seatedTest right and left gluteus medius

muscles+ K-27

One weakBoth

StrongBoth Weak

First evaluate for discal involvement

Phase onePhase oneStart in the seated position.Start in the seated position.

It is best to start with testing the gluteus medius It is best to start with testing the gluteus medius as it is innervated by the L5 and S1, primarily,as it is innervated by the L5 and S1, primarily,– but also some association with the L4 nerve.but also some association with the L4 nerve.

It is important to stabilize the opposite knee to It is important to stabilize the opposite knee to prevent against body rotation of the patient.prevent against body rotation of the patient.

In some cases, it will be difficult for the patient In some cases, it will be difficult for the patient to extend the leg as is shown due to pain.to extend the leg as is shown due to pain.

Phase onePhase one

The leg may be abducted to The leg may be abducted to a greater degree than is a greater degree than is shown.shown.

External rotation of the leg External rotation of the leg at the foot will help to isolate at the foot will help to isolate the gluteus medius from the the gluteus medius from the tensor fascia lata.tensor fascia lata.

The patient may aid against The patient may aid against rotation by grasping the rotation by grasping the table.table.

Whenever in doubt as to the Whenever in doubt as to the position of the patient or the position of the patient or the test just repeat the testing in test just repeat the testing in a way to eliminate the a way to eliminate the variable.variable.

Make Note of Any FindingsMake Note of Any Findings

This is called the ‘neutral This is called the ‘neutral position’.position’.

Very often, in cases of Very often, in cases of discal problems, one of discal problems, one of the two glutei will test the two glutei will test weak.weak.

Nevertheless, in many Nevertheless, in many patients, the initial testing patients, the initial testing does not evidence any does not evidence any weakness. This is not a weakness. This is not a problem.problem.

In the Absence of Obvious WeaknessIn the Absence of Obvious Weakness

Continue testing with the Continue testing with the patient therapy patient therapy localizing (TL) to the localizing (TL) to the acupuncture point K-27.acupuncture point K-27.

This will evidence any This will evidence any over-facilitation caused over-facilitation caused by a metabolic by a metabolic condition.condition.

The Home of All Associated PointsThe Home of All Associated Points

Therapy localization to Therapy localization to the point K-27 the point K-27 on the on the same side of the same side of the bodybody as the muscle as the muscle being tested.being tested.This is an important This is an important development in AK development in AK muscle testing as it muscle testing as it enables the examiner to enables the examiner to quickly and accurately quickly and accurately evaluate for over-evaluate for over-facilitated muscle facilitated muscle reactions.reactions.

K-27

Joseph Shafer



muscles+ K-27

One weakBoth

StrongBoth Weak

StrongWeak

Begin lateral

bending

without K-27

Metablolic Problem

Both Strong

Both Weak

+ K-27

Begin Lateral Flexion – Step TwoBegin Lateral Flexion – Step Two

Lateral flexion is Lateral flexion is designed to provoke designed to provoke mainly the discal element mainly the discal element in the lumbar spine.in the lumbar spine.

It is clear that this It is clear that this movement will also effect movement will also effect the posterior the posterior zygoapophyseal (facet) zygoapophyseal (facet) joints, but the test is still joints, but the test is still primarily for eliciting primarily for eliciting discal reactions.discal reactions.

LateralLateral flexionflexion

LateralizationLateralization

After the first gluteus After the first gluteus medius testing in the medius testing in the neutral position it is time neutral position it is time to add ‘challenge’ to add ‘challenge’ variables.variables.Lateral flexion as shown Lateral flexion as shown is made by asking the is made by asking the patient to lower the patient to lower the shoulder only.shoulder only.Be on guard not to allow Be on guard not to allow the patient to just the patient to just leanlean to to the side. This will not put the side. This will not put much pressure on the much pressure on the disc.disc.

LateralLateral flexionflexion

LateralizationLateralization

Once it has been Once it has been established that there is established that there is no over-facilitation, the no over-facilitation, the testing proceeds without testing proceeds without TL to K-27.TL to K-27.If there was weakness in If there was weakness in part one, look for part one, look for strengthening of the strengthening of the muscle.muscle.If no weakness was found If no weakness was found in part one, look to create in part one, look to create it with the movements.it with the movements.

Lateral Lateral flexionflexion

Test Both Sides in Lateral FlexionTest Both Sides in Lateral Flexion

IMPORTANTIMPORTANT

Remember in each Remember in each of the steps what of the steps what position of the body position of the body either strengthened either strengthened or weakened the or weakened the muscle being muscle being tested.tested.

Medial Medial flexionflexion

Test Both Sides in Lateral FlexionTest Both Sides in Lateral Flexion

Testing both sides is Testing both sides is important, even if important, even if weakness is found weakness is found upon testing the first upon testing the first gluteus medius gluteus medius muscle.muscle.Bilateral weakness Bilateral weakness would throw some would throw some doubt into using the doubt into using the gluteus medius as an gluteus medius as an indicator.indicator.


Postero-medial/central LesionPostero-medial/central Lesion

Assume the patient had Assume the patient had a weak left gluteus a weak left gluteus medius in the neutral medius in the neutral position.position.

Should the patient’s Should the patient’s muscle strengthen in muscle strengthen in this position, it this position, it indicates that there is a indicates that there is a possible postero-medial possible postero-medial or central disc lesion or central disc lesion right.right.


Panjabi and WhitePanjabi and WhiteThe Postero-medial/Central LesionThe Postero-medial/Central LesionPanjabi and White used Panjabi and White used pain as a criteria.pain as a criteria.Pain can be a subjective Pain can be a subjective tool and it can be absent tool and it can be absent even though sciatic even though sciatic involvement is evident. involvement is evident. An increase in pain would An increase in pain would be felt if the patient be felt if the patient laterally flexes away from laterally flexes away from the side of sciatica and the side of sciatica and decrease on ipsilateral decrease on ipsilateral flexion.flexion.

Medial or Medial or central central lesionlesion

Panjabi and WhitePanjabi and White

The patient must respond with a sense of The patient must respond with a sense of pain reduction or increase. This brings into pain reduction or increase. This brings into the test a great amount of subjectiveness.the test a great amount of subjectiveness.

The muscle test, even though manual, is The muscle test, even though manual, is much less prone to subjective response much less prone to subjective response than the above.than the above.

Postero-medial/central LesionPostero-medial/central Lesion

A medial/central A medial/central lesion may also be lesion may also be illustrated here.illustrated here.

If the patient was at If the patient was at first testing strong, but first testing strong, but weakens to lateral weakens to lateral flexion to the opposite flexion to the opposite side, the same type of side, the same type of lesion is indicated.lesion is indicated.


Strong muscle now weakens

Postero-lateral LesionPostero-lateral Lesion

A lateral or A lateral or intraforaminal lesion intraforaminal lesion can be illustrated can be illustrated here.here.

If the patient was at If the patient was at first testing weak, but first testing weak, but strengthens to lateral strengthens to lateral flexion to the opposite flexion to the opposite side, the above type side, the above type of lesion is indicated.of lesion is indicated.


A previously weak muscle strengthens

Panjabi and WhitePanjabi and WhiteThe Lateral or Intraforaminal LesionThe Lateral or Intraforaminal Lesion

In this instance, the In this instance, the pain is increased on pain is increased on flexion towards the flexion towards the symptomatic side and symptomatic side and reduced contralaterally.reduced contralaterally.

Lateral Lateral lesionlesion

Postero-lateral or Intraforaminal LesionPostero-lateral or Intraforaminal Lesion

Assume the patient Assume the patient had a weak left had a weak left gluteus medius in gluteus medius in the neutral position.the neutral position.

The patient’s The patient’s muscle will remain muscle will remain weak if not become weak if not become even weaker when even weaker when in the presence of a in the presence of a right postero-lateral right postero-lateral lesion.lesion.

Lateral Lateral lesionlesion

The Research of NachemsonThe Research of Nachemson

Measured the Measured the increase in L3/4 increase in L3/4 lumbar disc in lumbar disc in various positions.various positions.

This illustrates This illustrates pressure in the erect pressure in the erect position.position.


During physical During physical activity.activity.

Note the amount of Note the amount of pressure in the pressure in the supine, but supine, but extension position.extension position.


Note that the seated Note that the seated forward bending and forward bending and the seated forward the seated forward bending with weight bending with weight added create some of added create some of the greatest increase in the greatest increase in intradiscal pressure.intradiscal pressure.Therefore, testing the Therefore, testing the patient while seated patient while seated provides both a stabile provides both a stabile base from which to test base from which to test and the ‘disc challenge’ and the ‘disc challenge’ we are looking for. we are looking for.

Panjabi and WhitePanjabi and White

CentralCentral

paramedialparamedialLateralLateral

Panjabi and WhitePanjabi and WhiteOnce AgainOnce Again

LateralLateral ParamedialParamedial



muscles+ K-27

One weakBoth

StrongBoth Weak

StrongWeak

Begin lateral

bending

without K-27

Metablolic Problem

Begin TL to locate &

Treat Accordingly

Doubtful as to disc alone

Both Strong

Both Weak

+ K-27

Metablolic Problem

Weak becomes Strong or Strong becomes Weak

No Change

Disc?

Some other

problem

Yes

Low Back Pain Patient ProtocolPhase 2


Disc?

Withlateral

bending

Use tuning fork and extensor muscle

Go to foot muscles

Decide todo either or both



Disc?

Withlateral

bending


Go to foot muscles


Follow dermatome

&

Test opposite extensor

T. Anterior - L4T. Posterior - L5Peroneals - S1

Weak Muscle - Stong to same lateral bend as above?

Vibration postive & eliminated with same lateral bend?

Stong muscle weak to same lateral bend as above

No vibration response or scratch.



Disc?

Begin lateral

bending


Go to foot muscles


Follow dermatome

&







Sciatica not confirmed

Sciatica ConfirmedPossible

disc lesion

Disc Lesion not

confirmed

YesYesNo No

Yes

Confirmwith

sensoryChallenge



Disc?

With lateral

bending


Go to foot muscles


Follow dermatome

&







Sciatica not confirmed

Sciatica ConfirmedPossible

disc lesion

Disc Lesion not

confirmed

YesYesNo No

Yes

Confirmwith

sensoryChallenge

Yes

NoResponse

Confirmusing

foot muscles

Go to other tests

Fifth Lumbar NerveFifth Lumbar Nerve

The posterior tibial is The posterior tibial is one of the most difficult one of the most difficult muscles to accurately muscles to accurately test as patients will test as patients will compensate by using compensate by using the anterior tibial the anterior tibial muscle.muscle.

The posterior tibial The posterior tibial muscle is the most muscle is the most distal muscle for L5 distal muscle for L5 motor control.motor control.

a. Plantar flexion of the foot

b. Stabilize the heel

c. Keep toes flexed with thumb

Peroneus Longus and BrevisPeroneus Longus and BrevisS1 NerveS1 Nerve

Note the position of Note the position of the stabilizing hand the stabilizing hand at the calcaneus and at the calcaneus and the hand that resists the hand that resists the lateral the lateral movement of the movement of the foot. foot.

Peroneus Longus and Brevis

Taken from above.

The 4The 4thth Lumbar Nerve Lumbar NerveQuadriceps muscle test combined with lateral flexion.

L3 and L4 NervesL3 and L4 Nerves

The adductorsThe adductors

In cases of severe In cases of severe pain, this position pain, this position may be difficult to may be difficult to maintain by the maintain by the patient.patient.

One might be forced One might be forced to use alternative to use alternative testing methods or testing methods or muscles.muscles.

Adductor test in seated and lateral flexion position for L3/4 nerves

Knee in extension is a must

Maintain the foot in a neutral position

L1& L2 NervesL1& L2 Nerves

Fortunately these Fortunately these levels are less levels are less frequently involved frequently involved than those of L4/5 than those of L4/5 and L5/S1, but the and L5/S1, but the need to be able to need to be able to examine them might examine them might arise. arise.

Hip flexion for the ileo-psoas and L2/3

Lateral flexion is shown here, but it is necessary to stabilize the trunk during the test

When disc is not probable causeWhen disc is not probable cause

Rotation of the trunk either strengthens Rotation of the trunk either strengthens or weakens the muscles – Facet joints.or weakens the muscles – Facet joints.

Extension of the trunk weakens the Extension of the trunk weakens the muscles – Stenosis.muscles – Stenosis.

When the vibration challenge is When the vibration challenge is negative, but the muscles indicate negative, but the muscles indicate nerve - doubtful.nerve - doubtful.

Weakness is not Eliminated by Weakness is not Eliminated by Lateral FlexionLateral Flexion

If lateral flexion If lateral flexion doesn’t change the doesn’t change the weakness pattern, weakness pattern, begin rotation.begin rotation.

In the Absence of Positive In the Absence of Positive Response with Lateral Flexion, try Response with Lateral Flexion, try

RotationRotation

If rotation eliminates If rotation eliminates weakness or causes weakness or causes weakness the weakness the conclusion is the conclusion is the same.same.

The cause is The cause is vertebrogenic in vertebrogenic in character.character.

A classic A classic subluxation is subluxation is present.present.

Anterior FlexionAnterior Flexion

Anterior flexion is utilized Anterior flexion is utilized only to create weakness only to create weakness from strength. It should not from strength. It should not create strength unless the create strength unless the situation is very unusual.situation is very unusual.This test is usually positive This test is usually positive in young people with very in young people with very supple discs.supple discs.

Occassionally a Occassionally a spondylolisthesis will spondylolisthesis will cause this type of reaction.cause this type of reaction.

This finding and the This finding and the indication of elastic indication of elastic weakness within the disc is weakness within the disc is more often than not a bit more often than not a bit more difficult to treat with more difficult to treat with manipulation alone.manipulation alone.

Extension Provoked WeaknessExtension Provoked Weakness

When all previous When all previous provocation methods provocation methods are negative, on are negative, on occasion, extension of occasion, extension of the spine will create the spine will create weakness.weakness.

Extension weakness is Extension weakness is often caused by often caused by stenosis of the canal.stenosis of the canal.

Extension

Stenosis

Hypertrophyof LigamentumFlavum

The Hidden Cervical DiscThe Hidden Cervical Disc

Not infrequently, the Not infrequently, the hidden cervical disc hidden cervical disc will cause low back will cause low back pain due to pressure pain due to pressure on the medulla.on the medulla.

Compression of the Compression of the cervical spine in a cervical spine in a caudal direction will caudal direction will weaken the leg weaken the leg muscles.muscles.

Note that the knee Note that the knee of the patient must of the patient must be stabilized by be stabilized by the examiner or the examiner or else the patient else the patient will tend to test will tend to test weak. weak.

Occasionally, it Occasionally, it becomes becomes necessary to necessary to examine a patient examine a patient in a position a bit in a position a bit more particular.more particular.

Record in Memory all the Record in Memory all the Positive ResponsesPositive Responses

It is important in all these test It is important in all these test situations to remember which position situations to remember which position (body challenge) created the positive (body challenge) created the positive response and/or which position response and/or which position improved the weakness response. improved the weakness response.

In the treatment position the weakness In the treatment position the weakness may be lost.may be lost.

Do Not Make Hasty ConclusionsDo Not Make Hasty Conclusions

When a positive test using the gluteus When a positive test using the gluteus medius is found, it is not an immediate medius is found, it is not an immediate indication of a discal lesion.indication of a discal lesion.

One should then move distally and One should then move distally and repeat the positive test using another repeat the positive test using another muscle with the same innervation.muscle with the same innervation.

Repositioning Repositioning the patient in a the patient in a lateral bend or lateral bend or one of the other one of the other body challenge body challenge positions will re-positions will re-introduce the introduce the weakness weakness pattern in most pattern in most instances.instances.

Note the examiner’s body position toward the Note the examiner’s body position toward the midline of the patient.midline of the patient.

The patient’s femur The patient’s femur is internally rotated is internally rotated to present the to present the semimembranosis -semimembranosis -tendinosis for tendinosis for accurate testing of accurate testing of L4 or L5 nerve.L4 or L5 nerve.

Position for Testing S1Position for Testing S1

Biceps femoris.Biceps femoris.

Examiner body position Examiner body position is much less toward the is much less toward the midline of the patient.midline of the patient.

External rotation of the External rotation of the tibia and no internal tibia and no internal rotation of femur.rotation of femur.

Tuning Fork Tuning Fork Stimulus to Nerve Area Stimulus to Nerve Area and Local Muscle Testingand Local Muscle Testing

Local Local muscle muscle testing testing combined combined with with extension extension of the of the back.back.

As when using the As when using the extensor muscle as an extensor muscle as an indicator, the local muscle indicator, the local muscle will also return to strength will also return to strength upon passing the point of upon passing the point of nerve compression or nerve compression or irritation.irritation.

Occasionally, the Occasionally, the vibration challenge will vibration challenge will remain positive until L1/2.remain positive until L1/2.

Any ideas as to why?Any ideas as to why?

Low Back Pain Disc Treatment Protocol

Disc Lesion Confirmed?

Patient ProneYes Hamstring

musle weak

Place blocks under patient

Laterally bend patient

& retest

YesNo

weak?

Your inTrouble

Yes

No

Strong?

Jugular Compression and pump pelvis on

opposite side of sciatica

Change block

position

No

Yes

Strong

Begin TreatmentBegin Treatment

Place the blocks under Place the blocks under the pelvis diagonally as the pelvis diagonally as illustrated.illustrated.

One under the ASISOne under the ASISOne under the One under the AcetabulumAcetabulum

The blocks treat the The blocks treat the craniosacral respiratory craniosacral respiratory mechanism.mechanism.Most likely they de-rotate Most likely they de-rotate the pelvis and release the pelvis and release tension on the involved tension on the involved nerve at the neural nerve at the neural sheath. sheath.

Cassidy , Thiel e Kirkaldy-Willis Cassidy , Thiel e Kirkaldy-Willis Have NotedHave Noted

Experts agree that the pain associated Experts agree that the pain associated with the herniated disc is principally with the herniated disc is principally caused by:caused by:

Edema surrounding the nerve sheath.Edema surrounding the nerve sheath.

Other inflammatory processes in response to Other inflammatory processes in response to the hernia.the hernia.

Scientific research on animals has Scientific research on animals has shown an increase in Ig-G in shown an increase in Ig-G in degenerated discs.degenerated discs.

Phase One of Disc Treatment Phase One of Disc Treatment ProtocolProtocol

Find the muscle Find the muscle weakness associated weakness associated with the disc.with the disc.Put one block under the Put one block under the acetabulum and the the acetabulum and the the other under the ASIS of other under the ASIS of the pelvis.the pelvis.If the muscle strengthens If the muscle strengthens – keep the blocks in this – keep the blocks in this position to treat.position to treat.Retest the weak muscle.Retest the weak muscle.

If it remains weak change If it remains weak change the position of the blocks.the position of the blocks.

Change the Change the position to position to the opposite the opposite if if necessary.necessary.Left block Left block under ASISunder ASISRight block Right block under the under the acetabulum.acetabulum.

Step Two of Category IIIStep Two of Category III

Jugular compression, Jugular compression, if performed while if performed while treating the category treating the category III, will significantly III, will significantly reduce the amount of reduce the amount of time needed during time needed during this treatment phase.this treatment phase.

Jugular compression Jugular compression is manual occlusion of is manual occlusion of the jugular veins.the jugular veins.

Finding the Side to Stimulate Finding the Side to Stimulate ManuallyManually

As shown in the As shown in the illustration, the illustration, the sciatica side is on the sciatica side is on the left.left.

Therefore, the Therefore, the pumping maneuver pumping maneuver will be on the right.will be on the right.

Pump the Ischial Tuberosity While Pump the Ischial Tuberosity While Maintaining Jugular Compression.Maintaining Jugular Compression.

Sciatica left – pump right.Sciatica left – pump right.

If the hand is too small to If the hand is too small to manage bilateral manage bilateral compression of the compression of the jugular veins, compress jugular veins, compress the side where the SCM the side where the SCM is more taut.is more taut.

When the maneuver has When the maneuver has been successful, the been successful, the SCM will be felt to relax.SCM will be felt to relax.

After Successful Pumping of Cat IIIAfter Successful Pumping of Cat III

Almost always, Almost always, when the treatment when the treatment of Cat III has been of Cat III has been successful, successful, the the opposite hamstring opposite hamstring will become weakwill become weak..

Locate the cause of Locate the cause of the weakness by the weakness by therapy localizing therapy localizing the spine.the spine.

Therapy LocalizationTherapy Localization(TL)(TL)

Patients hand may be Patients hand may be used in classic mode.used in classic mode.

The use of the The use of the magnetmagnet is a relatively new is a relatively new development.development.

It is usual to use the It is usual to use the south pole of the south pole of the magnet to localize the magnet to localize the body, although the body, although the north pole may be used north pole may be used on occasion.on occasion.

Therapy LocalizationTherapy Localization(TL)(TL)

Alternatively, Alternatively, use the hand use the hand of the patient of the patient as it is the as it is the classic TL classic TL method in method in AK.AK.

Low Back Pain Disc Treatment Protocol

Disc Lesion Confirmed?

Patient ProneYes Hamstring

musle weak

Place blocks under patient

Laterally bend patient

& retest

YesNo

weak?

Your inTrouble

Yes

No

Strong?

Jugular Compression and pump pelvis on

opposite side of sciatica

Change block

position

No

Yes

Strong

SCM relaxes&

opposite hamstring weakens

No

Begin Phase 2

Go back and confirm

previous findings

Yes

Using the now weak opposite hamstring as an indicator, begin therapy localization with magnet or patient's hand until one area eliminates weakness.

Low Back Pain Disc Treatment ProtocolPhase 2 & 3


TL to strength found

Very often it is the

cervical area, but not

always.

Keep searching

untilfound.

Yes

No

Challenge the lesion using the weak hamstring as indicator

and manipulate.

Low Back Pain Disc Treatment ProtocolPhase 2 & 3


TL to strength found

Very often it is the

cervical area, but not

always.

Keep searching

untilfound.

Yes

No

Challenge the lesion using the weak hamstring as indicator

and manipulate.

TL Found?Yes

Go to internal/external

rotators of leg and gluteus maximus

Ugh!

Strong?

Yes

No

NoRepeat procedure from above:

TL then treat accordingly after each challenge

Continue until no

muscle tests weak

Patient back to seated position:Retest all previous positive signs to

be sure they are absent

Satisfied?

Finished

Yes

Yes!

Keep the patient on the blocks and search using TL to Keep the patient on the blocks and search using TL to locate where on the spine eliminates the weakness.locate where on the spine eliminates the weakness.

Frequently, the area reinforcing the weak muscle is the Frequently, the area reinforcing the weak muscle is the cervical spine rather than the lumbar spine.cervical spine rather than the lumbar spine.

Treat the Treat the cervical after cervical after challenge for challenge for direction in the direction in the manner to which manner to which you are you are accustomed.accustomed.

Blocks may be Blocks may be removed at this removed at this point.point.

Test other Test other muscles related muscles related to spinal to spinal stability using stability using the same the same methodology.methodology.

If weakened, TL If weakened, TL to locate the to locate the area that area that eliminates eliminates weaknessweakness..

As with the cervical area treatment of the As with the cervical area treatment of the lumbar area is as preferred.lumbar area is as preferred.

Directional challenge will indicate treatment direction.Directional challenge will indicate treatment direction.

Piriformis SyndromePiriformis SyndromeShould the Should the treatment not treatment not significantly significantly reduce reduce symptoms, check symptoms, check for piriformis for piriformis syndrome.syndrome.– This is This is

especially true especially true when the when the condition is condition is chronic.chronic.

This illustration This illustration shows external shows external rotation which rotation which contracts the contracts the piriformis.piriformis.

Piriformis SyndromePiriformis SyndromeType IIType II

Internal Internal rotation rotation elongates the elongates the piriformis.piriformis.In each In each instance, test instance, test the muscle the muscle indicated indicated previously previously during during sciatica sciatica evaluation.evaluation.

Therapy Localization for the Therapy Localization for the Piriformis Syndrome Using the Piriformis Syndrome Using the

Patient’s HandPatient’s Hand

Piriformis Syndrome Piriformis Syndrome and and

Magnet TLMagnet TL

Piriformis SyndromePiriformis Syndrome

Not infrequently, the positive TL will be Not infrequently, the positive TL will be to the opposite gluteal area and to the opposite gluteal area and piriformis.piriformis.

On a more rare basis, the syndrome will On a more rare basis, the syndrome will have a vertebrogenic origin.have a vertebrogenic origin.

Piriformis SyndromePiriformis Syndromeandand

Chinese Elbow TortureChinese Elbow Torture

Piriformis SyndromePiriformis Syndromeandand

Finger MassageFinger Massage

Re-examine following treatment Re-examine following treatment

An Alternative Test for the Medial An Alternative Test for the Medial Gluteal MusclesGluteal Muscles

Medial Gluteal Weakness and TLMedial Gluteal Weakness and TL

Following the TreatmentFollowing the TreatmentRetest in a Seated PositionRetest in a Seated Position

Women After Giving BirthWomen After Giving Birth

After giving birth, women can continue to After giving birth, women can continue to have pelvic floor muscle weakness for many have pelvic floor muscle weakness for many years.years.

The muscle reaction is often hidden and The muscle reaction is often hidden and causes pain and discomfort far removed causes pain and discomfort far removed from weakness.from weakness.

Pain is often felt at the low back and gluteal Pain is often felt at the low back and gluteal area by the woman.area by the woman.

Weakness is not always evident and testing Weakness is not always evident and testing for it is indirectly done.for it is indirectly done.

The Pelvic FloorThe Pelvic Floor

The gluteus The gluteus medius is medius is often tested often tested strong as in strong as in this example.this example.However, if However, if performed performed while while contracting contracting the pelvic the pelvic floor, floor, weakness weakness ensues.ensues.

The Ileo-psoas – Adductor Test The Ileo-psoas – Adductor Test Pelvic Floor ContractionPelvic Floor Contraction

Ileo-psoas/Adductor TestIleo-psoas/Adductor Test

Classically, this is the test for the ileo-Classically, this is the test for the ileo-psoas.psoas.

However, the test is dependent upon However, the test is dependent upon the adductors to help fixate the hip the adductors to help fixate the hip joint. joint. – Very often, with the adductors weak, the Very often, with the adductors weak, the

patient cannot perform the ileo-psoas test.patient cannot perform the ileo-psoas test.

In cases of doubt, retest in the classic In cases of doubt, retest in the classic way.way.

Normal Adductor StrengthNormal Adductor StrengthIndicated Prior to TestingIndicated Prior to Testing

Weak Adductors as Indicated Prior to Weak Adductors as Indicated Prior to TestingTesting

TL by the Patient to the Neurolymphatic TL by the Patient to the Neurolymphatic Treatment Area While Repeating the Previously Treatment Area While Repeating the Previously

Positive Test.Positive Test.

Stressful events are known to have Stressful events are known to have undesirable effects on individuals.undesirable effects on individuals.

Peripheral lymphocytes were measured in patients Peripheral lymphocytes were measured in patients with and without herniated discs.with and without herniated discs.

Killer cell activity was Killer cell activity was significantly lowersignificantly lower in patients with herniated in patients with herniated discs.discs.They conclude that the disc herniation is sufficiently stressful to They conclude that the disc herniation is sufficiently stressful to significantly change the health of the patient.significantly change the health of the patient.

Could it be possible that the reduced immune Could it be possible that the reduced immune response could inhibit the capacity of the patient to response could inhibit the capacity of the patient to anti-inflammatory activity?anti-inflammatory activity?

Sato N, Kikuchi S, Sato K (2002) Quantifying the stress induced by distress in patients with lumbar disc herniation in terms of natural killer cell activity measurements: chromium release assay versus multiparameter flow cytometric assay, Spine Oct 1;27(19):2095-100.

Is it True That Disc Degeneration is Is it True That Disc Degeneration is Mostly Caused by Mechanical Stressors?Mostly Caused by Mechanical Stressors?

Manual manipulation and other conservative Manual manipulation and other conservative therapies have been shown to have a therapies have been shown to have a beneficial effect on the discal low back pain.beneficial effect on the discal low back pain.

This reduces mechanical stress.This reduces mechanical stress.

But is this positive response and indication But is this positive response and indication that problems arise from mechanical origin?that problems arise from mechanical origin?

Recent research has begun to show that the Recent research has begun to show that the degradation of the disc is very often begun degradation of the disc is very often begun by changes in metabolism rather than by by changes in metabolism rather than by mechanical stress factors.mechanical stress factors.

Is This Process Mechanical in Is This Process Mechanical in Origin?Origin?

Case example: Case example: Born in 1982Born in 1982MRI 2002MRI 2002Age: 20 yearsAge: 20 yearsWhat to What to conclude?conclude?– ManipulateManipulate– OperateOperate– PrayPray– All threeAll three

Lee JY, Ernestus RI, Schroder R, Klug N (2000) Histological study of lumbar Lee JY, Ernestus RI, Schroder R, Klug N (2000) Histological study of lumbar intervertebral disc herniation in adolescents, Acta Neurochir (Wein); intervertebral disc herniation in adolescents, Acta Neurochir (Wein);

142(10):1107-10.142(10):1107-10.

1. Herniated discs are found rarely in the 1. Herniated discs are found rarely in the young: About 1 – 5% of all patients of a young: About 1 – 5% of all patients of a young age with herniations are young.young age with herniations are young.

2. In the past it was assumed that only 2. In the past it was assumed that only trauma and congenital anomalies were the trauma and congenital anomalies were the cause of herniated discs in the young.cause of herniated discs in the young.

Lee JY, Ernestus RI, Schroder R, Klug N (2000) Histological study of lumbar Lee JY, Ernestus RI, Schroder R, Klug N (2000) Histological study of lumbar intervertebral disc herniation in adolescents, Acta Neurochir (Wein); intervertebral disc herniation in adolescents, Acta Neurochir (Wein);

142(10):1107-10.142(10):1107-10.

Those studied had an average age of Those studied had an average age of between 14 and 19.between 14 and 19.

4. Out of 15 patients only one had the 4. Out of 15 patients only one had the hernia caused by trauma.hernia caused by trauma.

The remainder had hernias for the same reason as The remainder had hernias for the same reason as adults.adults.

11 patients had marked degeneration.11 patients had marked degeneration.

Lee JY, Ernestus RI, Schroder R, Klug N (2000) Histological study of Lee JY, Ernestus RI, Schroder R, Klug N (2000) Histological study of lumbar intervertebral disc herniation in adolescents, Acta Neurochir lumbar intervertebral disc herniation in adolescents, Acta Neurochir

(Wein); 142(10):1107-10.(Wein); 142(10):1107-10.

They concludeThey conclude

In every case where there is no history of In every case where there is no history of trauma one must conclude that the problem trauma one must conclude that the problem arises from metabolic degeneration – arises from metabolic degeneration – not not mechanicalmechanical..

With the degeneration already present, trauma With the degeneration already present, trauma has significance only as a transitory has significance only as a transitory deterioration and not the primary problem. deterioration and not the primary problem.

Cassidy , Thiel e Kirkaldy-Willis Cassidy , Thiel e Kirkaldy-Willis

Frequently the patient with disc Frequently the patient with disc herniation and sciatica suffers from herniation and sciatica suffers from swelling and inflammation around the swelling and inflammation around the nerve root that is independent of the nerve root that is independent of the size or position of the hernia. size or position of the hernia.

Berlemann U, Gries NC, Moore RJ (1998) The relationship between height, Berlemann U, Gries NC, Moore RJ (1998) The relationship between height, shape and histologicale changes in early degeneration of the lower shape and histologicale changes in early degeneration of the lower

lumbar discs, Eur Spine J. 7(3)212-7.lumbar discs, Eur Spine J. 7(3)212-7.

The effect of age on degeneration of the disc The effect of age on degeneration of the disc is controversial.is controversial.In the past it was published that disc In the past it was published that disc degeneration with age was inevitable.degeneration with age was inevitable.

Today, much research refutes this claim.Today, much research refutes this claim.

Even though degeneration of the disc is Even though degeneration of the disc is noted with age, it has not been possible to noted with age, it has not been possible to demonstrate that this has any significance.demonstrate that this has any significance.Disc height reduction is much more Disc height reduction is much more pronounced in the elderly.pronounced in the elderly.

Hutton WC, Ganey TM, Elmer WA, Kozlowska E, Ugbo JL, Doh ES, Hutton WC, Ganey TM, Elmer WA, Kozlowska E, Ugbo JL, Doh ES, Whitesides TE (2000) Does long-term compressive loading on the Whitesides TE (2000) Does long-term compressive loading on the

intervertebral disc cause degeneration? Spine, Dec 1;25(23):2993-3004.intervertebral disc cause degeneration? Spine, Dec 1;25(23):2993-3004.

Dogs were fitted with a device that Dogs were fitted with a device that mechanically compressed their discs for a mechanically compressed their discs for a period of up to 53 weeks.period of up to 53 weeks.All the discs at the end of the study were All the discs at the end of the study were examined radiographically and examined radiographically and immunohistologically.immunohistologically.‘‘Disc Bulging’, annular tears and reduced Disc Bulging’, annular tears and reduced height could not be demonstrated.height could not be demonstrated.The nuclei of the discs had less The nuclei of the discs had less proteoglycans, but this was insignificantly proteoglycans, but this was insignificantly low.low.

Hutton WC, Ganey TM, Elmer WA, Kozlowska E, Ugbo JL, Doh ES, Hutton WC, Ganey TM, Elmer WA, Kozlowska E, Ugbo JL, Doh ES, Whitesides TE (2000) Does long-term compressive loading on the Whitesides TE (2000) Does long-term compressive loading on the

intervertebral disc cause degeneration? Spine, Dec 1;25(23):2993-3004.intervertebral disc cause degeneration? Spine, Dec 1;25(23):2993-3004.

Their Conclusions?Their Conclusions?

Disc compression and loading, even for Disc compression and loading, even for prolonged periods of time, cannot be prolonged periods of time, cannot be

confirmed as a cause for the confirmed as a cause for the development of disc degeneration. development of disc degeneration.

Satoh K, Konno S, Nishiyama K, Olmarker K, Kikuchi S (1999) Presence Satoh K, Konno S, Nishiyama K, Olmarker K, Kikuchi S (1999) Presence and distribution of antigen-antibody complexes in the herniated nucleus and distribution of antigen-antibody complexes in the herniated nucleus

pulposus. Spine Oct 1;24(19):1980-4pulposus. Spine Oct 1;24(19):1980-4

Antigen-antibody complexes were Antigen-antibody complexes were frequently found in discal tissue taken frequently found in discal tissue taken from patients with herniations.from patients with herniations.Antigen-antibody complexes were Antigen-antibody complexes were absent in patients without herniations.absent in patients without herniations.The conclusion: Antigen-antibody The conclusion: Antigen-antibody activity is frequently found in patients activity is frequently found in patients with disc herniation.with disc herniation.

But their significance was for the moment not But their significance was for the moment not known.known.

Mooney V, Robertson J (1976) The facet syndrome, Mooney V, Robertson J (1976) The facet syndrome, Clin Orthop 115:49-56Clin Orthop 115:49-56

100 consecutive cases of back pain 100 consecutive cases of back pain were treated with injections into the were treated with injections into the facet joints.facet joints.

He demonstrated that facet pain could He demonstrated that facet pain could mimic the symptoms of disc pain.mimic the symptoms of disc pain.

Thus, patient symptoms, do not often explain Thus, patient symptoms, do not often explain the pains origin.the pains origin.

Cassidy JD, Thiel HW, Kirkaldy-Willis KW (1993) Side Posture Manipulation for Cassidy JD, Thiel HW, Kirkaldy-Willis KW (1993) Side Posture Manipulation for Lumbar Intervertebral Disk Herniation, J Manipulative Physiol Ther 16(2):96-103Lumbar Intervertebral Disk Herniation, J Manipulative Physiol Ther 16(2):96-103

Bozzao A, Gallucci M et al. (1992) Lumbar Disk Herniation: MR Imaging Bozzao A, Gallucci M et al. (1992) Lumbar Disk Herniation: MR Imaging Assessment of Natural History in Patients Treated Without Surgery, Assessment of Natural History in Patients Treated Without Surgery,

Neuroradiology 185:135-141.Neuroradiology 185:135-141.

Often patients recover from Often patients recover from lumbosciatica.lumbosciatica.

Yet they recover despite no change in the Yet they recover despite no change in the

position and size of the hernia.position and size of the hernia.

Freemont AJ, Watkins A, Le Maitre C, Jeziorska M, Hoyland JA (2002) Freemont AJ, Watkins A, Le Maitre C, Jeziorska M, Hoyland JA (2002) Current Understanding of Cellular and Molecular Events in Intervertebral Current Understanding of Cellular and Molecular Events in Intervertebral Disc Degeneration: Implications for Therapy, J Pathol Apr;196(4):374-379.Disc Degeneration: Implications for Therapy, J Pathol Apr;196(4):374-379.

In the past, the material recovered In the past, the material recovered from operations on herniated discs from operations on herniated discs was not considered to be a reliable was not considered to be a reliable example of the degenerated disc.example of the degenerated disc.

-Now it is known that the material definitely -Now it is known that the material definitely did not represent the degenerative process inside did not represent the degenerative process inside the disc. the disc.

Freemont AJ, Watkins A, Le Maitre C, Jeziorska M, Hoyland JA (2002) Freemont AJ, Watkins A, Le Maitre C, Jeziorska M, Hoyland JA (2002) Current Understanding of Cellular and Molecular Events in Intervertebral Current Understanding of Cellular and Molecular Events in Intervertebral Disc Degeneration: Implications for Therapy, J Pathol Apr;196(4):374-379.Disc Degeneration: Implications for Therapy, J Pathol Apr;196(4):374-379.

22. New operation techniques have the ability . New operation techniques have the ability to extract material much more anteriorly than to extract material much more anteriorly than before.before.

The terminology of disc degeneration tends to indicate The terminology of disc degeneration tends to indicate ‘‘wear and tearwear and tear’.’.

Now it is generally accepted that the term ‘wear and tear’ Now it is generally accepted that the term ‘wear and tear’ is far from the truth.is far from the truth.

3. Degeneration of the ‘microanatomy’ inside 3. Degeneration of the ‘microanatomy’ inside the disc (the process of degeneration) is an the disc (the process of degeneration) is an ACTIVE process. ACTIVE process. – It is a process under local molecular control.It is a process under local molecular control.

Urban JP (2003) Degeneration of the intervertebral disc, Arthritis Res Ther. Urban JP (2003) Degeneration of the intervertebral disc, Arthritis Res Ther. 5(3):120-30 5(3):120-30

Intervetebral discs have a biochemical Intervetebral discs have a biochemical make-up similar to cartilage.make-up similar to cartilage.

But they are diverse morphologically.But they are diverse morphologically.– Degeneration and change begins much more Degeneration and change begins much more

quickly than within other types of tissue.quickly than within other types of tissue.

What is interesting is that the onset of this What is interesting is that the onset of this degeneration is linked to the onset of degeneration is linked to the onset of lumbar pain.lumbar pain.

Urban JP (2003) Degeneration of the intervertebral disc, Arthritis Res Ther. Urban JP (2003) Degeneration of the intervertebral disc, Arthritis Res Ther. 5(3):120-305(3):120-30

Today, treatment is more conservative and less Today, treatment is more conservative and less surgical than in the past.surgical than in the past.

But in many cases, a clear diagnosis that But in many cases, a clear diagnosis that explains the cause of pain is not made and more explains the cause of pain is not made and more importantly, importantly, the prescribed therapy is not totally the prescribed therapy is not totally effectiveeffective. . In the future, new biologic methods will allow for In the future, new biologic methods will allow for a more complete diagnosis and treatment of the a more complete diagnosis and treatment of the disc.disc.

Battie MC, Videman T, Gibbons LE, Fisher LD, Manninen H, Gill K (1995) Determinants Battie MC, Videman T, Gibbons LE, Fisher LD, Manninen H, Gill K (1995) Determinants of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance

imaging finding in identical twins, Spine Dec 15;20(24):26001-12.imaging finding in identical twins, Spine Dec 15;20(24):26001-12.

115 identical twins (males) were 115 identical twins (males) were investigated using NMR scanning after a investigated using NMR scanning after a lifetime of different types of work. lifetime of different types of work.

Those with a work life with greater spinal Those with a work life with greater spinal “loading” were found to have greater “loading” were found to have greater lumbar disc degeneration.lumbar disc degeneration.

But what is interesting here is that the degeneration was primarily restricted to the UPPER LUMBAR region, not the lower.

Battie MC, Videman T, Gibbons LE, Fisher LD, Manninen H, Gill K (1995) Determinants Battie MC, Videman T, Gibbons LE, Fisher LD, Manninen H, Gill K (1995) Determinants of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance

imaging finding in identical twins, Spine Dec 15;20(24):26001-12.imaging finding in identical twins, Spine Dec 15;20(24):26001-12.

In the lower lumbar region, the In the lower lumbar region, the degeneration of the loading group was degeneration of the loading group was insignificantly different from that of the insignificantly different from that of the sedentary group.sedentary group.

Due to these findings they have concluded Due to these findings they have concluded that disc degeneration is caused by:that disc degeneration is caused by:

Genetic factorsGenetic factorsFactors as yet not identifiedFactors as yet not identified

Pain is not Just Mechanical in Pain is not Just Mechanical in OriginOrigin

In 1986 I read an abstract of an article In 1986 I read an abstract of an article whereby a researcher found evidence of whereby a researcher found evidence of histamines in degenerated discs of fresh histamines in degenerated discs of fresh cadavers.cadavers.From that moment I had lingering doubts From that moment I had lingering doubts as to the mechanical cause of disc as to the mechanical cause of disc degeneration.degeneration.

I used to think that they might have “snotty noses”.I used to think that they might have “snotty noses”.

Today research supports this idea.Today research supports this idea.

The Disc Pump ChallengeThe Disc Pump Challenge

The Disc Pump ChallengeThe Disc Pump Challenge

Test a muscle with an innervation Test a muscle with an innervation associated to the area being stimulated.associated to the area being stimulated.

Vigorously pump the vertebral area 2-3 Vigorously pump the vertebral area 2-3 times.times.

Retest the previously strong muscle. If Retest the previously strong muscle. If weak, it could indicate either a discal or weak, it could indicate either a discal or vertebral subluxation problem.vertebral subluxation problem.

The Disc Pump ChallengeThe Disc Pump ChallengeDistinguishing Vertebral From DiscogenicDistinguishing Vertebral From Discogenic

Classically in AK, when a vertebral subluxation Classically in AK, when a vertebral subluxation is challenged, the effect on a strong indicator is challenged, the effect on a strong indicator muscle will be registered almost globally.muscle will be registered almost globally.

The muscle weakness pattern with a positive The muscle weakness pattern with a positive disc challenge is locally only.disc challenge is locally only.

This provides us with a means of differential diagnosis.This provides us with a means of differential diagnosis.

If the vertebral subluxation is the cause, a If the vertebral subluxation is the cause, a muscle tested outside of the innervation area will muscle tested outside of the innervation area will also weaken whereas with the disc it will remain also weaken whereas with the disc it will remain strong.strong.

Pump the Vertebral Region and Test a Muscle Pump the Vertebral Region and Test a Muscle innervated from the area being challenged.innervated from the area being challenged.

Challenge for disc inflammation will Challenge for disc inflammation will not weaken a strong indicator with not weaken a strong indicator with

innervation from another level.innervation from another level.

Lumbar disc challenge will NOT weaken a deltoid unless the challenge is positive for vertebral subluxation.

If the Challenge Proves Positive If the Challenge Proves Positive for the Disc Onlyfor the Disc Only

It is very likely that the disc is It is very likely that the disc is chronically inflammed caused by chronically inflammed caused by metabolic factors.metabolic factors.

A good confirmation of findings will be when A good confirmation of findings will be when the M. resonance shows dehydrated and the M. resonance shows dehydrated and degeneration of the disc.degeneration of the disc.

Inflammation is usually due to auto-Inflammation is usually due to auto-immune factors.immune factors.

TL will usually NOT be over the disc.TL will usually NOT be over the disc.

A disc will A disc will NOTNOT therapy localize with therapy localize with ANYANY classic hand TLclassic hand TL

Certain body tissues or body parts will Certain body tissues or body parts will NOTNOT TL using the hand. TL using the hand.

These are:These are:Vertebral discVertebral disc

BloodBlood

Generalized lymphatic systemGeneralized lymphatic system

BrainBrain

Medulla of the boneMedulla of the bone

Illustrated Here:Illustrated Here:Disc pump and substance challenge – like histamine, Disc pump and substance challenge – like histamine,

inflammatory or immune stimulating substancesinflammatory or immune stimulating substances

When the Problem is OsseousWhen the Problem is Osseous

Osseous ChallengeOsseous Challenge

The stimulus must The stimulus must be different than be different than that of the disc in that of the disc in order to access the order to access the bone response.bone response.

Here a reflex Here a reflex hammer is used to hammer is used to sharply stimulate sharply stimulate the spinous the spinous process of the process of the vertebra.vertebra.

Digital Challenge of the BoneDigital Challenge of the Bone

Like the Disc Challenge, Bone Challenge, Like the Disc Challenge, Bone Challenge, When Positive Must be Distinguished From When Positive Must be Distinguished From

Vertebral SubluxationVertebral Subluxation

Differential diagnosis for bone vs. Differential diagnosis for bone vs. disc or vertebral subluxationdisc or vertebral subluxation

Like the disc ONLY SIM’s innervated Like the disc ONLY SIM’s innervated from the area will react.from the area will react.

A deep pumping action challenge is A deep pumping action challenge is used for the disc.used for the disc.

A sharp tap on the vertebral spinous A sharp tap on the vertebral spinous process creates a shock wave process creates a shock wave stimulating the bone.stimulating the bone.

What disturbances will cause a What disturbances will cause a positive bone challenge response?positive bone challenge response?

Osseous inflammationOsseous inflammation

MetastasesMetastases

Compression fracturesCompression fractures

OsteoporosisOsteoporosis

Magnet Therapy LocalizationMagnet Therapy Localization

As with the positive disc challenge, the bone As with the positive disc challenge, the bone challenge should continue with magnet TL.challenge should continue with magnet TL.

Bone does not TL well with the hand. It is best to use the Bone does not TL well with the hand. It is best to use the magnet…and much quicker to search.magnet…and much quicker to search.

Using the AK south pole of the magnet begin to Using the AK south pole of the magnet begin to search.search.

First over the bone that was positive.First over the bone that was positive. If it does not reinforce the weak muscle it is necessary to If it does not reinforce the weak muscle it is necessary to widen your search. Sometimes almost all over. The reaction widen your search. Sometimes almost all over. The reaction is most often metabolic in character.is most often metabolic in character.Often, if the problem is not osteoporosis, it is metabolic in Often, if the problem is not osteoporosis, it is metabolic in character at the immune system level.character at the immune system level.

Sacroiliac (SI) JointSacroiliac (SI) Joint

The sacroiliac joint is often quite straight-The sacroiliac joint is often quite straight-forward in evaluation and treatment in AK.forward in evaluation and treatment in AK.

If the joint is subluxated (lesioned), usually one If the joint is subluxated (lesioned), usually one may manipulate it using any one of a number of may manipulate it using any one of a number of techniques. techniques.

In AK, one may challenge the articulation In AK, one may challenge the articulation in order to determine the direction of in order to determine the direction of lesioning.lesioning.

When the SI Joint is not When the SI Joint is not Subluxated, but InflammedSubluxated, but Inflammed

It is well documented that the SI joint can It is well documented that the SI joint can become inflamed from viscerosomatic become inflamed from viscerosomatic reflexes.reflexes.

Reiters syndromeReiters syndrome

Very often the inflamed SI joint will not TL, Very often the inflamed SI joint will not TL, either.either.Therefore without an alternative method of Therefore without an alternative method of evaluating the inflamed SI joint, evaluating the inflamed SI joint, therapeutic efforts become hit or miss.therapeutic efforts become hit or miss.

What may cause SI joint inflammation?What may cause SI joint inflammation?

PIDPIDChronic uterine inflammationChronic uterine inflammationOvarian cystsOvarian cystsColitis and ulcerative colitisColitis and ulcerative colitis

ReitersReitersChronic prostatic inflammationChronic prostatic inflammation

A low grade inflammatory reaction at the inguinal lymphatics.A low grade inflammatory reaction at the inguinal lymphatics.Adult mumpsAdult mumpsCystitisCystitisInfections transmitted by sexual means.Infections transmitted by sexual means.

KidneyKidneyStonesStonesOther, post-infective reactionsOther, post-infective reactions

Other immune system reactions far removed from the areaOther immune system reactions far removed from the areaEspecially from the throat years after the tonsils have been removed.Especially from the throat years after the tonsils have been removed.

SI joint Challenge for Inflammation & SI joint Challenge for Inflammation & SubluxationSubluxation

Challenge with Challenge with pumping pumping pressure, the SI pressure, the SI joint and test a joint and test a hamstring hamstring on the on the same sidesame side..A weakening of A weakening of the hamstring the hamstring after challenge after challenge may indicate may indicate subluxation or subluxation or Inflammation.Inflammation.

SI joint Challenge for Inflammation & SI joint Challenge for Inflammation & SubluxationSubluxation

With a With a subluxation subluxation (lesion) of the (lesion) of the joint, the joint, the challenge will challenge will also weaken also weaken the hamstring the hamstring on the other on the other side of the side of the body.body.An irritated SI An irritated SI joint, not joint, not lesioned will lesioned will NOTNOT weaken weaken the opposite the opposite hamstring.hamstring.

As with the disc and bone challenge, it is possible As with the disc and bone challenge, it is possible to use a muscle far removed from the SI joint to use a muscle far removed from the SI joint challenged to come to the same conclusions.challenged to come to the same conclusions.

Neural Sheathe Inflammation Neural Sheathe Inflammation and Sciaticaand Sciatica

Jugular Jugular compression will compression will increase CSF increase CSF pressure gradients.pressure gradients.

Increased fluid Increased fluid pressure puts pressure puts stretch strain on the stretch strain on the dura.dura.

With JC test muscles related to the sciatic With JC test muscles related to the sciatic nerve being examinednerve being examined

JC compression is not illustrated here, but must be performed simultaneously with the muscle test.

When positive to JCWhen positive to JC

TL using the magnet to localized the TL using the magnet to localized the area eliminating the response.area eliminating the response.

Positive responses may be with the Positive responses may be with the south or north pole of the magnet south or north pole of the magnet indicating different origins of the indicating different origins of the problem.problem.

The CoccyxThe Coccyx

The coccyx can be a bit difficult to assess.The coccyx can be a bit difficult to assess.Motion palpation is not very valid here.Motion palpation is not very valid here.

Palpation is often made internally and is a bit Palpation is often made internally and is a bit messy.messy.

Classic methods do not address the Classic methods do not address the coccyx well even though admitting its coccyx well even though admitting its importance.importance.

Evaluating the Coccyx and Evaluating the Coccyx and Coccygeal LigamentsCoccygeal Ligaments

Challenge can be Challenge can be made with the tuning made with the tuning fork on and around fork on and around the coccyx while the coccyx while using the hamstring using the hamstring as an indicator as an indicator muscle.muscle.The coccyx may be The coccyx may be tapped digitally as tapped digitally as well.well.Weakness indicates Weakness indicates a positive test.a positive test.

Evaluating the Coccyx and Evaluating the Coccyx and Coccygeal LigamentsCoccygeal Ligaments

The piriformis The piriformis muscle may muscle may be be substituted substituted for the for the hamstrings hamstrings if desired.if desired.

Alternatively, one may use the extensor muscle reaction in place Alternatively, one may use the extensor muscle reaction in place of the local muscle.of the local muscle.

Note: The tuning fork stimulus must be on the opposite side of the muscle used to register the reaction.

Therapy for the CoccyxTherapy for the Coccyx

Therapy for the coccyx is dependent upon the Therapy for the coccyx is dependent upon the area registering the positive response.area registering the positive response.

If above the bone elements of the coccyx, a If above the bone elements of the coccyx, a local treatment is indicated.local treatment is indicated.

Ligament interlink is a good choice here.Ligament interlink is a good choice here.

The patient touches the area challenging positive while the The patient touches the area challenging positive while the examiner stimulates the EOP.examiner stimulates the EOP.

Other posibilitiesOther posibilitiesPelvic lesions and Category 1 type restrictionsPelvic lesions and Category 1 type restrictions

Lumbar vertebral lesionsLumbar vertebral lesions

Cranial and upper cervical lesions.Cranial and upper cervical lesions.

Tarsal TunnelTarsal Tunnel

Tarsal tunnel is Tarsal tunnel is evaluated in the same evaluated in the same way.way.

Note here that the Note here that the patient has the elbow patient has the elbow slightly bent, this may slightly bent, this may or may not influence or may not influence the response.the response.

When in doubt retest.When in doubt retest.

An Alternative Method of An Alternative Method of Neurologic DiagnosisNeurologic Diagnosis

With a tuning fork stimulus at a With a tuning fork stimulus at a dermatome level, it is possible to register a dermatome level, it is possible to register a reaction using a contralateral extensor as reaction using a contralateral extensor as an indicator muscle.an indicator muscle.

In this situation a muscle far removed from In this situation a muscle far removed from the level of examination may be used.the level of examination may be used.

Nevertheless, the muscle must be an Nevertheless, the muscle must be an extensor close to the midline of the body.extensor close to the midline of the body.

The Theory Behind the Use of the The Theory Behind the Use of the Contralateral ExtensorContralateral Extensor

All nociceptor responses cross-over to the opposite All nociceptor responses cross-over to the opposite side as they ascend within the spinal cord.side as they ascend within the spinal cord.Usually the cross-over is made several segments Usually the cross-over is made several segments above the level of entry into the spinal cord from the above the level of entry into the spinal cord from the periphery.periphery.Three spinal tracts are responsible for transporting Three spinal tracts are responsible for transporting nociceptor signals to the brain. These include light nociceptor signals to the brain. These include light touch, deep pain, superficial pain and vibration.touch, deep pain, superficial pain and vibration.

The spinothalamic tractThe spinothalamic tractDorsal ColumnDorsal Column

– The spinoreticular tractThe spinoreticular tract– The spinomesenphalic tractThe spinomesenphalic tract

The Theory Behind the Contralateral The Theory Behind the Contralateral ResponseResponse

Note the crossover Note the crossover of the tracts as they of the tracts as they ascend to the brain.ascend to the brain.


Each will enter Each will enter through the through the cerebellum and cerebellum and finally arrive after a finally arrive after a complex series of complex series of interactions, at the interactions, at the thalamus.thalamus.


At the thalamus we have At the thalamus we have the final stimulus to the the final stimulus to the pyramidal and extra-pyramidal and extra-pyramidal tracts as the pyramidal tracts as the involuntary response to involuntary response to sensory stimulus now sensory stimulus now exits the brain on the exits the brain on the opposite side.opposite side.Unconscious stimulus Unconscious stimulus exiting the brain on the exiting the brain on the opposite side is known to opposite side is known to have an ‘have an ‘inhibitoryinhibitory’ effect ’ effect at the skeletal muscle at the skeletal muscle end-point.end-point.


Unconscious stimulus exiting the Unconscious stimulus exiting the brain on the opposite side is known brain on the opposite side is known to have an ‘to have an ‘inhibitoryinhibitory’ effect at the ’ effect at the skeletal muscle end-point.skeletal muscle end-point.

The inhibitory effect is primarily to The inhibitory effect is primarily to the flexor muscles which permits the flexor muscles which permits the individual to use the extensor the individual to use the extensor muscles.muscles.


A classic loss of inhibition follows a A classic loss of inhibition follows a cerebral vascular accident.cerebral vascular accident.

Yet in less pathologic situations, the Yet in less pathologic situations, the CNS can lose ability to treat incoming CNS can lose ability to treat incoming signals, signs of lack of unconscious signals, signs of lack of unconscious control become evident in postural control become evident in postural abnormalities.abnormalities.

Tiredness and stress can bring these outTiredness and stress can bring these out

Loss of Neurons with ageLoss of Neurons with age


An abnormal reaction will occur when:An abnormal reaction will occur when:The incoming signal is disturbedThe incoming signal is disturbed

The incoming signal cannot be handled The incoming signal cannot be handled correctly by the brain.correctly by the brain.

The abnormal reaction will cause a The abnormal reaction will cause a contralateral extensor muscle to test contralateral extensor muscle to test weak (using AK testing).weak (using AK testing).

What is Responsible for the What is Responsible for the Extensor Weakness?Extensor Weakness?

When a peripheral challenge to the nervous When a peripheral challenge to the nervous receptors is within normal limits, the brain receptors is within normal limits, the brain receives the signal in a normal way and the receives the signal in a normal way and the descending signal from the brain remains descending signal from the brain remains under control.under control.However, when the stimulus arriving into the However, when the stimulus arriving into the brain is aberrant in nature, the central brain is aberrant in nature, the central response is in turn disturbed temporarily.response is in turn disturbed temporarily.

The temporary confusion neurologically causes the The temporary confusion neurologically causes the patient to lose dynamic control of contraction of the patient to lose dynamic control of contraction of the extensors due to lack of inhibition from the brain to the extensors due to lack of inhibition from the brain to the flexor muscles.flexor muscles.

Illustration of Extensor Muscle Illustration of Extensor Muscle Testing.Testing.

This illustration This illustration shows the classic shows the classic position for the position for the testing the middle testing the middle trapezius.trapezius.

Our interest is to test extensor response, not just Our interest is to test extensor response, not just isolate a single muscle.isolate a single muscle.

It is possible to make the test in a non-classic position It is possible to make the test in a non-classic position

If the patient suffers If the patient suffers from sciatic nerve from sciatic nerve involvement it is involvement it is possible to create a possible to create a reaction in this manner.reaction in this manner.

The S1 dermatome is The S1 dermatome is stimulated here.stimulated here.

The End!The End!

Muscle Testing in Applied Kinesiology

Documents

Transcript of Muscle Testing in Applied Kinesiology