The Chiroprac,c Theories: How does Spinal Manipulaon Exert ... · life? • CNS orders a contrac,on...
Transcript of The Chiroprac,c Theories: How does Spinal Manipulaon Exert ... · life? • CNS orders a contrac,on...
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TheChiroprac,cTheories:HowdoesSpinalManipula,onExertit’s
ClinicalEffect?Dr.J.KimRoss
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TheTheories1. OvercomeMuscleSpasmbyreseHngmuscle
spindles2. S,mula,onofMechanoreceptors3. BreakingScarTissueinjoints4. Removalofacutejointlocking(Trapped
Meniscoid)5. Restora,onofmovementimprovesjoint
nutri6onandlubrica6on6. ReleaseofendorphinsfromtheCNS7. ADIO(boneoutofplace,blockingnerveflow)
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1.MuscleSpindle/GolgiTendonTheory
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GolgiTendonOrgan
1bafferent
αmotorneuron
Inhibi6on
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MuscleSpindles
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HowcantheGaingoAwryineverydaylife?
• CNSordersacontrac,onandtheintraandextrafusalfibrescontractsospindles,llprovidinginfoaboutlength
• Thenaposturalfaultoccurssuddenlyandtheintrafusalfibresgoslackbuttherewasnoorderfromγtofollowthemovement(so1aafferentsgosilent).Nowγincreaseac,vitytosothat1acangiveinforma,onaboutlengthagain.
• Sogainisincreasedtoac,vatethespindle• Nowbodypartsgobacktooriginalposi,onbutγgainwon’tletithappen
• Sonowinnormalposturethemuscleisinspasm
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HowdoesManipula,onHelp?
• StretchtheintrafusalfibresagainstaspindlemaintainedresistancewouldproduceabarrageofafferentimpulseintenseenoughtosignaltheCNStoreducetheγdischarge
• GTO’swouldbes,mulated(becausethemusclewass,fffromtheγac,vity)andthatwillresultinαandγinhibi,onwhichwillcausethemuscletorelax
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HowdoesManipula,onHelp?
Notethebarrageofafferentac,vityimmediatelyontheonsetoftheimpulse.Doesthisallowthegaininthegammasystemtobeturneddown?Thentheafferentac,vitybecomessilent.Aretheysilentbecausethemuscleisnowrelaxed?
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Lehmanetal,(2001)
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2.MechanoreceptorS,mula,on• InthespinewehaveTypeI,TypeIIandTypeIVmechanoreceptorsassociatedwiththejointcapsule
• TypeIhaveaconstantdischarge(slowadap,ng)eveninanon-movingjoint(becausethereisalwayssometensioninthecapsule
• TypeIIarerapidlyadap,ngandhencearesilentinnon-movingjoints.Howeverwouldrespondquicklytomovement(physiologicaloranadjustment)andthengosilentagainevenifthemovementiss,lloccurring.
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MechanoreceptorS,mula,on
• TypeIcanindicatethedirec,onofmovement(bycomparingdifferentpartsofthecapsule)
• Duringtrac,onallpartsofthecapsulewouldbestretchedwhileothermovementswouldslackensomepor,onofthecapsuleandstretchothers
• TypeIIindicateonlythatmo,onhasoccurred.
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HowDoesManipula,onHelp?
• Throughs,mula,onofmechanoreceptors,manipula,onwouldtrigger3possiblemechanisms:
1. ReflexogenicEffects
2. PerceptualEffects
3. PainSuppression
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ReflexogenicEffects
• Mechanoreceptorafferentsprojecttofusimotorneurons(γneurons)oftheassociatedwithmusclespindles
• Hencetheyinfluencemuscletonebyaffec,ngthegainofthespindles
• Theyalsosynapseintersegmentallysomusclesfromjointsremotetothejointcausingthedischarge,alsoexperienceatonealtera,on
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Manipula,on&ReflexogenicEffects
• Manipula,onthenwoulds,mulatethemechanoreceptorswhichwouldalterγoutput,whichwouldaltermuscletone.
• Soitcoulddecreasemusclespasmatajointandadjacentjoints,oritcouldincreasemuscletonedependingonthesitua,on
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Manipula,on&PerceptualEffects• TypeImechanoreceptorscontributetotheperceptualexperiencesofposturalsensa,onandkinesthesis.
• Inflamma,oninadamagedjointmayalterthiscontribu,on
• Manipula,oncouldreduceinflamma,onandhencereduceinappropriatefiringofthesereceptors
• And/ormanipula,onmaydirectlyaltertheoutputofthesereceptorsandnormalizethemsothatkinesthe,csenseisreturnedtonormal
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Fig2Thearrangementofpa,ent,helmetwithpointer,andrecordsheetwithcoordinatesystemfortheHRAprocedure.
ImprovementaBerchiroprac6ccareincervicocephalickinesthe6csensibilityandsubjec6vepainintensityinpa6entswithnontrauma6c
chronicneckpain.PalmgrenPJ,SandströmPJ,LundqvistFJ,HeikkiläH.JManipula,vePhysiolTher.2006Feb;29(2):100-6.
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ImprovementaBerchiroprac6ccareincervicocephalickinesthe6csensibilityandsubjec6vepainintensityinpa6entswithnontrauma6c
chronicneckpain.PalmgrenPJ,SandströmPJ,LundqvistFJ,HeikkiläH.JManipula,vePhysiolTher.2006Feb;29(2):100-6.
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ImprovementaBerchiroprac6ccareincervicocephalickinesthe6csensibilityandsubjec6vepainintensityinpa6entswithnontrauma6c
chronicneckpain.PalmgrenPJ,SandströmPJ,LundqvistFJ,HeikkiläH.JManipula,vePhysiolTher.2006Feb;29(2):100-6.
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PainSuppression(GateControlTheory)
• UnmyelinatedCfibresarepainsensors• TheyalsoinhibitaninhibitoryinterneuronhenceintensifyingthepainsignaltotheCNSviaaprojec,onneuron
C-fibre
- -+ +
+InhibitoryNeuron
Projec,onNeuron
MechanoreceptorNeuron
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Manipula,on&PainSuppression
• Ifthejointisnotmoving,themechanoreceptorsarenots,mulated.Ifthemechanoreceptorsarenots,mulated,thereisnothingtoinhibitthesignalfromtheCfibres.
• Manipula,onrestoresthemo,on,s,mula,ngthemechanoreceptorswhichinturninhibitsthepainfromtheCfibresbys,mula,ngtheInhibitoryInterneuron.
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3.BreakingJointAdhesions
• Iffacetjointadhesionsexisttheycouldtakeplaceatthecapsule/synoviumorthecar,lage
• Car,lageunlikelybecauseyouneedexudatetoformadhesionsandyouneedcapillariestoproduceexudate.Car,lagedoesnothavecapillaries
• Goodexampleofcapsularadhesionsis“frozenshoulder”alsoknownasadhesivecapsuli,s.
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HowDoesManipula,onHelp?
• Thesuddengappingbreakstheadhesionsandthejointnowreturnstoitsnormalmovementpaperns.
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Crameretal(2000)
Lumbarside-postureSMTproducesgappingoftheZjoints.Side-postureposi,oning(alone)producesgapping,butlessthanabove.Thus,sidepostureSMTwouldappeartobeabletobreakupadhesionswithinhypomobilejoints.SidePostureLumbarManipula,ongapstheupsidejoints
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IfadhesionsbreakthenROMshouldincrease!
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Whipenham&Nilsson(2001)
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4.TheTrappedMeniscoid
• Synovial,ssuewithacertainamountofadiposepackinginthebase.
• Roleistoincreasecongruenceofthejointsurfaces.
• Ideathatthemeniscoidendsupinan“awkward”posi,onthatdoesnotallowthejointsurfacestoapproacheachotherhencelimi,ngmo,onofthejoint.
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AnIdealMeniscus
Looseconnec,veandadipose,ssue
Synovial,ssueandbloodvessels
Denseconnec,veTissue
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AFibro-AdiposeMeniscoid
LumbarFacetJoint LumbarFacetJoint(car,lagesurfacesseparated)
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TheMeniscusEntrapmentTheory
Normalposi,on Apextrappedanddeformscar,lagecrea,ngarecesswhichtrapsit
Manipula,onseparatesthesurfacesallowingtheapexto“escape”
Notetensionincapsulewhichwouldleadtopain
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HowDoesManipula,onHelp
• Theadjustmentthenwould“free”themeniscoidfromthatimpedingposi,onandthejointreturnstonormal
• Howevernotlikelythatthebaseofthemeniscoidcouldwithstandthetensiontocreatecapsulartension
• Itwouldmorelikelytearfromitsbaseleavingaloosebodyofapexinthejoint.
• Thatloosebodycouldbereleasedbymanipula,on
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5.Restora,onofMovementImprovesJointNutri,onandLubrica,on
• Rabbitswithfullthicknesscar,lagedefectsweredividedintothree
• treatmentgroupswiththerapyins,tutedimmediatelypostopera,velyasfollows:
1. •Immobilisa,onwithacast2. •Intermipentac,vemo,on(cageac,vity)3. •Con,nuouspassivemo,on
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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.
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Restora,onofMovementImprovesJointNutri,onandLubrica,on
• ThebenefitsofCPMforhealingcar6lage:1. •Enhancednutri,onandmetabolicac,vity2. •Acceleratedhealingofar,cular,ssues3. •Regenera,on
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HowDoesManipula,onHelp?• Intheorymanipula,onwouldrestoremovementandthemovementwouldensureproperlubrica,onandremovalofinflammatoryproducts
• WhenCPMisdoneauercompletekneereplacementhowever,pa,entsdonotexperienceanadvantageovernothavingCPM
• Butthatfinding(regardingCPM)cannotbegeneralizedtotheeffectsofnormaljointmovement.Itiss,llverypossiblethatrestora,onofmovementisbeneficialtojoints.
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6.ReleaseofEndorphins
• Althoughtheevidenceiscontradictory,ithasbeensuggestedthatadjustmentscausethereleaseofendorphinsfromthebrain,henceinducingpaininhibi,on.
• Theevidencemaybecontradictorybecauseineachstudythe“dose”ofmanipula,onmaybedifferent.
• Perhapsthereisathreshold“dose”neededtoproducearelease.
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SummaryofPoten,alEffectsofSpinalManipula,on
ReleaseofEndorphins
MuscleSpindle/GolgiTendonOrgan
BreakingJointAdhesions
MechanoreceptorS,mula,on
TrappedMeniscoid VertebralMo,on
Pain
Lubrica,on
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7.ADIO
• Above,Down,Inside,Out• BoneoutofplaceblocksnervousflowwhichnormallytravelsfromAboveDownandInsideOut.
• Boneoutofplacehasnotbeendocumented.• Thatbeingsaid,manypa,entswithvisceralsymptomshavebeenhelpedbyadjus,ngvertebra.
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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.