Spinal Manipulation

Joint Trauma: Perspectives of a Chiropractic Family Physician

By Frank M. Painter|May 23, 2012|Chiropractic Care, Degenerative Joint Disease, Diagnosis, Evaluation & Management, Spinal Manipulation|

Joint Trauma:
Perspectives of a Chiropractic Family Physician

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Clinical Monograph 8

By R. C. Schafer, DC, PhD, FICC

INTRODUCTION

The general stability of synovial joints is established by action of surrounding muscles. Excessive joint stress results in strained muscles and tendons and sprained or ruptured ligaments and capsules. When stress is chronic, degenerative changes occur.

The lining of synovial joints is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid that is a nutritive lubricant having bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in intra-articular fractures where the fracture line is exposed to synovial fluid. Synovial versus mechanical causes of joint pain are shown in Table 1.

Table 1. Synovial vs Mechanical Causes of Joint Pain

Feature	Synovitic Lesions	Mechanical Lesions
Onset	Symptoms fairly consistent, during use and at rest.	Symptoms arise chiefly during use
Location	Any joint may be involved.	Primarily involves weight-bearing joints.
Course	Usually fluctuates. Episodic flares are common.	Persistently worsening progression. No acute exacerbations.
Stiffness	Prolonged in the morning.	Little morning stiffness.
Anti-inflammatory effect	Aided by cold and other anti-inflammatory therapies.	Anti-inflammatory therapy of only minimum value.
Major pathologic features	Negative radiographic signs or diffuse cartilage loss, marginal bony erosions, but no osteophytes.	Radiographic signs of cartilage loss and osteophyte developments

Periarticular Lesions

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Lower Back Trauma (Lumbar Spine and Pelvis)

By Frank M. Painter|May 20, 2012|Chiropractic Care, Chronic Pain, Evidence-based Medicine, Low Back Pain, Orthopedic Tests, Rehabilitation, Spinal Manipulation|

Lower Back Trauma (Lumbar Spine and Pelvis)

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Clinical Monograph 24

By R. C. Schafer, DC, PhD, FICC

Although it may be easier to teach anatomy by dividing the body into arbitrary parts, a misinterpretation can be created. For instance, we find clinically that the lumbar spine, sacrum, ilia, pubic bones, and hips work as a functional unit. Any disorder of one part immediately affects the function of the other parts. We should also keep in mind that an axial kinematic chain of weight-supporting segments extends from the occipital base to the soles of the feet.

Because the number of professional papers concerning the cause and diagnosis of low-back pain is voluminous, emphasis herein is placed on points that the author believes are important but not often emphasized in popular literature.

BACKGROUND

A wide assortment of muscle, tendon, ligament, bone, nerve, and vascular injuries in this area is witnessed during posttrauma care. As with other areas of the body, the first step in the posttrauma examination process is knowing the mechanism of injury if possible. Evaluation can be rapid and accurate with this knowledge.

Low-back disability rapidly demotivates productivity and athletic participation. The mechanism of injury is usually intrinsic rather than extrinsic. The cause can often be through overbending, a heavy steady lift, or a sudden release –all which primarily involve the muscles. IVD disorders are more often, but not exclusively, attributed to extrinsic blows and intrinsic wrenches. An accurate and complete history is invariably necessary to offer the best management and counsel.

Initial Assessment

A player injured on the field or a worker injured in the shop should never be moved until emergency assessment is completed. Once severe injury has been eliminated, transfer to a backboard can be made and further evaluation conducted at an aid station.

Neurologic Levels

Neurologic assessment should be made as soon as logical. Muscle tonus (flaccidity, rigidity, spasticity) by passive movements is determined. Voluntary power of each suspected group of muscles against resistance is tested, and the force is compared bilaterally. Check pupil size, ability to follow finger motion, and reaction to light. Cremasteric (L1–L2), patellar (L2–L4), gluteal (L4–S1), suprapatellar, Achilles (L5–S2), plantar (S1–S2), and anal (S5–Cx1) reflexes are evaluated. Patellar and ankle clonuses are noted. Coordination and sensation by gait, heel-to-knee and foot-to-buttock tests, and Romberg’s station test are checked. These are typical minimal evaluations.

Initial Assessment

Tenderness. Tenderness is frequently found at the apices of spinal curves and not infrequently where one curve merges with another. Tenderness about spinous or transverse processes is usually of low intensity and suggests articular stress. Tenderness noted at the points of nerve exit from the spine and continuing in the pathway of the peripheral division of the nerves is a valuable aid in spinal analysis pointing to a foraminal lesion. However, the lack of tenderness is not a clear indication of lack of spinal dysfunction. Tenderness is a subjective symptom influenced by many individual structural, functional, and psychologic factors that can make it an unreliable sign. An area for clues sometimes overlooked is the presence and symmetry of lower-extremity pulses.

Keep in mind that lumbopelvic tenderness as well as pain can be referred from pelvic and lower abdominal viscera.

LUMBAR SUBLUXATION SYNDROMES

Functional revolts associated with subluxation syndromes can manifest as abnormalities in sensory interpretations and/or motor activities. These disturbances may be through one of two primary mechanisms: direct nerve disorders or be of a reflex nature.

Nerve Root Insults

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Posttraumatic Subluxation-Fixation Implications: Etiology, Effects, and Common Coincidental Factors

By Frank M. Painter|May 17, 2012|Chiropractic Care, Diagnosis, Rehabilitation, Spinal Manipulation, Subluxation|

Posttraumatic Subluxation-Fixation Implications:
Etiology, Effects, and Common Coincidental Factors

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Clinical Monograph 5

By R. C. Schafer, DC, PhD, FICC

INTRODUCTION

The kinetic aspects of spinal biomechanics are an important consideration in traumatology since the totality of function is essentially the sum of its individual components. However, although reminders are frequently given, the multitude of causes and effects of an articular subluxation complex (spinal or extraspinal) will not be detailed here that is primarily directed to chiropractic clinicians and advanced students who are well acquainted with standard hypotheses. For a detailed description, the reader is referred to:

Basic Principles of Chiropractic:
The Neuroscience Foundation of Clinical Practice
Arlington, Virginia, American Chiropractic Association, 1990.

Basic Implications

The biomechanical efficiency of any one of the 25 vertebral motor units, from atlas to sacrum, can be described as that condition (individually and collectively) in which each gravitationally dependent segment above is free to seek its normal resting position in relation to its supporting structure below, is free to move efficiently through its normal ranges of motion, and is free to return to its normal resting position after movement. The degree of fixed derangement (subluxation-fixation) of a bony segment within its articular bed and normal range of motion may be an effect in the range of microtrauma to macroscopic damage. Regardless, it is always attended by some degree of mobility dysfunction; neurologic insult; and overstress of the muscles, tendons, and ligaments involved and their respective mechanoreceptors.

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What is The Chiropractic Subluxation?

Once produced, the lesion becomes a focus of sustained pathologic irritation in which a barrage of impulses streams into the spinal cord where internuncial neurons receive and relay them to motor pathways. The contraction that provoked the subluxation initially is thereby reinforced, thus perpetuating both the subluxation and the pathologic process engendered. Sensory reflex phenomena can also be involved, and they frequently are. The nerve impulse creates a multitude of cellular reactions and responses besides those of even the most intricate, subtle, and variable sensations and motor activities. Once this is appreciated, we must add the complexities of trophic effects, neuroendocrine interrelations, biochemical affinities, proprioceptive buildup, summation increments, facilitation patterns, the input of the ascending and descending reticular activating mechanisms, genetic neurologic diatheses, synaptic overlaps, demoralization and disintegration of synaptic thresholds, the neurologic spread and buildup, reflex instability, predisposition to sensorial aberrations, undue cerebrovisceral or viscerocerebral interactions, psychosomatic overtones, and those many phenomena that science is only beginning to understand or are beyond our present understanding. This underscores that the quality and sometimes quantity of nerve function relates directly or indirectly to practically every bodily function and contributes significantly to the beginning of physiologic dysfunction and the development of pathologic processes.

Structural Imbalance (more…)

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Shoulder Girdle Trauma

By Frank M. Painter|May 16, 2012|Chiropractic Care, Diagnosis, Evaluation & Management, Rehabilitation, Shoulder, Spinal Manipulation, Sports|

Shoulder Girdle Trauma

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Clinical Monograph 16

By R. C. Schafer, DC, PhD, FICC

The articulations of the scapula, clavicle, and the humerus function as a biomechanical unit. Only when certain multiple segments are completely fixed can these parts possibly function independently in mechanical roles. Forces generated from or on one of the three segments influence the other two segments. Thus, they will be described here as a functional unit. Please underscore this point in your mind as you read this paper.

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Soft-Tissue Neck Trauma

By Frank M. Painter|May 12, 2012|Chiropractic Care, Evaluation & Management, Rehabilitation, Spinal Manipulation|

Soft-Tissue Neck Trauma

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Clinical Monograph 15

By R. C. Schafer, DC, PhD, FICC

The mechanical relationship between the head and neck has been crudely compared to a brick attached to a flexible rod. As the structural mass of the head is so much greater than that of the neck, it is no wonder that injuries of the neck are so prevalent. Even the person with a short neck and well-developed neck muscles and ligaments is not free of potential injury.

BACKGROUND

The viscera of the neck serve as a channel for vital vessels and nerves, the trachea, esophagus, and spinal cord, and as a site for lymph and endocrine glands. When the head is in balance, a line drawn through the nasal spine and the superior border of the external auditory meatus will be perpendicular to the ground.

Anterior injuries are more common to the head and chest as they project further forward, but a blunt blow from the front on the head or chest may cause an indirect extension or flexion injury of the cervical spine and soft tissues of the neck. In any neck injury, the injury may not be the product of a single force. For example, while extension, flexion, and lateral flexion injuries are often described separately, rotational, compressive, tensile, and shearing forces are invariably part of the picture.

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Chronic Neck Pain and Chiropractic Page

The anterior and lateral aspects of the neck contain a variety of vital structures that have no bony protection. Partial protection is provided by the cervical muscles, the mandible, and the shoulder girdle.

After neck injury, a careful neurologic evaluation must be conducted, and every examination should begin with a thorough case history. See Table 1. Note any signs of impaired consciousness, inequality of pupils, or nystagmus. Do outstretched arms drift unilaterally when the eyes are closed? Standard coordination tests such as finger-to-nose, heel-to-toe, heel-to-knee, and for Romberg s sign should be conducted, along with superficial and tendon reflex tests.

Table 1 Typical Questions Asked During the Investigation of Joint Pain

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ACOEM Recognizes the Value of Chiropractic for Chronic Spinal Pain

By Frank M. Painter|April 4, 2012|Chiropractic Care, Chronic Pain, Guidelines, Spinal Manipulation|

ACOEM Recognizes the Value of Chiropractic for Chronic Spinal Pain

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SOURCE: Dynamic Chiropractic 2008 (Sep 23); 26 (20): 1

Tina Beychok, Associate Editor

Pain is the most prevalent health condition among U.S. workers and the most expensive in terms of lost productivity. Recent studies suggest more than six in 10 adults over the age of 30 experience chronic pain. Furthermore, health care expenditures for back and neck pain have risen to more than $80 billion a year in the U.S. – a dramatic increase over the past eight years, without evidence of improved health. In addition to the costs of lost productivity, an estimated $64 billion per year is lost due to workers continuing to work, even though pain reduces their job performance. This phenomenon is called “presenteeism.”

Unfortunately, workers’ comp can be a quagmire of contradictory and insufficient rules and regulations as to what treatments are and aren’t covered. The American College of Occupational and Environmental Medicine (ACOEM) has been in the process of revising its Occupational Medicine Practice Guidelines, which have not always taken a positive view of chiropractic manipulation. In fact, the second edition of the guidelines, released in 2005, was heavily criticized by some in the chiropractic community. [1]

ACOEM’s latest chronic pain guidelines (a chapter of the overall guidelines) may represent a step in the right direction in terms of recognizing the value of chiropractic care. The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.

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