Artigo - Disfunção intervertebral

8/8/2019 Artigo - Disfuno intervertebral

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Journal of Osteopathic Medic ine, 2003; 6(2): 64-73 2003 Research Media

CommentaryIn terver tebra lspinal lesion

d ysfu n ct io n a d iscu ss io n of the m a n i p u l a b l e

Fryer , G .School o f Health Sciences, Victoria University, Melbourne, Austral ia

A b s t r a c tThe co ncept o f t he ma nipu lab le sp ina l les ion - a muscu loske le ta l d is tu rbance tha t can be detec tedw i th manua l pa lpa t ion and cor rec ted w i th man ipu la t ion - i s exam ined and ev idenc e fo r t he theor iesof the dys func t ion is d iscussed. A m ode l f o r in te rver tebra l dys func t ion is presented tha t descr ibesboth mechan ica l and neuro log ica l seque lae to sp ina l in ju ry , lead ing to a de f ic i t in reg iona lpropr iocept ion , cha nge s in segm enta l and po lyse gm enta l m usc le ac t iv it y and mo tor cont ro l , andpred ispos ing the segm ent to fu r ther s t ra in . The ev idence fo r t he proposed mode l and mec han ism so f m anua l t r ea t m en t i s d is cussed . R eco m m enda t i ons and d i r ec t ions a r e ou t l ined f o r fu t u r eresearch.Ke yw ord s : os teopathy , in te rvertebra l dys func t ion , man ipu lab le sp ina l les ion , somat ic dys func t ion

T H E M A N I P U L A B L E L E S I O NM an u al t h e rap y an d man ip u l a t i o n o f t h e sp in e i s n o t n ew.T h e r e i s e v i d e n c e o f t h e u s e o f m a n u a l t h e r a p y p r o c e d u re sin an c i en t Th a i lan d , Ch in a , Eg y p t an d Gree ce , a s we l l a s i t su se b y b o n ese t t e r s f ro m th e mid d l e ag es t o r e l a t i v e ly r ecen tt i m e s . ~ M o d e r n m a n u a l t h e r a p y p r o f e s s i o n s a l l h a v edescr ibed sp inal dysfunc t ions that are claim ed to be detectedwi th man u a l p a lp a t i o n an d co r r ec t ed wi th man ip u l a t i o n .T h e s e p r o f e s si o n s h a v e s t a m p e d t h e ir o w n ' b r a n d n a m e s 'o n t h ese a l l eg ed ly 'man ip u l ab l e ' sp in a l le s i o n s . F o r t h ech i ro p rac t i c p ro fes s io n , t h e man ip u l ab l e sp in a l l e s i o n i sk n o w n a s t h e ' s u b l u x a t i o n ' , ' c h i r o p r a c t i c s u b l u x a t i o ncom plex ' o r 'manipu lab le sub luxat ion ' .2.3 Europe an medicalman ip u l a to rs an d p h y s io th e rap i s t s h av e u se d t h e t e rm ' j o in tf i x a t i o n o r b lo c k ag e ' .4 In t h e f i e l d o f o s t eo p a th y , i t w aso r ig in a l l y ca l l ed t h e ' o s t eo p a th i c l e s i o n ' o r ' o s t eo p a th i cs p i n a l l e s i o n ' , 5 a n d n o w m a y b e r e f e r r e d t o a s t h e' i n t e r v e r t e b r a l l e s i o n ' , 6 ' i n t e r v e r t e b r a l d y s f u n c t i o n ' ," seg m en ta l d y s fu n c t i o n " o r " so m at i c d y s fu n c t i o n " . 1' 6-~0S o m a t i c d y s f u n c t i o n h a s b e e n d e f i n e d b y T h e E d u c a t i on a lCounci l on Osteopath ic Pr incip les 1~as :" Imp a i r ed o r a l t e r ed fu n c t io n o f r e l a t ed co mp o n en t s o f t h esom at ic (body f ramew ork) system: skeletal, ar th ro idal , andmy o fa sc i a l s t ru c tu res , an d r e l a t ed v ascu l a r , l y mp h a t i c , an dn eu ra l e l emen t s . "T h e t e r m ' s o m a t i c d y s f u n c t io n ' m a y b e u s e d b r o a d l y tod esc r i b e a d i s t u rb an ce i n an y r eg io n o f t h e b o d y , wh erea s

Gary Fryer, BAppSc (Osteo), N D, School of Health Sciences, VictoriaUniversity, PO B ox 14428, MCM C, M elbourne, 8001, [email protected] ived 15/11/02, R evised January 20/01/03 , Accep ted i5 /03/03

' s eg me n ta l d y s fu n c t i o n ' o r ' i n t e rv er t eb ra l d y s fu n c t i o n ' iso f t en u sed t o d en o t e a so mat i c d y s fu n c t i o n t h a t ap p ear s t oin v o lv e a si n g le sp in a l l ev e l ) ' I n t e rv er t eb ra l d y s fu n c t i o n 'wi l l b e u se d i n t h i s a r t i c le b ecau se t h e au th o r b e l i ev es i t i st h e mo s t d esc r i pt i v e t e rm an d l i k e ly t o b e u n d e r s to o d ac ro ssth e m an u a l t h e rap y d i sc ip li n es .Iu t e rv er t eb ra l d y s fu n c t i o n i s n o t sy n o n y mo u s wi th sp in a lpain . Osteopaths ha ve argue d that in terver tebral dysfunct ionm ay o r ma y no t d i rect ly cause sp inal pain?, 9Al th o u g h acu t es e g m e n t a l d y s f u n c t i o n s m a y c r e a t e l o c a l p a i n , s o m eo s t eo p a th s c l a im th a t ch ro n i c d y s fu n c t i o n s may b e n o n -p a in fu l , b u t p o t en t i a l l y c r ea t e a r eg io n o f a l t e r ed mo b i l i t ythat can pre d ispo se to sp inal s t rain and pa in elsewhere.8 .9Os t eo p a th s h av e a l so c l a imed t h a t s eg men ta l d y s fu n c t i o nm ay p ro d u ce d i s tan t ad v er se e f f ec t s o n seg men ta l l y r e la t edv i sce ra b y d i s t u rb in g t h e au to n o m ic n e rv o u s su p p ly a t t h a tlevel .7 , 9,12 In terver te bral dys func t ion has bee n claim ed tob e a p recu r so r o f c l i n ica l d i sease an d p a in sy n d ro m es an dso i t h as b een a rg u ed t h a t t h e t r ea tmen t o f in t e rv er t eb ra ld y s fu n c t i o n i n asy mp to mat i c p e r so n s m ay p rev en t c li n i ca ld i s e a s e . 13 I t h a s b e e n p r o p o s e d t h a t i n t e r v e r t e b r a ld y s fu n c t i o n d o es n o t i n v o lv e t i s su e p a th o lo g y b u t i s adisturbance of unction o f t h e r e l a t e d c o m p o n e n t s o f t h emu scu lo - sk e l e t a l sy st em.14 Th e as su mp t io n o f ab sen ce o fan y t i s su e p a th o lo g y i s n e i t h e r su p p o r t ed n o r r e fu t ed b yev id en ce ; t h a t i s , th e re i s n o c u r r en t ev id en ce t h a t d i r ec t l yr e l a t es to t h e n a tu re o f i n t e rv er t eb ra l d y s fu n c t i o n . Th ere i sgrow ing ev ide nce of fu nct ionaP 5-26 and cer ta in s t ructuralchan ges 27-3 associate d w i th lo w b ack pain (LB P) , bu t th ism a y o r m a y n o t b e r e l e v a n t t o t h e c l i n i c a l e n t i t y t h a to s t eo p a th s c l a im to d e t ec t w i th p a lp a t io n .

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2003 Resea rch Med ia Fryer G. Intervertberal dysfunction: a discussion of the man ipulable spinal lesion

D i a g n o s t i c i n d i c a t o r s o f i n t er v e r t e b ra l d y s f u n c t i o nAuthors in the f i e ld o f o s t eopa thy c l a im tha t in t e rve r t eb ra ldysfunction can be detected by skilled m anu al palpation. 1,10,3~32The diagnos t ic indica tors of segm enta l dysfun ct ion are sa idt o b e s e g m e n t al a s y m m e t r y o f b o n y l a n d m a rk s , r an g e o fmo t ion abnorm a l i ty (inc rea s ed , dec rea s ed o r a change inqual i ty) , an d t is sue texture changes . I , 7 Som e auth ors a lsoinc lud e ten de rne ss . 1, 3~, 33, 34 Th e acr on ym 'T A R T' iss ome t imes us ed a s a mem ory a id fo r the fea tu re s o f t i s s uet e x t u r e, a s y m m e t r y , r a n g e o f m o t i o n a b n o r m a l i t y a n dtende rnes s . O the r man ipu la t ive p ro fe s s ions us e s imi la rd i a g n o s t i c c r i t e r i a t o d i a g n o s e m a n i p u l a b l e l e s i o n s .Phys iotherapis ts have place d em phas is on the a l te red qual i tyo f o i n t m o t i o n , o r ' e n d - f e e l ' ,35,36 wh erea s the chir opra cticp ro fe s s ion have t rad i tiona l ly emphas i s ed s t a t ic a s ymm et ry ,b u t h a v e m o r e r e c e n t l y a d v o c a t e d m o t i o n p a l p a t i o n ,pa lpa t ion o f s o f t t i s s ues and t ende rnes s ? , 3,37R e l i a b i li t y o f d e t e c t i o n o f i n t e rv e r t e b r a l d y s f u n c t i o nG i v e n t h a t t h e d i f f e r e n t m a n u a l t h e r a p y p r o f e s s i o n s -os t eopa ths , ch i rop rac to rs , phys io the rap i s t s , and med ica lm a n i p u l a t o r s - h a v e a l l i n d e p e n d e n t l y d e s c r i b e d aman ipulable spinal les ion, i t seems l ike ly tha t such a les ionex i s ts . Seve ra l au tho rs , howeve r , have recen t ly l amen tedthe l a ck o f in t e r -examine r re l i ab i li t y in a t t empt ing to de tec ts uch dys func t ions , and have ra i s ed the pos s ib i l i t y tha tintervertebral dysfimctionm ay be a f igm ent of the collect ivemanu a l the rapy imag ina t ion .38-4There is present ly an urgentneed to d evelop objec t ive mean s of exam ining and val ida t ingthe ae t io logy o f in t erve r teb ra l dys fun c t ion and to e s t ab l is hre l iable meth ods for i ts c l in ica l de tec t ion.O f a l l t he d iagnos t i c s igns o f in t e rve r t eb ra l dys func t ion ,palp ation for tend erne ss appe ars to b e the m ost reliable. 41-44T he re l i ab i li t y o f pa lpa tion fo r s t a t i c a s ymm et ry ha s beenrepor t ed to be poor in the examin a t ion o f bo th the s p ineand pelvis . 4, 45, 46 Similar ly , seg me nta l m oti on tes t in g(wi thou t pa in p rovoca t ion ) o f the s p ine ha s cons i s t en t lydemo ns t ra t ed poor concordance . 47T he m e thods tha t o s t eopa ths mos t com mo nly us e in c l in ica lp rac t i c e to de tec t i n t e rve r t eb ra l dys func t io n a re l a rge lyunk now n becaus e the re ha s been no de s c r ip t ive s u rvey toestablish this . It is possible that ma nua l diagnostic techn iquesva ry f rom os teopa th ic p rac t it i one r to p rac t it i one r , s choo lto s choo l , and f rom cou n t ry to coun try . M os t au tho rs o fmo de rn os t eopa th ic t ex t s u rge the p rac t i t i one r no t to re lyon a s ing le pa lpa to ry t e s t, bu t com bine mu l t ip l e f ind ingss uch a s jo in t r ange o f mo t ion and end- fee l , t i ss ue t ex tu re ,and t ende rnes s to de tec t i n t e rve r t eb ra l dys func t ion .1,7-10,31,33, 34 A num ber of s tudies hav e d em ons tra ted tha t pa lp at ionus ing s eve ra l c r i t e r ia c an be h igh ly s pec i f i c and s ens i tivefor d iagno s ing sym ptom atic in tervertebra l j oints.35,48,49Jul le t a l . 35 s u c c e s s f u l l y i d e n t i f i e d s y m p t o m a t i c c e r v i c a lzygapophy s ia l j o in t s , con f i rm ed by d iagnos t i c b locks , byus ing the c r i t e r ia o f abnorma l end - fee l, abnorma l qu a l i ty o fre s i s tance to m ot ion , and rep rodu c t ion o f loca l o r r e fe r redpa in . Ph i l l i p s and T w om ey49 foun d tha t m anua l pa lpa t ionwa s highly sensitive and specific for detecting a sym ptom aticlumbar s egme n t when they inco rpora ted a s ub jec tive pa in

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re s pons e f rom the pa t i en t .Few s tud ie s have examined the re l i ab i l i t y o f de tec t ings ymptom a t i c o in t s w i thou t t ende rness o r pa in p rovoca t ion .J u l l e t a l . 36 repor t ed g ood concordance b e tween examine rsd e t e c t i n g s y m p t o m a t i c c e r v i c a l j o i n t s ( u s i n g p a s s i v eaccess o ry , m o t ion pa lpa t ion , and a s s e s s men t o f abnorm a lt i s sue s t i ffne s s a s s oc ia t ed w i th m us c le reac t iv i ty ) when nove rba l r epo rt o f pa in was a l lowed . A l though they p re s en tedno s t a ti s ti c a l ana lys is beyon d pe rcen tage ag reemen t , t he i rresul ts lend support to the view tha t , whi le pa in prov ocat ionimproves the re l i ab i l it y o f de tec t ing s ym ptoma t i c jo in t s ( ap r o c e d u r e n o t a d v o c a t e d i n a n y o s t e o p a t h i c t e x t ) ,a s s e s s men t o f o in t m o t ion and t i s s ue t ex tu re a re impor tan tclinical signs.

I N T E R V E R T R B A L D Y S F U N C T I O N : P R O P O S E DE X P L A N A T I O N ST here ha s been m uch s pecu la t ion on the ae t io logy o f theman ipu lab le l e s ion w i th va r ious au tho rs imp l i ca t ing thep a r a s p i n a l m u s c l e s , 8 z y g a p o p h y s i a l j o i n t s , 5 a n d t h eintervertebra l d iscTM52 a s the u nde r ly ing caus e o f mo t ionre s t r ic t ion and ti s s ue t ex tu re change . T he mod e l tha t i sc i t e d i n m o s t o s t e o p a t h i c t e x t s i s K o r r ' s n e u r o l o g i c a lcon cep t o f the facil itate d segment. l,7, 8,10,53

N e u r o l o g i c a l m o d e l sO s t e o p a t h i c r e s e a r c h e r s D e n s l o w a n d K o r r c o n d u c t e ds tudies f rom the 1940 ' s to the ear ly 19 60 's tha t they c la im edprov ided ev idence o f s egm en ta l s p inal co rd hype r -ac t iv i ty .T hey repor t ed ev idence o f s pon taneous e l ec t romyograph ic(E M G ) ac t iv i ty and inc rea s ed s ympa the t i c ou tpu t a t s p ina ll e v e l s a s s o c i a t e d w i t h c l i n i c a l l y d e t e c t e d s e g m e n t a ldysfunctions.54-59K o r r d e v e l o p e d t h e ' f a c i l it a t ed s e g m e n t 'c o n c e p t , w h e r e h e p r o p o s e d t h a t m i n o r t r a u m a t os e g m e n t a l l y i n n e r v a t e d m u s c u l a t u r e c o u l d p r o d u c e ad i s co rdan t ba rrage o f a f fe ren t inpu t f rom m us c le s p ind lep ropr iocep to rs in to the do rs a l ho rn o f the s p ina l co rd a nda l t e r t h e f i r i n g t h r e s h o l d s a n d e x c i t a b i l i t y o f th ein te rconnec ting neu rones . A l l a c t iv i ty pa s sing th rou gh tha ts egmen t wou ld become exagge ra ted , p roduc ing inc rea s ednoc icep t ion (pa in ) , a lpha and g am ma m oto r ac t iv i ty tos e g m e n t a l m u s c l e s , a n d s y m p a t h e t i c o u t p u t . K o r r ' sneu ro log ica l mode l was an a t t empt to exp la in the c l in i ca lf ind ings o f s egmen ta l dys func t ion : t ende rness and pa in dueto fac i l i t a t ed a s cend ing noc icep t ion , j o in t r ange o f m o t ionres t r ic tion due to the res is tance o f shortened and overac t ivemuscles , and t is sue texture changes du e to sus ta ined musclecontrac t ion and symp athet ic induced c i rcula to ry changes . 13In 1990, Van Busk irk6 highl ighted defic iencies with Ko rr 'sneu ro log ica l mode l , i n pa r t i cu la r the p ropos ed ro le o f themu scle spindle. Experim ental evidence, argued Van Busk irk,i n d i c a t e d t h a t t h e m u s c l e s p i n d l e w a s n o t c a p a b l e o fproducing ref lex mu scle contrac t ion and spindle s ilence w ascomm on . Van Bus k i rk c l a imed tha t t he noc icep to rs ( f reenerve ending s , pa in receptors ) were the on ly proprioceptorsc a p a b l e o f p r o d u c i n g r e f l e x m u s c l e c o n t r a c t io n a n ds ympa the t i c d i s cha rge , and had a cen t ra l ro l e in s egm en ta ldysfunct ion. He proposed tha t noxiou s s t imuli ( from viscera


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Journal o f Osteopath ic Medic ine, 2003; 6(2): 64-73 2003 Research Media

or s oma t i c t i s sues ) wou ld p roduce axon re f l ex changes tha tp r o m o t e i n f l a m m a t i o n a t a l l th e t e r m i n a l b r a n c h e s o f t h a taxon, fu r ther sens i t is ing other nociceptors. Affe rent neuronsr e a c h i n g t he d o r s a l h o r n w o u l d p r o d u c e r e f l e x m u s c l econ t rac t ion and s ympa the t i c d i s cha rge (p roduc ing v i s ce ra land imm une e f fec ts ) . Ove r t ime the mus c le wou ld becomef ib ro t ic and i f s t r e t ched o r re - s t ra ined noc icep to rs w ou ldbe ac t iva ted o nce again . 6Both these m odels a t t ribute the res t r ic ted range o f segmenta lmo t ion and pa lpab le t i s s ue changes p r inc ipa l ly a s a re s u l to f s us t a ined pa ra s p ina l mus c le con t rac t ion . A l thoug h theconcept s o f 'm us c le s pa s m ' and 'pa in - s pas m-pa in cyc le ' a rep o p u l a r e x p l a n a t i o n s f o r h a r d a n d t e n d e r m u s c l e s , t h eeviden ce is lacking . 61 Led erm an 62 has recen t ly que s t ionedthe concep t o f 'neu ro log ica l mus c le tone ' - l ow l eve l mo to rac t iv i ty tha t con t r ibu te s to the re s t ing tone o f a re l axedmus c le - and the popu la r be l i e f ha t th i s tone can be ' t u rnedup ' t o p roduce mus c le s pa s m. 'Neuro log ica l ' mus c le toneappears to be controv ers ia l , as some authori t ies in the f ie ldof E M G cla im tha t re laxed mu scles have no mo tor ac t iv i ty , 63wh ile oth er authorities 64 still describe low level mo tor ac tivitycon t r ibu ting to re s t ing mu s c le tone . T he a s s e s s men t o f ve rylow leve l E M G ac t iv i ty in pa ra s p ina l mus c le s i s d i f f i cu l tand co mpl ica ted by e l ec tr i c a l no i se g ene ra ted by the hea r t ,respira to ry muscles , an d extran eous sources . 65T h e t w o m a i n p r o b l e m s w i t h t h e p ro p o s a l o f m u s c l econ t rac t ion as a com ponen t o f in te rve r t eb ra l dys func t iona r e th e l a c k o f e v i d e n c e o f a b n o r m a l E M G a c t i v i t ya s s oc ia t ed w i th pa lpa to ry f ind ings and the l a rge bod y o fev idence tha t demons t rat e s dec rea sed E M G ac t iv i ty in deeppar aspi nal m usc les of patie nts w ith LBP. 22,23,66-72 De nslo wand Kor r ' s s tud ie s54-59 are ov er f ifty ye ars old an d w ere, bytoda y ' s s t anda rds , poor ly de s c r ibed w i th in s u f f i c i en t da tareporte d a nd n o s ta t is t ica l analys is . 73 Slosberg74 sugges tedtha t the s i ze o f the need le s u s ed by D ens low w ere l a rge rand m ore disruptive than the fine-w ire electrodes used today,a n d t h u s r e p r o d u c t i o n o f t h e s e s t u d i e s w i t h m o d e r nequ ipmen t w ou ld h e lp ve r i fy the i r s ign i f ic ance .Dens lo w appea red to have mis g iv ings abou t h i s o r ig ina lresearch. In 1975 , th i r ty - fou r yea rs a f t e r the pub l i ca t ion o fhis or iginal a r t ic le tha t described increased paraspinal EM Gactivity,75 Den s low s ta ted tha t :" Howeve r , fo l lowing fu r the r expe r ience w i th the s e me thods

and add i t iona l s tud ie s by o the r re s ea rche rs , i t wasrecogn i s ed tha t i f s u f f i c i en t c a re was us ed in b o l s t e r ingt h e s u b j e c t w i t h p i l lo w s a n d s a n d b a g s , t h ee lec t romyograph ic ev idence o f mus c le con t rac t ion ins ome o f the abn orma l a rea s d i s appea red . '75

Dens low conceded tha t , a l though the re appea red to bemus c le s in the reg ion o f c l in i ca l ly de tec ted os t eopa th icl e s ions tha t d i s p layed inc rea s ed E M G ac t iv i ty , no t a l lpalpable paraspinal tissue texture changes co uld be explaine dby mus c le con t rac t ion . T he on ly recen t inves t iga t ion o fE M G ac t iv i ty o f abnorm a l to pa lpa t ion pa ra sp ina l mus c le sfound n o s ign i f i c an t inc rea s ed ac t iv ity .73 This p i lo t s tud ys hou ld be rega rded a s inconc lus ive due to the s ma l l s amples ize , problem s w ith ar tefac t , and appa rent increased ac t iv i ty

in the on ly s ym ptoma t i c sub ject . T he i s sue o f E M G ac t iv i tyin re l axed pa ra sp ina l mus c le s tha t appea r to be abnorma l topalpat ion requires fur ther inves t iga t ion.

M e n i s c o id e n t r a p m e n t a n d e x t r a p m e n tThree com mo nly occurr ing meniscoid-l ike inc lus ions foun dwi th in the zygapophys ia l o in t s o f the s p ine have been we l ld e s c r i b e d . 76 T h e l a r g e s t o f t h e s e , t h e f i b r o - a d i p o s emen i s co id , i s a f ib ro - fa t ty va s cu la r s t ruc tu re up to 5m mlong , and p ro jec ts f rom the s upe r io r and in fe r io r marg ins o fthe jo in t c aps u le . Va r ious au tho rs have s pecu la t ed tha t i tmay be pos s ib le fo r the men i s cus to become en t rapped( s w o l l e n a n d i n f l a m e d f r o m m i n o r t r a u m a , w h i c h m a ypreven t the g l id ing o f the opp os ing jo in t s u r face s ) o rex t rapped (buck led and caug h t on the jo in t ma rg in du r ingfu l l f l ex ion , wh ich m ay p reven t the s upe r io r jo in t s u r facef rom g l id ing dow nwards and backwards ) . 10,34,76E x t rapm en t o f men i s co id s t ruc tu re s, Bog duk a rgues , i s ap laus ib le caus e o f the " acu te locked b ack" tha t r e s ponds toman ipu la t ion . B og duk s t a t e s , howev e r , t ha t t h is theo ry i sl ike ly to be d i f f i cu l t t o p rove becaus e m en i s co id s t ruc tu re sa re mos t p robab ly impos s ib le to de tec t w i th d iagnos t i cimag ing .76 Altho ugh m eniscoid extrapm ent ma y expla in theacu te locked back tha t p reven t s the s u f fe re r f rom s t and ingu p r i g h t , i t d o e s n o t a c c o u n t f o r t h e m o r e c o m m o n l yd iagnos ed s ub -acu te o r ch ron ic in t e rve r t eb ra l dys func t ion .

Zygapophysial joint sprainSpra ins o f the zygapop hys ia l o in t have been po s tu la t ed a sa caus e o f s p ina l pa in an d in t e rve r teb ra l dys func t ion .76-78Stud ie s u s ing d iagnos t i c b locks have con f i rmed tha t t hezygapoph ys ia l j o in t i s a com mo n s ource o f low back pa inand can p roduce bo th loca l s p inal and re fe r red pa in , bu t thenature o f the les ion remains e lusive .76 Bog duk rep orted tha tz y g a p o p h y s i a l j o i n t c a p s u l e t e a r s, c a p s u l a r a v u l s i o n ,subchondral fractures, an d intra-articular h aem orrhag es hav ebeen fo und in b iomechan ica l and pos t -mor tem s tud ie s , andthese les ions m ay underl ie zygap ophy s ia l o int pa in . 76 I t hasbeen s ugges ted tha t minor t r auma m ay caus e zygapophys ia ljo in t c aps u le s p ra ins and p roduce jo in t e f fus ion . M Spra ina n d e f f u s i o n m a y a c c o u n t f o r t h e d i a g n o s t ic s i g n s o fsegmenta l dysfunct ion: pa in and d eep paraspinal tenderness(capsule inf lammation) , the res t ric ted oint motio n and end-fee l ( tense jo int e ffus ion) , and t is sue texture chang es (spreadof in f l am mat ion to the pe r i -a rt i cu la r m us c le s and t i ss ues ).R h o d e s a n d B i s h o p,79 in a rev iew o f the use o f d iagnos t icu l t ra s ound o f the s p ine, r epo r t ed a s tudy whos e au tho rc la imed to v i s ua l i s e in f l ammat ion o f the zygapophys ia lcaps u la r l i gamen t s in a s ma l l number o f low back pa inpat ients . The quoted s tu dy has been cr i t ic ised for its poo rlydes c r ibed me thod s , i n s u f f i c i en t da ta , l a ck o f i l l u s t ra tedul t rasound images and s tat is tical analy s is ) Naz arian e t a l ) 1have pub l i s hed the on ly qua l i ty s tudy inves t iga t ing thepo ten t i a l o f d i agnos t i c u l t r a s ound fo r de tec t ing s igns o fce rv ica l and lumbar zygap ophys ia l j o in t i n f l am mat ion ins y m p t o m a t i c p a t i e n ts a n d w e r e u n a b l e t o d e m o n s t r a t eabnorm a l echoge n ic i ty in o r ad jacen t to the s e jo in t s .

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2003 Research Media Fryer G. Intervertberal dysfunction: a discussion of the manipulable spinal lesion

Peri-art icular adhesionsA d h e s i o n s w i t h i n t h e z y g a p o p h y s i a l j o i n t a n d t h i c k e n in g o ft h e jo i n t c a p s u l e h a s b e e n s u g g e s t e d a s a c a u s e o f r e s t ri c te dsegmental mobili ty.2.77.7~ A l t h o u g h t h i s ma y n o t a c c o u n t f o rd y s f u n c t i o n s o f sh o r t d u r a t i o n o r t h e a s s o c i a t e d t i ss u et e x t u r e c h a n g e s , a d h e s i o n f o r m a t i o n a n d c a p s u l e t h i c k e n i n gm a y b e l o g i c a l c o n s e q u e n c e s o f c a p s u l e s p r ai n a n d e x p l a i nt h e l o n g - t e r m c h a n g e s t o p a s s i v e r a n g e a n d q u a l i t y o f o i n tmo t i o n f o l l o w i n g j o i n t i n j u ry .

Intra-discal nuclear d isplacementTh e r e i s n o q u e s t i o n t h a t i n t e r v e r t e b r a l d i s c s a r e i n n e r v a t e da n d a r e a c o m m o n s o u r c e o f c h r o n i c l o w b a c k p a i n . 76 S o m ea u t h o r s h a v e a t t r i b u te d t h e s i g n s o f s e g m e n t a l d y s f u n c t i o nt o i n t er n a l d i s r u p t i o n o f th e d i s c a n d m i g r a t i o n o f t h enucleus .2 ,5~.52 I t i s feas ib le tha t deg ene ra t iv e cha nge s in thed i s c ma y a f f e c t t h e q u a l i t y o f p a s s i v e m o t i o n a t t h a t s e g me n t ,b u t i t i s u n c e r ta i n i f c h a n g e s i n th e d i s c w o u l d p r o d u c es e g m e n t a l t is s u e t e x tu r e c h a n g e , o r h o w ma n i p u l a t i o n mi g h ti mp r o v e r e s t r ic t e d p a s s i v e mo t i o n a s c l a i me d b y o s t e o p a t h s .T h e d i s c is c a p a b l e o f p r o d u c i n g r e f l e x m u l t i f id u sc o n t r a c t i o n , 82 a n d t h i s c o u l d b e r e s p o n s i b l e f o r p a l p a b l ep a r a s p i n a l t i s su e c h a n g e , a l t h o u g h t h e e v i d e n c e f o r a b n o r ma lEM G a c t i v i t y a s s o c i a t e d w i t h p a l p a t o r y f i n d i n g s i s l a c k i n g .N o n e t h e l e s s , t h e d i s c h a s t h e p o te n t i a l to p r o d u c e s o m e o ft h e c a r d i n a l s i g n s o f i n t e r v e r t e b r a l d y s f u n c t i o n .

O t h er t h eor ie sA n u m b e r o f o t h e r t h e o r i e s h a v e b e e n a d v a n c e d t o e x p l a i ni n t e r v e r t e b r a l d y s f u n c t i o n , m o s t w i t h l i t t l e e v i d e n c e t os u p p o r t t h e m. T h e c h i r o p ra c t ic p r o f e s s i o n o r i g in a l l y b e l i e v e dt h a t t h e m a n i p u l a b l e ' s u b l u x a t i o n ' w a s a m a l p o s i t i o n o fb o n e s b u t m o d e m c h i r o p ra c t ic a u t h o r s h a v e l a rg e l y m o v e da w a y f r o m t h e c o n c e p t o f s t a ti c m a l p o s i t io n a n d e m b r a c e da m o r e c o m p l e x d e f i n i t i o n w i t h s i m i l a r i t i e s t o s o m a t i cd y s f u n c t i o n e n c o m p a s s i n g m o t i o n r e s tr i ct i on , v a s c u l a r a n dn e u r o l o g i c a l c o n s e q u e n c e s . 2,3, 83,84A x i a l r o t a ti o n o f c a d a v e r l u m b a r s p i n e s h a s b e e n o b s e r v e dt o p r o d u c e m o v e m e n t o f o i n t f a t p a d s ( w i t h i n t h e j o i n t b u te x t e r n a l t o t h e s y n o v i u m ) i n a n d o u t o f t h e j o i n t c a p s u l e ,p r e s u m a b l y t o k e e p t h e j o i n t v o l u m e r e l a t iv e l y c o n s t a n t YI t h a s b e e n s u g g e s t e d t h a t s p r a i n a n d c a p s u l e i n f l a mm a t i o nm a y n a r r o w t h e c o m m u n i c a t in g f o r a m e n a n d p r e v e n t t h ef a t p a d m o v i n g i n a n d o u t o f t h e c a p s u le , c r e a ti n g a c h a n g ei n j o i n t p r e s s u r e , r e s i s t a n c e t o mo t i o n a n d a l t e r e d e n d - f e e l YT h i s m e c h a n i s m , h o w e v e r , w o u l d b e d i f fi c u lt t o i n v e st i ga t ea n d t h e p r o p o s a l r e m a i n s p u r e l y s p e c u l a t i v e .

A P R O P R I O C E P T I V E - D E F I C I T M O D E L F O RI N T E R V E R T E B R A L D Y S F U N C T I O NTh i s p r o p o s e d m o d e l d e s c r i b e s c o n c u r r e n t p a t h o - a n a t o mi c a la n d f u n c t i o n a l c h a n g e s t h a t ma y b e i n i t ia t e d b y m i n o r i n j ur y ,a n d p r o d u c e a d e f i c i t in l o c a l p r o p r io c e p t i o n , s u b s e q u e n tc h a n g e s i n s e g me n t a l a n d p o l y s e g m e n t a l mu s c l e a c t i v i t y a n dm o t o r c o n t r o l , a n d c r e a t e a c y c l e w h i c h p r e d i s p o s e s t h es e g me n t t o o n g o i n g s t r a i n ( F i g u r e 1 ) . Th e e x i s t e n c e - l e ta l o n e t h e n a t u r e - o f i n t e r v e r t e b r a l d y s f u n c t i o n i s l a r g e l y

6 7

s p e c u l a t iv e a n d t h e f o l l o w i n g m o d e l , l i k e o t h e r s b e f o r e i t ,i s a ls o s p e c u l a t i v e a n d i n n e e d o f f u rt h e r c o r r o b o r a t i n ge v i d e n c e .I t i s p o s s i b l e t h a t i n t e r v e r t e b r a l d y s f u n c t i o n i s i n i t ia t e d b ym i n o r t r a u m a a n d t i s s u e d a m a g e a s t h i s w o u l d a c t i v a t en o c i c e p to r s , w h i c h a p p e a r n e c e s s a r y t o p r o d u c e t h ef u n c t i o n a l c h a n g e s . T h e c l in i c a l s i g n s p r o d u c e d b y t i s s u ed a m a g e w o u l d p r e d o m i n a t e i n t h e ac u t e s ta g e o fd y s f u n c t io n . T h e r e s u lt i n g n e u r o l o g i c a l d i s t u r b a n c e w o u l dl e a d t o i m p a i r e d c o o r d i n a t i o n a n d s t a b i l it y o f th e r e g i o n ,m a k i n g i t v u l n e r a b l e t o f u r t h e r i n j u r y a n d r e c u r ri n g a c u t ea n d s u b - a c u t e e p i s o d e s o f pa i n .

S p rain o f t h e in terver t eb ra l j o in t co mp lexA s p r e v i o u s l y d i s c u s s e d , z y g a p o p h y s i a l j o i n t p a i n h a s b e e nd e m o n s t r a t e d t o b e a c o m m o n s o u r ce o f L B P a n dz y g a p o p h y s i a l j o i n t c a p s u l e t e a r s, c a p s u l a r a v u l s i o n ,subcho ndra l f rac tures , an d in tra-ar t icular haem orrhag es haveb e e n f o u n d i n b i o m e c h a n i c a l a n d p o s t - m o r t e m s t u d ie s a n da r e l i k e l y t o u n d e r l i e j o i n t p a i n . 7~ I n j u r i e s t o s y n o v i a l j o i n t s ,s u c h a s t h e k n e e , c l e a r l y d e m o n s t r a t e s y n o v i a l e f f u s i o n a n ds u b s e q u e n t p a i n a n d l i m i ta t i o n o f m o t i o n . Z y g a p o p h y s i a lj o i n t c a p s u l e s p r a i n a n d e f f u s i o n c o u l d p o t e n t i a l l y c a u s et y p i c a l s y m p t o m s o f t h e a c u t e i n t e r v e rt e b r a l d y s f u n c t i o n :l o c a l p a i n a n d t e n d e r n e s s , p a i n f u l l i m i t a t i o n o f mo t i o n , a n da l t e r e d e n d - f e e l .Z y g a p o p h y s i a l j o in t e f f u s i o n h a s n o t y e t b e e n d e m o n s t r a t e da s a c a u s e o f a c u t e s p i n a l p a i n . T h e o n l y w e l l d e s i g n e ds t u d y j t h a t h a s a t t e m p t e d t o d e t e c t s ig n s o f z y g a p o p h y s i a lj o i n t i n f l a mma t i o n f a i l e d t o l o c a t e e v i d e n c e o f in f l a mm a t i o ni n t h e c e r v i c a l a n d l u m b a r r e g i o n s . T h i s s t u d y e x a m i n e dp a t ie n t s w i t h n e c k a n d L B P a n d , a s th e r e s e a r c h e r s d i d n o tr e p o r t t h e a v e r a g e d u r a t i o n o f s y m p t o m s , i t w a s l i k e l y t h a tt h e s u b j e c t s w e r e s u f f e r i n g f r o m s u b - a c u t e o r c h r o n i c p a i n .I t is q u i t e p o s s i b l e t h a t z y g a p o p h y s i a l j o i n t e f f u s i o n m a yo n l y b e e v i d e n t i n t h e a c u t e s t a g e o f o i n t i nj u ry .S p r a i n o f t h e a n u l u s f i b r o s u s , i n t e r v e r t e b r a l l i g a me n t s , a n dm u s c l e s w o u l d a l s o p r o d u c e l o c a l p a i n a n d t e n d e r n e s s .P e r i p h e r a l s e n s i t i s a ti o n o f t h e n o c i c e p t o r s c o u l d e n h a n c es e g me n t a l t i s s u e i n f l amm a t i o n a n d p o t e n t i a l l y p r o d u c e t i s s u etexture chan ge ident i f iable w i th pa lpa t ion . 6 Increa sed t i ssuef l u i d ma y l i m i t th e c a p a c i t y o f t h e p e r i - a r ti c u l a r s o f t ti s s u e st o s tr e t c h a n d d e f o r m wi t h mo v e m e n t , a n d s o ma y c o n t r i b u t et o a l te r e d r a n g e o f m o t i o n a n d e n d - f e e l.

Act ivat ion o f n oc icep tive p at h way sS p r a i n a n d i n f l a mma t i o n o f t h e z y g a p o p h y s i a l j o i n t c a p s u l e ,t h e p e r i - a r t i c u l a r t i s s u e s , o r t h e a n u l u s f i b r o s u s o f t h e d i s cw o u l d p r o d u c e r e l e as e o f i n f la m m a t o r y c h e m i c a l s a n ds e n s i t i s e n o c i c e p t o r s ( p a i n r e c e p t o r s ) . T h i s p e r i p h e r a ls e n s it i sa t io n w o u l d p r o d u c e l o c a l p a i n a n d t e n d e r n e s s . F o rm o s t i n d i v i d u a l s, t h e p a i n a n d t e n d e r n e s s w o u l dp r o g r e s s i v e l y d i m i n i s h a s th e i n j u r e d t i s s u e s h e a l e d .D e p e n d i n g o n th e i n t e n s it y o f t h e a f f e re n t b o m b a r d m e n ta n d t h e s u s c e p t i b i li t y o f t h e i n d i v id u a l , n e u r o p l a s t i c c h a n g e si n t h e d o r s a l h o r n o f t h e s p i n a l c o r d m a y e v e n t u a t e ,p r o d u c i n g c h e m i c a l a n d p h y s i c a l c h a n g e s i n t h e p a i n


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J o u r n a l o f O s t e o p a t h ic M e d i c in e , 2 0 0 3 ; 6 ( 2 ) : 6 4 - 7 3 2 0 0 3 R e s e a r c h M e d i aproces s ing reg ions o f the do rs a l ho rn and c rea t ing thephen om ena know n as 'centra l sens i t isa t ion ' . These changesto pa in proc ess ing ma y long out las t the or iginal t i s sue in jury ,and re s u l t i n p e rmanen t hype ra lge s i a ( inc rea s ed s ens i t iv ityto pa inful s timuli) an d a l lodynia (pa in evoked from norm allynon-pa in fu l s t imu l i ). I t i s l i ke ly tha t mos t ch ron ic pa in i scentrally generated, w ithou t any long er a tissue basis , despitethe fac t tha t t i s sues m ay be tend er w hen palpated. IS, ~6

A c t i v a t io n o f t h e s y m p a t h e t ic n e r v o u s s y s t e mOs teopa ths have c l a imed tha t i n t e rve r teb ra l dys fun c t ion isc a p a b l e o f p r o d u c i n g l o n g - t e r m a d v e r s e e f f e c t s o ns egmen ta l ly inne rva ted v is ce ra , know n a s s om a to -v i s cera lreflexes.7,9,12,86 Som e lim ited experimental evidence supportsthe concep t tha t nox ious s oma t i c a f fe ren t s c an mod i fyvisceral activity via segm ental sym pathetic efferen t activity, 7bu t th i s theo ry ha s been cha l l enged . 62 Al tho ugh th ere is noconvin cing evidence of segmental sympathetic hy per-activityassocia ted with the m anipulab le les ion, i t is l ike ly tha t pa ina n d e m o t i o n a l d i s t re s s c a n c e r t a i n l y p r o d u c e g e n e r a ls y m p a t h e t i c a r o u s a l t h a t , i n t h e l o n g - t e r m , m a y h a v ede t r imen ta l e f fec t s on the pa t i en t ' s hea l th .

N o c i c e p t o r a c t i v i ty d i s t u r b s p r o p r i o c e p t i o nT here i s g row ing ev idence tha t pa in in t e rfe re s w i th no rma lj o i n t a n d m u s c l e p r o p r i o c e p t i o n . R e c e n t s t u d i e s h a v edemon s t ra t ed dec rea sed p rop r iocep t ion in a s s oc ia t ion w i thexpe rim enta l mu scle pa in , 88, 89 lum bar mu scle fa t igue ,9subjec ts w i th LBP, 91 lum bar spinal s tenos is , 92 and chro nicce rv icobrach ia lg ia .93 Volunteers suffer in g with p a in h avedem ons t ra t ed dec rea s ed awarenes s o f d i rec t ion o f lumb armot ion and pos i t ion ,992 cuta neo us tou ch perc eption , 88, 93and ja w mu scle spindle affere nt ac t iv i ty . 89 Intervertebra ls p r a in s c o u l d p o t e n t i a l l y a c t i v a t e j o i n t a n d m u s c l enoc icep to rs and re s u l t i n d imin i s hed p rop r ioeep t ion f romtha t s egmen t .Spinal pa in and dis turbed propriocept ion produces a chang ei n C N S s t r a t e g y a n d i n c r e a s e d ' g u a r d i n g ' a c t i v i t y i npo lys egmen ta l pa ra s p ina l m us c le s.Increased lumbar paraspinal ac t iv i ty has been dem ons tra tedin vo lun tee rs w i th L B P in fu l l f l ex ion ( l a ck o f f l ex ion -rel ax ati on ), 17-23 ela xe d sta nd ing , 19,22,24 an d as a reac tion tostress.25, 26 The incr ease d ac tivit y is not like ly du e to refle xcon t rac t ion , bu t a combina t ion o f vo lun ta ry 'gua rd ing 'behaviouriS, 21 and a complex change in motor controlstrategy53

PATHO -ANATOM ICAL FUNCT IONAL

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A

R e f le x n h i b it io n f d e e ps e g m e n t a l s t a b il is i n g "p a r a s p i n a lm u s c l e s

I n c re a s e d " g u a r d i n g "activity o f s u p e r f ic i a lp a r a s p i n a lm u s c l e s

F i g u r e 1 . A p r o p r io c e p t iv e - d e f ic i t o d e lo f n t e r v e r t e b r a l y s f u n c t i o n68


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2003 Research Media Fryer G. Intervertberal dysfunction: a discussion of the manipulable spinal lesion

Zedk a e t a l.23 dem onstra ted hat decreased flexion-relaxatio noccurred as a resul t of experimenta l paraspinal muscle pa ina lone and the inc rea s ed pa ra s p ina l mus c le ac t iv i ty wasv i r tua l ly uncha nged even wh en s ub jec t s we re ca re fu l lyguided to perform mov em ent a t pre-experimenta l pa in rangeand ve loc i ty . T hey conc luded tha t pa in f rom any s p ina ls t ruc tu re ( jo in t, l i gamen t o r m us c le ) ma y p roduce a changein C NS s t rat egy , wh ich re s u l t ed in the mu s c le work in g in' p a i n m o d e ' t o p r o te c t th e s p i n e f r o m e x t r em e m o v e m e n twhen eve r pa in was s igna l l ed .Sp ina l pa in and a reg iona l de f i c i t in p rop r iocep t ion m ayre s u l t i n the inab i l i t y to execu te coo rd ina ted con t rac t ionso f d e e p s e g m e n t a l m u s c u la t u r e, a n d t h e ' p a i n m o d e ' C N Sstrategy appears to activate the mo re superficial mu sculatu res p a n n i n g s e v e r a l s p i n a l s e g m e n t s . T h i s a t t e m p t tocom pensate with increased, non-specific activity m ay furtheradve rs e ly a f fec t t he con t ro l and p rop r iocep t ion o f tha treg ion . In the au tho r ' s expe r i ence , pa ti en t s o f t en remarktha t the i r pa in fu l r eg ion " fee l s l i ke i t does no t be long tothem" and o f t en have t roub le re l ax ing and a l lowing ther e g i o n t o " l e t g o " , w h i c h m a y b e a r e s u l t o f i m p a i r e dpropr iocep t ion and con t ro l .

Spina l pa in produces inh ib i t ion and a trophy o f deeps egmenta l mus c le sT here i s a l a rge body o f ev idence tha t c l ea r ly demons t ra t e stha t lumba r p araspinal muscles o f subjec ts wi th L BP opera tes ub-max ima l ly . M any s tud ies have demo ns t ra t ed reducedac t iv i ty in f ree dynam ic movemen t s ,22,23,66.67 redu ced mu sclestren gth , 6s-7 an d incr eas ed m usc ula r fatig abi lity 7, 71, 72 ofpa ra s p ina l mus c le s in vo lun tee rs w i th L B P. A l thoug h muc hof th i s change in mus c le a c t iv i ty can be a t t r ibu ted to de -cond i t ion ing a s s oc ia t ed w i th m od i f i ed pa t i en t a c t iv i ty andbehav iou r , s om e s tud ie s have repor t ed rap id and s e l ec tivea t rophy o f the mu l t i f idus tha t s ugges t s r e f l ex inh ib i tion .Hides e t a l . 27 used diagnos t ic u l t ra soun d to s tudy the cross -s ec t iona l a rea o f the lumbar mul t i f idus mus c le s o f pa t ien t ssufferin g from th eir first episod e o f unilateral acute/subacuteL B P and found tha t s pec i f ic was t ing o f mu l t i f idus wasevident a t the spinal level and s ide de term ined symp toma ticby c l in i cal examina t ion . M ul t i f idus a t rophy has a l s o beenobs e rved in s ub ject s w i th ch ron ic L BP us ing M R 128 andcomp ute r tomography .94 Ind ahl et al. 95 dem ons trated reflexinh ib i t ion o f mu l t i f idus ac t iv i ty a f t e r in j ec ting s a l ine in to aporc ine zyg apoph ys ia l j o in t , p robab ly caus ed by re f l exinh ib i t ion fo l lowing a s t re tch o f the jo in t c aps u le . T h i sp roces s m ay l ike ly occu r fo l lowing zygapo phys ia l j o in tspra in and effus ion.Refle x inhibi t ion ofpar aspina l ac t iv i ty appears to ta rget thed e e p p a r a s p i n a l m u s c l e s , w h i c h a r e t h e m u s c l e s t h a tcontr ibute mos t to in tervertebra l s tabi l i ty .9698 The deepparaspinal m uscles, togeth er wit h the transversus abdo min usmu scle, are believe d to be a critical factor in lum bar stability,do no t au toma t i ca l ly recove r once back pa in ha s re s o lved ,and m ay l eave the s p ine vu lne rab le to no rma l ly t r iv ia lep iso de s o f tra um a. 27, 96, 97, 99, 100 Th ese de ep pa ra sp in almus c le s appea r to o f fe r mo s t s t ab i l i ty in the s p ina l mid -range 'neu t ral zone ' , r a the r than end range o f m o t ion .96 La ck

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of active control from the d eep stabilis ing m uscles, co mb inedwi th impa i red p rop r iocep t ion and non-s pec i f i c gua rd ingac t iv i ty, m ay the re fo re inc rea se the l ike l ihood o f fu r the rspinal s train, possibly in mid-range mo tion and in the absenceof any o bv ious s t ra in o r t rauma .Z ygap ophys ia l jo in t caps u le f ibros is and in terver tebra ldisc resorptionRepea ted s p ra in and in f l amm at ion o f the jo in t c aps u le m ayre s u l t i n p ro l i fe ra t ion o f f ib rob la s t s and s ho r t en ing andthickenin g of the capsule. In tervertebra l d isc dis rupt ion anddegrada t ion ma y re s u l t i n i s o la t ed d i s c re s o rp t ion . 76 T hes elong- t e rm changes cou ld po ten t i a l ly p roduce d ec rea s edrange o f motion, decreased accessory ' jo int p lay ' and a l te redjo in t ' end - fee l ' .

T H E R A P E U T I C M E C H A N I S M S O F M A N U A LT R E A T M E N TT he m echan i s ms re s pons ib le fo r the the rapeu ti c e f fec t o fm a n u a l t e c h n i q u e s a r e p o o r l y u n d e r s t o o d a n d l a r g e l ys pecu la t ive . T he fo l lowing p ropos ed mechan i s ms o f a c t ionare based on the au thor 's mo del of intervertebra l dys f imct ionand are consistent with available evidence. It m ay be possibletha t manua l t e chn iques p roduce phys io log ical e f fe c t s - s ucha s h y p o a l g e s i a , im p r o v e m e n t o f m o t o r r e c r u it m e n t , o rp la s t ic changes in connec t ive t i s sue - whe th e r o r no t anintervertebra l dysfun ct ion exis ts.

R e d u c i n g z y g a p o p h y s i a l j o i n t e f f u s i o n a n d p e r i -articular oedemaM o v e m e n t o f s y n o v i a l j o i n t s h a s b e e n s h o w n t o p r o m o t e' t r ans - s ynov ia l f low ' , mo v ing f lu ids in and ou t o f the jo in tth rough the s yno v ia l mem brane , a s we l l a s s t imu la t inglym pha tic an d blo od flo w aro und the join t. 101-103Ac t ive andp a s s i v e s p i n a l m o v e m e n t s h a v e b e e n d e m o n s t r a t e d t oproduce pressure f luc tuat ions in zy gapoph ys ia l o ints ,i4 andthes e f luc tua t ions a re l i ke ly to inc rea s e the ra t e o f t r ans -s y n o v i a l f lo w . I f a c u t e a n d s u b - a c u t e i n t e r v e r t e b r a ldysfu nct ions involve capsule spra in, synov ia l e ffus ion, andpe r i -a r ti cu la r oedema , ma nua l t e chn iques s uch a s pa s s ivearticula t ion m ay produce pressure f luc tuat ions and s t imula tet rans - s ynov ia l f low and m ove the exces s f lu id ac ros s themem brane an d ou t o f the jo in t . Ac t ive t e chn iques , s uch a smus c le ene rgy , ma y he lp d ra in f lu id f rom the pe r i -a r t icu la rt i s sues , becaus e mus c le con t rac t ion and re l axa t ion wou ldass is t lymph at ic dra inage from the peri-art icular lymphat ics .H igh ve loc i ty low am pl i tude t e chn iques (HV L A) o r ind i rec tt e chn iques wou ld p ro bab ly have l i tt l e e ffec t , a s a rhy thmicm o v e m e n t w o u l d l i k e l y b e n e e d e d t o m o v e f l u i d ac r os s amem brane an d a l low f i l l i ng and re - f i ll i ng o fpe r i -a r t i cu la rl y m p h a t i c s F

Stre tch ing zygapoph ys ia l jo in t caps u leIt has been prop osed tha t multiple sprains to an intervertebraljo in t m ay re s u l t i n zygapophys ia l o in t c aps u le f ib rosi s andshortening. 78 Repet i t ive , rhyth mic s t re tching (as perfo rme dwith ar t icula t ion) is l ike ly to be the m os t e ffec t ive mean s toe longa te the capsule . Quick, short , ba l l is t ic s t re tches , such


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as HV L A, m ay be l e ss l i ke ly to p roduce v i s coe la s ti c o rplas t ic changes to the connect ive t is sue . There is a ra t ionale ,howeve r , fo r pe r fo rming HV L A b e fo re o the r te chn iques ,as the cavitation and subsequent ga s bubb le form ation wo uldi n c r e a s e j o i n t v o l u m e , 15 a l l o w g r e a t e r j o i n t s u r f a c eseparation, an d greater capsule elonga tion and stretch durin gpass ive ar t icula t ion.

Man ip u lat ion in d u ced h yp oalges iaM anipu la t ive the rapy i s commonly employed to re l i eves p ina l pa in . Res ea rche rs have d emon s t ra t ed reduc t ions inpain usin g cer vical m obilis ation , 6-18cervical HVLA,109,110and thorac ic HV LA techniqu e . 111 One s tud y11 fo un d tha tHV L A w as more e f fec t ive than mus c le ene rgy in reduc ingpa in , bu t mo re re s ea rch i s r equ i red to con f i rm th i s . I t ha sbeen p ropos ed tha t man ipu la t ion ma y p roduce hypoa lges iaby activating descen ding inhibitory pathw ays from the dorsa lperiaq uedu cta l gray area (dPA G) of the mid bra in , 18, 112re lease ofendorp hins , or inhibi t ion of pa in a t the spinal cord.Ch ris tia n et a1.113failed to demonstrate elevated plasm a levelsofendo rphins fol lowing manipulat ion, but the dPA G appearst o h a v e a r o le d u e t o t h e o b s e r v a t i o n o f c o n c u r r e n ts ympa the t i c ne rvous s ys t em ac t iva t ion w i th man ipu la t ionin du ced hypoalgesia.l8.112E xpe r imen ta l ev idence s upport sthe pos s ib i l i t y o f inh ib i t ion a t t he s p ina l co rd acco rd ing tothe ga te -con t ro l t heo ry , whe re mech anorecep to r a f fe ren t scarr ied by large diameter axons inhibi t nociceptor afferentsat th e dorsal horn . 114An y t echn ique tha t p roduces movem en to f the jo in t and s t re tch o f the caps u le w i l l s t imu la te jo in tproprioceptors , and potent ia l ly m ay be capable of producinginh ib i tion o f pa in .

Imp rovem en t o f p rop r iocep tion an d m otor con tro lChanges in p rop r iocep t ion and moto r con t ro l ma y unde r l i ebo th s ho r t and long t e rm bene f i t s fo r pa t i en t s r ece iv ingma nua l the rapy . Res ea rche rs have demo ns t ra t ed tha t L BPpat ients exhibi t imp aired prop riocept io n 9-92 and a l te redmu scle recrui tm ent , 17-26 and i t i s hyp oth es ised tha t th isimpairm ent may occur regional ly as a resul t of in tervertebra ls p ra in . M anua l t e chn iques o f t en invo lve app ly ing gen t l es t re tch and p re s s u re to mus c le s , and s pec i fi c mob i l i s a t ionof spinal a r t icula t ions , wh ich wil l s t imula te oint an d muscleproprioceptors . I t has been propo sed tha t careful , specif ic ,and pu rpos e fu l jo in t m ovem en t in a re l axed pa t i en t w i l ls t imula te jo in t proprioceptors , h ig hl ight a d iffere nt pa t terno f a f fe ren t a c t iv i ty in the p rop r iocep t ive - impa i red reg ion ,and a l low the CNS to no rma l i s e the p rop r iocep t ive andm oto r coo rdin at io n fro m that segm ent . 78, 115 Sim ilar ly ,ind i rec t te chn iques , s uch a s func t iona l and coun te r s t rain ,m ay h igh l igh t a d i f fe ren t pa t te rn o f a f fe ren t f eedback toa l t e r a n d i m p r o v e r e g i o n a l p r o p r i o c e p t i o n a n d m o t o rcontrol .In the au th o r ' s ex pe r i ence , i t is no t unus ua l fo r pa t i en t s tovolunteer fee l ings of be ing more "balan ced ' , wi th the pa infulr e g i o n " b a c k i n p l a c e " a n d " p a r t o f t h e b o d y a g a i n " ,fo l lowing t rea tmen t . Such com men ts cou ld be a t t r ibu tedto a p l acebo re s pons e , bu t a l s o s ugges t an improvem en t inpropriocept ion andm oto r control. Al tho ugh ac t ive exerc iseis cons idered more effec t ive han pass ive t rea tment for motor

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learning,62 min or specific regions of impa ired proprioceptionm ay respond to specific pass ive s t imula t ion, and subsequentno rma l pa t i en t a c t iv i ty may be s u f f i c i en t fo r improvedpropr iocep t ive in t eg ra t ion and m oto r l e a rn ing .Few s tud ie s have a t t empted to inves t iga te the e f fec t o fman ipula t ion on propriocept ion and motor control. C ervica lHV L A h as been repor t ed to improve he ad re -pos it ion inga f t e r a c t ive d i s p lacemen t in pa t i en t s w i th ch ron ic neckpa in ] 16 and patien ts w ith v ertigo and dizzin ess. 117 Cerv icalmob i l i s a t ion ha s been dem ons t ra t ed to improve bod y s wayin p atients wi th w hip lash traum a, 118 and decrease superficialneck mus c le rec ru i tmen t du r ing s t aged ce rv ica l f l ex ion . 18HVL A has been c l a imed to d imin i s h quadr i ceps mus c leinhibi t ion] i9 and mechan ica l spinal manip ula t ion (ac tivator)has been c la im ed to increase the m ean volun tary contrac t ionof the paraspin al m uscles . 12 Thes e s tudies suppo rt thep r o p o s i t i o n t h a t m a n u a l t h e r a p y c a n i n f l u e n c epropr iocep t ion and moto r con t ro l , bu t more re s ea rch i sneeded .

D I R E C T I O N S F O R R E S E A R C HRel iab le d e tec t ion o f in terver teb ra l d ys fu n ct ionT he re l i ab i li t y o f the c l in i ca l de tec tion o f in t e rve r teb ra ldysfun ct ion has no t been c learly es tablished. Recent s tudieshave fa i l ed to s how accep tab le in t e r-examine r ag reemen tfo r de tec t ion o f s t a t i c a s ymm et ry o f bony l andm arks ,4,45,46mo t ion pa lpa t ion , 47 o r w h ich s egme n t to m an ipu la t e? 8, 39T he de tec t ion o f s ymptoma t i c s egmen t s u s ing combinedc r i te r i a ( inc lud ing pa in p rovoca t ion ) ha s been fo und to besen siti ve an d re liable, 35,4s,49but these s tudies m ay s im ply beconf i rm ing the re l i ab i li t y o f pa in p rovoca t ion ra the r thanthe T ART c r i t e r i a . R es ea rche rs need to re -examine thed iagnos t i c c ri t er i a o f the m an ipu lab le l e s ion and f ind w aysto mak e the de tec t ion o f dys func t ion more re l iab le . On lyafter acceptable re l iabi l i ty has been es tabl ished can theva l id i ty o f the d iagnos i s be t e s t ed .

Diagn os t ic imagin g o f zygap op h ys ia l jo in t e f fu s ionZ yga poph ys ia l jo in t sp ra in and e f fus ion ha s been p ropos edas a po ten t i a l com ponen t in in t e rve r t eb ra l dys func t ion .76-78Diagnos t i c imag ing , s uch a s d i agnos t i c u l tr a s ound , M R Iand CT , m ay be capab le o f de tec t ing s igns o fpe r i -a r t i cu la rin f lammat ion o r zygapophys ia l jo in teffusio n in patients w iths y m p t o m a t i c i n t er v e r te b r a l d y s f u n c t i o n s , w h i c h w o u l ds uppor t j o in t s p ra in and e f fus ion a s hav ing a ro le in s p ina lpa in and the man ipu lab le l e s ion . One s tudy found no s ignof nf lamm ation n the cervical and lum bar regions o f pa t ientswith neck and LBP, 81 but i t could be poss ible tha t e ffus ionm ay be v i s ua l i s ed on ly in acu te ep i s odes o f s p ra in .

Dete rm ine the nature o f altered tissue texture associatedwith th e m an ip u lab le l e s ionDe ns lo w and Ko r r ' s s4-57 obs e rva t io ns tha t ' l e s io ned 'segmen ts d isplayed spontaneous paraspinal muscle ac t iv i tya t r e s t p rov ided the founda t ion o f m uch os t eopa th ic theo ry.A s p r e v i o u s l y d i s c u s s e d , t h e s e s t u d i e s a r e d a t e d a n dinadequa te and have no t been ve r i f i ed by any s tudy s ince .


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2003 Res ea r c h Med i a F r y e r G . I n te r v e r tbe r a l dy s func t ion : a d i s c us s i on o f t he ma n i pu l ab l e s p i na l l es i on

T h e n a t u r e o f r e l a x e d p a r a s p i n a l m u s c l e s d e t e c t e d a s t e n d e ra n d a b n o r m a l w i t h p a l p a ti o n n e e d s r e - i n v e s t i g a t i o n w i t hE M G . S u c h r e g i o n s c o u l d b e e x a m i n e d a t r e s t, d u r i n g q u i e ts i tt i ng a n d s ta n d i n g, a n d d u r i n g d y n a m i c m o v e m e n t s t od e t e r m i n e i f t h e s e m u s c l e s a r e a b n o r m a l l y o v e r a c t i v e o ru n d e r - a c t i v e r e l a t iv e t o n o r m a l r e g i o n s . D i a g n o s t i c i m a g i n gc o u l d b e e m p l o y e d t o d e t e r m i n e i f t h e s i z e o r sh a p e o f t h e s em u s c l e s w a s d i f f e r e n t t o t h e s u r r o u n d i n g m u s c u l a t u r e .I n v e s t ig a te th e e f fe c t o f s p in a l p a in o n p r o p r io c e p t io na n d t h e e f f i c a cy o f o s t eo p a t h i c t r e a t m e n t t o i m p r o v e i tF u r t h e r e v i d e n c e i s n e e d e d t o c o n f i r m t h a t p a t ie n t s w i t hs p i n a l p a i n o r c l i n i c a l ly d e t e c t e d i n t e r v e r te b r a l d y s f u n c t i o nh a v e a d e f i c i t i n p r o p r i o c e p t i o n a n d m o t o r c o n t r o l . H e a dr e - p o s i t i o n in g , a w a r e n e s s o f b o d y p o s i t i o n a n d m o t i o n , a n dp o s t u r a l b a l a n c e a n d s w a y c a n b e u s e d t o c o n f i r mp r o p r i o c e p t i v e d e f i c i t o f p a t i e nt s a n d a s o u t c o m e m e a s u r e st o d e t e r m i n e t h e e f f i c a c y o f o s t e o p a t h i c t r e a tm e n t .

C O N C L U S I O NC o n c e p t s , t h e o r i e s a n d s u p p o r t i n g e v i d e n c e f o r t h em a n i p u l a b l e s p i n a l l e s io n h a v e b e e n r e v i e w e d . A m o d e l f o ri n t e r v e r t e b r a l d y s f u n c t i o n h a s b e e n p r e s e n t e d t h a t d e t a i lsm e c h a n i c a l a n d f u n c t i o n a l c h a n g e s f o l l o w i n g m i n o r t r a u m aa n d i t i s h o p e d t h i s w i l l s t im u l a t e d i s c u s s i o n a n d r e s e a r c hi n t o t h e n a t u r e o f i n t e r v e r t e b r a l d y s f u n c t i o n a n d t h em e c h a n i s m s o f m a n u a l t h e ra p y. F u t u r e r e s e a r c h s h o u l de x a m i n e m e t h o d s f o r r e l i a b l e d e t e c t i o n o f in t e r v e r t e b r a ld y s f u n c t i o n , s i g n s o f j o i n t e f f u s i o n , c h a n g e s i n a s s o c i a t e dp a r a s p i n a l m u s c l e s i z e a n d a c t i vi t y, a n d t h e e f f e c t o f s p i n a lp a i n o n p r o p f i o c e p t i o n . O n c e o b j e c t i v e s ig n s o f d y s f u n c t i o na r e e s t a b li s h e d , r e s e a r c h e r s c a n a c c u r a t e l y i n v e s t i g a t e t h ee f f i c a c y o f m a n u a l t h e ra p y .

A c k n o w l e d g m e n t sThe author wishes to thank Peter Gibbons for his constructive commentsduring preparation o f this m anuscript.

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