Chiropractic Manipulative Chiropractic Manipulative Therapy: Neurological and Therapy: Neurological and Orthopedic Basis Orthopedic Basis Lisa K. Bloom, D.C. Diplomate of the International Board of Chiropractic Neurology Diplomate in Applied Chiropractic Sciences Associate Professor, Diagnosis and Practice New York Chiropractic College Phone: 315-568-3180 Email: [email protected]Monroe Community Hospital Grand Rounds Presentation
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Chiropractic Manipulative Therapy: Neurological and Orthopedic Basis Lisa K. Bloom, D.C. Diplomate of the International Board of Chiropractic Neurology.
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Chiropractic Manipulative Therapy: Chiropractic Manipulative Therapy: Neurological and Orthopedic BasisNeurological and Orthopedic Basis
Lisa K. Bloom, D.C.Diplomate of the International Board of Chiropractic Neurology
Monroe Community HospitalGrand Rounds Presentation
Chiropractic care centers Chiropractic care centers around the maintenance of around the maintenance of
appropriate movement of the appropriate movement of the spinal joints and optimizing spinal joints and optimizing
biomechanics throughout the biomechanics throughout the musculoskeletal system.musculoskeletal system.
Premise
The primary lesion addressed The primary lesion addressed in chiropractic is the in chiropractic is the vertebral vertebral subluxation complexsubluxation complex (VSC). (VSC).
This refers to discrete areas of hypomobilty within the spinal
column
There is a distinct difference There is a distinct difference between medical and chiropractic between medical and chiropractic
use of the term use of the term subluxation:subluxation:
Medical use of the term refers to a hypermobility associated with instability resulting from a loss of integrity of the joint capsules
Chiropractic use of the term refers to a hypomobility with no loss of stability
VERTEBRAL SUBLUXATION COMPLEX
HYPOMOBILITY
ALTERED BIOMECHANICS DECREASED MECHANORECEPTOR
ACTIVITY
DECREASED INHIBITION OFNOCICEPTOR ACTIVITY
BREAKING OF CELLS - DEGENERATION
FIRING OF SPINAL CHEMOSENSITIVE
NOCICEPTORSINFLAMMATION
INCREASED SYMPATHETICNERVOUS SYSTEM ACTIVITY
The purpose of the spinal The purpose of the spinal adjustment is…adjustment is…
to restore normal movement and resolve the resultant biomechanical,
physiological and neurological effects of segmental hypomobility.
Biomechanical Effects of Biomechanical Effects of HypomobilityHypomobility
Altered intersegmental movement patterns Results in compensatory changes in motor
patterns, etc. Creates cellular damage in sites of
Loss of normal motion within a joint Loss of normal motion within a joint results in changes in every structural results in changes in every structural
component of the joint;component of the joint;subchondral bone to the synovium, from subchondral bone to the synovium, from
meninges to the ligamentum flavum.meninges to the ligamentum flavum.
Amiel D, et al. Acta Ortho Scand, 1982
Palmoski M, et al. Arth Rheum, 1979
Paine & Haung. J Neurosurgery, 1972
Lantz C. Chiro Res J, 1988
Enneking & Horowitz. J Bone Joint Surg, 1972
Evans EB, et al. J Bone Joint Surg, 1960
Current orthopedic literature Current orthopedic literature recognizes that recognizes that changes in the changes in the pattern of forces transmitted pattern of forces transmitted through joints, which occurs through joints, which occurs
during the immobilization process, during the immobilization process, is universally recognized as is universally recognized as
contributing to connective tissue contributing to connective tissue degeneration and local changes in degeneration and local changes in the chemical composition of that the chemical composition of that
tissue….tissue….
We also know that mechanical We also know that mechanical failure of ligaments, discs, failure of ligaments, discs,
capsules and other connective capsules and other connective tissue tissue can result from local can result from local
variations in chemical variations in chemical composition.composition.
Measurable changes within Measurable changes within the joint complex...the joint complex...
Chondrocyte loss is measurable within one day
Proteoglycan loss is measurable within one week
Effects of hypomobility Effects of hypomobility on the intervertebral on the intervertebral
disc...disc...
The nucleus pulposus is the The nucleus pulposus is the the area of the disc most the area of the disc most
susceptible to dessication. susceptible to dessication.
The nucleus pulposus is dependent on movement for
nutrition and survival...
COMPRESSION TRACTION
waste out
nutrition in
waste out
disc space
NeurologicalNeurological EffectsEffectsof the Vertebral of the Vertebral
Subluxation ComplexSubluxation Complex
MechanoreceptorsMechanoreceptors Position sensitive Motion sensitive Vibration sensitive Pressure sensitive Provide continuous feedback about where
the body is in space...
MECHANORECEPTOR ACTIVITY
VSC
ALTERED BIOMECHANICS COMMUNICATED TO THECNS VIA MECHANORECEPTORS
BRAIN AND SPINAL CORD RESPOND CREATINGCOMPENSATION IN MUSCLE
SECONDARY SITES OFALTERED BIOMECHANICS
TISSUE DAMAGE
NOCICEPTORACTIVATION INFLAMMATION
SYMPATHETIC NERVOUS SYSTEM ACTIVATION
NociceptorsNociceptors Thermo-, mechano-, polymodal and
chemosensitive Spinal nociceptors are almost
exclusively chemosensitive Most of the dorsal horn afferents are
nociceptors Fire with harmful or potentially
harmful stimuli …
PainPain
Not carried by nociceptors Cortical event Most nociceptive activity never reaches the
cortex and the patient will remain symptom-free in the presence of tissue damage
Factors that influence the Factors that influence the perception of painperception of pain
Intensity of the stimulus Duration of the stimulus Descending inhibition
NOCICEPTOR ACTIVITY
VSC
ALTEREDBIOMECHANICS
NOCICEPTORSTIMULATION
SYNAPSE IN CORD
SPINOTHALAMIC TRACT
IML
CORTEX“PAIN”
SYMPATHETIC CHAIN
BLOOD VESSELSSWEAT GLANDSHAIR FOLLICLES
DISC
ORGAN SYSTEMS
ANTERIOR HORN CELL
MOTOR RESPONSE
10% only!
THALAMUS
10% only!
Nociceptor SitesNociceptor SitesGrieve G. Common Vertebral Joint Problems, Grieve G. Common Vertebral Joint Problems,
19881988
Skin Subcutaneous tissue Adipose Joint capsules All spinal ligaments Blood vessels Cancellous bone
Periosteum Muscles Tendons Fascia Aponeurosis Dura mater Epidural tissue
Nociceptor activity and the Nociceptor activity and the sympathetic nervous sympathetic nervous
system…system…
The dorsal horn is a central focal The dorsal horn is a central focal point for mediating autonomic point for mediating autonomic
and somatomotor reflexesand somatomotor reflexesinitiated by nociceptive initiated by nociceptive
stimulation.stimulation.
Price D. Psychological and Neural Mechanisms Price D. Psychological and Neural Mechanisms of Pain, 1988; Raven Press, NY.of Pain, 1988; Raven Press, NY.
The Effects of Nociceptive The Effects of Nociceptive ActivityActivity
Segmental responses of muscle spasm and sympathetic hyperactivity.
Cabell J. Sympathetically maintained pain. In: Willis W, Cabell J. Sympathetically maintained pain. In: Willis W, ed. Hyperalgesia and Allodynia. Raven Press, NY; ed. Hyperalgesia and Allodynia. Raven Press, NY;
1992.1992.
Noxious chemical stimulation Noxious chemical stimulation of specific spinal structures of specific spinal structures
produce measurable changes produce measurable changes in sympathetic nerve activity in sympathetic nerve activity
and visceral function.and visceral function.
Budgell B, et al. Spinovisceral reflexes evoked by noxious and Innocuous stimulation of the lumbar spine. J
Neuromusculoskel Syst; 1995;3:122-131.
Cabell J. Sympathetically maintained parin. In: Willis W, ed. Hyperalgesia and Allodynia. Raven Press, NY; 1992.
Sensitization of spinal cord Sensitization of spinal cord neurons primarily by C fibers neurons primarily by C fibers
from from muscles, joints and muscles, joints and periosteumperiosteum causes prolonged causes prolonged
increased excitability of the increased excitability of the nociceptors…nociceptors…
C fibers from muscles cause a more prolonged sensation than those
innervating skin
……over time recruitment of over time recruitment of adjacent spinal levels occur adjacent spinal levels occur
which become involved in the which become involved in the complex array of reflexes.complex array of reflexes.
Though this facilitation is initiated by somatic afferents, it is sustained by an
intrinsic spinal cord process…
Results in:Results in:
Altered somatic function Altered visceral function Allodynia Sustained pain syndromes
Bonica JJ. Clinical importance of hyperalgesiain Hyeralgesia and Allodynia; WD Willis Jr.,ed.
1992; Raven Press, Ltd., NY; 17-43.
Effects of Spinal NociceptorEffects of Spinal Nociceptor Stimulation of the Hypothalamus Stimulation of the Hypothalamus
and Reticular Formationand Reticular Formation
Nausea Pallor Dizziness Faintness Syncope
Changes in blood pressure
Changes in respiration Changes in heart rate No pain
There is good evidence to There is good evidence to support the importance of support the importance of input from spinal afferents input from spinal afferents
in reflex activity of the in reflex activity of the sympathetic nervous sympathetic nervous
system.system. D. Jordan, 1997 Schramm and Poree, 1991 Hayes, et al, 1991 Weaver and Stein, 1988 Stein, et al, 1989
Qu, et al, 1988 Meckler and Weaver,
1988 Taylor and Schramm,
1987 Stjernberg, et al, 1986
Nociceptor activity can cause Nociceptor activity can cause reflexive stimulation of the reflexive stimulation of the
This may become chronic without the presence of pain or any other
symptom.
Spinal LearningSpinal Learning (Law of Facilitation)(Law of Facilitation)
Altered motor and sensory patterns are “learned” by the
nervous system and the musculoskeletal systems
Biomechanical stresses
Low grade chronic tissue damage
Release of depolarizing agents (bradykinin, potassium, etc.)
Nociceptor stimulation and inflammation
Edema
Immobilization and myospasm
Rebuilding of movement patterns
SPONOLEARNING
Reasonable conclusions:Reasonable conclusions:
Hypomobility is the key ingredient for immobilization degeneration to begin
The ID process is progressive if not interrupted
Poor biomechanics will damage cells causing dysafferentation
Nociceptors will cause the sympathetic nervous system to fire
This reflexively facilitates the sympathetic nervous system
Due to nociceptive mediation, pain will come on much later though the degenerative process is measurable within one day/week of the onset of hypomobility
Chiropractic Manipulative Therapy: Chiropractic Manipulative Therapy: Neurological and Orthopedic BasisNeurological and Orthopedic Basis
Lisa K. Bloom, D.C.Diplomate of the International Board of Chiropractic Neurology