Chiropractic Manipulative Therapy: Neurological and Orthopedic Basis

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Chiropractic Manipulative Therapy Neurological
and Orthopedic Basis
Monroe Community Hospital Grand Rounds
Presentation

• 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 [phone]
• Email lbloom_at_nycc.edu

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Chiropractic care centers around the maintenance
of appropriate movement of the spinal joints and
optimizing biomechanics throughout the
musculoskeletal system.

• Premise

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The primary lesion addressed in chiropractic is
the vertebral subluxation complex (VSC).

• This refers to discrete areas of hypomobilty
  within the spinal column

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There is a distinct difference between medical
and chiropractic use of the term 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

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VERTEBRAL SUBLUXATION COMPLEX
HYPOMOBILITY
ALTERED BIOMECHANICS
DECREASED MECHANORECEPTORACTIVITY
BREAKING OF CELLS - DEGENERATION
FIRING OF SPINAL CHEMOSENSITIVENOCICEPTORS
INFLAMMATION
DECREASED INHIBITION OF NOCICEPTOR ACTIVITY
INCREASED SYMPATHETIC NERVOUS SYSTEM ACTIVITY
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The purpose of the spinal adjustment is

• to restore normal movement and resolve the
  resultant biomechanical, physiological and
  neurological effects of segmental hypomobility.

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Biomechanical Effects of Hypomobility

• Altered intersegmental movement patterns
• Results in compensatory changes in motor
  patterns, etc.
• Creates cellular damage in sites of biomechanical
  stresses
• Immobilization Degeneration

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Loss of normal motion within a joint results in
changes in every structural component of the
jointsubchondral bone to the synovium, from
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

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Current orthopedic literature recognizes that
changes in the pattern of forces transmitted
through joints, which occurs during the
immobilization process, is universally recognized
as contributing to connective tissue degeneration
and local changes in the chemical composition of
that tissue.
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We also know that mechanical failure of
ligaments, discs, capsules and other connective
tissue can result from local variations in
chemical composition.
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Measurable changes within the joint complex...

• Chondrocyte loss is measurable within one day
• Proteoglycan loss is measurable within one week

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Effects of hypomobility on the intervertebral
disc...
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The nucleus pulposus is the the area of the disc
most susceptible to dessication.

• The nucleus pulposus is dependent on movement
  for nutrition and survival...

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COMPRESSION
TRACTION
waste out
nutrition in
?disc space?
waste out
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Neurological Effectsof the Vertebral Subluxation
Complex
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Mechanoreceptors

• Position sensitive
• Motion sensitive
• Vibration sensitive
• Pressure sensitive
• Provide continuous feedback about where the body
  is in space...

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MECHANORECEPTOR ACTIVITY
VSC
ALTERED BIOMECHANICS COMMUNICATED TO THE CNS VIA
MECHANORECEPTORS
BRAIN AND SPINAL CORD RESPOND CREATINGCOMPENSATIO
N IN MUSCLE
TISSUE DAMAGE
SECONDARY SITES OF ALTERED BIOMECHANICS
NOCICEPTOR ACTIVATION
INFLAMMATION
SYMPATHETIC NERVOUS SYSTEM ACTIVATION
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Nociceptors

• 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

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Pain

• 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

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Factors that influence the perception of pain

• Intensity of the stimulus
• Duration of the stimulus
• Descending inhibition

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NOCICEPTOR ACTIVITY
PAIN
10 only!
10 only!
CORTEX
VSC
THALAMUS
ALTERED BIOMECHANICS
SPINOTHALAMIC TRACT
NOCICEPTOR STIMULATION
SYNAPSE IN CORD
IML
ANTERIOR HORN CELL
SYMPATHETIC CHAIN
BLOOD VESSELS SWEAT GLANDSHAIR FOLLICLESDISC
MOTOR RESPONSE
ORGAN SYSTEMS
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Nociceptor SitesGrieve G. Common Vertebral Joint
Problems, 1988

• Skin
• Subcutaneous tissue
• Adipose
• Joint capsules
• All spinal ligaments
• Blood vessels
• Cancellous bone

• Periosteum
• Muscles
• Tendons
• Fascia
• Aponeurosis
• Dura mater
• Epidural tissue

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Nociceptor activity and the sympathetic nervous
system
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The dorsal horn is a central focal point for
mediating autonomic and somatomotor
reflexesinitiated by nociceptive
stimulation.Price D. Psychological and Neural
Mechanisms of Pain, 1988 Raven Press, NY.
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The Effects of Nociceptive Activity

• Segmental responses of muscle spasm and
  sympathetic hyperactivity. J. Bonica,
  1990 1992 H. Hooshmand, 1993

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Nociceptive input normally triggers sympathetic
activity.Cabell J. Sympathetically maintained
pain. In Willis W, ed. Hyperalgesia and
Allodynia. Raven Press, NY 1992.
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Noxious chemical stimulation of specific spinal
structures produce measurable changes in
sympathetic nerve activity and visceral function.
Budgell B, et al. Spinovisceral reflexes evoked
by noxious and Innocuous stimulation of the
lumbar spine. J Neuromusculoskel Syst
19953122-131. Cabell J. Sympathetically
maintained parin. In Willis W, ed. Hyperalgesia
and Allodynia. Raven Press, NY 1992.
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Sensitization of spinal cord neurons primarily by
C fibers from muscles, joints and periosteum
causes prolonged increased excitability of the
nociceptors

• C fibers from muscles cause a more prolonged
  sensation than those innervating skin

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over time recruitment of adjacent spinal levels
occur which become involved in the complex array
of reflexes.

• Though this facilitation is initiated by somatic
  afferents, it is sustained by an intrinsic spinal
  cord process

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Results in

• Altered somatic function
• Altered visceral function
• Allodynia
• Sustained pain syndromes

Bonica JJ. Clinical importance of hyperalgesia in
Hyeralgesia and Allodynia WD Willis
Jr.,ed. 1992 Raven Press, Ltd., NY 17-43.
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Effects of Spinal Nociceptor Stimulation of
the Hypothalamus and Reticular Formation

• Nausea
• Pallor
• Dizziness
• Faintness
• Syncope

• Changes in blood pressure
• Changes in respiration
• Changes in heart rate
• No pain

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There is good evidence to support the importance
of input from spinal afferents in reflex activity
of the sympathetic nervous system.

• Qu, et al, 1988
• Meckler and Weaver, 1988
• Taylor and Schramm, 1987
• Stjernberg, et al, 1986

• D. Jordan, 1997
• Schramm and Poree, 1991
• Hayes, et al, 1991
• Weaver and Stein, 1988
• Stein, et al, 1989

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Nociceptor activity can cause reflexive
stimulation of the sympathetic nervous system...

• This may become chronic without the presence of
  pain or any other symptom.

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Spinal Learning (Law of Facilitation)

• Altered motor and sensory patterns are learned
  by the nervous system and the musculoskeletal
  systems

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Biomechanical stresses ? Low grade chronic tissue
damage ? Release of depolarizing agents
(bradykinin, potassium, etc.) ? Nociceptor
stimulation and inflammation ? Edema ? Immobilizat
ion and myospasm ? Rebuilding of movement
patterns ? SPONOLEARNING
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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

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• 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

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Chiropractic Manipulative Therapy Neurological
and Orthopedic Basis
Monroe Community Hospital Grand Rounds
Presentation

• 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 [phone]
• Email lbloom_at_nycc.edu