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

Diplomate in Applied Chiropractic Sciences

Associate Professor, Diagnosis and Practice

New York Chiropractic College

Phone: 315-568-3180

Email: lbloom@nycc.edu

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

biomechanical stresses “Immobilization Degeneration…”

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.

J. Bonica, 1990 & 1992H. Hooshmand, 1993

Nociceptive input normally Nociceptive input normally triggers sympathetic activity.triggers sympathetic activity.

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

sympathetic nervous system...sympathetic nervous system...

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

Diplomate in Applied Chiropractic Sciences

Associate Professor, Diagnosis and Practice

New York Chiropractic College

Phone: 315-568-3180

Email: lbloom@nycc.edu

Monroe Community HospitalGrand Rounds Presentation