Principles of Manual Medicine

Ed Crowley

Conference September 9, 2004

Reference:  Philip E. Greenman,  Michigan State University , May 2004

Normal Vertebral Motion

n    Each Vertebrae has the ability to rotate around an axis and to translate along an axis

n    This results in 6df for each vertebrae

n    Vertebral Motion can then be described as overturning movement ( rotation around an axis ) and translatory movement ( translation along an axis )

Forward Bending

n      Superior vertebra rotates anteriorly around the x-axis and translates somewhat forward along the z-axis

n      The inferior facet of the superior vertebra moves superiorly in relation to the superior facet of the inferior vertebra

n      This Is facet “opening”

Backward Bending

n     The vertebra rotates backward around the x-axis and moves posteriorly along the z-axis

n     The inferior facet of the superior segment slides inferiorly in relation to the superior facet of the inferior vertebra

n     This is facet closing

Side Bending

n    Rotation around anteroposterior z-axis and translation along the horizontal x-axis

n    Side bending is seldom a pure movement and is usually coupled with rotation

n    In side bending to the right, the right facet joint “closes” and the left facet joint “opens

Rotation

n    Rotation of the vertebra is around the y-axis

n    Rotation is always coupled with side bending with the exception of the atlantoaxial joint

n    Side bending are coupled movements and do not occur individually

n    Coupled movements change in response to the anteroposterior curves of the vertebral axis

Neutral Mechanics / Type I

n    Results in coupled movements with side bending and rotation to the opposite sides

n    Occurs when in an erect position with normal anteroposterior curves

n    In the lumbar vertebrae the middle segment maximally  side bends and rotates to the opposite side as to the segment below the apex

n    Segments above the apex rotate to the same side and the curve gradually reduces

Nonneutral Mechanics / Type II

n    Results in side bending and rotation to the same side

n    Occurs when there is alteration in the anteroposterior curve into forward or backward bending

n     Nonneutral mechanics occur in the lumbar spine when it is flexed and neutral mechanics when it is extended

Theories of Vertebral Motion Dysfunction

n     Entrapment of synovial or meniscoid material between the joint surfaces

n     Lack of congruence between the contact surfaces of the joint

n     Alteration in the physical and chemical properties of the synovial fluid and surfaces

n     Altered length and tone of muscle

n     Changes in the biomechanical and biochemical properties of the myofascial elements

Understanding Vertebral Motion Dysfunction

n    Dysfunctions can be described as single segment dysfunctions or group dysfunctions involving three or more vertebrae

n    Vertebral  dysfunctions can be described in terms of MOTION restriction and POSITION in which the segment is restricted

n    A flexed right rotated right side bent segment has motion restrictions in extension left rotation and left side bending

The Motion Spectrum

n    Ankylosis à Hypomobility à Normal Motion àHypermobility à Instability

n    Manual medicine procedures are most appropriate for segments in the spectrum of  hypomobility

Dysfunctions of single vertebral motion segment

n      In the neutral position The right transverse process appears to be more posterior than the left

n      In forward bending the right transverse process is more prominent

n      In backward bending both transverse processes appear to become more symmetric

Neutral Group Dysfunction

n     1. A group of segments

n     2. Minimal flexion or extension component

n     3. restriction of a group to side bending to the side of convexity and rotation to the side of concavity

n     ERSleft

Nonneutral  Group Dysfunction

n     Always relate the superior segment to that of the inferior

n     L5 is extended, rotated and side bent left ERSleft

n     L4 is flexed, rotated, side bent right FRS right

Conclusions

n     There is no substitute for a good history and evaluation

n     Manual medicine cannot be mastered by reading a text

n     There is a role for manual medicine for acute and chronic back pain