20 Approaches to treatment
Clinical cases for thoughtGeneral concepts in treatment application
1. Education—The patient should be taught about their condition, the expected time course of treatment, and any side effects that they may also expect.
2. Graded application of therapy—All treatment modalities should be applied in a graded fashion, proceeding from low intensity to an intensity that produces the desired therapeutic effect.
3. Monitor the effect of the treatment on the neuraxis—Monitoring of each therapy should be conducted as soon as possible following the therapy and then at appropriate intervals such as hourly, daily, or weekly, depending on the intensity of the therapy. Monitoring the effect of the intervention can be accomplished by monitoring the changes in time to activation, and fatigue in a neural circuit before and after the intervention.
The time to activation (TTA) of a neuron is a measure of the time from which the neuron receives a stimulus to the time that an activation response can be detected. Obviously, in clinical practice the response of individual neurons cannot be measured but the response of neuron systems such as the pupil response to light can be. As a rule, the time to activation will be less in situations where the neuron system has maintained a high level of integration and activity, and greater in situations where the neuron has not maintained a high level of integration and activity or is in the late stages of transneural degeneration. Again, an exception to this rule can occur in situations where the neuron system is in the early stages of transneural degeneration and is irritable to stimulus and responds quickly. This response will be of short duration and cannot be maintained for more than a short period of time.
Treatment should be composed of a three-pronged approach:
1. Modulation of the central integrative state (CIS) of a system, to maximise function of the viable neurons within the dysfunctional system, to promote regeneration and decrease iatrogenic loss of neurons, and to stimulate a repair process in any injured neurons;
2. Assist oxygen delivery to the system; and
3. Ensure that adequate fuel and other physiologically necessary substrates are delivered to the system.
Treatment approaches
Manipulation
Afferent modulation of the neuraxis via manipulation of spinal joints
Vertebral joint manipulation has been reported to have an effect on numerous signs and symptoms related to central nervous system function including visual dysfunction (Carrick 1997; Stephens et al. 1999), reaction time (Kelly et al. 2000), central motor excitability, dizziness, tinnitus or hearing impairment, migraine, sleep bruxism (Knutson 2001), bipolar and sleep disorders, and cervical dystonia. There have also been reports that spinal joint manipulation may assist in the improvement of otitis media and asthma in addition to other non-musculoskeletal complaints. Ample evidence exists to suggest that noxious stimulation of spinal tissues can lead to autonomically mediated reflex responses, which may explain how spinal joint manipulation can relieve some of these non-musculoskeletal complaints.
Several studies have investigated the effect of changes in spinal afferentiation as a result of manipulation on the activity of the sympathetic nervous system (Korr 1979; Sato 1992; Chiu & Wright 1996). Suprasegmental changes, especially in brain function, have demonstrated the central influence of altered afferentiation of segmental spinal levels (Thomas & Wood 1992; Carrick 1997; Kelly et al. 2000). Immune system function may be mediated through spinal afferent mechanisms that may operate via suprasegmental or segmental levels by modulating the activity of the sympathetic nervous system (Beck 2003).
Based on the above, it is likely that spinal joint manipulation may influence the CIS of various neuronal pools through changes in afferent inputs from joint and muscle receptors. A few studies have reported that upper cervical spinal joint manipulations have asymmetrical effects on measures of central nervous system function (Carrick 1997). This may account, in part, for reduction of symptoms in migraine sufferers following spinal manipulation, as asymmetry in blood flow to the head is thought to be a key feature in migraine and other headache types (Drummond & Lance 1984; Drummond, 1988, 1993).
A number of potential pathways exist that might explain why spinal manipulations have the potential to excite the rostral ventrolateral medulla (RVLM) and therefore result in modulatory effects on the neuraxis (Holt et al. 2006). The pathways and mechanisms most likely involved include the following:
1. Cervical manipulations excite spinoreticular pathways or collaterals of dorsal column and spinocerebellar pathways. Spinoreticular fibres originate at all levels of the cord but particularly in the upper cervical segments. They synapse on many areas of the pontomedullary reticular formation (PMRF).
2. Cervical manipulations cause modulation of vestibulosympathetic pathways. This may involve the same pathways as above or could reflect modulation of vestibular neurons at the level of the vestibular nuclei.
3. Cervical manipulations cause vestibulocerebellar activation of the nucleus tractus solitarius (NTS), dorsal motor nucleus of vagus, and nucleus ambiguus.
4. Manipulations may result in brain hemisphere influences causing descending excitation of the PMRF, which will exert tonic inhibitory control of the intermediolateral (IML) cell column.
5. Lumbosacral manipulations may result in sympathetic modulation due to direct innervation of the RVLM via dorsal column nuclei or spinoreticular fibres that ascend within the ventrolateral funiculus of the cord.
6. Spinal manipulation may alter the expression of segmental somatosympathetic reflexes by reducing small-diameter afferent input and enhancing large-diameter afferent input. This might influence sympathetic innervation of primary and secondary organs of the immune system.
7. Spinal manipulations might alter the expression of suprasegmental somatosympathetic reflexes by reducing afferent inputs on second-order ascending spinoreticular neurons. This might influence sympathetic innervation of immune system organs at a more global level.
8. Spinal manipulations might alter central integration of brainstem centres involved in descending modulation of somatosympathetic reflexes. This may occur via spinoreticular projections or interactions between somatic and vestibular inputs in the reticular formation. Both somatic (high-threshold) and vestibular inputs have been shown to increase output from the RVLM, which provides tonic excitatory influences on the IML cell column of the spinal cord. Proprioceptive (low-threshold) inputs from the cervical spine have been shown to have an antagonistic effect on vestibular inputs to the RVLM. Neurons in the brainstem reticular formation also mediate tonic descending inhibition of segmental somatosympathetic reflexes. Segmental somatosympathetic reflexes appear to be most influential in the absence of descending inhibitory influences from the brainstem.
9. Spinal manipulations might alter central integration in the hypothalamus via spinoreticular and spinohypothalamic projections and the influence of spinal afferents on vestibular and midline cerebellar function. Direct connections have been found to exist between vestibular and cerebellar nuclei and the hypothalamus, nucleus tractus solitarius, and parabrachial nuclei. The latter two nuclei project to the hypothalamus in addition to visceral and limbic areas of the medial temporal and insular regions of the cortex.
10. Spinal manipulations might influence brain asymmetry by enhancing summation of multimodal neurons in the CNS, monoaminergic neurons in the brainstem or basal forebrain regions, or cerebral blood flow via autonomic influences, or by influencing the hypothalamic-mediated isoprenoid pathway.
A variety of manipulations can be performed to stimulate afferent systems
Many excellent textbooks and video programs exclusively describing how to perform manipulations of virtually every joint of the body have been written (Carrick 1991, 1994). I will simply provide an overview of some of the more common manipulations that I have found clinically effective.
1 Positioning the patient for lumbar and pelvic manipulations
The standard position for lumbar and pelvic manipulations is referred to as the lateral recumbent position. The patient is lying comfortably on their side with the superior leg slightly bent at the knee and hip (Fig. 20.1A). The patient’s arms are crossed loosely over their chest. The patient should be stable and balanced while in this position and should not feel like they are going to roll off the table (Fig. 20.1B).
2 Lumbar mammillary push manipulation
Contact
The contact hand is semi-flexed into an ’L’ shape with the fingers reinforcing each other. The tips of the second and third fingers on the hand contacting the mammillary process vertebra of choice is the most efficient contact for this manipulation (Fig. 20.2A).
Adjuster’s position
The manipulating neurologist should be positioned standing but in a crouching position to the side of the patient; the contact arm is bent with the elbow contacting the patient’s hip for added support and control. The non-contact hand maintains a gentle supporting pressure on the patient’s shoulder. The contact hand maintains a gentle pressure on the contact (Fig. 20.2B). The manipulating neurologist then centres his/her sternal area over the contact and pushes against the patient’s shoulder and the patient’s hip in opposing directions until mild pressure is established.
Thrust
The thrust is a body drop impulse along the facet joint line of the lumbar vertebra in question, usually about 45° inferior to superior and anterior to posterior, in such a way that the thrust on the lumbar vertebra causes the vertebra to rotate away from the contact (Fig 20.2B).
3 Sacroiliac manipulation
Contact
The pisiform of the contact hand establishes a contact on the sacral angle above the second sacral tubercle to manipulate the ipsilateral or ’up-side’ sacroiliac joint. A contact on the sacral arch below the second sacral tubercle can be used to manipulate the sacroiliac joint on the contralateral or ’down side’ (Fig. 20.3A).
Adjuster’s position
The manipulating neurologist should be positioned standing but in a crouching position to the side of the patient. The manipulating neurologist contacts the angle of the sacrum with the hand closest to the patient and stabilises the patient’s superior shoulder with the other hand. Maintain a gentle pressure on the contact so that the patient is locked against the neurologist and the table (see Fig. 20.3A). The manipulating neurologist then centres his/her sternal area over the contact, making sure that his/her shoulder is held as tightly to his/her body as possible.
Thrust
The thrust is a body drop impulse along the joint line of the sacroiliac joint, usually about 45° inferior to superior and posterior to anterior (Fig 20.3B).
Clinical comments
1. The line of drive of the thrust is aligned too much in the posterior to anterior plane, the thrust should be inferior to superior as well; and
2. The elbow of the contact arm is allowed to move away from the body of the neurologist (winging). This position puts a great amount of strain on the shoulder and results in shoulder problems at a later time.
4 Ilium flexion push manipulation
Contact
The ischium of the ilium is cupped into the contact hand with the heel of the hand establishing a firm contact (Fig. 20.4A).
Adjuster’s position
The manipulating neurologist should be positioned standing but in a crouching position slightly to the rear and side of the patient. The contact arm is bent so that the shoulder is firmly behind the contact. The non-contact hand maintains a gentle supporting pressure on the patient’s shoulder. The contact hand maintains a gentle pressure on the contact (Fig. 20.4B). The manipulating neurologist then centres his/her sternal area behind the contact and pushes against the patient’s ischium until a mild pressure is established.
Thrust
The thrust is a body drop impulse with a scoop-like motion along the facet joint line of the ilium in question, in such a way that the thrust on the ilium moves the ilium into flexion (Fig. 20.4B).
Clinical comments
This manipulation must be performed with the patient relaxed. The support hand does not thrust or twist the body but simply stabilises. The manipulating neurologist must concentrate the line of drive of the thrust through the contact. The contact is more focused and the adjustment easier to perform if the manipulator positions their shoulder immediately behind the contact for maximum thrust power. Compared with other manipulations, this manipulation requires considerable power to accomplish properly. Asking the patient to exhale just before thrusting can also be helpful.
5 Anterior coccyx manipulation
Contact
A pisiform contact with the thrust hand contacting the knuckle of the thumb, which is in firm contact with the posterior inferior coccyx, is the most efficient contact for this adjustment (Figs 20.5A–C).
Adjuster’s position
The adjuster should be behind and centred to the patient with a gentle pressure on the contact (Fig. 20.5D).
6 Bilateral thenar thoracic manipulation
Contact
The manipulating neurologist contacts the transverse process of the thoracic vertebra in question with the pisiform of their contact hand. The non-contact hand contacts the contralateral transverse process to aid in stabilisation (Fig. 20.6A).
Adjuster’s position
The manipulating neurologist should be positioned standing to the side the patient, with their contact hand contacting the transverse process of the thoracic vertebra in question (Fig. 20.6A).
7 Anterior thoracic manipulation
Indication
This manipulation can be used to address any thoracic segment from T2 to T12 that has shifted posteriorly, or is not moving into rotation. This manipulation can also be used to stimulate the ipsilateral cerebellum or contralateral cortex in relation to the contact.
Contact
The contact hand is formed into a fist, and a contact established along the thenar eminence of the thumb on the hand contacting the transverse process (TVP) of the thoracic vertebra of choice is the most efficient contact for this manipulation (Fig. 20.7A).
Adjuster’s position
The manipulating neurologist should be positioned standing but in a crouching position to the side of the patient, with their arm encircling the patient to maintain a gentle pressure on the contact (see Fig. 20.7B). The manipulating neurologist then centres his/her sternal area over the contact and lowers their body onto the patient’s chest until mild pressure is established.
Thrust
The thrust is a body drop impulse along the facet joint line of the thoracic vertebra in question, usually about 45° inferior to superior and anterior to posterior above T6 and 45° superior to inferior and anterior to posterior below T6, in such a way that the thrust on the thoracic vertebra causes the vertebra to rotate away from the contact (Fig. 20.7C).
8 Crossed bilateral thoracic manipulation
Contact
The manipulating neurologist contacts the transverse process of the thoracic vertebra in question with the pisiform of their contact hand. The non-contact hand contacts the contralateral transverse process to aid in the delivery of the torque component of this manipulation (Fig. 20.8A).
Adjuster’s position
The manipulating neurologist should be positioned standing to the side of the patient, with their contact hand contacting the transverse process of the thoracic vertebra in question (Fig 20.8A).
Thrust
The thrust is inferior to superior and posterior to anterior along a line of drive following the facet lines of the thoracic vertebra in question with the contact hand. The non-contact hand thrusts in the opposite direction, producing a torque around the joint (Fig. 20.8B).
Clinical comments
This manipulation must be performed with the patient relaxed. The manipulating neurologist must concentrate the line of drive of the thrust through the contact. The torque component of the manipulation allows for a greater speed of delivery and thus makes the manipulation easier to perform. Asking the patient to exhale just before thrusting can also be helpful.
9 Standing thoracic long-axis manipulation
Contact
The manipulating neurologist contacts the patient’s thoracic spine area with their sternum (Fig. 20.9A).
Patient position
The patient should be comfortably standing, facing away from the manipulator; their arms should be crossed over their chest. The patient is asked to lie back onto the manipulating neurologist, who grasps the patient’s elbows with their palms in a reinforced cupped contact. The patient is then asked to relax and take a deep breath in and out and allow their body to relax.
Adjuster’s position
The manipulating neurologist should be positioned standing behind the patient, with their arms around the patient and grasping the patient’s elbows (Fig. 20.9B). The manipulating neurologist then centres his/her sternal area behind the contact. With a mild pull on the patient’s elbows and a push against the patient’s back, a mild pressure is established to remove any slack between the patient and the manipulator.
Thrust
The thrust is an impulse generated by a quick contraction of the biceps. The line of drive should be inferior to superior and anterior to posterior in nature (Figs 20.9A and 20.9B).
Clinical comments
This manipulation must be performed with the patient relaxed. The manipulating neurologist must concentrate the line of drive of the thrust through the contact. Compared with other manipulations, this manipulation requires considerable power to accomplish properly. Asking the patient to exhale just before thrusting can also be helpful.
10 Sitting atlas lateral flexion manipulation
Contact
A contact along the medial aspect of the thumb of the thrust hand contacting the most lateral edge of the posterior arch of the atlas is the most efficient contact for this manipulation (Fig. 20.10A).
Adjuster’s position
The manipulating neurologist should be positioned standing behind and slightly to the side of the patient. The patient’s head should be at the level of the manipulator’s mid-sternal area. The non-contact hand should be gently cupping the contralateral ear and supporting the head; the contact thumb should apply a gentle pressure on the contact (see Fig. 20.10A). The head is laterally flexed to the side of contact until a firm end feel is established. Extension of the neck should be avoided.
Thrust
The thrust is an impulse along the facet joint lines of the atlas in a lateral plane (Fig. 20.10B).
11 Sitting ’cervical pull’ manipulation
Contact
A contact along the palmer aspect of the third finger of the thrust hand contacting the posterior arch of the cervical vertebra of choice is the most efficient contact for this manipulation (Fig. 20.11A).
Adjuster’s position
The manipulating neurologist should be positioned to the side opposite the contact, with a gentle pressure on the contact (see Fig. 20.11A). The head can be laterally flexed either to the side of contact or away from the contact. When laterally flexing away from the contact the manipulation takes advantage of the normal coupled motion of the cervical vertebral motion units and produces a greater stimulus.
12 Sitting atlas rotation manipulation
Contact
A contact along the medial aspect of the first finger of the thrust hand contacting the posterior arch of the atlas is the most efficient contact for this manipulation (Fig. 20.12A).
Adjuster’s position
The manipulating neurologist should be positioned standing in front and slightly to the side of the patient. The patient’s head should be at the level of the manipulator’s mid-sternal area. The non-contact hand should be gently cupping the contralateral ear and supporting the head; the contact thumb should apply a gentle pressure on the contact (see Fig. 20.12A). The head is laterally flexed to the side of contact until a firm end feel is established. Extension of the neck should be avoided.
Thrust
The thrust is an impulse along the facet joint lines of the atlas in an inferior to superior plane (Fig. 20.12B).
13 Supine cervical manipulation
Contact
A contact along the palmer aspect of the first finger of the thrust hand contacting the posterior arch of the cervical vertebra of choice is the most efficient contact for this manipulation (Fig. 20.13A).
Adjuster’s position
The manipulating neurologist should be positioned standing but in a crouching position to the head of the patient, with a gentle pressure on the contact (see Fig. 20.13A). The head can be laterally flexed to the side of contact until a firm end feel is established.
14 Supine atlas rotation manipulation
Contact
A contact along the lateral aspect of the first finger of the thrust hand contacting the posterior arch of the atlas is the most efficient contact for this manipulation (Fig. 20.14A).
Adjuster’s position
The manipulating neurologist should be positioned standing but in a crouching position to the head of the patient, with a gentle pressure on the contact (see Fig. 20.14A). The head can be laterally flexed to the side of contact and rotated away from the contact until a firm end feel is established.
