Approaches to treatment

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20 Approaches to treatment

General concepts in treatment application

The general approach to different treatment applications in functional neurology can be summarised by the following three steps:

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.

The time to fatigue (TTF) in a neuron is the length of time that a response can be maintained during a continuous stimulus to the neuron. The TTF effectively measures the ability of the neuron to sustain activation under continuous stimulation, which is a good indicator of the adenosine triphosphate (ATP) and protein stores contained in the neuron. This in turn is a good indication of the state of health of the neuron. The TTF will be longer in neurons that have maintained high levels of integration and stimulus and shorter in neurons that have not maintained a high state of integration. TTF can be very useful in determining whether a fast time to response (TTR) is due to a highly integrated neuron system or a neuron system that is in the early stages of transneural degeneration.

For example, in clinical practice, the response of one pupil to light can be compared to the other pupil’s response. If both pupils respond very quickly to light stimulus (fast TTR), and they both maintain pupil contraction for 3–4 seconds (long TTF) this is a good indication that both neuronal circuits are in a good state of health. If, however, both pupils respond quickly (fast TTR) but the right pupil immediately dilates despite the continued presence of the light stimulus (short TTF), this may be an indication that the right neuronal system involved in pupil constriction may be in an early state of transneural degeneration and more detailed examination is necessary.

Treatment should be composed of a three-pronged approach:

In some instances when the CIS of a system is so poor that any stimulus will cause injury, it may be necessary to avoid direct excitatory activation of the system. In these instances it may require the promotion of inhibition of the neuronal pool by excitation of an antagonist pool of neurons.

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).

Spinal afferents may also influence output from the locus ceruleus, which influences cortical and subcortical neuronal activity, including trigeminal and vestibular thresholds, as shown in animal research. Locus ceruleus has widespread projections to all levels of the neuraxis, including the hypothalamus and to other monoaminergic nuclei.

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.

2 Lumbar mammillary push manipulation

3 Sacroiliac manipulation

4 Ilium flexion push manipulation

5 Anterior coccyx manipulation

6 Bilateral thenar thoracic manipulation

7 Anterior thoracic manipulation

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.

8 Crossed bilateral thoracic manipulation

9 Standing thoracic long-axis manipulation

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.

10 Sitting atlas lateral flexion manipulation

11 Sitting ’cervical pull’ manipulation

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

13 Supine cervical manipulation

14 Supine atlas rotation manipulation

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.