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Our time together today?
Clinical Concepts in the management of the Craniocervical Junction (CCJ) Vertebral Subluxation (part 3 of 4)Jeff Scholten, DC
“It is well known that the total CSF volume in the adult is approximately 130 ml, of which about 60 ml is contained within the cranial cavity, and about 70 ml is stored within the vertebral canal.”
“During the head rotation, the sub occipital muscles could draw the cervical dural sleeve by the MDB and then head movements might work like a muscle pump which drives CSF based on deformations of the dural sac.”
“ …the stroke volume during the entire cardiac cycle was increased significantly in cranial direction after the head rotations.
Thus it was speculated that head movements could be a significant contributor to CSF dynamics in the craniocervical junction, besides mentioned factors in the past, such as heartbeat and respiration.”
Homunculus
Sensory (posterior)
Motor
Cortical Blood Flow?
Where does the blood come from?
Cortical Blood Supply• Anterior Cerebral Artery (from
ICA) – Inner cortex
• Middle Cerebral Artery (from ICA) – Outer cortex
• Posterior Cerebral Artery (from VA) – Back-base of cortex
Dickholtz
Kessinger
Coupled motion
Motion about multiple axes that reduce stress in each other
Lack of appropriately coupled motion is difficult to adapt to both biomechanically and neurologically.
A Method to Measure, Confirm and Localize Joint Dysfunction and its Impact on Cartilage.Authors: Ola Grimsby, PT, DMT, FFAAOMPT and David Harshfield M.D., M.S.
Slide credit David Harshfield
Instantaneous Axis of Rotation
Imaging evaluation must begin to correlate
the Static-structural findings with
the Kinematic-functional assessment
if we are ever to truly begin to understand
osteoarthritis
Instantaneous Axis of Rotation
Osteoarthritis is inherently caused by biomechanical dysfunction in joints caused by ligamentous insufficiency induced disruption of the instantaneous axis of rotation ( IAR- motion) for each position.
Instantaneous Axis of Rotation
Refers to two dimensional analysis
Aberrancies relate to joint degeneration
Position, Time, Nutrition, Genetics, Coping
Helical Axis of Motion (HAM)The axis of motion when three-dimensional motion occurs between objects (a screw axis of motion)
Can parameters of the helical axis be measured reliably during active cervical movements? Marco Barbero, etal. Musculoskeletal Science and Practice, Elsevier, February 2017
"Torqued subluxations" and "torqued alignments" involve THREE directions.”
“no ADJUSTMENT is ever given unless THE TORQUED VERTEBRA IS UNTORQUED; until the three-direction locked vertebra is three-directionally unlocked; with its "staying-put value" in exact ratio as the three-directional production is reversed to a three-direction reduction; as the torque is untorqued; as the lock is unlocked.”
“Abnormal ranges of motion may not show in the full range of motion studies
Abnormalities of the spine might be revealed by abnormal patterns of motion within individual segments”
Narrative Review of the In Vivo Mechanics of the Cervical Spine After Anterior Arthrodesis as Revealed by Dynamic Biplane Radiography, William Anderst, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
Subluxation
• ?
Subluxation
“A (sub)luxation of a joint, to a Chiropractor, means pressure on nerves, abnormal functions creating a lesion in some portion of the body, either in its action, or makeup.”
Palmer DD, Palmer BJ: The Science of Chiropractic 1906
Subluxation
“Vertebral Subluxation
1. Loss of juxtaposition of a vertebra with the one above, the one below, or both.
2. Occlusion of an opening.
3. Nerve impingement.
4. Interference with the transmission of mental impulses.”
Stephenson RW: Chiropractic Text Book. Palmer School of Chiropractic. Davenport, IA, 1927
Subluxation
“A motion segment in which alignment, movement integrity, and/or physiological function are altered although contact between the joint surfaces remain intact.”
Gatterman, M: Foundations of Chiropractic Subluxation
Definitions
“Motion Segment – a functional unit made up of two adjacent articulating surfaces and the connecting tissues binding them to each other.”
“Spinal Motion Segment – two adjacent vertebrae and the connecting tissues binding them together.”
Gatterman, M: Foundations of Chiropractic Subluxation
Definitions
“Manual Therapy – procedures by which the hands directly contact the body to treat the articulations or soft tissue.
Mobilization – movement applied singularly or repetitively within or at the physiologic range of joint motion, without imparting a thrust or impulse, with the goal of restoring joint mobility.”
Gatterman, M: Foundations of Chiropractic Subluxation
Definitions
“Manipulation – a manual procedure that involves a directed thrust to move a joint past the physiologic range of motion without exceeding the anatomical limit.”
Gatterman, M: Foundations of Chiropractic Subluxation
Definitions
“Adjustment – any chiropractic therapeutic procedure that uses controlled force, leverage, direction, amplitude and velocity directed at specific joints of anatomic regions. Chiropractors commonly use such procedures to influence joint and neurophysiologic function.”
Gatterman, M: Foundations of Chiropractic Subluxation
Definitions
“Subluxation Complex – a theoretical model of motion segment dysfunction (subluxation) that incorporates the complex interaction of pathologic changes in nerve, muscle, ligamentous, vascular and connective tissues.”
Gatterman, M: Foundations of Chiropractic Subluxation
Definitions
“Subluxation Syndrome – an aggregate of signs and symptoms that relate to pathophysiology or dysfunction of spinal and pelvic motion segments or to peripheral joints.”
Gatterman, M: Foundations of Chiropractic Subluxation
Definitions
“Manipulable Subluxation – a subluxation in which altered alignment, movement, or function can be improved by manual thrust procedures.”
Gatterman, M: Foundations of Chiropractic Subluxation
Role of Collagen:Solving the energy dilemma
Muscles and collagen are supporting tension
Collagen can provide a substitution mechanism for muscles to save energy by
allowing the animal to keep its posture without using muscles all the time
Muscles are energy guzzlers
Slide credit David Harshfield
Maximum 50 Kg
Muscle IAPClick
Slide credit David Harshfield
Click
The Crowbar
Less More
Fascia
Muscles
(Compression) (Compression)
Shut down muscles to minimize stress
Slide credit David Harshfield
Muscle
Fascia
20%
80%
For a200 kg lift
Slide credit David Harshfield
Muscle
Immature
fascia
Moves like a LPB
subject
People with LBP have a significant increase in muscle
activity
ClickSlide credit David Harshfield
Trunk flexion
MomentL4/5
0 15 30 45 60
Fascia
Muscle
Coordination spine/pelvis
IAP high
Big tummy benefit
Fascia is POWER( Note the flexed spine )
Slide credit David Harshfield
IAP high
Extension
IAP low
Flexion
IAP controls fascia
Slide credit David Harshfield
Visco-elasticity
take over the load
This is why continuous
postural changes are
necessary
while alternate structureswith time and need to restLoaded structures deform
Slide credit David Harshfield
3Dlordosis control
With multifidus
Control of Lordosis
Psoas
Psoas
Multifidus
Click
Slide credit David Harshfield
4 layers • Deepest layer contains multifidus (rotator(s) brevis,
longus, & semispinalis)
3 K • 25-100 per day
L,T,C regions• Language – Capital T, second toe, fifth toe
• Practice
Muscular Reactivation
Functional Disabilities
Discussion How patients tend to respond to short periods of reduced pain
How to plan to help patients avoid these issues
0 15 30 45 60
Moment at L4/5
Fascia
MuscleTrunkflexion
Trunk flexion affects the
distribution of loads between
muscles andfascia
Coordination spine/pelvis
Slide credit David Harshfield
Fascia is more than being part of a
force transmission system
Fascia is necessary for the stability and
survivability of the spinal column under
load
A subject with a damaged fascia may
not be rehabilitated
Conclusion
Slide credit David Harshfield
Viscoelasticity (Viscosity & Elasticity)
Consider loaded deformation over time
Requires rest by allowing other structures to take over
Necessitates continuous postural changes
Viscoelasticity
The conservation of energy with motion
Dynamic Stability
Do you care about Posture?How do you measure it?
Static vs Dynamic
Dynamic is easier – sway speed, deviation considerations
Static is never truly static – so how can you measure it?
APDM
Least Potential Energy position
Do we stand on our bones?
Increased Moments of Force
• Average weight of the human head 12 lbs (8-16 lbs)• increased vs decreased cervical & lumbar lordosis• increased vs decreased thoracic kyphosis
• Increased lordosis in cervical spine as a function of T1 anteroflexion(thoracic kyphosis)
• Increased lordosis in lumbar spine as a function of sacral base angle
• Reduced cervical lordosis, increases moment of force on VP
• Influence on lumbar spinal stress• FHP• Breast size• Abdominal fat
Soft tissue deformation - Creep, Hysteresis
• Creep – soft tissue elongation over time under load
• Hysteresis – the amount of elongation the tissue will maintain
• A muscle held under slight tension for 20-40 minutes will take 24-48 hours to return to its previous length
• Elastic vs contractile elements of muscle
Moving away cost more…
Less
More MoreEnergy
Wall
Energy
Wall
Material will deform
Collagen will stretch
Whiplash Considerations
Radiologists tend to opine on pathological processes where as we consider biomechanical aberrancies
Coupled motion disturbances