1. Chiropractic Manipulative Therapy: Neurological and Orthopedic Basis
Monroe Community Hospital
Grand Rounds Presentation
Chiropractic Manipulative Therapy: Neurological 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:

2. Premise
Chiropractic care centers around the maintenance of appropriate movement of the spinal joints and optimizing biomechanics throughout the musculoskeletal system.

3. This refers to discrete areas of hypomobilty within the spinal column
The primary lesion addressed in chiropractic is the vertebral subluxation complex (VSC).
This refers to discrete areas of hypomobilty within the spinal column

4. There is a distinct difference between medical and chiropractic use of the term 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

5. VERTEBRAL SUBLUXATION COMPLEX
HYPOMOBILITY
ALTERED BIOMECHANICS
DECREASED
MECHANORECEPTOR ACTIVITY
BREAKING OF CELLS - DEGENERATION
FIRING OF SPINAL CHEMOSENSITIVE NOCICEPTORS
INFLAMMATION
DECREASED INHIBITION OF
NOCICEPTOR ACTIVITY
INCREASED SYMPATHETIC
NERVOUS SYSTEM ACTIVITY

6. The purpose of the spinal adjustment is…
to restore normal movement and resolve the resultant biomechanical, physiological and neurological effects of segmental hypomobility.

7. Biomechanical Effects of Hypomobility
Altered intersegmental movement patterns
Results in compensatory changes in motor patterns, etc.
Creates cellular damage in sites of biomechanical stresses
“Immobilization Degeneration…”

8. Loss of normal motion within a joint results in changes in every structural component of the joint; subchondral bone to the synovium, from 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

9. Current orthopedic literature recognizes that changes in the pattern of forces transmitted through joints, which occurs during the immobilization process, is universally recognized as contributing to connective tissue degeneration and local changes in the chemical composition of that tissue….

10. We also know that mechanical failure of ligaments, discs, capsules and other connective tissue can result from local variations in chemical composition.

11. Measurable changes within the joint complex...
Chondrocyte loss is measurable within one day
Proteoglycan loss is measurable within one week

12. Effects of hypomobility on the intervertebral disc...

13. The nucleus pulposus is the the area of the disc most susceptible to dessication.
The nucleus pulposus is dependent on movement for nutrition and survival...

14. COMPRESSION
TRACTION
waste out
nutrition in
disc space
waste out

15. Neurological Effects of the Vertebral Subluxation Complex

16. Mechanoreceptors Position sensitive Motion sensitive
Vibration sensitive
Pressure sensitive
Provide continuous feedback about where the body is in space...

17. MECHANORECEPTOR ACTIVITY
VSC
ALTERED BIOMECHANICS COMMUNICATED TO THE
CNS VIA MECHANORECEPTORS
BRAIN AND SPINAL CORD RESPOND CREATING COMPENSATION IN MUSCLE
TISSUE DAMAGE
SECONDARY SITES OF
ALTERED BIOMECHANICS
NOCICEPTOR
ACTIVATION
INFLAMMATION
SYMPATHETIC NERVOUS SYSTEM ACTIVATION

18. Nociceptors 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 …

19. Pain 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

20. Factors that influence the perception of pain
Intensity of the stimulus
Duration of the stimulus
Descending inhibition

21. SWEAT GLANDS HAIR FOLLICLES DISC
NOCICEPTOR ACTIVITY
“PAIN”
10% only!
10% only!
CORTEX
VSC
THALAMUS
ALTERED
BIOMECHANICS
SPINOTHALAMIC TRACT
NOCICEPTOR
STIMULATION
SYNAPSE
IN CORD
IML
ANTERIOR HORN CELL
SYMPATHETIC CHAIN
MOTOR RESPONSE
BLOOD VESSELS
SWEAT GLANDS HAIR FOLLICLES DISC
ORGAN SYSTEMS

22. Nociceptor Sites Grieve G. Common Vertebral Joint Problems, 1988
Skin
Subcutaneous tissue
Adipose
Joint capsules
All spinal ligaments
Blood vessels
Cancellous bone
Periosteum
Muscles
Tendons
Fascia
Aponeurosis
Dura mater
Epidural tissue

23. Nociceptor activity and the sympathetic nervous system…

24. The dorsal horn is a central focal point for mediating autonomic and somatomotor reflexes initiated by nociceptive stimulation. Price D. Psychological and Neural Mechanisms of Pain, 1988; Raven Press, NY.

25. The Effects of Nociceptive Activity
Segmental responses of muscle spasm and sympathetic hyperactivity J. Bonica, & H. Hooshmand, 1993

26. Nociceptive input normally triggers sympathetic activity. Cabell J
Nociceptive input normally triggers sympathetic activity. Cabell J. Sympathetically maintained pain. In: Willis W, ed. Hyperalgesia and Allodynia. Raven Press, NY; 1992.

27. Noxious chemical stimulation of specific spinal structures produce measurable changes in sympathetic nerve activity and visceral function.
Budgell B, et al. Spinovisceral reflexes evoked by noxious and Innocuous stimulation of the lumbar spine. J Neuromusculoskel Syst; 1995;3:
Cabell J. Sympathetically maintained parin. In: Willis W, ed. Hyperalgesia and Allodynia. Raven Press, NY; 1992.

28. Sensitization of spinal cord neurons primarily by C fibers from muscles, joints and periosteum causes prolonged increased excitability of the nociceptors…
C fibers from muscles cause a more prolonged sensation than those innervating skin

29. …over time recruitment of adjacent spinal levels occur which become involved in the complex array of reflexes.
Though this facilitation is initiated by somatic afferents, it is sustained by an intrinsic spinal cord process…

30. Results in: Altered somatic function Altered visceral function
Allodynia
Sustained pain syndromes
Bonica JJ. Clinical importance of hyperalgesia
in Hyeralgesia and Allodynia; WD Willis Jr.,ed.
1992; Raven Press, Ltd., NY;

31. Effects of Spinal Nociceptor Stimulation of the Hypothalamus and Reticular Formation
Nausea
Pallor
Dizziness
Faintness
Syncope
Changes in blood pressure
Changes in respiration
Changes in heart rate
No pain

32. There is good evidence to support the importance of input from spinal afferents in reflex activity of the sympathetic nervous system.
Qu, et al, 1988
Meckler and Weaver, 1988
Taylor and Schramm, 1987
Stjernberg, et al, 1986
D. Jordan, 1997
Schramm and Poree, 1991
Hayes, et al, 1991
Weaver and Stein, 1988
Stein, et al, 1989

33. Nociceptor activity can cause reflexive stimulation of the sympathetic nervous system...
This may become chronic without the presence of pain or any other symptom.

34. Spinal Learning (Law of Facilitation)
Altered motor and sensory patterns are “learned” by the nervous system and the musculoskeletal systems

35. 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

36. 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

37. 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

38. Chiropractic Manipulative Therapy: Neurological and Orthopedic Basis
Monroe Community Hospital
Grand Rounds Presentation
Chiropractic Manipulative Therapy: Neurological 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: