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Vertebral Subluxation
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Vertebral Subluxation - December 16, 2001 2:59:00 PM
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mcap
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Dear Group:
In some of the Chiropractic Madness thread posts there was discussion of the vertebral subluxation theory. It appears that there is a controversy within Chiropractic circles about this phenomenon.
In my limited exposure to the theory.....I will say that I am not convinced, in any way, that problems are caused by vertebrae that are "out of alignment" or subluxed in some way that is ameniable to manipulation. It doesn't make sense when you consider the biomechanics.
But before we go blasting that theory....I think we need to take a look at what we do. Is our obsession with SIJ misalignment any different. I see no conclusive evidence that the SIJ moves in any way that would lend itself to palpation, evaluation and treatment based on positional faults. Yet.....I consistently hear therapists tell patients exactly how their pelvi are out of alignment and what they are going to do to "put it back."
It would seem to me that muscle energy, manipulation, certain exercises and other techniques all have a neurophysiological effect. It is possible the increases in motion and the reduction of pain are the result of some neuromuscular phenomenon.
What do yall think???????????????
mcap
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Re: Vertebral Subluxation - December 17, 2001 12:56:00 AM
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henryryry
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From: Brisbane, Australia.
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mcap and SJBird,
Many chiropractors and even physios believe with the establishment of functional MRI's, this question will be answered. For the moment, as I always believe, it is an evidence of absence on the subluxation theory rather than an absence of evidence.
Henry***
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Re: Vertebral Subluxation - December 17, 2001 3:24:00 AM
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henryryry
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From: Brisbane, Australia.
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SJBird,
Yes, by functional, I mean dynamic (I think Australians and US use different terms). I am hoping the tube would get bigger, because it sure does look quite crowded there. I think the other problem is over-radiation of the patient and the therapist involved... perhaps something we need to sacrifice for the studies. Wondering if they are looking for volunteers (not that I would be interested...).
Henry***
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Re: Vertebral Subluxation - December 17, 2001 5:10:00 AM
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Diane
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From: Vancouver, B.C., Canada
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Hello,
Re: the original question about whether there might be a neuromuscular component present in manual therapy to account for its apparent efficacy... I always obey the law, Hilton's Law that is. (Found under "Hilton's Law" in any medical dictionary, also by entering it into google)
Hilton was a medical physiologist who said that the nerve that supplies a joint will also supply the muscles that operate on the joint and the skin over the joint. So that makes me think it's impossible to treat a joint without activating neuromuscular reflex activity. Since we have to palpate through skin and connective tissue and muscle to feel the joint...
Diane
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Re: Vertebral Subluxation - December 17, 2001 8:06:00 AM
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mcap
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SJSJSJSJSJSJSJSJSJSJ:
Note that I didn't say the SIJ was never a pain generator. On the contrary....I beleive that it is implicated in a fair number of LBP cases (at least 10%, probably more like 15-20). There have been a number of good studies using diagnostic injections that validate SIJ problems. However, I do object to the whole positional fault/palpation thing......
Functional MRIs are already in use here. I am not sure how big it is. I would imagine that space constraints aren't the only or most significant obstacle. I would imagine that timing is. IN an MRI (Iv'e had one), you must keep the body part perfectly still for long periods of time to capture the images. In a dynamic situation, I am not sure how this is done. But if it is any kind of free movement, as we need to study in the L-Spine, then the body part would be impossible to stabilize. Studies to look at pelvic motion are being performed but I think they are using flouroscopy.
As for exposure with an MRI......as far as I know......there is none!! That is one of the advantages of the test.
We need an fMRI (as it is here with us Yanks) web site so we can have a better look. Anyone who knows....please chime in.
mcap
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Re: Vertebral Subluxation - December 18, 2001 12:01:00 AM
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henryryry
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From: Brisbane, Australia.
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SJ,
I read a recent article in the European Journal of Spine looking at functional MRI during lumbar flexion. They concluded that three types of lumbar flexion could occur based on what they observed... so yes, I think the patients were actually moving inside the machine. It is something that many researchers are doing... but I think the studies for its sensitivity and specificity still need a lot more work before we can safely say that fMRI is worth a try. Plus I would imagine it would be something quite expensive!!
Henry***
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Re: Vertebral Subluxation - December 18, 2001 1:46:00 PM
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mcap
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SJSJSJSJSJSJSJSJSJSJSJSJSJSJSJSJ:
How could the SIJ be a problem without a positional fault???????? Simple.
Haven't you ever treated l-spine disorders without a positional fault. Is there a positional fault in all knee disorders. There may be a MOVEMENT problem but it doesn't mean that there is a static positional fault that needs to "realigned."
The SIJ tests are dynamic....true.....but determining the correct treatment to apply requires the use of palpation of the static joint. Furthermore, the movement isn't significant enough to lend itself to accurate dynamic palpation.
The question we really want to answer is how much and how differently does the joint move in people afflicted with an SIJ disorder? So far.....in people with SIJ, there has been no appreciable difference when compared to healthies.
mcap
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Re: Vertebral Subluxation - December 19, 2001 3:09:00 AM
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mcap
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SJSJSJSJSJSJSJSJSJSJSJSJSJSJSJSJSJSJ:
Let's for one second assume that the SIJ has to have near perfect alignment......Not sure if it does....but if it does......how would one palpate this? Remember that the sum total of motion is a few millimeters of translation and a few degress of rotation.
This is a very interesting area. The only good studies previously done were with implantable devices and X-rays. This is not something likely to get through IRB nowadays [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
And.....I am not sure how anyone could be a thoughtful and concientious clinician and still not feel like they were missing something......all the time [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
As I tell my students....beware of those who think they have it all figured out [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
Later,
mcap
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Re: Vertebral Subluxation - December 19, 2001 3:25:00 AM
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mcap
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SJSJSJSJSJSJSJSJ:
Also...in patients with ACL laxity.....we see aberation in the instant center of rotation. Perhaps something similar is possible in the SIJ. But...the knee basically flexes and extends in the sagittal plane (with the odd smidgen of rotation and translation). The SIJ.......I don't even want to think about it.
It is a load bearing joint. The movements dissapate forces. I would focus inquiry into the joints ability to do this. Cintegraph (not quite sure what the technical name is) might make this possible. But the problem persists that it is difficult to orientate yourself and find a marker to measure without implantable devices.
mcap
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Re: Vertebral Subluxation - December 19, 2001 3:30:00 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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Yes, in fMRI the subject is required to move to obtain the necessary image of the structure in motion (!). I have seen studies - on video - of patellar motion through full range, with and without "patellar stabilising brace". Verrry interesting and useful (no positional change in patella BTW). The machines are very expensive and our local hospital radiology person does not see one here in the future. She thinks it will be used mostly in research. She will keep me abreast of future developments and studies - especially regarding spinal motion research.... Very necessary to "bunk" or "de-bunk" vertebral subluxation, disc and segmental motion (see Stuart McGill's work in Waterloo, Canada, with fluoroscopy - he captured a single segmental injury as it was happening!)
McGill "Achieving spine stability: blending engineering and clinical approaches" in: 4th Interdisciplinary World Congress on Low Back and Pelvic Pain, Montreal, Nov, 2001
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Re: Vertebral Subluxation - December 19, 2001 4:37:00 AM
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henryryry
Posts: 100
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From: Brisbane, Australia.
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HI,
just an aside question... is there any difference between a positional fault and a subluxation? If so, what is the difference. I have seen mulligans use the term positional fault, but it just seems to me to be the same reasoning as subluxations.
I agree with mcap that static position of the joint matters far less than the dynamic mobility. The best example is to look at some shocking abnormalities and asymmetries in the lumbar spine x-rays, and yet the person is continually active without pain. I often wonder what does a few degree of "subluxation" or positional fault matter, then as a physio replied to me, what does a few degree of mobilisation do to the joint? To date, I continue to search for the answer to this paradox.
Henry***
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Re: Vertebral Subluxation - January 1, 2002 7:45:00 PM
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pablo
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From: ACT, Australia
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Hi,
Just to add to the SIJ controversy. Perhaps the SIJ doesn't move enough for us to be able to palpate normal position and whatever movement occurs. The fact that there appears to be the same amount of movement in symptomatic and asymptomatic individuals has been researched using implanted metallic spheres and x-ray. There is no movement difference at the SIJ between sides in symptomatic individuals, even when we can palpate a difference in movement. The conclusion to this is that what we palpate is an illusion of movement at the SIJ, most likely a result of changes in soft tissue tension. (Blomberg, S., I think, presented at IFOMT 2000).
However, there is mounting evidence that the SIJ behaves differently in symptomatic individuals. Stiffness at the SIJ has been measured using doppler ultrasound, and it was found that symptomatic subjects have a significant difference in the stiffness values between sides than non-symptomatic subjects (who had no significant difference between sides). I can't remember the references for these, but think it is work by Carolyn Richardson, Julie Hides and others at the University of Queensland. There is also evidence of muscle dysfunction with this, extending to transversus abdominus, the diaphragm, and the pelvic floor (research by Paul Hodges). So there is a lot of evidence suggesting that the SIJ can be a source of dysfunction and pain.
Maybe it isn't subluxed, or out of position. Maybe all it takes is for it to lose it's ability to transmit loads appropriately between the trunk and lower limbs through a change in stiffness. Maybe it is this change in stiffness we feel when we palpate. Whether this then causes pain I do not know, but it is associated with neuromuscular dysfunction.
Pablo
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Re: Vertebral Subluxation - January 2, 2002 9:21:00 AM
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mcap
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Pablo:
I agree with your points. A change in the stiffness of the joint will affect it's ability to transmit loads.
The question still remains....what does this say about typical PT evaluation and treatment of the joint? Is their any reliability to evaluating "stiffness" when there is so little movement possible and when there is muscular tension and soft tissue contributions????
mcap
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Re: Vertebral Subluxation - January 2, 2002 12:12:00 PM
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pablo
Posts: 9
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From: ACT, Australia
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mcap,
This I can't answer. I think that reliability and validity studies of manual methods to assess SIJ stiffness are not too far away. Like any clinical test, though, these tests should probably not stand alone. I think physiotherapists should make clinical decisions about treatment based on a more thorough evaluation and careful interpretation of their findings. This I think requires looking at many different possibilities and looking beyond one's favourite theory that explains it all.
Pablo
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