Physiology of Manipulation & What to look for in a good Chiropractor

1. Physiology of Manipulation&What to look for in a good Chiropractor

2. AP/Lateral Lateral AP

3. Facet Joint • The facets are small flat plate-like joints that have little, but very important motion. There are two facet joints between each pair of vertebra, one on each side. Without the facet joints, you would not have flexibility or motion in the posterior motor unit of the spine. • The facet joints are what are known as synovial joints. These joints have cells that produce synovial fluid. This fluid circulates only through motion. • If the joint is fixated this fluid builds, increasing joint pressure, and hydrostatic pressure on the nerve root directly anterior to the joint. This fluid also provides lubrication and nutrients to the articular cartilage.

4. Facet Joint Lateral Posterior

5. Ligaments • Anterior Longitudinal Ligament (ALL) - A primary spine stabilizer About one inch wide, the ALL runs the entire length of the spine from the base of the skull to the sacrum. It connects the front (anterior) of the vertebral body to the front of the annulus fibrosis.     • Posterior Longitudinal Ligament (PLL) - A primary spine stabilizer About one inch wide, the PLL runs the entire length of the spine from the base of the skull to sacrum. It connects the back (posterior) of the vertebral body to the back of the annulus fibrosis.     • Supraspinous Ligament - This ligament attaches the tip of each spinous process to the other.     • Interspinous Ligament - This thin ligament attaches to another ligament, called the ligamentum flavum, that runs deep into the spinal column.     • Ligamentum Flavum - The strongest ligament - This yellow ligament is the strongest one. It runs from the base of the skull to the pelvis, in front of and between the lamina, and protects the spinal cord and nerves. The ligamentum flavum also runs in front of the facet joint capsules. • Interstransverse Ligament – This ligament attaches to each transverse process.

6. Spinal Ligaments

7. Cervical Spinal Muscles 1. Semispinalis Capitus (head rotation/pulls backward) 2. Iliocostalis Cervicis (extends cervical vertebrae) 3. Longissimus Cervicus (extends cervical vertebrae) 4. Longissimus Capitus (head rotation/pulls backward) 5. Longissimus Thoracis (extension/lateral flexion vertebral column, rib rotation) 6. Iliocostalis Thoracis (extension/lateral flexion vertebral column, rib rotation) 7. Semispinalis Thoracis (extends/rotates vertebral column) Sternocleidomastoid Extends & rotates head, flexes vertebral column

8. Spinal Muscles (contd.) • Sternocleidomastoid • Scalenus • Spinalis Cervicis • Spinalis Capitus • Semispinalis Cervicis • Semispinalis Capitus • Splenius Cervicis • Longus Colli Cervicis • Longus Capitus • Rectus Capitus Anterior • Rectus Capitus Lateralis • Iliocostalis Cervicis • Longissimus Cervicis • Longissimus Capitus • Rectus Capitus Posterior Major • Rectus Capitus Posterior Minor • Suboccipital Obliquus Capitus Inferior (inferior oblique) • Obliquus Capitus Superior (superior oblique)

9. Synovium • Synovium Synovium is the name given to the soft tissue lining the cavities of joints, tendon sheaths and bursae. It is like other connective tissue packing, being a mixture of fatty, areolar and fibrous tissue. The surface of synovium is permeable to water, small molecules and proteins, but not to hyaluronan, which is the molecule that makes synovial fluid viscous. This allows synovium to trap synovial fluid within the cavity. Beneath the surface cell layer is a net of small blood vessels, important in the development of synovial inflammation. Joint, tendon sheath and bursal synovium all have the same structure.

10. Synovial Fluid Normal synovial fluid is clear, colorless and noticeably thick and stringy, like egg white. Its viscous and elastic properties are due to hyaluronan, a long chain glycosaminoglycan carbohydrate . Synovial fluid is effectively a liquid connective tissue. Because there are no fibrous components to it, the water and the hyaluronan ground substance move around together within the synovial space, whereas in other tissues water moves and the ground substance stays put. Water diffuses in and out of the synovial cavity more easily than hyaluronan. The amount of water in a joint depends on passive equilibration of plasma with vascular and lymphatic compartments, as for all connective tissue fluid. It goes up and down with exercise and rest. Water can enter the joint rapidly during inflammation but once mixed with hyaluronan cannot leave so rapidly unless the joint ruptures. If joints are stretched suddenly (manipulation), even the fluid does not fill all the space and the lining may jump into the vacuum formed, causing a “CRACK”.

11. Adjustment, Manipulation, Cracking • Joints Cracking • When two parts forming a joint are pulled away from each other, the joint capsule increases in volume but the synovial fluid in the capsule no longer fills it all. Gases dissolved in the fluid quickly fill the empty space causing a sharp cracking sound. The general term for this is cavitation

12. Cavitation • The sudden formation and collapse of low-pressure bubbles in liquids by means of mechanical forces, such as those resulting from rotation of a marine propeller. • The pitting of a solid surface. • Medicine. The formation of cavities in a body tissue or an organ, especially those formed in the lung as a result of tuberculosis.

13. “Crack” - Providers • Practice of spinal manipulation • In the context of healthcare, spinal manipulation is performed by several professional groups. In North America, it is most commonly performed by chiropractors, osteopaths, and physical therapists. • Mechanisms of action and clinical effects • The effects of spinal manipulation have been shown to include: • Temporary relief of musculoskeletal pain. • Shortened time to recover from acute back pain (RAND). • Temporary increase in passive range of motion (ROM). • Physiological effects on the central nervous system, probably at the segmental level. • No alteration of the position of the sacroiliac joint, just better motion.

14. Tendon Sheath & Bursae • Tendon sheaths and bursaeThe synovial lining in these structures is similar to that within joints, with a slippery non-adherent surface allowing movement between planes of tissue. Synovial tendon sheaths line tendons only where they pass through narrow passages or retinacula, as in the palm, at the wrist and around the ankle. Elsewhere the tendon lies in a bed of loose fibrous tissue. Bursae occur at sites of shearing in subcutaneous tissue or between deeper tissues such as muscle groups and fascia. Many bursae develop during growth but new or adventitious bursae can occur at sites of occupational friction.

15. What to look for in a good Chiropractor • Use of adjustment/manipulation as a modality – not a religion! • Realize what we can and cannot do, proper evaluation, diagnostics, treatment method, and RESULTS. • Use better science and use what is there; not philosophical claims = SUBLUXATION. • Care based on symptoms and response. • Use of allied health professionals – refer, should see quick response to care.

16. Good Chiropractor (contd.) • ART provider (Active Release Technique): breaks down adhesions and nerve entrapments. Typically cuts treatment time in half! Finally learn what an adhesion feels like. • Ultimately comes down to “good hands”. • Caring cannot be “faked”. • Rehab and RELEASE !!!!

17. DC vs. MD vs. DO vs. PT - Wilk • "Following a decade of litigation, a federal appellate court judge upheld a ruling by U.S. District Court Judge Susan Getzendanner that the AMA had engaged in a "lengthy, systematic, successful and unlawful boycott" designed to restrict cooperation between MDs and chiropractors in order to eliminate the profession of chiropractic as a competitor in the U.S. health care system.“ • 1976 - 1987

18. Wilk Results • Now ethical to associate or refer to DC’s • The AMA eliminated Principle 3 in 1980 during a major revision of ethical rules (while the Wilk litigation was in progress). Its replacement stated that a physician "shall be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services." Thus, the AMA now permits medical doctors to refer patients to doctors of chiropractic for such manipulative therapy if the medical doctor believes it is in the best interests of the patients. • Ultimately effective or would not have survived AMA, cannot pull the wool over that many eyes!

19. An issue of the past: • Working relationship greatly improved - referrals • Some prejudices remain (well . . . maybe a lot) • Both professions need to do a better job of patient care • Realize your limits and place in patient care • Anatomy of Hope – Dr. Jerome Groopman

20. Ruptured Biceps Femoris

21. Echymosis

22. Some more.

23. Know what this is?

24. Levido Reticularis Reaction to heat!