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  1. 1. ANALELE ŞTIINŢIFICE ALE UNIVERSITĂŢII “AL. I. CUZA” IAŞI Tomul I, s. Biofizică, Fizică medicală şi Fizica mediului 2005 BIOMECHANICS OF VERTEBRAL MANIPULATIONS IN CHRONIC LOW BACK PAIN Laura Marinela Ailioaie1, D.A. Chiran2, C. Ailioaie3 KEYWORDS: law back pain, vertebral manipulation, spine. Chronic low back pain is one of the most common ailments causing disability in the modern society. The aim of the present study applied on 18 patients was to offer an alternative to the preferred treatment for the symptomatic lumbar pain, i.e. the usual surgical decompression, consisting in a special program of lumbar manipulations, in order to reduce painful disk lesions. The patients were randomly divided into two groups. Group I (10 patients) received vertebral manipulations and conventional medication for pain relief. The control group (Group II – 8 patients) was submitted only to classical treatment for chronic low back pain. At the end of this study, 80% of the patients in group I accused no longer low back problems, comparing with only 37.5% of the patients in the control group with a similar outcome. All patients who received vertebral manipulations have clearly improved in terms of both reduced pain and increased functioning. 1. INTRODUCTION Law back pain exists in epidemic proportions almost in the entire world. The costs of this health care problem are enormous. Diagnostic and treatment costs ask for huge amounts[1,2]. Treatment for low back problems is controversial. A large number of patients and practitioners still believe that in the case of intervertebral disk injuries, the surgery approach is the only therapeutic method with a satisfying result[3]. The vast majority of patients have nerve root compression and canal stenosis triggering low back pain. Regarding the lumbar spine, compression can be caused by thickened posterior vertebral elements, facet joints, marginal osteophytes, or soft tissue structures. Little consensus exists among clinicians as to the best forms of treatment. In the scientific literature published up to the present day and which compares the evolution of the patients treated by surgical methods to the patients with conservatory recuperative treatment, the conclusion is that positive evolution results were equal, surprisingly. Recent guidelines published in USA indicate that for the clinical entity of low back problems with duration of less than 3 months, “Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal 1 “Al. I. Cuza” University of Iasi, Faculty of Physics & Laser Clinic, Iasi. 2 “Gr. T. Popa” University of Medicine and Pharmacy Iasi, Faculty of Medicine. 3 Laser Clinic & “Gr. T. Popa” University of Medicine and Pharmacy Iasi, Faculty of Medicine.
  2. 2. LAURA MARINELA AILIOAIE,, D.A. CHIRAN, C. AILOAIE 112 [4] manipulation.” . These findings suggest that most patients with acute low back problems are most appropriately treated within the domain of vertebral manipulations. Certainly, the physical therapists are the best at managing patients with low back pain arising from simple muscular strains and/or mild to moderate ligamentous sprains, but what about the management of patients with lesions of the intervertebral disk? X-rays and, recently, imaging techniques using nuclear magnetic resonance may guide treatment by an excellent characterization of the morphology of the spine and of the other soft tissues[5]. Law back pain results from diminished functions or modified somatic structures (vertebrae, intervertebral disk) and of the lymphatic, conjunctive, vascular and neurological elements associated to it. Vertebral manipulations are applied when the following signs appear: palpable modifications of the soft tissues (tensions, contractions, retractions, indurations, etc.) vertebral misalignments, absent or diminished specific physiologic movement. These three aspects can simultaneously be present in the same injury at the level of the spine. A vertebra with fault position may limit the movement, causes painful tensions, progressive edema indurations of the periarticular tissue, obstacles which disturb the appropriate bone irrigation for the respective spine fragment, which provokes a painful malfunction of the organs innerved by the corresponding nerves. It is important to recognize the types of fill-ins which appear, as well as the vertebral regions where this mechanic stress is localized, which provokes degenerative states at the spine level, with neural consequences. For example, the prolonged flexion of the trunk is the most offensive posture for the spine, which leads to the reduction of the sanguine irrigation, with consequences in the local metabolism (Fig. 1). Fig.1. Circulatory system and the nerve roots for the cord. Different combinations of these vessels and arachnoid’s space can be deformed in different postural loads and pathologic conditions.
  3. 3. 113 BIOMECHANICS OF VERTEBRAL MANIPULATIONS … The vertebrae which are blocked or only limited in their physiologic movements, maladjusted articulations, tensioned ligaments, deeply contracted muscles, lead to loss of the silhouette and to plasticity of the fascia. The retracted fascia hardens, become less permeable to the fluid flow and to the nerve influx. Vessels and nerves have no longer the possibility to accomplish appropriately their specific functions of transportation, of nutrition and defense, and pain appears as result of the affected tissue degeneration. The aim of the present study was to offer an alternative to the preferred medical treatment for the symptomatic lumbar pain, i.e. the usual surgical decompression, consisting in a special program of lumbar manipulations, which are able to immediately reduce painful disk lesions and to provide new guidelines for the conservative management. 2. PATIENTS AND METHODS Study Design In the study were included 18 patients with low back pain, aged 31-57 years (average patient - approximately 45 years old) of both sexes. In order to be included in the study, the patients must not present any of the followings: fever, history of cancer, unexplained weight loss, urinary tract infection, intravenous drug use, saddle anesthesia, or prolonged use of corticosteroids. The patients were randomly divided into two groups. Group I (10 patients) received vertebral manipulations and conventional medication for pain relief. The control group (Group II – 8 patients) was submitted only to classical treatment (including physical therapy and massage) for low back pain. Specific aspects of the examination, history, imaging, and treatment of patients with intervertebral disk lesions for conservative management were applied. In order to produce an appropriate treatment regimen for any suffering patient it is important to exactly identify the source of the patient's complaints and the mechanism of the injury or affliction. A prerequisite for the genesis of pain-producing impulses is the presence of pain-sensitive nerve endings (nociceptors) within a particular tissue. 77.7% of the patients have suffered two or more years with pain problems before the present treatment. Most had already tried a number of different medical and alternative therapies without success. At the time they were included in the study, patients estimated their pain intensity at the average value 6 out of 10 on a Visual Analogue Scale (VAS) (0 = no pain; 10 = worst pain presumable). The patients received 36 sessions of multidisciplinary treatment by vertebral manipulations over 3 months. Vertebral manipulation encompasses many different techniques, categorized as one of two types: nonspecific long-lever manipulations and specific, short-lever, high-velocity vertebral adjustments. The first use the femur, shoulder, head, or pelvis to manipulate the spine in a nonspecific manner; whereas short-lever spinal adjustments use a specific contact point on a process of a vertebra to affect a specific vertebral joint.
  4. 4. LAURA MARINELA AILIOAIE,, D.A. CHIRAN, C. AILOAIE 114 Protocol of Lumbar Manipulations An adequate treatment is recommended to permit the misaligned fasciae to find their point of equilibrium. The triad of vertebral manipulation is made of vertebral palpation, massage and proper osteobiomechanic treatment of the vertebrae. The methods included in our protocol of lumbar manipulation, in order to treat low-back pain are presented in Fig. 2 – Fig.13. Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 13 Transversal pushing from left to right (Fig.2) and from right to left (Fig.3), energetic, are using the thumb on the spine apophasis of the 5th law back vertebra and orthogonal on this one to the D1 level. In case of malfunction, the subject will feel an acute pain. This simple method informs us, in an authentic and certain manner, about the existence or non-existence of a vertebral pain in rotation. The appreciation at the
  5. 5. 115 BIOMECHANICS OF VERTEBRAL MANIPULATIONS … law back level of the vertebra tendency to flow upwards and backwards is presented in Fig.4. The vertebral assembly, being separate from the posterior arrow, will suffer abnormal constructions upward and backward, which are translated by ligament sufferance. Direct manipulation of L5 vertebra maneuver is presented in Fig.5. The patient opposes a different force from that applied by the physical therapist to the law back part. The same procedure for the superior vertebrae of law back is presented in Fig.6. Direct technique from sitting position: the patient opposes a resistance force in an opposed direction from that applied by the physical therapist (Fig.7). The direct technique from sitting position, with neutral fixation of the law back by the physical therapist, while the patient opposes a counter force of that one indicated by the arrows, is presented in Fig.8. The same technique using a couple of forces, while the patient opposes forces different from those applied by the practitioner is presented in Fig.9. The miotensive indirect technique is presented in Fig.10; the localization is obtained because of the active counter-resistance from the physical therapist’s hand at the law back level; the muscular tension of the subject is opposite to the physical therapist’s hand, situated under the patient’s knee. For the next vertebral manipulation, the patient lies in lateral decubit. The physical therapist holds the inferior member by the ankle and rubs the tight with an easy internal rotation. This determines an isometric labor through the stimulation of the transverses, of the abdominal oblique muscles and of the psoas muscle. The most attentive dose of the resistance prevents the participation of the inferior member muscles. The impact is between L1-L5, depending on the dose of the force appropriate to the internal rotation of the inferior member of the subject (Fig. 11). The next procedure is the indirect technique from the inferior member with rubbed knee. The inferior members of the subject remain in contact with each other. The physical therapist lays a hand on the tight of the subject at 15 cm above the knee. The other hand fixes the law back to avoid the imbalance. The subject makes an abduction through isometric contraction against the resistance imposed by the physical therapist (Fig.12). The stimulation of all vertebral levels is achieved as follows: the patient sits on the edge of the table, laying the back against the practitioner’s thoraces. In a perfect status of relaxation, the subject lays his head freely on the shoulder of the practitioner. The system as a whole effectuates round movements lead by the therapist, firstly in one direction, and then in the other (Fig.13). 3. RESULTS AND DISCUSSIONS The study demonstrated that the most common low back pain—producing tissue was the annulus fibrosis, and the most common sciatica-producing tissue was an injured nerve root. Flexion, specifically prolonged flexion, is bad for the spine, especially in pathologic conditions. The patients’ outcome in group I with vertebral manipulations versus “conventional” medical treatment (shortwave diathermy, pelvic tilt exercises, proper lifting mechanics education, massage and anti-inflammatory drugs), demonstrate good or excellent outcomes for this conservative method. On average, at the end of the study, patients from group I rated their pain intensity at 1.8 out of 10 on the VAS, comparatively with a score of only 4.5 out of 10 on the VAS, for the control group (Fig.14).
  6. 6. LAURA MARINELA AILIOAIE,, D.A. CHIRAN, C. AILOAIE 116 The results proved a clear and meaningful decrease in self-perceived pain intensity for the first group. Nearly all patients in Group I have obtained significant improvement in their symptoms and a majority of 80% of the patients no longer accused low back problems by the end of their treatment, comparatively with only 37.5 of the patients in the control group with a similar outcome (Fig.15). The remainders have shown little or no clear improvement. 10 100 8 80 6 60 4 % 40 2 20 0 0 Group I Group II (control) Group I Group II (control) Fig. 14. Average Rated Pain on VAS Fig. 15. Percentage of Patients Who (Scale: 0 – 10) at the End of the Study. No Longer Accused Low Back Problems at the End of the Study. The pathologic changes in the spinal cord are ascribed to decreased function created by tension resulting from altered alignment. Once this process occurs, it may set up a positive feedback loop. Prolonged loading of the neural tissue may result in impaired oxidative metabolism in the mitochondria. The stresses and strains may cause longitudinal progressive cellular disruption and degeneration. The above mentioned program of vertebral manipulations could lead to symptomatic improvement or resolution of the low back problems, for an anatomic outcome and improved posture. 4. CONCLUSIONS Among the conservatory treatments, vertebral manipulations are clinically efficient, reduced as costs and with satisfying effects for the patient. REFERENCES 1. A.L. Nachemson, Clin Orthop, 279: 8–20, 1992. 2. RA. Deyo, D. Cherkin, D. Conrad, E.Volinn, Annu Rev Public Health, 12: 141–56, 1991. 3. E. Volinn, J. Mayer, P. Diehr, D. Van Koevering, F.A. Connell, J.D. Loeser, Spine, 17: 575–81, 1992. 4. S. Bigos, O. Bowyer, G. Braen, K. Brown, R. Deyo, S. Haldeman, Clinical practice guideline No. 14. AHCPR Publication No. 95-0642. Rockville (MD): Dept. of Health and Human Services (US), Agency for Health Care Policy and Research, Public Health Service; 1994. 5. L.M. Ailioaie, C. Ailioaie, Biofizica locomotiei umane, Ed. Vasiliana ’98, Iaşi, 2000.