Archive for the ‘Manipulation in Improving Motion and Joint Health ~Review of Medical literature’ Category

Manipulation in Improving Motion and Joint Health ~Review of Medical literature

March 17, 2010

In recent years, numerous studies have confirmed the essential role of manipulation and motion in the maintenance of disc health, joint lubrication (synovial fluid), and articular cartilage nutrition.

Increasingly, researchers have concluded: that impaired joint mobility (fixated/stuck joints/joint restriction), which alters the joint lubrication mechanism, may be the principal mechanism in spinal degeneration.

Image 1-Excess scar tissue with no motion(stuck joint) #2 shows joint motion=Healthy joint tissue

What is its aim? To normalize a “bind” or resistance to motion which is interfering with normal function.

Dr. Karl Lewitt, M.D., (who wrote “Physical Medicine”) calls these dysfunctional/stuck/fixated joints “Segmental Dysfunctions”.

This “bind” is what Sandoz called the “pathological barrier”.

The joints of the body do not have a blood supply (avascular), which leaves them dependent on movement.

The current information suggests a valuable role in joint manipulation in preserving the joint lubrication abilities and enhancing the removal of waste products in these vulnerable, avascular structures.

In 1995, Buckwalter, MD (1) concluded based on his research, that intervertebral discs undergo age-related degenerative changes.

The most important cause appears to be declining joint nutrition and lubrication of the central disc, which allows an accumulation of cell waste products, degraded matrix molecules, and a fall in pH.

He noted that the factors, which may increase the rate and severity of declining changes by altering joint nutrition  include:   immobilization, sustained disc loading, vibration and spinal deformity.

Buckwalter’s findings echo the conclusions of a 1993 paper by Holm, PhD (2) in which a summary illustration noted that discs have an uneven distribution of the few cells they contain and that these cells are subjected to much metabolic variation.

This makes discs/joints susceptible to lubrication/nutrition deficiencies. This is worsened by:   a lack of motion, instability, calcification of end plates of the vertebrate, solute shortage, and smoking.  All of which can result in molecular breakdown, increased degeneration enzyme activity, instability, and cell death.

What we know today is that movement of the vertebral motion segments is essential for joint health and lubrication. Passive diffusion, driven by pressure gradients across semi-permeable membranes, is insufficient to maintain the nutritional needs of the joints and vertebral discs.

As Kraemer, MD (3) concluded: -the continual alteration between loading and unloading promotes the cleansing mechanism of the disc. Unchanging long-term posture leads to an interruption of the pressure dependent transfer of joint fluid. The spinal disc and joints of the body lives because of movement.

Current concepts concerning the central role of motion and joint nutrition in reducing spinal degeneration were derived from compelling studies published in the 1980’s by internationally renowned researchers investigating the relationship between movement and disc function.

In a study by Holm, PhD and Nachemson, M.D. (4) (I Kevin Parker, D.C. do not approve of this type of study…but it was a study…so here we go) the authors performed posterior fusions covering three spinal discs in dogs. This procedure preserves normal disc height and permits passive diffusion but prevents fluid flow; that is, pressure dependent transfer of fluid, and creep deformation.

At, 3, 5, 8 months after fusion the dogs were sacrificed. The discs included within the fusion exhibited a decrease utilization of energy, glucose, and oxygen as compared to adjacent discs.

In addition, the discs within the area of fusion also had decreased water content, metabolic and cellular activity. Increased enzymatic degradation and cell death was also reported. The authors concluded that the metabolic hypoacidity might predispose the disc to degeneration due to decreased supply of cellular joint nutritional requirements.

Another study published also by Holm, PhD and Nachemson, MD (5) found that if dogs exercised a half hour a day for a period of three months, their discs exhibited increased synthesis of proteoglycans, increased transport rate of large molecules into the disc matrix, increased uptake of glucose, oxygen and glycogen, and increased aerobic metabolism.

Overall, these findings indicated that “the spine should be subjected to adequate motion and exercise to ensure adequate supply to the joints and discs. Prolonged bed rest and/ or traction has a proven deleterious effect. “

Motion, with its accompanying fluid flow and variations in creep deformation, were necessary to preserve the nutritional status of discs and joints.

These studies are consistent with a larger body of evidence that has evaluated the clinical effects of bed rest and immobility, both of which have been universally and thoroughly discredited as effective methods of treatment for both back and neck problems.

Waddell, MD noted in 1987 (6) that there is a loss of 3% muscle strength per day with complete bed rest.

The 1994 AHCPR guidelines on Acute Low Back Problems in Adults (7) warned about the potential complications of bed rest including a 1.0% to 1.5% loss of l muscle mass per day, as well as a 15% loss of aerobic capacity in 10 days.

The very recently revised and released 1996 British guidelines (8) summarize the literature on bed rest, noting that there are now 9 randomized controlled studies on bed rest, and their findings confirm that bed rest is counter-productive.

Similarly, the Quebec Task Force on Whiplash Associated Disorders (9) confirmed that prolonged use of cervical collars probably prolongs disability.

Today it is understood that motion plays a critical role in maintaining tissue and joint lubrication/nutrition for both discs and joint articular cartilage.

We know that articular cartilage receives its nutrition through the circulation of synovial fluid, which is a filtrate derived from blood vessels within the synovial membrane.

In addition, the synovial membrane also contains lymphatic ducts, which provide the pathway for the removal of waste products out of the synovial fluid and the joint space.

What is essential to recognize is that the synovial fluid has absolutely no inherent capacity to circulate….there is no heart forcefully pumping synovial fluid to the joints. Its movement through the joint space is dependent on movement and changes in intra-articular pressure.

Other good articles:

Chiropractic Manipulation and Rehab

The Science of Spine and Joint Health

Continuous Passive Motion (CPM)-Motion Assisted Adjusting-Leander Technique

An excellent review article by Levick, a professor of physiology, noted in the fall of 1996 (10) that: “Movement alters intra-articular pressure (IAP) which is subatmospheric in extension. Acute flexion can raise IAP just over atmospheric pressure. There is trans-synovial flow into the joint cavity when IAP is subatmospheric and a flow out when supra-atmospheric.

So changes in joint angle generate a turnover of synovial fluid. Active motion can cause marked changes in IAP.

When a joint is immobilized cartilage slowly degenerates. One cause is the lack of mechanical stimulation to chondrocytes.

Also, transport of solutes from blood to central cartilage is unduly slow in an immobilized joint and is greatly speeded by joint movement.

Glucose diffusion is too slow to sustain normal chondrocyte metabolism in a large immobilized joint. The nutritional benefit of joint movement arises because movement stirs synovial fluid and so washes nutrients through the joint space. ”

In 1995 Twomey, PhD and Taylor, MD, PhD (11) reviewed the current literature on movement and its impact on joint articular cartilage and disc nutrition/lubrication.

They concluded that discs and facet joints require movement to ensure the proper flow of fluid and nutrients across and through joint surfaces. Disc nutrition is very dependent on movement.

Exercise and joint movement ensures the passage of synovial fluid over articular cartilage, enabling it to be expressed and “sucked back” into cartilage.

Nelson, D.C. (12) in an excellent review article in 1994 concluded that in cartilage, intermittent loading facilitates fluid transfer between cartilage and synovial fluid. Motion under load results in a diffusion rate, which are 3X to 4X control levels. Immobilization leads to degradive changes within 1 week and may become permanent if prolonged.

Clearly, there is an abundance of current studies that indicate maintenance of joint movement is essential in preserving the nutritional and lubrication needs of intervertebral discs and articular cartilage.

Of course, this evidence fits very nicely with the methods, purpose and philosophy of chiropractic care. Many chiropractic clinicians believe our job is restore and maintain normal range of motion, symmetry of motion, biomechanics, load distribution, proprioception and motor programs by the use of spinal and joint manipulations.

The controlled input of specific, high acceleration forces may overcome abnormal restrictive barriers in or around joints that are confirming or limiting its normal range of motion, thereby restoring movement and the fluid flow and circulation of synovial fluid necessary for safeguarding adequate joint articular nutrition and joint health.

There are numerous studies documenting that chiropractic can, indeed, improve symmetry and range-of-motion. Nansel, PhD (13,14,15) for example, documented increases in both symmetry and range of motion in the cervical spine using chiropractic manipulation in a series of studies.

Very recently, in 1996, the RAND study (16) concluded that the published research “provides evidence that manipulation of the spine increases range of motion and intersegmental mobility.”

Doctors of Chiropractic, Osteopaths, M.D.’s, P.T.’s  that perform spinal and joint manipulations have witnessed these positive outcomes clinically with their patients for 100 years in the United States.

Asian and European countries have also seen these positive outcomes for thousands of years.

We must not rely only on the outcomes of our clinical findings, but also on other sources of information like the types of studies reviewed in this article, which support the fundamental chiropractic principles of restoring and maintaining joint motion, optimal function and health.

These concepts are inherently appealing and communicate very well to patients wishing to improve their quality of life and well-being that we offer a unique, natural and holistic approach which encourages and nourishes the body’s own innate capacity for optimal health.

References:

1. Buckwalter, Spine 1995; 20(11):1307-14

2. Holm. Acta Orthop Scand (suppl 25) 1993;64:13-15

3. Kraemer. Spine 1985; 10(1):69-71

4. Holm, Nachemson. Clin Ortho Rel Res 1982; 169:243-258

5. Holm, Nachemson. Spine 1983;8(8): 866-873

6. Waddell. Spine 1987; 12(7):632-644

7. Bigos, et al. Acute Low Back Problems in Adults. Clinical Practice Guidelines. December 1994: 53

8. Waddell, et al. Clinical guidelines for the management of acute low back pain. Royal College of General Practioners 1996

9. Spitzer, er al. Quebec Task Force on Whiplash-associated Disorders 1995;20(8S):1S-73S

10. Levick. Science and Medicine;Sept/Oct: 52-61

11. Twomey, Taylor. Spine 1995; 20(5):615-619

12. Nelson. Top Clinc Chiro 1994;1(4):20-29

13. Nansel, et al. JMPT (Journal of Manual and Physical Therapeutics) 1989;12(6):419-27

14. Nansel, et al. JMPT 1991;14(8):450-456

15. Nansel, et al. JMPT 1990;13(6):297-304

16. Coulter, et al. The Appropriateness of Manipulation of the Cerical Spine. RAND; 1996:32

——————————————————————————–

Chiropractic: suggests that the altered mechanoreceptive afferent driven motor mismatch can be corrected by the firing of the mechanoreceptors of the facet joint capsules which are activated by means of a chiropractic adjustment. (1)

Chiropractic spinal adjustments have proven to be more effective in treating chronic spinal pain when compared to medication, exercise, and needle acupuncture (2,3,4,5,6,7,8,9).

1. Indahl A, Kaigle AM, Reikeras O et al (1997) Interaction between the porcine lumbar intervertebral disc, zygapophysial joints, and paraspinal muscles. Spine 22:2834–2840

2. WH Kirkaldy-Willis and JD Cassidy, Spinal manipulation in the treatment of low back pain, Canadian Family Physician, Vol. 31, March 1985, pp536-40.

3. TW Meade, S Dyer, W Browne, J Townsend, AO Frank. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal, June 2, 1990;300: 1431-7.

4. The Lancet, Chiropractors and low back pain, July 28, 1990, p. 220.

5. TW Meade, S Dyer, W Browne, AO Frank. Randomised comparison of chiropractic for low back pain: results from extended follow up. British Medical Journal, August 5, 1995;311: 349-51.

6. Woodward MN, Cook JC, Gargan MF, Bannister GC. Chiropractic treatment of chronic ‘whiplash’ injuries. Injury. 1996 Nov;27(9):643-5.

7. S Khan, J Cook, M Gargan, G Bannister. A symptomatic classification of whiplash injury and the implications for treatment. Journal of Orthopaedic Medicine 21(1) 1999:22-5.

8. Lynton GF Giles and Reinhold Muller, Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation, Spine, July 15, 2003; 28(14): 1490-1502

9. Reinhold Muller, PhD, Lynton G.F. Giles, DC, PhD, Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes, Journal of Manipulative and Physiological Therapeutics, January 2005, Vol. 28, No. 1.

 

 

Advertisements