Scan of the Front Cover

INTRODUCTION — EXPLANATION

This started out to be a book on the Natural Therapeutics in the United States; We were going to give you a history of this drugless and natural therapy… However when we received our permission to quote Dr. Downing’s book, we had to forget the history of Natural Therapeutics for some other time. This work was too important, it ranked first with us. We trust that you too will derive much benefit from Dr. Downing’s teaching.

Massage and bone-setting have existed among the peoples of the Earth, in one form or another since time immemorial. The Chinese, The Egyptians, The Hindus, The Greeks and Romans and the Europe people too followed in some form this method, Germany, Sweden, Bohemia etc. In 1813 Peter Hendrik Ling founded the Central Gymnastic State Institution, from which we have our Swedish Massage. In 1874 Dr. Andrew Tyler Still gave to the world his science of Osteopathy. He was a student of nature, he decided that God who made man, had placed in his body everything, necessary for Health, that drugs were superfluous. In November of 1892 he opened The American School of Osteopathy. "Osteopathy is a system of mechanical treatment designed to release impingement on vessels, the theory being, that disease manifestations are caused by pressure obstructing normal blood flow. Still's own words are “In no case can the disease begin without a broken or suspended current of arterial blood, which by nature was intended to supply and nourish all nerves, ligaments, muscles, skin, bones and artery itself. The rule of the artery must be absolute, universal, and unobstructive, or disease will be the result. All nerves depend wholly on the arterial system for their qualities such as sensation, nutrition and motion, even though by the law of reciprocity they furnish force, nutrition and motion to the artery itself."

Chiropractic was given to the world by Daniel David Palmer in the year 1895, at Davenport, Iowa, where the Fountain Head School is still located there. Because this book will be in the hands of Chiropractors, we will not devote much space to this science.

Naprapathy is the brain child of Oakley Smith of Chicago, Ill. this term is derived from the Bohemian word “Napravit” which means to mend, to repair, to correct. This is a system of manual manipulation done with the hands, a system of mechanical treatment directed to the spinal area for the purpose of stretching tense tight ligaments, the theory being, that disease manifestations are caused by pressure on nerves exerted by shrunken ligaments called ligatites. This system of manipulation was given to the world in 1905... The school still exists in Chicago.

There are other manipulative professions, such as Mechano-therapy, Zone Therapy, Neuropathy, and others that we know nothing about.


SIMPLIFIED SPINAL TECHNIQUE

by

Dr. C. Harrison Downing, Prof.

Osteopathic Technique.

THE MASSACHUSETTS COLLEGE OSTEOPATHY

Here -Table of Contents

Chapter 1. Introduction

Osteopathy -- Definition--Structure and Function-- Significance of Structure in regard to Disease -- The Cell in Disease – The Osteopathic Lesion -- The Circulation -- The Nervous System -- Heads Law -- Hilton's Law -- Causes of Disease -- The Germ Theory -- A.T. Still's Achievements and Contributions to Medicine.

Chapter 2. The Osteopathic Spinal Lesion

Causes -- Pathology of the Spinal Lesion -- Effects of Lesions upon the Vascular System -- Effects of Lesions upon the Nervous System -- Symptoms and Diagnosis of Spinal Lesions-- Obstacles to Overcome in the Correction of Lesions -- Principles of Technic Diagnosis -- Visualization and Analysis of Lesion -- Normalization of Soft Tissue -- Principles of Osseous Adjustment -- Direct Action Technic -- Indirect Action Technic -- Bony Landmarks of the Normal Spine...

Chapter 3. Lesions of Occipito-Atlantal Articulation

Anatomy of Occipito-Atlantal Articulation -- Lesions of the Occipito Bono -- The Bilaterally Anterior Occiput -- The Unilaterally Anterior Occiput The Bilaterally Posterior Occiput – The Unilaterally Posterior Occiput -- The Lateral Occiput -- The Impacted Occiput.

Chapter 4. Lesions of the Cervical Vertebrae

Anatomy of the Atlanto-Axial Articulation -- Lesions of the Atlanto-Axial Articulation -- The Rotation Lesion of the Atlas -Cervical Lesions from Second to Seventh -- Anatomy of Cervical Vertebrae – Normal Movements of Cervical Spine -- Flexion of the Cervical Vertebrae -- Extension of the Cervical Vertebrae - Lesions of the Cervical Column -- Etiology of Cervical Lesions -- The Rotation-Sidebending Lesion-- Torsion Lesions -- Directly Literal Lesions.

Chapter 5. Lesions of the Thoracic Vertebrae

Anatomy of the Thoracic Vertebrae -- Normal Movements of the Thoracic Column -- Lesions of the thoracic Vertebrae -- The Flexion lesion -- Bilaterally Anterior Lesion -- The Extension Lesion Bilaterally Posterior Lesion -- Group Extension Lesions -- The

Side bending Lesion--- The Rotation Lesion Differentiation Rotation and Sidebending Lesion..

Chapter 6. Lesions of the Lumbar Vertebrae

Anatomy of the Lumbar Vertebrae -- Movements -- Flexion -- Ex-tension -- Sidebending of the Lumbar Vertebrae -- Rotation -Lesions of the Lumbar Vertebrae -- Flexion Lesion -- Sidebending Lesion -- Rotation Lesion -- Rotation and Sidebending Lesion.

Chapter 7. Lesions of the Sacroiliac Joint

Anatomy of the Sacroiliac Articulation,---Lesions of the Sacroiliac Articulation,---The Bilaterally Anterior Sacrum---The Bilaterally Posterior Sacrum---The Unilaterally Anterior Sacrum--The Unilateral Posterior Sacrum---The Twisted Pelvis---The Posterior Innominate—The Anterior Innominate.

Chapter 8. Lesions of the Ribs

Articulation of the Ribs—Movements of the Ribs—Pump Handle Movement—Bucket Handle Movement---Combines Bucket Handle and Pump Handle Movement--- Vertebro-Sternal Ribs --- Vertebro-Chondral Ribs --- Vertebral Ribs --- Muscles of Respiration --- Lesions of Bibs --- Pump Handle Lesions (Elevated) --- Pump Handle Lesions (Depressed) --- Lesions of Second to Sixth Rib --- Lesions of Seventh to Tenth Ribs --- Lesions of Eleventh and Twelfth Ribs --- Inspiration Bucket Handle Lesion, -- Expiration Pump Handle Lesion,---Combined Pump and Bucket Handle Lesion --- Forced Inspirational Lesions of First and Second Ribs ---Inspirational Combined Bucket and Pump Handle Lesion --- Inspirational Combined Bucket and Pump Handle Lesion --- Expirational Bucket Handle Lesion --- Inspirational Pump Handle Lesion---Lesions of Seventh, Eighth, Ninth, Tenth Rib --- Lesions Of the Eleventh and Twelfth Ribs --- Flat Dorsal --- Dome Diaphragm.


Contents

INTRODUCTION.. 5

THE OSTEOPATHIC SPINAL LESION. 9

CAUSES:- 9

PATHOLOGY: 9

(A) Gross changes: 9

(B) Microscopic Changes: 10

Effects of Lesion upon the Vascular System: 10

Effects of Lesions upon the Nervous System: 10

Reflexes worthy of mention are:- 10

SYMPTOMS AND DIAGNOSIS OF SPINAL LESIONS. 11

Obstacles to overcome in the correction of a lesion: 11

The Principles of Technique: 12

The principles of osseous adjustment are as follows:- 13

Osseous Technique may be divided into two general classes:- 13

BONY LANDMARKS OF THE NORMAL SPINE: 14

Thoracic Region: 14

Lumbar Region: 14

OCCIPITO-ATLANTAL LESIONS. 15

LESIONS OF THE OCCIPUT: 15

Bilaterally Anterior Occiput 16

THE UNILATERAL ANTERIOR OCCIPUT. 17

BILATERALLY POSTERIOR OCCIPUT. 17

UNILATERALLY POSTERIOR OCCIPUT. 18

THE LATERAL OCCIPUT. 18

IMPACTED OCCIPUT. 19

CERVICAL LESIONS. 20

The Common Lesions of this Joint are:- 20

The Lateral Atlas: 21

Lesions (Lateral Occiput to the right...Lateral Atlas to the right). 21

THE FLEXION LESION. 22

CERVICAL LESIONS FROM THE SECOND TO THE SEVENTH INCLUSIVE. 22

LESIONS OF THE THORACIC VERTEBRAE. 27

Lesions of the Thoracic Vertebrae: 27

THE FLEXION LESION syn. BILATERALLY ANTERIOR LESION. 28

THE EXTENSION LESION syn. BILATERALLY POSTERIOR. 28

Differential Diagnosis: 30

SACRO-ILIAC LESIONS. 32

Lesions of the Sacro Iliac Articulation: 32

THE BILATERALLY ANTERIOR SACRUM (Synonym, BILATERALLY POSTERIOR INNOMINATE.) 33

THE BILATERALLY POSTERIOR SACRUM (Synonym: BILATERALLY ANTERIOR IN-NOMINATE.) 34

THE BILATERALLY POSTERIOR SACRUM (Synonym: BILATERALLY POSTERIOR IN-NOMINATE.) 34

THE UNILATERALLY POSTERIOR SACRUM (Synonym: UNILATERALLY ANTERIOR IN-NOMINATE.) 36

THE TWISTED PELVIS PROPER. Syn. TRUE TWISTED PELVIS. 37

Technic. (Anterior Innominate and Fifth Lumbar.) 37

Technic for Posterior of Anterior Innominate: 37

RIB LESIONS. 38

LESIONS OF THE RIBS. 39

LESIONS OF THE LUMBAR VERTEBRAE. 43

Lesions: 44

THE FLEXION LESION: Bilaterally Posterior Lumbar. 44

THE EXTENSION LESION: Bilaterally Anterior Lumbar 45

SIDEBENDING ROTATION LESION: 46


CHAPTER 1

INTRODUCTION

OSTEOPATHY---Osteopathy is a philosophy of medicine (healing) having a cm-plate system of therapeutics, basing its treatment of all abnormal conditions of the body on the natural laws and vital principles governing life: namely the adjustment of all of these vital forces of the body whether physical, chemical or mental, in as far as we have knowledge thereof ... (C. H. Downing)

Osteopathy is the name of that system of the healing art which places chief emphasis on the structural integrity of the body mechanism as being the most important single factor in the maintenance of the wellbeing of the organism in health or disease … (Dr. Atzen)

Mason W. Pressley, AB., PhD., D.O., defines Osteopathy as---"That science which consists of such exact, exhaustive and verifiable knowledge of the structure and function of the human mechanism, anatomically, physiologically and psychologically, including the chemistry and physics of its known elements, as has been made discoverable certain organic laws and remedial resources within the body itself by which nature) under the scientific treatment peculiar to Osteopathic practice apart from all ordinary methods of extraneous, artificial or medicinal stimulation and in harmonious accord with its own mechanical principles, molecular activities and metabolic processes, may recover from displacements, disorganizations, derangements and consequent disease and regain its normal equilibrium of form and function in health and strength.

STRUCTURE AND FUNCTION---All living matter is subject to the "LAW of CHANGE." As represented in man, evolution should be taken as adaptational or environmental, the effort of the body to maintain its highest efficiency. Consequently the normal of an individual is variable multi-D subject to change. Nomality is never twice alike. The relationship between structure and function is never constant, Both develop coordinately, one interdependent upon the other, and this same interdependence holds true throughout every manifestation of life, throughout all its changes, whether in health or disease and regardless of the plane affected, whether physical mental or chemical.

Therefore, the integrity of one is always dependent upon the integrity of the other. There cannot be a change or perversion of function without a corresponding change of structure, whether it be within or beyond the limits of what is broadly considered normality, and vice versa, we cannot have a disturbed or perverted structure without a corresponding effect upon function,

SIGNIFICANCE OF STRUCTURE IN REGARD TO DISEASE—Hulett says, "Function is infinitely self-regulative,"…that structure is a part which is less immediately and less completely subject to vital control…the more inert tissues such as bone, ligament, cartilage and other connecting structures. Hence, where a disorder is maintained, we assert from reason and observation, that the structural condition is the factor that prevents a return to normal functioning.

The unhampered tendencies of the body are always toward the normal in health and disease. All reactions of the body whether constructive or destructive have that ultimate end in view. The logical conclusion, therefore, must be, that perverted structure is the greatest preventative to a return to normal in disease, if all external causes leading to a perversion of function are eliminated.

THE CELL IN DISEASE—The human cell is a nucleated, circumscribed mass of protoplasm capable of assimilation, growth and reproduction. It is the albuminous material basis of life. Cells collectively form tissue; tissue, organs and organs, systems. Each cell has it particular function. "The cell cannot of itself cause disease either in itself or in its neighbour. It is inherently healthy and a disturbance in its metabolism is due to impairment if its blood, lymph, nerve or protoplasmic continuity." (Hulett) This is fundamentally true.

A disordered cell shows four primary disturbances. They are:

(1) Cellular irritability. (2) Metabolism. (3) Structure. (4) Special function. Irritability may be increased or decreased and the stimulus may be thermal, mechanical, chemical, electrical or nervous. Primarily, irritability is increased, secondarily decreased, that due to the fact that potential energy is diminished within the cell beyond a point of response.

Metabolism is influenced in that catabolism is greatly increased and is consonant with increased irritability. It is likewise decreased only when potential energy is lost or diminished beyond a point of response.

The special function of a cell is the expenditure of kinetic energy and is dependent upon potential energy (therefore, the same rule). The cell as a defensive organism is of the greatest importance. For example: in bacterial infection we have a poisonous toxin produced. This acts as a chemical irritant or stimulus to the cell. Irritability is increased and catabolism immediately follows in the form of antibodies or anti-toxins. The cell in order to maintain its own individual life must fight for it. To carry this out with the highest efficiency there must be like efficiency on the part of the circulation and nerve supply, unless the cell has been the recipient of direct injury and then it cannot perform its function. For only throughout these factors can the material necessary to the anabolism of the cell be obtained, or substances be manufactured to carry on the increase of function, demanded in the way of defense, namely the formation of antibodies and anti-toxins. lie can, therefore, logically state: First....faulty metabolism on the part of a cell begins when that cell does not functionate in the manner or extent intended by nature. Second....this is due to a lack of potential energy caused by a deficient circulation or nerve supply, thereby lessening the cells resources, or else due to direct injury to the cell.

THE OSTEOPATHIC LESION---The Osteopathic Lesion is any structural disturbance with consequent functional deflection. The effects produced by lesions are by direct pressure or by tension with secondary pressure. The structures involved by this pressure are arteries, veins, lymph channels, nerves and adjacent structures. The more adynamic or static the structure affected, the lower the power or self adjustment. The blood vessels and nerves are highly self adjustive. The severity of the symptoms from a lesion may depend more upon the length of time involved than the amount of structural defect. Moreover, the nature rather than the amount of structural perversion will determine the prognosis. This is due to the greater vital significance of certain tissues and the extent of Nature's adaptational efforts. A lesion may be Primary or Secondary. A primary lesion is one directly incident to the cause, i.e. trauma. A secondary lesion is one dependent on a previous existing lesion. This may be adaptational, i.e. the hypertrophied heart in valvular diseases. The spinal lesion, when secondary, is produced by the great medium of nerve reflex and may exist to a variable extent after the causative factor or primary lesion has disappeared. Secondary lesions may be counterbalancing, Major lesion is the term applied to the lesion causing the greatest functional disturbance. A Minor Lesion is one causing a lessor disturbance. Minor lesions are often reflex from major lesions.

Osteopathic Lesions (Spinal) are usually bony sublucations with ligamentous tension or shortening and tension or contracture. By impingement-lesion effect the circulation particularly at certain segments of the spinal cord. The result is either passive hyperemia (drainage effected) or anemia (arterial impingement) with ultimate nutritional disturbances and impoverishment of nerve supply.

Lesions may be classified as: (1) Positional - in the form of subluxations, dislocations, displacements. (2) Gross anatomical - in the form of contractures, atonicities, hypertrophies, hyperplasms, atrophies, fatty infiltration; tumore, etc. (3) Microscopic Pathological - in the fun of parenchymatous, fatty, colloid, albuminous, mucoid, hyaline and other cellular degenerations.

THE CIRCULATION --- Dr. Still stated in 1874, "A disturbed artery marks the time to an hour and minute when disease begins to sow its seeds of destruction in the human body." "That in no case could it be done without a broken or suspended current of arterial blood which by nature, is intended to nourish and supply all nerves, ligaments, muscles, skin, bones and the artery itself. The rule of the artery must be absolute, universal and unobstructed or disease will be the result. All nerves depend wholly upon the arterial system for their qualities such as nutrition, sensation and motion, even though by the law of reciprocity they furnish force, nutrition and senation for the artery itself."

The artery carries nutritional substances and oxygen to the tissues. Impingement will result in anemia and deficient oxidation. Internal respiration depends upon partial pressure between carbon dioxide in the tissues and oxygen in the arterial blood, and any circulatory interference will effect this function. Upon lymph fall directly the nutrition and drainage of the cell. The venous function is that of drainage. Interference will cause passive hyperaemia and storing up in the tissues of catabolic products. The vein is more easily compressible than the artery on account of its thinner and more flaccid wall.

THE NERVOUS SYSTEM---Reflexes are of extreme importance to the Osteopath. The reflex arc acts as probably the greatest cause of the Osteopathic spinal lesion; and moreover, its field is unlimited.

The vaso motor system deserves special mention, treatment of which, by Osteopathic means, does most to regulate and coordinate the distribution of the blood. Physiologists have demonstrated the fact that there are both constrictor and dilator nerves. However, the Osteopathic Physician confines his efforts to the constrictors, considering the dilators as vaso constrictor paralysis. The secretory augmenters and inhibitor nerves depend partially for efficient functioning upon cooperative efforts of the vase motors.

Two important basic laws worthy of mention are: HEAD’s LAW: "When a painful stimuli is applied to a part of low sensibility in close central connection with a part of much greater sensibility; the pain produced is felt in the part of higher sensibility rather than in the part of lower sensibility to which the stimuli was actually applied."
HILTON IS LAW: "A nerve trunk which supplies the muscles of any given joint also supplies the muscles which move the joint and the skin over the insertion of such muscles."

Inhibition and stimulation in the vast majority of conditions can be obtained only directly. Hulett very concisely expresses it as follows: "(1) The necessity for stimulation presupposes an existing inhibition, the removal of the cause of that existing inhibition constitutes the legitimate method of stimulation.
(2) The necessity for inhibition presupposes an existing stimulation; the removal of the cause of that existing stimulation constitutes the legitimate method of inhibition."

With but few exceptions we can state that the physicians should treat the lesion and let stimulation or inhibition take its own course. "Find it ....fix it... .and leave it alone." (A. T. Still)

Exceptions are sometimes met with in which stimulation or inhibition may be directly employed with very beneficial and profitable results.

CAUSES OF DISEASE—They may be (1) Physical (2) Chemical (3) Psychical. All causes must be primarily external and secondarily internal. External causes are: Environmental or abuse of function. Chemically may be: dietary, ingestion of drugs, alcoholism, etc. Physical may be: Trauma, exposure, thermal, occupational, etc. Psychical may be: Fear, anger, hatred, and worry, or overuse, underuse or abuse of function. Internal causes are primarily hereditary; secondarily acquired. All external causes must become internal; likewise, they may be chemical, psychical or physical. Chemical may be faulty metabolism, i.e., lithemic diathesis, saline starvation or other acidosis, perversions of internal secretions. Physical, such as Osteopathic spinal lesions, displaced organs, posture, etc. Psychical, by reflex disturbances, etc.

THE GERM THEORY—The relationship between bacteria and disease is not clear, particularly on account of two factors. (1) The extreme variations in individual immunity. (2) The virulence of the germ. However, science is fast proving that the germ itself as an entity is not enough to cause disease, but is exciting cause, and dependent on tissue devitalized by predisposing factors. however, the course and pathology of the disease is markedly influenced by the type of invading organisms, each typo having its own particular manner and method of destructive activity. The toxin rather than the bacteria itself is the prime agent of tissue injury. Certain bacteria have a predilection to attack certain parts of the body; in fact bacteria may be perfectly harmless in one portion of the body and be highly pathogenic in another.

DR. STILL'S ACHIEVEMENT AND CONTRIBUTIONS TO MEDICINE
1. The importance of structure in disease, and a better and broader outlook of disease - and its causes - particularly the causes.
2. The greatest contribution to therapeutics in the whole history of medicine, so stupendous and complete in character as to revolutionize the whole therapeutic world.
3. The first, best and most complete theory of natural immunity formulated; since proven by scientific investigation to be true. "The body itself contains within itself all the chemicals and all the medicines necessary for the cure of disease." (Dr. A. T. Still).
4. The fallacy of drug medication.

CHAPTER 2

THE OSTEOPATHIC SPINAL LESION. CAUSES:-

(A) The vast majority of lesions are caused by reciprocal innervation through the medium of the reflex arc. An enumeration of some of the factors causing reflex phenomena is as follows:

1. Psychic, (fear, anger, hatred, worry).

2. Orificial. (adenoids, hooded clitoris, phimosis).

3. Environmental, (poor hygiene or sanitation, etc.)

4. Functional, (misuse, overuse, or underuse).

5. Thermal, (exposure to extremes of heat or cold).

6. Chemical, (drugs, ptomaines, etc.).

Broadly speaking reciprocal innervation may be clue to a multitude of physical, chemical, or psychical irritative disturbances; moreover, it may be intimately connected with any of the following Classifications.

(B) Postural defects:- Disturbance of centers of gravity.

1. Heredity, (inherent weakness as congenital luxations„ etc.).

2. Habitual, (faulty posture sitting and standing).

3. Occupational, (postural anomalies as in shoemakers, tailors, etc.).

4. Acquired secondarily, (certain diseases as TB, Infantile paralysis, flat feet, pot belly, obesity, fracture, etc.; Postural defects may be in the form of lordosis, scoliosis, or kyphosis).

(C) By way of the blood stream:- (Toxemia).

1. Exogenous Toxins: Bacterial, Chemical, Dietetical.

2. Endogenous Toxins: Fatigue, Lithemic Diathesis, Faulty Metabolism causing (a) Acidosis (b) Saline Starvation.

(D) Directly Incidental:

(1) Trauma, (wrenches, falls, blows, etc.).

PATHOLOGY: (A) Gross changes:

1. Malposition or subluxation of the vertebrae in lesion.

2. Unequal muscular tension:

(a) Unilateral. Lesion:

1. Contracture of muscles between the vertebrae above on the side which rotates anteriorly.

2. Tension of muscles between the vertebrae in lesion and the vertebrae below on the opposite side.

(b) Bilateral Posterior (Flexion) Lesion:

1. Contracture bilateral between vertebrae in lesion and one above.

2. Tension bilateral between vertebrae in lesion and one below.

(c) Bilateral Anterior (Extension) Lesion:

1. Contracture bilateral between the vertebrae in lesion and the one below.

2. Tension bilateral between the vertebrae in lesion and the one above.

3. Ligamentous shortening and thickening occurs coordinately with muscular contracture. In lengthening and tension of ligaments the same rule applies as is carried out under muscular tension.

4. Compression changes are found in intervertebral disc.

5. Oedema or induration of the surrounding tissues.

(B) Microscopic Changes:

Oedema and acidosis are found in the tissues surrounding the vertebrae in lesion. Carbon dioxide tension is plus; oxygen tension is minus, due to interference with internal respiration and partial pressure. This is principally due to the circulatory disturbance. Low grade fibrosities of the connective tissue elements occurs consisting of a hyperplasia and hypertropy. Interstitial changes depend upon the chronicity of the lesion and degree of catabolic toxaemia.

The muscular changes occur in the following order: (1) Contracture (2) Congestion and capillary haemorrhage (3) Oedema and acidosis. The acidosis is due to defective excretion of catabolic products particularly carbonic and sarcolactic acid. (4) Low grade myosis with interstitial hypertropy as the final result. According to Dr. Louisa Burns, the small muscles in closest connection to the vertebrae in lesion are most effected.

Induration, thickening and shortening of the ligaments occurs. In the chronic lesion the ligamentous changes are more pronounced while in the acute the muscular contractures predominate.

Pathologically, there is acidosis and interstitial hypertrophy.

The nerve changes according to Dr. Louisa Burns vary somewhat but usually show some degenerative influence. She states that the nerve trunk may have a slightly thickened neurilemma granular medullary sheath and slightly swollen axis cylinder. Sympathetic unmyelinated nerves are not effected.

The synovial membranes are first congested and there is an increased output of synovial fluid. Later the synovial membranes become thickened and roughened and the output of synovia is decreased.

The articular capsules are thickened particularly on the side which rotates anteriorly.

The number of stimuli passing through a given segment must necessarily be decreased.

Effects of Lesion upon the Vascular System:

Circulation to the cord is markedly influenced due to pressure. As the veins are more subject to compression than the arteries the result is usually a congestion. However, the arteries might be impaired and produce anemia. Clinically, little attention is paid to these factors for although we could assume logically that congestion or passive hyperanemia would primarily cause an excess of stimulation, and secondary inhibition, the end result would be to all practical purposes the same. Moreover, we should not lose sight of the fact that the circulatory disturbance is a secondary effect, the cause of which is some structural anomaly.

Circulatory interference of the cord is not only found in the segment corresponding to the vertebrae in lesion, but to a lesser degree in the segment above and below the lesion. This gives rise to the pleuri-segmental innervation mentioned by Tasker in "Principles of Osteopathy."

Effects of Lesions upon the Nervous System:

Careful study of the physiology of the nervous system, and particularly of the reflex arc shows us that the field of reflex action is practically limitless. Further consideration of Hoad's and Hilton's Laws make it appear all the more so. Reciprocal Innervation may take place wherever there are afferent or efferent nerves either in the Cerebro Spinal or Sympathetic systems.

Reflexes worthy of mention are:-
(1) Cerebra spinal: (a) Motor (b) Sensory
(2) Sympathetic: (a) Vasomotor (b) Vicero-motor (c) Secretory

Of great importance to the Osteopath are the Vasomotors, particularly the Constrictors, inhibition or incoordination of which is the predominate cause of congestion or passive hyperaemia, especially in the viscera where the physical element of pressure is not so markedly a factor as it is in the skeleton system. However, that does not imply that Vasomotor disturbances do not occur in both, but only that in the former the ratio of Vasomotor incoordination is greater in proportion to the pressure disturbances than it is in the latter.

SYMPTOMS AND DIAGNOSIS OF SPINAL LESIONS

1. (Malposition or subluxation of the vertebrae in lesion.

2. Tenderness or hyperasthesia of lesioned area due to irritation (tissue toxemia) and pressure (oedema).

3. Restricted motion of vertebrae in lesion with those adjacent, in physiological movements of the spine.

4. Slight elevation of surface temperature, degree of rise dependent Up-in acuteness of co-existent inflammation.

5. Disturbance of function of parts supplied through spinal segment influenced by the lesion.

6. Referred pain. (Head's Law)

7. Position that patient assumes in relation to existing structural anomalies.

8. Unequal muscular tension and other soft tissue anomalies.

9. Pigmentary changes of skin around lesioned area.

10. If chronic impacted lesion there will be an area of hypermobility nearby.

11. Subjective symptoms, history of trauma, fall, etc.

12. In acute lesions muscular contractions predominate, while in chronic lesions ligamentous thickening predominates.

Obstacles to overcome in the correction of a lesion:

1. Inertia of rest.

2. Contracture of muscles.

3. Shortened and thickened ligaments.

4. Presence of adhesions, ankylosis, etc.

5. The elimination insofar as possible of all factors concerned in the production of the lesion.

FORCE plus VELOCITY correctly applied, is essential to produce motion in any lesioned articulation. A certain amount is necessary to overcome the inertia of rest present. A still greater amount is needed when we stop to consider the hypertonic condition of muscles and ligaments in the lesioned area. If thickened ligaments and interstitial fibrosis of muscles are present, still more force is applicable and repetition may be necessary, for example, the chronic spinal lesion. We realize last of all in the presence of adhesions and ankylosis that there is a limit to the amount of effectual force and velocity that can be safely used. In other words, adhesions and ankylosis complicating a lesion are factors which limit us in the production of any appreciable amount of motion without danger to the patient.

The Principles of Technique:

(I) Diagnosis, Visualization and Analysis of lesion. A positive diagnosis must first be made, following which we must visualize the planes of articulation and the structural maladjustment. This having been done we can then analyze the mechanics of movement of the lesion, that we may evolve a definite technique by which we can retrace the pathway taken by the vertebrae in lesion, and also create favorable physiological locking of the spine in the direction that corrective force is to be applied.

(II) Normalize soft tissues through manipulation and muscular relaxation.
Methods:

(a) Approximation of attachments of muscles:

1. with manipulation of the belly of the muscle at right angles to the course of the fibres.

2. with steady firm pressure.

3. without pressure or manipulation.

(b) Separation of the attachments of muscles:

1. with manipulation of the belly of the muscle at right angles to the course of its fibres.

2. with firm, deep pressure.

3. without manipulation or pressure.

(c) with neither approximation or separation:

1. firm deep pressure.

2. manipulation of belly of the muscle at right angles to the course of its fibres.

(d) Functional relaxation by active exercise.

Too much importance should not be attached to soft tissue manipulation, the osseous lesion being the main factor of clinical significance. Bony adjustment, vigorously applied tends to increase the number of stimuli passing through the given segment in a given space of time, moreover, it tends to break the vicious circle of reflex activity at its source, the spinal center in which or near which the cell of origin of the nerve, effected are found. Muscular contraction is the result of a continuously acting stimuli, and osseous adjustment has greater effect upon the seat or source of the irritation. Muscular relaxation is not only necessary to maintain bony adjustment, but it is of value in the diagnosis of underlying bony lesions, as contractures sometimes prevent a satisfactory palpation of the osseous condition. The operator should remember to make his soft tissue treatment soft and gentle in character.

Abrupt and too vigorous manipulation, stimulus of cold hands, overtreatment and hurting the patient are some of the factors to be guarded against. The best method to use depends entirely upon the condition in hand. To produce the best relaxation in the average case, use approximation of the attachments with manipulation of the belly of the muscle. Approximation of the attachments tends to produce physiological relaxation of the muscle through removal of the tension. We assume that manipulation frees the circulation, and promotes better drainage of the muscle, and if correctly given, the benefits more than counteract the stimulation we naturally might affect intramuscularly…from the knowledge of the fact that it is easier to stimulate than inhibit.

Approximation of the attachments of the muscle with deep pressure or deep pressure alone is indicated in such conditions as excessive vomiting, diarrhoea, hysteria, headache, gall stone colic, renal colic, lumbosacral pains in child birth, etc.

Active and passive exercise have their own particular fields and we will not enlarge upon them here.

The principles of osseous adjustment are as follows:-

1. Physiologically lock the spine in the particular area and the particular plane in which corrective force is to be applied. (This principle may or may not be taken advantage of, depending upon the type of technique used.)

2. Anatomically lock the spine when necessitated by special forms of indirect action technique.

3. Physiologically relax the articular processes of the vertebrae in lesion by demanding a passivity and partial relaxation upon the part of the patient.

4. Adjust, catching the articulation unawares, in other words, at the psychological moment when the patient is at the greatest point of relaxation.

5. The OBJECTIVE should be the point of greatest leverage of the vertebrae in lesion. (Avoid as much as possible long leverages, they are awkward, faulty and uncertain. Short leverages are specific.)

6. The POINT OF CONTACT is the anatomical part of the technician through which the corrective force is applied. It may be thumb, pisiform bone, hypothenar eminence, combined thumb and index finger, etc. The APPLIED FORCE is the THRUST.

Osseous Technique may be divided into two general classes:-

(1) Direct Action Technic:- Technic in which the entire corrective force used is applied to some portion of the vertebrae in lesion, as the objective. There may or may not be preparatory physiological movement to the full limit along the plane that corrective force is applied for the purpose of safe guarding other vertebrae and creating a favorable fixation above and below the lesion, that corrective force may be effectual. This is what is meant by such expressions as "taking the slack off," locking the vertebrae," etc.

(2) Indirect Action Technic: Technic in which forces of gravity, muscular leverages, anatomical locking or fixation above or below the lesion by means other than physiological locking are used.


BONY LANDMARKS OF THE NORMAL SPINE: Cervical Region.

1. Transverse process of the atlas is felt midway between the mastoid process and the angle of the jaw.

2. The spine of the Axis is the first prominence below the Occiput in the median line.

3. The spines of the third, fourth and fifth cervical vertebrae are felt with the patient supine.

4. The sixth cervical spine feels like a small tubercle overlapping the seventh.

5. The seventh cervical spine, Vertebrae prominens, is easily felt but is sometimes confused with the spine of the first dorsal. Strong flexion of the cervical column causes greater flexion of the seventh cervical and brings the spine into greater prominence than it does first dorsal. In normal position spine of first dorsal is slightly more prominent.
Place one finger transversely across the lower portion of the back of the neck, bend back the cervical spine, underneath the finger is the seventh cervical spine.

6. The transverse processes of the cervical vertebrae nay be palpated as follows:

(a) Posteriorly and to the side the Posterior tubercles of the transverse processes can be felt.

(b) Anteriorly and to the side the Anterior tubercles of the transverse processes can be felt by pushing; back the belly of Sterno-Cleido-Mastoid muscle.

Thoracic Region:

1. The transverse processes of the thoracic vertebrae are situated at the level of the spine above and. about one inch to the side.

2. The first thoracic spine is the most prominent in the region.

3. The spine of the third thoracic is on a line drawn through the roots of the spines of the scapulae.

4. The spine of the seventh thoracic is on a line drawn through the inferior angles of the scapulae.

5. The eleventh thoracic vertebrae is considered as the middle of the spine.

6. Dorso-Lumbar and Cervico-Thoracic junctions arc weak points of the spine because they are the dividing points for muscular origins and insertions.

Lumbar Region:

1. The first Lumbar spine is on a level with a point one inch and a half below tie ensiform cartilage (same level as pyloric orifice of stomach.)

2. The third Lumbar spine is usually on a level with the umbilicus.

3. The fourth Lumbar spine is on the same level as :lie crest of the Ilia.

4. The transverse processes of Lumbar vertebrae lie half an inch higher than the highest point of the same spine.

I cannot emphasize too greatly the psychological value of a positive attitude upon the part of the operator. The patient cannot assume anything but a negative attitude, from the mere fact that we demand of him a passive and relaxed physical state. This gives the physician a tremendous advantage and opens a vast field for psycho-therapeutics and suggestive therapy on account of the receptive state of the patient's mind. It is also of immense value to him in the application of his work…adjustment. Dominate your patient and your technique as well. Acquire a thorough knowledge of the mechanics of the spine particularly planes of articulation physiological and anatomical movements for locking the spine and ADJUST, don't treat. Your work will then be a success.

CHAPTER 3

OCCIPITO-ATLANTAL LESIONS

The Occipito-Atlantal Articulation is condyloid in character and is composed of the superior articular facets of the atlas together with the condyles of the occipital bone. The condyles of the Occipital bone arc oval shaped and their articular surfaces are convex from before backward and from side to side. They look downward, slightly forward and lateral-ward. The anterior extremities are directed slightly forward and medial-ward and, therefore, converge somewhat. The posterior extremities are on a level with the middle of the foramen magnum.

The superior articular facets of the lateral masses of the atlas are elongated, large, oval, concave depressions which approach each other anteriorly. They face upward, slightly medialward and backward to form a fossa for the reception of the corresponding condyle of the occiput. The floor of the facets is deeper at each end with a slight elevation in the middle, the Isthmus. The peculiar conformation of the atlas should not be overlooked, especially that the atlas is without body or spinous processes, (the posterior tubercle excepted), but has larger lateral masses and prominent transverse processes.

The Vertebral artery and Suboccipital (first Cervical nerve) pass in the groove behind the superior articular facets. Important structures in front of the Anterior arch and Transverse Process of the Atlas are from within outward:

1. Superior Cervical Ganglion

2. Internal Carotid Artery

3. 10th, 11th and 12th Cranial Nerves (Vagus, Spinal Accessory and Hypoglossal)

4. Internal Jugular Vein.

Normal movements of the Occipito-Atlantal Articulation are flexion, extension, and sidebending.

LESIONS OF THE OCCIPUT:

There are ten possible lesions of the Atlanto-Occipital joint. They are tabulated in the order of frequency of occurrence as follows (Forbes):-

1. Bilaterally Posterior Occiput (Flexion Lesion)

2. Unilaterally Posterior Occiput on Right (Torsion Lesion)

3. Unilaterally Posterior Occiput on Left (Torsion Lesion)

4. Lateral Occiput on Right (Sidebending Lesion)

5. Lateral Occiput on Left (Sidebending Lesion)

6. Unilaterally Anterior on Right, Posterior on Left (Pseudo rotation Lesion)

7. Unilaterally Anterior on Left, Posterior on Left, (Pseudo rotation Lesion)

8. Bilaterally Anterior Occiput (Extension Lesion)

9. Unilaterally Anterior Occiput on Right (Torsion Lesion)

10. Unilaterally Anterior Occiput on Left (Torsion Lesion)


Bilaterally Anterior Occiput

The Bilaterally Anterior Occiput is an extension movement on a transverse axis, wherein the condyles of the occiput move bilaterally forward, upward and slightly outward on the superior articular facets of the atlas with consequent immobilization in this position. The posterior extremities of the condyle are at a much lower level than the anterior.

Etiology. Bilateral sub-occipital contractures of the Rectus Capitus Posticus„ Major and Minor are particularly responsible. Contractures of most of the extensors of the head and Cervical spine will effect this articulation. (The posterior Cervical musculature of the joint is stronger than the Anterior.) The lack of protection of the special senses of the face make the back of the head and sub-occipital region more susceptible to trauma, wrenches, etc. Forceful extension from sudden starting of a car, unexpected stepping down from higher levels, etc. are frequent causes. It is associated sometimes with postural conditions, especially round shoulders and kyphosis of the Dorsal area when compensation does not take place in the Cervical region. Functional abuse associated with occupational or habit, etc., necessitating long continued extension as looking up, i.e., painters, paperhangers, etc.

Diagnosis. Sub-occipital contractures and tenderness are invariably present and bilateral in character. The head is held in hyper-extension with chin pointing upward and forward, as this position must be assumed in relation to existing structural conditions. The tissue surrounding the tips of the transverse processes of the atlas are abnormally sensitive. The normal separation of the ramus of the mandible and outer anterior portion of transverse process is bilaterally increased, while a corresponding bilateral decrease or approximation occurs between the outer posterior portion of the transverse process and the tip of the mastoid process. "Disturbance of function and subjective symptoms vary somewhat. Together with referred pain (Head's Law) in the form of occipital headaches, shooting pains thru back of head and neck, and other sensory disturbances. The articulation should be tested for restricted motion, a diagnostic feature of all lesions. Ashmore points out that there is usually an associated straightening of the Cervical curve, an effort to counterbalance. This may be primary or secondary.

Treatment. Relax as much as possible Suboccipital and Posterior Cervical Muscles. Reduce bony subluxation unilaterally by correcting one side at a time.
Technic: Correct first as Unilateral Anterior Occiput on Right. Patient in spine position. Operator at head of table, flexes, sidebends and rotates the Cervical arch or atlas on right side into greater prominence. The slightly flexed index finger of the right hand of operator is placed lengthwise and firmly against upper posterior portion of the posterior arch of the atlas on the right side. The palm of same hand should rest against the back and right side of the head. The left hand of the operator should be placed along the left side of the head and face so that the palm of the hand is over external ear and tips of fingers extend over the ramus of jaw. Keeping firm pressure against the atlas with strong traction of the head operator should draw neck back to limit of motion on the right. (Do not disturb sidebending or flexion.) maintaining firm pressure against atlas and strong traction, particularly of the occiput on the right. Operator should give quick rotation movement of the head to the right using the left hand. By this method the occiput is lefted and brought backward into its proper position. The right side corrected; use the same technic for the opposite side.

Technic With Patient Sitting on Stool.

The mechanical principles are the same as are used with patient supine. Operator stands at the side of the patient on the same side as lesion he wishes to correct. The head is held in crotch of flexed forearm so that chin rests in apex, forearm is against side of head, and hand rests on vertex. Patient is instructed to lean against operator. The patient's head is held in a position of flexion and side bending to the side opposite the lesion. Fixation is made with operator's thumb against posterior arch of atlas on lesioned side. Traction and quick rotation of head backward toward the side of lesion to bring the occiput back into normal relationship with fixed atlas below, constitutes the Treatment. This adjustment is unilateral. If a Bilateral Lesion, adjustment should be given for both sides.

THE UNILATERAL ANTERIOR OCCIPUT.

The Unilateral Anterior Occiput is a Torsion Lesion with movement upon a vertical axis drawn thru opposite articular facet. The movement on this side is in the nature of a screwing motion of the condyle of the Occiput upon the articular facet of the atlas. The condyle of the lesioned side moves forward, upward, and slightly medialward, and becomes fixed at a slightly higher level than its fellow.

Etiology. Trauma, directly or indirectly transmitted, is a frequent cause, i.e., falls, wrenches, etc. May be counterbalancing for some lesion lower in the spine which is disturbing the vertical line of gravity, as twisted pelvis, etc. It may be secondary to such conditions as, faulty posture, lateral curvatures, unequal muscular tension, ptosis of upper eyelid, defective hearing in one ear.

Diagnosis. Unequal muscular tension in sub-occipital area is usually present. Sub-occipital tenderness, particularly upon anterior or lesioned side is of diagnostic value. The tissues surrounding transverse process of atlas upon the side in lesion are abnormally sensitive. The normal separation between the end of the transverse process and the angle of the jaw is increased on the side of lesion, while a corresponding decrease or approximation occurs between end of transverse process and tip of mastoid. The position that patient head assumes in relation to existing structural conditions is suggestive. Standing the patient holds head slightly extended and tilted toward side opposite lesion. With the patient supine it will be noticed that the mid line of the forehead, nose and chin are not in alignment with the sternum so that the midline bisects the mid line of the trunk. The chin is directed to the side opposite the lesion. Some obliteration of Cervical curve is usually present. Restricted motion is more evident on side of lesion.

Treatment. The same as is given in the adjustment on the Bilateral Anterior Occiput.

BILATERALLY POSTERIOR OCCIPUT.

The Bilaterally Posterior Occiput is a flexion movement on a transverse axis, wherein the condyles of the occiput move bilaterally backward, downward, and slightly inward on the articular facets of the atlas below with consequent immobilization in this position. The anterior extremities are at a lower and the posterior at a higher level than normal.

Etiology. Functional disturbance of this joint in flexion occurs more often than in any of its other classified movements. Occupational or functional disturbances in which the head is constantly flexed, i.e., students, jewellers, office workers, habitual faulty posture, etc., are frequent causative. Atonicity of the extensors or hypertonicity of flexors, particularly the former, may be responsible. Dorsal kyphosis, posterior lumbar, and etc, where compensation takes place by accentuation of the Cervical curve, if long standing, will produce flexion lesion of the occiput. The special senses of the face protect the individual to a considerable extent from lesions of traumatic origin. This lesion occurs frequently, in fact, is one of the most common occipital lesions found.

Diagnosis. The head is held in abnormal position of flexion, due to underlying structural condition. The tissues surrounding the transverse process of the atlas are unduly sensitive. Normal separation between the angle of the jaw and the end of the transverse process is bilaterally decreased, while the opposite holds true between the end of the transverse process and the tip of the mastoid process. Patients complain often of a sense of strain at the base of the occiput. Restricted motion of articulation. Accentuation of the Cervical curve, disturbance of function and subjective symptoms further than that they are diagnostic factors to be taken into consideration.

Treatment. Eliminate all etiological factors insofar as possible. Reduce bony subluxations unilaterally...one side at a time as it is the most efficient way.
Technic: Patient spine with head and Cervical -column over end of table. Correct right side first. Operator places right hand under patient's occiput, left hand under chin, and abdomen against vertex of patient's head. The Cervical column should be flexed to limit of motion, and head, in full extension, should be lefted so that the weight of the body is pulling downward on atlas. Carry the head to right side. This gaps the articulation (do not side bend the head but hold firm and stationary so as to allow gapping to take place.) To make adjustment three things must be carried out synchronously;

(a) Downward and forward pressure of abdomen against vertex of patient's head to increase extension.
(b) Forceful upward thrust against base of occiput with right hand.
(c) Strong upward pull against chin with left hand. Keeping patient in same position, shift hands and repeat on the opposite side.

UNILATERALLY POSTERIOR OCCIPUT.

The Unilateral Posterior Occiput Lesion is an immobilized tension lesion, caused by movement upon a nearly vertical axis drawn thru articular facet of the atlas. The condyle of lesioned side moves backward, downward, and slightly medialward. The anterior extremity of the condyle is at a lower level than the posterior.

Etiology. Unusual muscular tension, trauma, faulty posture, occupational factors, forceful unexpected flexion, principally on the side of the lesion, counterbalancing to other conditions, functional or habitual anomalies, refraction errors, etc., all are etiological factors which may produce this lesion.

Diagnosis. With patient standing the head assumes the position of flexion with slight twist and tilt so that the chin points slightly to side in lesion. The tissues surrounding transverse process on the side in lesion are sensitive. Normal separation between the angle of jaw and end of transverse process is de-creased on side of lesion and opposite holds true between end of transverse process and tip of mastoid process on the same side. Subjective symptoms vary. Patient often complains of a sense of discomfort in sub-occipital region. Motion restricted in lesioned articulation.

Treatment. Use unilaterally same technic described under treatment of Bilaterally Posterior Occiput.

THE LATERAL OCCIPUT.

The Lateral Occiput is a lesion wherein the joint is fixed in position of side-bending or lateral flexion. The condyle of one side moves medialward and downward while the opposite side moves outward and upward. There is lateral tilting to the side which has moved medialward and downward, consequently a larger share of the weight of the Occiput is held on that side.

Etiology. Unequal muscular tension, especially contracture of any of the following muscles:- Rectus Capitis Lateralis, Semispinalis, and Splenius Capitus, and Sterno-Cleido-Mastoideus. May be secondary to rotation lesions in the neck Trauma, occupational, postural defects, etc., may be causative.

Diagnosis. If sidebending is to right, Occiput will appear displaced to left followed by lateral curvature in the in the Cervical area....convexity on right. The transverse process on the right will appear to be nearer the Occiput and Mastoid process, and more prominent laterally. Mastoid process of same side would be less prominent and tip would tend to point more medialward. The direct opposite would hold true on the left. Restricted motion, sensitiveness over transverse processes, position patients head assumes, standing or supine, subjective symptoms, etc., are diagnostic aids.

Treatment. Relax lateral musculature. Technic for reduction of subluxations:-
Hypothetical lesion (Lateral Occiput to Right). Patient supine with head and Cervical column over end of table. Operator stands at head of table and grasps head as follows:

a) Right hand against right side of head and face.

b) Abdomen against vertex of patient's head.

c) Left hand against left side of head with fingers firmly against posterior arch of atlas.

Operator sidebends Cervical spine to right and head to left. Three things to be carried out synchronously:

I. Increase side bending of head with pressure of abdomen.

II. With right hand operator should make strong thrust with a little rotary twist to the right.

III. Fingers of the left hand should hold arch of atlas firmly, while palm of hand exerts lifting pressure to dislodge anterior extremities of the condyle (usually posterior), and if not maintaining patient's head in same position shift left hand, so that fingers are under angle of the jaw (palm in same position). Use the following method to finish reduction of posterior extremities of condyles: -

a. Increase side bending by pressure of abdomen.

b. Strong pressure against base of Occiput with right hand.

c. Lifting pressure with left hand, now with rocking motion and strong outward rotary movement, directed to bring greatest tension and separation to left latero-posterior position of articulation; correction is completed. It is easier whenever possible to correct unilaterally. You can localize your efforts more specifically and efficiently by doing so. The same applies to moving any object. It is easier to move things by prying at the edges. The above technic, like the farmer moving the large rock, aims to follow out that principle.

IMPACTED OCCIPUT.

The Impacted Occiput (Functional) is not a true lesion, there being no articular locking or gross immobilization of the joint. Condition consists of hypertension of the sub-occipital muscles with increased approximation of the articular facets. Treatment is traction.

CHAPTER 4

CERVICAL LESIONS.

The Atlanto Axial-Joint has four distinct articulations, each covered by a synovial membrane. The atlas revolves on a nearly vertical axis around the odontoid process of the axis, forming a pivot joint with two articular surfaces, one between the odontoid process and the anterior arch of the atlas and the other between the odontoid process and the transverse pigment. The lateral articular processes are arthrodial articulations. The articular surfaces are raised in the center and fall away at the edges, thus allowing, at first, some ligamentous slackening in rotation, thereby increasing the amount of this movement. The mobility of this joint for rotation is marked, the atlas and skull moving en mass upon the axis, Movement beyond a certain limit, however, is prevented by the alar or check ligament. Primary movement is asymmetrical, the axis of movement being in the atlanto axial articulation of side to which head is rotated. This soon changes and the movement becomes symmetrical around the odontoid process of the axis.

According to Gray's Anatomy, the muscles producing this movement are the Sterno-Cleido-Mastoid and Semi-spinalis capitis of one side acting With the Longus capitis, Splenius, Longissimus capitis, Rectus capitis posterior major and Obliquis capitis superior and inferior of the opposite side. The second Cervical Nerve passes out behind the superior articular process of the axis.

The Common Lesions of this Joint are:-
(1) Unilaterally Anterior Atlas on the Right, Posterior on the Left, (Rotation Lesion to the Left).
(2) Unilaterally Anterior Atlas on the Left, Posterior on the Right, (Rotation Lesion to the Right).

The above lesions of the atlas are those maintained in rotation. The nature of the joint is such that these lesions are many times nothing more than a functional disturbance due to unequal muscular tension. They are often secondary, counterbalancing to other lesions.

The atlas cannot be bilaterally displaced anteriorly or posteriorly on account of the odontoid process of the axis, the anterior arch of the atlas, and the transverse ligament without fracture of the odontoid process or anterior arch of atlas, or rupture of the transverse ligament. This knowledge is taken advantage of in execution by hanging, in which the transverse ligament is ruptured and odontoid process driven into substance of spinal cord.

Etiology. The lesion is usually due to reciprocal innervation thru the medium of the nerve reflex. Many times it is due to unequal muscular tension or equilibrium from other causes. It is one of the most common counterbalancing or secondary lesions found. It is invariably present in unilateral and side bending lesions of the occiput. Often it is counterbalancing for cervical and upper Thoracic lesions and sometimes first and second rib lesions through Scalenes muscle. Functional abuse may be a predisposing factor, a good example of which would be the violinist in the act of playing.

Diagnosis. There is more sensitiveness in the sub-occipital area over transverse process of atlas, which has rotated posteriorly and posterior tubercle of process is more prominent posteriorly than normal, while opposite is true of other side. The relative position of transverse process is significant; also the position that patient's head assumes. With patient supine there is limited rotation toward anterior side. (Test by rotating head from side to side, being careful to eliminate all extraneous Cervical movement.)

Treatment. The etiological factors should receive more attention, particularly if they are structural lesions to which the Atlanto Axial disturbance is merely secondary or counterbalancing.

Technic. The correction of Atlas lesions is a simple matter in itself. Indirect or Direct Action technic may be used.
Indirect Action Technic: Patient supine. Fixation with fingers of one hand on vertebra below (Axis), especially the transverse process upon the same side that vertebra in lesion (Atlas) has rotated forward. With other hand against side of face and head, retrace the pathway of lesion movement by rotating occiput and atlas en mass toward anterior side. The patient's head should be held in position of side bending toward side which is unilaterally posterior. This movement causes a separation on side which is unilaterally anterior thereby allowing plenty of room for a backward movement on that side. With slight variations same technic may be used with patient in sitting posture.

Direct Action Technic: The objective should be transverse process, which has rotated posteriorly. Point of contact is usually the index finger. Adjustment should be carried out in the following order:
(1) Slight obliteration of the Cervical curve.
(2) Side bend to side on which lesioned vertebra is unilaterally posterior. This creates a physiological approximation on posterior side.
(3) Rotate head to side on which lesion is unilaterally anterior. This movement together with side bending tends to produce as much of a physiological locking as is possible.
(4) Approximation by pressure upon vertex of head. This creates compression at right angles to the plane of articulation and adds physically to the locking (Law of Friction). This might be properly considered an anatomical locking.
(5) Apply corrective force with index finger against transverse process, which is posterior. This technic with variations may be applied with patient sitting.

Other Lesions of: the Atlas are:- (1) Lateral Atlas to the sight. (2) Lateral Atlas to the Left. (3) Extension Lesion of the Atlas. (4) Flexion Lesion of the Atlas.

The Lateral Atlas:

Due to the inclination of the articular facets of the Axis, slight lateral gliding may take place with rotation in the Atlanto-Axial joint. This is a sort of slowing movement of Atlas as it rotates around the odontoid process so that the side which moves anteriorly tends to slip laterally and slightly downward, while opposite tends to slip medially and slightly upward, crowding odontoid process on that side. The result is that the side which rotates forward is more lateral and at a lower level than normal, while other is at a higher level and more central. The Atlas, therefore, is laterally displaced on the side which rotates anteriorly. For example, a lateral Atlas to the right is the result of a rotation to the left in which the Atlas has moved forward, slightly outward and downward on the right.
These lesions are usually compensatory for rotated or lateral Occipital

Lesions (Lateral Occiput to the right...Lateral Atlas to the right).

Diagnosis. Marked lateral projection of end of transverse process of Atlas on side which is rotated anteriorly, while opposite side moves more medially. The relative position of the transverse process in the presence of a lateral Occipital lesion is such that sharp discrimination must be made. In such case it is better to depend upon the relative position of the posterior tubercle of transverse process, which has rotated posteriorly with that of the opposite side. For other diagnostic factors, see those given under diagnosis of Rotation Lesions.

Treatment. Adjust as a rotation lesion, using the same technic with only slight variation. If Direct Action Technic is used, emphasis should be made upon preliminary rotation (less side bending and approximation).
The Extension Lesion is nothing more than a functional or counterbalancing movement in which there is separation in front with slight upward gliding of Atlantal articular surface upon anterior articular surface upon anterior articular surface of odontoid and approximation posteriorly with slight compression of articular disc.

THE FLEXION LESION.

The Flexion Lesion is a functional disturbance with movement the reverse of that of the extension lesion.

Treatment. Treatment of both lesions should be directed to the etiological factors and not to the conditions themselves.

CERVICAL LESIONS FROM THE SECOND TO THE SEVENTH INCLUSIVE

A typical Cervical vertebra will be reviewed here only relatively to those factors important to Osteopathic mechanics to which later reference may be made. The body of the vertebra is small and broader laterally than antero-posteriorly also its anterior surface is at a slightly lower level than its posterior. The superior surface has prominent lips upon the posterior and lateral borders, while the inferior surface has projecting lips on anterior border. This helps prevent a slipping backward of the vertebra, a protection of nature on account of the Cervical curve convex anteriorly. The lateral lipping is a protection against lateral displacements.

The superior and inferior articular processes on either side are situated at the junction of the pedicles and lamina, forming by their fusion lateral columns of bone. The articular facets are nearly flat, and oval in outline. The superior face upward, backward and slightly medialward and the inferior downward, forward and slightly outward.

The Third Cervical vertebra is the smallest of the Cervical vertebra.

This fact, together with its relative position in the Cervical spine, makes it particularly responsive to lesioning forces.

Considerable care should be taken in palpation around the anterior or costal tubercle of transverse process of sixth Cervical vertebra, as the Carotid artery is easily compressed against it. This tubercle is known as Chassaignac's Tubercle or Tuberculum Caroticum.

Normal motion between the second Cervical (axis) and the third Cervical, particularly flexion, is less free than elsewhere in the Cervical spine, because of the thinness of the inter-vertebral fibrocartilage.

According to Morris' Anatomy, the pulpy nucleus or central portion of intervertebral fibrocartilage, situated somewhat behind cantor of disc, forms a ball of very elastic and tightly compressed material which constitutes a central elastic pivot or ball upon which the middle of the vertebra rests and around which the bodies of the vertebra can twist, tilt, or incline. It is separated from immediate contact with the bone by a thin plate of cartilage. Embryologically, it is a persistent part of the notocord.

The articular processes steady, influence and limit the movements of the spinal column, assist in bearing super incumbent weight of the body, and endow spine with capacity of movement by muscular agencies.

Normal movements of the Cervical spine are flexion, extension, rotation and side bending or lateral inclination.

Rotation and side bending are inseparable because of the position and inclination of the articular facets, causing movement to take place upon an oblique axis. However, from above downward the obliquity of the articular facets increase, therefore, although rotation is a predominant factor in the upper Cervical region, the reverse is true in the lower, and side bending becomes the predominant factor. Due to this fact, Ashmore calls lesions of the upper Cervical area Rotation-Side bending, and those of the lower Cervical area Side bending-Rotation. It should not be overlooked that flexion and extension influence rotation and side bending in that the ratio of rotation is increased with the spine in extension. In rotation side bending or side bending rotation, the ratio of anterior articular movement, -upward and forward, - on one side is approximately ten times greater than downward and backward articular movement of opposite side, as the latter can move only slightly (approximately one sixteenth of an inch) before it reaches its limit, the lower anterior lip catching over body of vertebra below, the transverse process of vertebra hooking over superior articular process of vertebra below, and the lower anterior portion of the articular facet catching at base of superior articular facet of vertebra below. The transverse articular contact fixation of this side becomes an axis for further movement upward and forward of anterior side.

According to Fryette, when any area is in slight or easy physiological flexion and sidebent, the bodies move toward the convexity, and if any area is in hyperflexion or to a lesser extent extension and sidebent, the bodies rotate toward the concavity. Moreover, that this is due to the fact that in slight or easy flexion, articular facets are not in contact or locked and the load is thrown more upon the bodies of the vertebra, so that the superimposed weight becomes an important factor, and when spine is sidebent, the bodies have a tendency to crawl out from under the load by rotating toward the convexity. Sidebending rotation with body rotated to the convexity applicable to mid-dorsal in a position of hyper-flexion, --- in fact, I believe it to be found only under the above circumstances to any appreciable extent.

In this case sidebending is the primary movement until apposition of the articular facets occurs, from which point movement becomes side bending rotation, and body must rotate toward concavity, as plane of movement is then controlled or directed by the articular facets. The preceding factors are of considerable value in the study of functional curvatures, etc.

Flexion of the Cervical Vertebrae: This occurs upon a transverse axis through center of that portion of the body of each vertebra which is in contact with the nucleus pulposus of the inter-vertebral discs below. The nucleus pulposus of the inter-vertebral disc remains throughout the entire movement of flexion, the pivot or ball bearing over which movement must take place.

The inferior articular facets of vertebra move upward and forward, on the superior of the vertebra below and become bilaterally anterior in their relation to those of the vertebra below.

The posterior ligaments are tensed, due to the separation of their attachments, and the relative length of the column is increased posteriorly, thereby obliterating to a more or less extent the normal cervical curve. (The degree of obliteration is dependent upon the amount of flexion. This same rule holds true to the relative increase in the length of the cervical spinal column posteriorly.)

Anteriorly all changes are approximational in character. The relative length of the spine anteriorly is diminished, the convexity of the cervical curve anteriorly lessened, and anterior portion of inter-vertebral discs pinched and adjacent ligaments slackened.

Whitaker states in the Journal of the A. 0. A., hay 1915, that in moderate flexion the lumbar and cervical spine (below the occiput) are locked, and that in extreme flexion the whole spine is locked against rotation and side bending. This is important when fixation or immobilization is desired for corrective purposes.

Extension of the Cervical Vertebrae. The inferior articular facets of the vertebra or vertebrae move bilaterally downward and backward upon the superior articular facets of the vertebra below. However, movement of the inferior articular facets downward and backward is short-lived, as transverse articular fixation soon takes place. Primarily, movement occurs upon the same axis as that of flexion, the nucleus pulposus acting as the pivot or ball bearing. It is logical to assume, after relative comparison of the amount of flexion and extension in the cervical area, together with their respective articular movements, that the axis of rotation must shift from the nucleus pulposus and body of the vertebra to a transverse axis drawn through articular process of the vertebra, thus allowing further separation anteriorly. Posteriorly all changes are approximational in character with vertebra below, in brief, the reverse of flexion with relative length of column decreased, ligaments slackened, and anterior convexity increased.

Whitaker in his monograph states that forced extension locks the entire spine because the inferior articular facets of each vertebra are jammed down on the lamina of the vertebra below. Moderate extension locks all but the last one or two dorsal and lumbar. The upper dorsal is the first to lock. This is important when fixation or immobilization is desired for any corrective purpose. It is Nature's way of protecting and reinforcing vertebra in extreme positions.

The Common Lesions of these Articulations are:-
(1) Rotation-Side bending or Side bending-Rotation lesion to the right. (Syn. Unilaterally Anterior on the Left, Posterior on the Might.)
(2) Rotation-bide bending or bide bending-Rotation lesion to the left. (Syn. Unilaterally Anterior on Right, Posterior on Left.)

Other Possible Lesions are:- (1) Flexion Lesion. (2) Extension Lesion. (Syn., Bilaterally Anterior and Bilaterally Posterior respectively.)

According to Tucker cervical vertebra may also be:-
(1) Unilaterally Posterior on Right or Left. (Torsion Lesion)
(2) Unilaterally Anterior on Right or Left. (Torsion Lesion)
(3) Directly Lateral on Left or _sight. (Syn. Lateral displacement.)

Etiology of Cervical Lesions. They may be due to nerve reflex phenomena, postural, occupational or functional anomalies, traumatism (wrenches, twists, direct violence), other spinal lesions (counterbalancing or compensory), extension or inflammation (primary infection elsewhere), muscular incoordination, defective hearing, eyesight, etc.

A CERVICAL VERTEBRA, SECOND TO SEVENTH INCLUSIVE, MAINTAINED UNILATERALLY ANTERIOR ON THE RIGHT, POSTERIOR ON THE LEFT, AND VICE VERSA A VERTEBRA IMMOBILIZED UNILATERALLY ANTERIOR ON THE LEFT, IS A ROTATION-SIDE BENDING OR SIDE BENDING-ROTATION LESION TO THE LEFT, POSTERIOR ON THE RIGHT IS A ROTATION-SIDE BENDING OR SIDE BENDING-ROTATION LESION TO THE RIGHT.

Diagnosis. (Hypothetical lesion third cervical unilaterally anterior on left, posterior on right.) The above lesion is a rotation side-bending to the right.

1. Spinous process is to the left and body of the vertebra is to the right and slightly tilted so that inter-vertebral disc is pinched on the right side.

2. The transverse process on the left has moved upward and forward and is approximated with left transverse process of vertebra above. The anterior or costal tubercle is more prominent anteriorly and is sensitive.

3. The transverse process on the right is downward and backward and approximated with transverse process of vertebra below. Posterior tubercle is more prominent posteriorly and is sensitive.

4. Notion is restricted within the joint.

The main points to base the diagnosis on are the following:

Relative comparison in position of anterior and posterior tubercles of transverse process of one side with those of opposite side, tenderness over spinous, articular and transverse processes, restricted motion of joint, position that patient's head and cervical column assume in relation to underlying structural condition (lengthening of neck on anterior side), the nature and location of soft tissue changes and subjective symptoms. Note: Malformations in the way of deviations of the spinous processes are so often found that the relative position of the spinous processes cannot be relied upon as an accurate diagnostic feature. They help to substantiate your other findings. Too much emphasis is sometimes given to them because they are so Obvious and freely palpable.

Treatment. Relaxation of cervical musculature if necessary. best method is approximation of attachments of muscles with manipulation of the belly of the muscle at right angles to the course of the fibers.
Reduce bony subluxation by direct or indirect action technic.

Direct Action Technic:- Patient supine or sitting on stool, correct as follows:

1. SLIGHT OBLITERATION OF CERVICAL CURVE BY EASY FLEXION (not sufficient to lock cervical vertebra).

2. SIDE BENDING HEAD AND CERVICAL COLUMN TO SIDE UNILATERALLY POSTERIOR (right). (This opens up the articulations on side which has rotated anteriorly and helps in physiological locking process of opposite side.)

3. ROTATION TO THE SIDE UNILATERALLY ANTERIOR (left) TO LIMIT OF MOTION. (This, together with sidebending and slight flexion previously completed, physiologically locks spina on that side to further upward forward movement of inferior articular facets—all except vertebra immobilized.

4. APPROXIMATION DOWNWARD UPON VERTEX OF HEAD. (This strengthens and helps maintain the physiological locking) It safeguards the patient and the student until he has acquired an exact nicety of technic.

5. ADJUSTMENT by quick upward forward thrust against objective. (Transverse process which is posterior.) The applied force with patient supine is usually the index finger, in this case, of the right hand. With the patient sitting, the applied force is usually the middle finger. Note:- The anterior side needs no corrective manipulation, — separation of the articular facets by flexion and side bending, allowing plenty of room for downward and backward movement of inferior articular facets of lesioned vertebra when corrective thrust is applied to opposite side.

Indirect Action Technic:- Fixation of vertebra below on same side that lesioned vertebra has rotated upward and forward by grasping neck and maintaining pressure particularly against transverse process of that side. Next, retrace pathway of lesion movement by slight flexion, followed by side bending to side which is posterior and rotation of head and cervical column to side which is anterior. This technic may be used with patient sitting or supine.

A cervical vertebra, second to seventh inclusive, where inferior articular processes are maintained bilaterally anterior, is a flexion lesion. There is approximation, the spinous and transverse processes of the vertebra in lesion with those of the vertebra, above and corresponding separation with those of the vertebra below. This lesion may occur singly, but is usually found as a group lesion, (counterbalancing or compensatory). If compensatory group lesion, correct the etiological factors. If found singly, correct with indirect action technic, heretofore described, by correcting first one side then the other. Other methods using strong extensions may be used. Fortunately these lesions are rarely found and then usually in lower cervical.

A cervical vertebra, second to seventh inclusive, whose inferior articular facets are maintained bilaterally posterior, is an extension lesion. The amount of articular displacement is relatively small in comparison to that found in the flexion lesion. The transverse and spinous processes of lesioned vertebra are approximated with those of vertebra below. The obliquity of the plane of the spinous process is increased, consequently the process is less prominent and palpable posteriorly. Normal separation with vertebra above is increased. This lesion may occur singly, but more often is found as a group lesion when accentuation of the cervical curve is desired for counterbalancing purposes. If group lesion correct causative factors. If found singly, correct unilaterally, first one side then the other, by strong obliteration of the cervical curve nearly to the point of locking them, using modification of direct action technic, heretofore described. Other methods using strong flexion may be substituted.

TORSION LESIONS:- (Unilaterally :Interior or Unilaterally Posterior). Tucker says that unilaterally posterior lesions are most frequent….that there is not necessarily a corresponding anterior displacement on the opposite side. A flexion lesion of the opposite side may bring about a separation posteriorly on this side with engagement of the transverse process against the superior edge of articular process below. The mechanics of these conditions are not clear.

The Unilaterally Anterior lesion may be reduced by the indirect action technic, previously described. The Unilaterally Posterior lesion may be reduced by the direct action technic, previously mentioned.

DIRECTLY LATERAL LESIONS:- according to Tucker arc maintained evidently by a catch in the lateral lip against the tissues of the base of the bone. The mechanics of correction should suggest themselves. In brief, correction should consist of strong side bending with rocking motion to separate and dislodge catch.

CHAPTER 5

LESIONS OF THE THORACIC VERTEBRAE

The typical Thoracic vertebrae increase in size from above downward. The most distinguishing features are the depressions on the bodies and transverse processes respectively for reception of the head and tubercles of the ribs. The spinous processes are long, directed obliquely downward and end in tuberculated extremities. The superior articular facets face backward and a little upward and lateralward. The inferior articular facets face forward, downward and mediaIward. The transverse processes are thick, strong and project obliquely backward and lateralward. (Note) The inferior articular facets of the twelfth thoracic partake of the nature of the lumbar vertebra.

All movements in the thoracic area are restricted to reduce interference with respiration. According to Gray the almost complete absence of an upward inclination of the superior articular facets prohibits any marked flexion, while extension is checked by the contact of the inferior articular margins with the laminae and the contact of the spinous processes with one another. Rotation is quite free around a vertical axis drawn thru the mid-ventral line of the bodies of the vertebra. Rotation and sidebending are always combined but one may preponderate depending upon which is the primary movement. Flexion, extension and side-bending are more free in the lower thoracic area and rotation in the upper thoracic region. The thoracic spine is convex posteriorly. This is due largely to the fact that the bodies of the vertebra are slightly thicker behind than in front. The thoracic spine is first to lock in extension and the last to lock in extreme flexion of the entire spine.

Lesions of the Thoracic Vertebrae:

1. Flexion Lesions.

2. Extension Lesions.

3. Rotation Sidebending Lesions to the Right or Left.

4. Sidebending Rotation Lesion to the Right or Left.

Forbes says that although rotation and sidebending are invariably combined and one never occurs without the other, yet the direction and amount of each varies, depending upon which is the primary movement. Furthermore, when the upper half of the dorsal column is drawn to the left and down to make a lateral curvature, convex to right, the bodies of the vertebra are directed to the convexity of the lateral curvature. This is true in all lateral curvatures in the thoracic area when primary movement is sidebending and rotation is secondary. Although an invariable accompaniment of sidebending. He further states that when rotation is the primary movement and the bodies of the vertebrae look to the concavity of the lateral curvature, which makes a lateral curvature convex to the left. In this case the bodies of the vertebrae look to the concavity of the lateral curvature. This condition is properly considered a lateral curvature, but a rotation and the sidebending, although an invariable accompaniment is secondary to the rotation.

A structural curvature of the thoracic area is characterized by a rotation of the body to the convexity; a functional curvature by rotation to the concavity. A functional movement of sidebending rotation is possible however in the thoracic area in flexion in which the body rotates to the convexity. This movement is found most frequently in the mid dorsal area.

THE FLEXION LESION syn. BILATERALLY ANTERIOR LESION.

The Flexion lesion is an immobilization of the vertebra in a position of flexion. It is Bilaterally Anterior if considered from the relative position of the inferior articular facets of the vertebra in lesion with the superior of the vertebra below. However from its relative change in position in the dorsal column (the obliquity of the spinous process is decreased and the convexity of the thoracic curve increased) it assumes greater prominence posteriorly and is therefore considered by many as an en masse posterior lesion. It may be single or in group formation with production of Dorsal Kyphosis.

Etiology. Sudden strain with dorsal spine in position of flexion, trauma, infections, lifting heavy weights, are some of the many causes of individual lesions. The group lesion is usually formed by a gradual process extending over a long period of time. Occupation, faulty postural habits, atomicity of the extensors, hyper-tonicity of the flexors, etc., are predisposing factors.

Diagnosis. The spinous process is now posterior (less oblique), separated from vertebra below, and approximated with vertebra above.

The body of vertebra is slightly tilted and anterior superior margin is somewhat anterior.

The inter-vertebral disc is compressed anteriorly and under tension posteriorly. The articular facets have moved bilaterally upward and forward together with some separation of the articular surfaces posteriorly due to the tipping and different level maintained by the vertebra in lesion.

The posterior ligaments according to Ashmore are stretched, thinned and atrophied, the anterior thickened and contracted.

Restriction of motion with vertebra below is such that the amount of separation of spinous processes cannot be changed. Movement is free between vertebra in lesion and one above although there is approximation of the spinous processes. In the group lesion the convexity of the normal thoracic curve is increased (kyphosis).

Treatment. Flexion lesions of the dorsal area can best be reduced with the patient sitting or prone on the table. When possible preparatory extension should be made and adjustment followed out with patient in this position. Direct Action technic preferable in the nature of a thrust should be used. In the dorsal area it should not be delivered against the spine but against the transverse process either one side at a time or both sides at the same time, that depending upon the method used by operator. The applied force should be directed inferiorly and forward at an angle of about 140° to the planes of articulation. With patient in the position operator should staid at head of table facing buttocks.

THE EXTENSION LESION syn. BILATERALLY POSTERIOR

The Extension Lesion is an immobilization of a vertebra in the position of extension. It is Bilaterally Posterior if considered from the relative position of the inferior articular facets of the vertebra in lesion with the superior of the vertebra below. However, from its relative change in position in the dorsal column (the obliquity of the spinous process is increased and the convexity of the dorsal curve decreased) it assumes less prominence posteriorly and is therefore considered by many as a mass anterior lesion. It may occur singly or in group formation with production of Dorsal Lordosis.

Etiology. Primary extension lesions of individual vertebra are less common than primary flexion lesions.

Secondary lesions, compensatory in character, are frequent following the formation of a flexion lesion below. Trauma, falls, wrenches, muscular contractures or inflammations may be predisposing factors in the production of primary lesions. The group extension lesion is invariably secondary to a flexion lesion elsewhere, a typical example being the straight spine. It may be associated with such conditions as posterior sacrum, abdominal obesity, congenital dislocations of the femur, etc.

Diagnosis. The spinous process is less prominent posteriorly being directed more obliquely downward. It is separated from vertebra above and approximated with vertebra below.

The body of vertebra is slightly tilted downward and backward from before backward so that the anterior inferior margin is somewhat posterior.

The inter-vertebral disc is compressed posteriorly and under decompressed anteriorly.

The articular facets have moved bilaterally downward and backward together with some separation of the articular surfaces anteriorly due to tipping and different level maintained by the vertebra in lesion. In the chronic group lesion the anterior longitudinal ligament is stretched and atrophied and the posterior shortened and thickened. Corresponding changes are found in the muscles.

Treatment. The extension lesion cannot be corrected specifically by Direct Action Technic but rather by indirect methods usually by means of strong flexion bringing the greatest degree of tension upon the vertebra or vertebrae in lesion. If lesion is secondary to flexion lesion elsewhere it is necessary to correct the primary lesion first. A thrust should not be given to lesion directly but may be used advantageously at times above and below lesion. In group lesions with weak musculature physiological and corrective exercises should be given i.e. hugging exercise — patient grasping own shoulder blades firmly. The matter of posture should also be gone into with patient.

The vertex pressure movement described by Ashmore may be used for upper dorsal. Modifications of this technic may be used as long as the principles of adjustment are correctly applied. The operator should remember to carry out a degree of flexion which brings the greatest stress upon the articulation in lesion and make the direction of this approximating force so as to pass thru the body of the vertebra in lesion and anterior to the nucleus pulposus of inter-vertebral disc.

The following method is very valuable. Patient sitting back of operator with hands clasped over base of skull in area over occipital protuberance. Operator should pass arms under patient's axilla and allow the hands to rest over those of the patient. Instruct patient to take a deep breath. At the end of the expiration the operator should left patient slightly with arms tightly pressed against axilla. With patient in this position of slight traction give sudden, forceful flexion of the head with hands gagging your flexion so as to bring the greatest tension upon the vertebra in lesion.

Lesions of the lower thoracic may be corrected by the same principles as is used in the vertex pressure technic. Patient's hands should be clasped over cervical column for purpose of protection and also to shorten leverage. Then forward flexion should be carried out until the vertebra in lesion is under the greatest amount of tension. Adjust downward, backward, approximational pressure so that the direction of force is transmitted thru the body of the vertebra and inter vertebral disc anterior to the nucleus pulposus.
A good method for the correction of the individual lesion of the lower dorsal area is as follows: Patient on side in position similar to the sidebending rolling or torsion movement used in correction of sidebending lesions in the lumbar area. Patient's upper limb should be thrown over semi-flexed lower limb so that upper thigh falls across under thigh above knee and remainder of upper extremity falls unsupported over the edge of table. Patient's upper shoulder girdle should be pushed backward with fleshy portion of operators forearm. Care should be taken so as to lock lumbar area and lower dorsal in flexion up to and including the vertebra below lesion. The dorsal area down to and including the vertebra in lesion should be locked in extension. With patient in this position downward and forward thrust should be given to upper transverse process of vertebra below lesion. Follow by the same technic on opposite side.

In the group extension lesion of the dorsal area i.e., the straight spine, considerable benefit may be derived from Forbe's method of placing the patient on the side and making diagonal transverse pressure upon the lateral aspect of the ribs consonant with deep inspiration upon part of patient.

A SIDEBENDING LESION is a lesion maintained in primary sidebending and secondary rotation. Sidebending in the thoracic area follows forward flexion and is slight in the upper dorsal but may easily occur in the lower dorsal region, Strong lateral wrenches or strains with the patient in a position of flexion will produce this lesion.

A ROTATION LESION is a subluxation of a vertebra in primary rotation and secondary sidebending. The Rotation Lesion predominates in the thoracic area.

Differential Diagnosis:

Third Dorsal Sidebent to Right

1. Vertebra tilted to right.

2. Spinous process to right toward concavity.

3. Bodies rotate to left toward convexity.

4. Right transverse process moves downward; left transverse process moves upward and backward. Left most prominent.

5. Left third rib posterior to adjacent ribs and approximated to second rib of same side. Right third rib anterior and approximated to fourth of same side.

6. Inter-vertebral disc compressed on the right.

7. Occurs in flexion with strong sidebending to the right.

Third Dorsal Rotated to Right

1. Vertebra tilted to right.

2. Spinous process to left.

3. Bodies rotate to right.

4. Left transverse process moves upward and forward; right downward and backward. Right most prominent.

5. Right third rib posterior to adjacent ribs and approximated to fourth rib of same side. Left third rib anterior and approximated to second of same side.

6. Inter-vertebral disc compressed on right.

Note:- The main point to remember in a differential diagnosis between primary rotation and sidebending in the dorsal area is that in rotation to the right and in a sidebending to the right a tilting to the right but a rotation to the left. Moreover that this lesion is typical only to the dorsal area in a position of flexion.

Treatment. Rotation lesions of the first to fourth thoracic inclusive. Patient sitting. Objective: transverse process which is posterior. Applied force: pisiform bone of proximal hand. Place opposite hand firmly over vertex and forearm alongside of head and neck with chin lying in apex of semi-flexed elbow. Then flex head and cervical column and follow with strong rotation and sidebending until slack is completely taken up. Then adjust at the end of expiration with sudden vigorous downward, backward and slightly lateralward approximation on vertex together with upward forward thrust against the vertebra in lesion.

Another very good method for the adjustment of the same lesion is as follows: Hypothetical lesion of the Third Dorsal rotated unilaterally anterior on the right, posterior on the left. (Rotation Lesion to the Left.) Patient sitting on stool, operator on table facing the patient's back. Operator should place the thumb of right hand against the right side of spinous process of vertebra in lesion. Patient's left axilla should be over operator's semi-flexed knee and patient sidebent to that side. Patient's right arm should hang limply over left thigh. Operator should make complete circumduction of patient's head ending with head and cervical column in position of sidebending to the right. Adjust at the end of expiration with downward, backward and slightly lateralward approximation upon vertex of head with left hand and strong pressure and thrust against right side of spinous process of vertebra in lesion with thumb of right hand.

Technic for the correction of Rotation Lesions of Fifth to Eleventh inclusive.

Patient sitting. Objective: transverse process which is posterior. Applied force: pisiform bone. Have patient interlock arms. Operator then passes his arm between patient's interlocked arms and grasps the shoulder of opposite side firmly. Then flex, sidebend and rotate toward anterior side. This exaggerates and to a limited extent retraces pathway of lesion movement. Then adjust at the end of expiration with the patient in above position making upward forward thrust against transverse process which is posterior with pisiform bone of proximal hand.

Correction of same with patient in prone position:

Double thrust. Hypothetical lesion of the sixth Dorsal, rotated unilaterally anterior on the right, posterior on the left. (Rotation Lesion to the Left.) Operator stands at the left side of patient places pisiform bone of right: hand firmly against the transverse process which is posterior. Operator then places pisiform bone of left hand against right transverse process of vertebra below lesion. At the end of expiration a double thrust is given. However the maximum and essential thrust should be upward and forward upon posterior transverse process of vertebra in lesion.
The sidebending lesions of the thoracic area should be corrected by the same method as described for the correction of rotation lesions which is as follows:- A Side-bending Lesion to the Right should be corrected as a rotation to the Left. It is a good plan to follow up this technic with strong physiologic. movements of spine which tend to retrace the pathway of the primary lesion movement. The applied force should be directed interiorly and forward with transverse process which has moved upward and backward as the objective.

CHAPTER 6

SACRO-ILIAC LESIONS.

THE SACRO-ILIAC JOINT IS AMPHIARTHRODIAL. It is covered by a rudimentary synovial membrane and is capable of slight yielding motion, especially in flexion, due to the elasticity of the sacro-iliac ligaments. Structurally the sacro-iliac articulation has the characteristics of a double keystone. The anterior superior spine and the symphysis pubis are in a perpendicular plane parallel to the line of gravity of the body. The sacrum is suspended by ligaments and has some extent the characteristic of a wedge. Motion is physiologically increased in females near parturition because of the softening and relaxation of these ligaments. Prof. Montgomery of Harvard mentions the fact that there is proneness of sacroiliac subluxations in pregnant women.

Ligaments of Importance:- The Posterior Sacro-Iliac Ligament is exceptionally strong and is the chief bond of union between the sacrum and ilium. It consists of three sets of fibers: (a) Superficial Horizontal. (b) Deep Horizontal. (c) Oblique. The superficial fibers connect the first and second transverse tubercle of the back of the sacrum to the tuberosity of the ilium, and the deep fibers are immediately internal to the superficial. The oblique fibers connect the third transverse tubercle of the sacrum to the posterior superior spine of the ilium.

The Anterior Sacro-iliac is a weak ligament composed of thin bands attaching the anterior part of the sacrum to the pre-auricular sulcus and margin of auricular surface of the ilium.

The ilio-femoral Ligament is the strongest ligament in the body. It attaches above to the anterior inferior iliac spine, below divides Y shaped, one hand attaching to the great trochanter and the other to the inter-trochanteric line. "The ilio-femoral ligament is the chief agent in maintaining the erect position without muscular fatigue, for a vertical line passing the center of gravity of the trunk, falls behind the center of rotation of the hip joint, therefore the pelvis tends to fall backward but is prevented by the tension of the ilio-femoral ligaments." (Gray's anatomy)

The Ilio-lumbar Ligament is attached to the front part of the fifth lumbar vertebra; laterally it divides and is attached by two bands to the ilium. Other ligaments of less importance will not be considered here.

Lesions of the Sacro Iliac Articulation:

1. Positional, as regards the sacrum.

a) Bilaterally Anterior Sacrum

b) Bilaterally Posterior Sacrum

c) Unilaterally Anterior Sacrum

d) Unilaterally Posterior Sacrum

2. Positional, in the same order as above but from the standpoint of the innominates.

e) Bilaterally Posterior Innominate

f) Bilaterally Anterior Innominate

g) Unilaterally Posterior Innominate (Pseudo-twisted pelvis)

h) Unilaterally Anterior Innominate (Pseudo-twisted pelvis)

i) True Twisted Pelvis

THE BILATERALLY ANTERIOR SACRUM
(Synonym, BILATERALLY POSTERIOR INNOMINATE.)

This lesion is more common than the Diagnosis. This is due to the difficulty in verifying the condition, consequently this lesion frequently escapes the notice of the examiner. Tucker says that over 90% of sacro-iliac lesions are either bilateral or unilateral sacrums. Frost maintains that they are usually antedate unilateral conditions.

Etiology. The majority of predisposing factors are chronic in character, their formation being a long continued process of change. A few of the causes may be as follows: straight spine, pot belly, lumbar lordosis, faulty posture, round shoulders with flat chest and depressed ribs, fallen arches, bilateral weakness of the flexors or hypertonicity of the extensors, vertical line of gravity anterior to normal. A much smaller percentage of bilaterally anterior sacrums may be due to traumatism, falls, etc. The reason for the much creator percentage of anterior lesions of the sacrum is because of the direction of the lesioning forces in relation to the pelvic structures. Forces directed upward through the acetabulum would tend to force the innominated upward and backward and the body weight would tend to force the sacrum downward and forward if the movement was gliding or arthrodial. If the movement was rotation the axis of rotation or fulcrum would be through the sacro-iliac joint and the second sacral segment.

The Lesion consists of a slight slipping downward and forward of the sacrum on the ilia, together with a rotation through the second sacral segment. This occurs bilaterally. The ligaments in connection with this joint may be placed on tension or relaxed according to whether their attachments are approximated or separated.

Diagnosis. The diagnosis is not easy. The two most noticeable factors are, increase in the sacro-vertebral angle and decrease in the pelvic inclination (normal 30° or 40° in horizontal position, before backward, line drawn from symphysis pubis through posterior superior spine of the ilium. The antero-posterior diameter is lessened (normal 4.25inch to 4.7inch i.e. 10.8cm to 12cm). Motion in the joint is limited. The base of the sacrum is downward and forward and the apex is upward and backward. The posterior superior spines are more prominent posteriorly and are nearer together. (normal approximations are 3.25" to 3.75" i.e. 8.25cm to 9.5cm.) The iliac crests are more flaring superiorly and the anterior superior apines farther apart (normal distance 8 1/2" to 9 1/2" i.e. 21.5cm to 24cm). The fifth lumbar has the appearance of being markedly anterior, the spine of the fourth overlapping the fifth and approximating it. With the patient supine, both feet are strongly everted. The apex of the angle formed by the junction of the ilium and sacrum on the posterior aspect is the seat of localized tenderness. In bilateral lesions both junctions are sensitive. The sacro-tuberous and spinatous ligaments are tense. Examination should be directed above and below the lesion to disclose etiological factors.

Treatment. Patient prone (face down, on table). Legs should be slightly abducted multi-D feet everted. Pillows should be placed under the thighs to obtain ilio-fem-oral leverage. Operator may apply direct pressure to apex of sacrum. Still better, the operator can, by standing on a stool at the side of the table apply pressure by knee to the apex of the sacrum and use his hands to exert pressure against ilia in outward forward rotary movement, thumb behind posterior superior spine, fingers along upper border of ilium. To enhance the value of this treatment have the patient place his hands on the table and slowly and strongly extend as operator applies extra pressure to ilia, and return slowly to the prone position when extra sacral pressure is applied to the apex. This lesion can be corrected as a unilaterally posterior innominate of first one side and then the other. Predisposing causes must be removed to obtain any permanent results.

THE BILATERALLY POSTERIOR SACRUM
(Synonym: BILATERALLY ANTERIOR IN-NOMINATE.)

This is a rare condition consisting of an upward and backward rotation of the base of the sacrum. It is an extension lesion of the sacrum increasing the longitudinal axis. The false pelvis is broader, the diameter of the inlet larger and the outlet smaller. Both innominates are downward and forward, the converse of the sacrum. Rotation is through the sacro-iliac joint and second sacral segment.

Etiology. The causes are usually chronic, a few of which are: posterior lumbar, atonicity of the flexors, hyper-tonicity of the extensors, lines of gravity posterior to normal, parturition, faulty sitting especially extreme slouching with the weight resting on the apex of the sacrum. Bedridden patients who have spent a long time on their backs. Etherization without a lumbar pad. The usual forms of trauma.

Diagnosis. In the main is conversely that of the bilaterally anterior sacrum. The sacro-vertebral angle is decreased and the pelvic inclination increased. The fifth lumbar and the base of the sacrum are more prominent posteriorly. The apex of the sacrum is more anterior. The sacro-tuberous and spinatous ligaments are relaxed. The posterior superior spines are further apart, not so prominent and at a higher level. The anterior superior spines are at a lower level and the distance between them is increased although mensuration does not always show this. The crests flare more anteriorly than normal. Motion is limited in the joint. With the patient on his back the feet tend to relax in inversion. There is considerable tenderness along the inner border of posterior portion of the crests of the ilia. The sacroiliac junction, "Sacro-iliac", shows decrease in its posterior angle, the angle being more obtuse and the apex less acute. The nature of the predisposing causes may aid in the Diagnosis.

Treatment. Patient on back. Then eminence of partially closed hand against base of sacrum. The arm of the other hand flexed at right angles and placed across the anterior superior spines. Hand grasping one ilia and the fleshy portion of the forearm just medial to point of elbow (belly of flexor digitorum profundus) against opposite. Pressure and counter pressure upward on the base of the sacrum and downward and outward on the ilia. This condition may be corrected unilaterally first one side then the other. Attention must be given to predisposing causes, elimination of which are necessary for permanent correction.

THE BILATERALLY POSTERIOR SACRUM
(Synonym: BILATERALLY POSTERIOR IN-NOMINATE.)

This lesion is a torsion movement thru the second sacral segment, a true rotation movement is not possible. A gliding movement is downward and forward on the side of the lesion and portions of sacro-iliac ligaments allowing this movement are weak and stretched. This is particularly true of the fibers of the posterior sacro-iliac ligament. There cannot be a lesion of one side without compensatory changes of the other. The movement is complex and asymmetrical. There is a tendency toward separation between the sacrum and the ilium posteriorly on the side opposite the lesion, the same holds true anteriorly on the side in lesion. The 5th lumbar is rotated, the spine opposite to the side of the lesion due to the pull of the ilio-lumbar ligament. The 12th rib on the side of the lesion is usually in lesion due to the pull and contracture of the quadratus lumborum and lateral spinal muscles.

Etiology. Unequal muscular tonicity, unilateral hyper-tonicity of extensors, atomicity of flexors, unequal ligamentous tension of sacro-iliac ligaments, torsion forces, sudden wrenches, falls, occupational and postural anomalies, scoliosis, functional curvature, rachitic children.

Diagnosis. Patient sitting, the posterior superior spine is more prominent at lower level and nearer the median line of the body. The sacro-iliac joint on the side of the lesion is more sensitive than the opposite. Tenderness is found on side opposite the lesion along the inner border of the crest. Patient on face: compensatory functional curvature in the lumbar area shows up, the convexity on the lesion. Patient on back, side opposite the lesion appears higher off table except leg which appears nearer to the table due to the relative position of the acetabula. The ilium opposite side of the lesion flares more anteriorly and the anterior superior spine and crest is at a lower level. The silo in lesion appears to hug the body more, making the hip look smaller than the opposite. There is a slight difference at the symphysis pubis, the side in lesion being slightly elevated. The buttock on lesion side is at a lower level than its fellow of the opposite side. The leg on the side of the lesion is shorter and the foot is everted (due to the pull of the sartorius muscle.) Standing, the shoulder of the patient on the side of the lesion is lower than the opposite shoulder. Muscular tension in the lateral spinal muscles of the lumbar area is more pronounced on the lesioned side. Motion is decreased in the lesioned joint. Test for motion with patient prone, sitting or standing. There is marked sensitiveness at the point of division of the gastrocnemius muscle.

Treatment. (a) Patient face down, place pillow under thighs, legs slightly in abduction, foot everted (pull thru ilio-femoral ligament). Counter pressure, one hand on the lower portion of the sacrum, the other against the posterior superior spine of the ilium. The patient can aid by attempting torsion movement... try to turn toward the side of lesion using to some extent the aria on the lesioned side.

(b) Patient on Back: Pillow under sacrum and posterior superior spines, the operator standing beside the patient on the side of the lesion. Then flex the leg on the thigh and the thigh on the abdomen slightly beyond a right angle with the table — so that the point of the knee is in the same vertical plane as the highest portion of the iliac crest. Interlock fingers and make a thrust downward, forward and medialward in the same plane as that in which the thigh is held. Patient should be instructed to breathe deeply. The thrust should be given at the end of expiration.

(c) Another very good method is as follows: Patient on back, lesion side near the end of the table and operator on the same side facing the head of the table. The fingers of the hand distal to the table should be placed underneath the posterior superior spine and the heel of the hand should rest underneath the head of the femur. The leg and thigh on the side of the table. The proximal hand should hold the opposite innominate firmly to the table, the thumb over the pubis and the fingers along the crest of the ilium. The thumb over the pubis helps to determine when corrective movement in the lesion occurs. The operator should straddle the patient's thigh and hold it firmly in slight abduction and inversion. The leg and the foot should be held firmly in the same position. Then corrective force should be applied in intermittent extension of the thigh with concomitant outward and upward pressure of the fingers of the distal hand and firm pressure with the proximal hand. The leverage with the use of the thigh in this position is tremendous, causing tension of the ilio-femoral ligament, adductor muscles, and a portion of the quadratus femoris, iliacus, psoas major etc. This technic if carefully and correctly applied is of value.

(d) The whip motion with the patient on his back, often corrects. With the leg and thigh in flexion and at right angles and at the limit of adduction, the patient is instructed to kick out vigorously and at the same time the operator extends the limb forcibly. This should be done in the straight longitudinal axis of the body. With the patient on his back, the operator should place one hand under the femur on the anterior medial aspect of the knee to keep the leg in abduction... The best hold for forcible extensions is just above the ankle. Forcible extension alone is sometimes tried with the patient on the side.

(e) Sitting up: Swart's strap technic for the posterior innominate is of value. It consists in passing the strap across the lesioned hip just below the crest of the ilium and on the opposite side above the crest of the ilium (so the strap on that side does not touch the ilium) and then by passing the strap around the patient's heel on the side of the lesion. The strap is then buckled, short enough so that the patient's leg will be about one third flexed. The patient should then attempt to straighten the lag by forcible pressure against the strap.

(f) Standing: Place the patient against the wall. hake pressure against the posterior superior spine in lesion, and counter extension of the thigh on the same side. The same principle as in Technic (c).

Before or after the correction of the innominate, the fifth lumbar vertebra should be corrected as there is always an accompanying twist of this segment, the spine to the side opposite the lesion. In this connection attention should also be directed to the twelfth rib which is many times pulled down by contraction of the quadratus lumborum.

THE UNILATERALLY POSTERIOR SACRUM
(Synonym: UNILATERALLY ANTERIOR IN-NOMINATE.)

The twisted Pelvis: This is a torsion lesion consisting of an upward and backward rotation of the innominate. The fifth lumbar vertebra is rotated less markedly than in the unilaterally posterior innominate, but whatever rotation is found is usually anterior on the side in lesion making the spinous process more marked on that side. Whether or not there is a lesion of the twelfth rib on the side opposite the lesion depends upon the pull of the quadratus lumborum. There are always compensatory changes on the opposite side just the reverse of those found in the unilaterally anterior sacrum.

Etiology. Atonicity of extensors or hypertonicity of flexors. Sacro-iliac strain, torsion forces, trauma, falls, wrenches, etc. The factors causing the bilaterally posterior sacrum may cause unilateral lesions.

Diagnosis. Patient in sitting position. The posterior superior spine is less prominent and at a higher level and also further from the median line of the body. There is sensitiveness along the inner border of the iliac crest. With the patient on his face a functional curvature will be easily recognized. With the patient on his back, the thigh on the side of the lesion is not so high off the table as that on the good side. Patient prone the buttock of the lesion side is at a higher level than its opposite fellow. The iliac crest on the lesion side flares more anteriorly and the anterior superior spina is at a lower level. The lesioned side appears larger than the opposite (patient will often notice this). There may be detected a slight difference at the pubic junction, the side of the lesion being at a lower level. The lag on the side of the lesion is longer, and the foot tends more to inversion. With the patient standing the high shoulder is on the side of the lesion. Motion in the joint is limited. Subjective symptoms vary. Note: Confusion sometimes exists in the diagnosis of the twisted pelvis as to whether the prime lesion is an anterior innominate on one side or a posterior of the opposite. The physician must use good judgment in case there is any doubt. Three valuable points to base a diagnosis on are:-

1. Subjective symptoms,

2. Sensitiveness and,

3. Amount of structural perversion.

The physician could well assume that the side in which the above factors are more pronounced is the lesioned side. If all doubts cannot be cleared up it is advisable to correct both sides.

Treatment. Patient sitting with back to operator. Grasp the innominate (iliac crest) firmly in the proximal hand, the tips of the fingers in the depressions below the anterior superior spine, the palm of the hand along the crest and the thumb in the depression under the posterior superior spine. Note: If the operator's hand is not large enough to accomplish the above modify to suit convenience. Instruct the patient to hold his arms across his chest. Next, the distal hand of the operator should grasp the patient's shoulder on the side of the lesion with the forearm against the patient's chest. Holding the innominate firmly, bring the patient forward into the limit of flexion. The patient should be instructed to relax and allow the entire weight to rest on the operator’s forearm before making the above move. From the point of extreme flexion a sweeping rotation should be made toward the side opposite the lesion. At the completion of this move the lesion should be corrected.

Patient slightly on the non-lesioned side. The leg and thigh on the side of the lesion flexed and abducted. The operator facing the patient on the side opposite the lesion, grasps the leg and encircles the body with it so that the angle of the flexed knee is against the operator's side (side nearest the head of the table), Upward and forward pull is exerted upon the ischial tuberosity with the hand distal to the head of the table. The forearm and arm proximal to the head of the table holds the thigh firmly against the side making consonant with above, extension of thigh by means of the body in the same plane that thigh is held (adducted and flexed). Counter pressure should be brought against the anterior superior spine and crest with the proximal hand. The patient should be instructed at the beginning of the manipulation to turn toward the operator as much as is possible and then relax.

ANTERIOR INNOMINATE. Patient on the lesioned side with the lesioned thigh flexed strongly against the abdomen. The operator should place his knee against the base of the sacrum. One hand should grasp the shoulder firmly holding the torso in slight forward rotation to the uppermost side. The other hand should grasp the flexed knee firmly and exert a quick strong adduction in an upward and backward pull just inside of the limit of motion.

THE TWISTED PELVIS PROPER. Syn. TRUE TWISTED PELVIS.

The True Twisted Pelvis is an anterior lesion of one innominate, posterior Iesion of the other, a rotation of the fifth Lumbar spine toward the side anterior and a deflexion of the Coccyx toward the posterior side: clinically important inasmuch as it cannot be permanently corrected until all of the above factors have been reduced.

The Ture Twisted Pelvis and the Pseudo Twisted Pelvis differ in that the pseudo twisted pelvis may be corrected by the reduction of the prime lesion only. It is only a matter of time before a pseudo twisted pelvis becomes a true twisted pelvis, therefore clinically the differential diagnosis would be made upon the chronicity of the condition. This in turn to be ascertained from the history, subjective and objective symptoms. One very important feature is the presence or absence of a lumbar functional curve. To detect this have the patient lie face down upon the table completely relaxed. If found it is a very good sign that the lesion is chronic.

The lesion should be corrected in the following order: (1) Anterior In-nominate. (2) Fifth Lumbar. (3) Posterior Innominate. (4) Coccyx. (Note: the Ant. Innominate and the Fifth L. may be corrected together.)

Technic. (Anterior Innominate and Fifth Lumbar.)

Operator should instruct patient to lie on side facing him, the anterior innominate uppermost. The fifth lumbar spine is rotated upward away from the table. Patient is instructed to flex under leg at both knee and thigh and then flex upper thigh allowing it to lie across the under leg and to drop perfectly relaxed over the edge of the table. Operator should place his forearm against shoulder girdle and rotate spine backward to limit of motion. Operator should then place forearm of arm proximal to hip against tuberosity of ischium of anterior innominate and then place thumb against the spine of the fifth lumbar. With-spine at limit of torsion thrust should be made, downward, forward, and slightly backward against the ischium, at the same time steady, firm, downward pressure is maintained against the side of the spinous process of the fifth lumbar.

Technic for the correction of Posterior Innominate has been previously described.

Technic for correction of Deflected Coccyx: Operator should place patient on face and correct by lateral pressure against coccyx. Rectal treatment should never be given unless absolutely necessary.

Note: Operator should also give due attention to the twelfth Rib on the side of the Posterior Innominate and also functional curvatures in the lumbar spine. Technic for Depressed Twelfth Rib is given under Rib Lesions, Chapter 7. Strong lateral sidebending toward side of anterior innominate for functional curvature.

Technic for Posterior of Anterior Innominate:

Patient prone. Operator stands opposite side to be adjusted. The leg on lesioned side should be flexed to right angles, adducted to angle of 45°. This produces a leverage through the external rotators of the thigh and the ilio-femoral and capsular ligaments. This tends to create a gapping of the sacro-iliac articulation. Synchronously with this movement a thrust should be given against the posterior superior spine if correction for a posterior innominate is desired. If an anterior innominate, thrust should be given against the base of the sacrum on the lesioned side.

CHAPTER 7

RIB LESIONS.

The costo-transverse articulations and the articulations of the heads of the ribs are arthrodial in character. The heads of the ribs are bound down to the bodies of the vertebrae very tightly by the radiate and interarticular ligaments but allow a slight gliding movement. The same holds true of the costo-transverse articulations.

Movements:- may be classified as follows,

1. Pump handle.

2. Bucket handle.

3. Combined bucket handle and pump handle.

4. Enarthrodial.

Pump Handle Movement:- In inspiration and expiration the ribs revolve on a transverse axis drawn thru the costa-transverse and costo-vertebral articulation. This results in a rotation of the rib on a long axis the tubercle and head of the rib acting in a hinge like manner, the latter having also a screwing motion. This movement increases the antero-posterior diameter of the thoracic cavity and does not materially affect the transverse. (See Gray's Anatomy, Pg. 399-402 or diagrams C-D Fig. 440.)

Bucket Handle Movement:- In inspiration and expiration the motion is a rotation on a plane thru the costo-transverse and costo-sternal junction. The rotation in the costo-transverse articulation is such that the tubercle moves upward, backward, and medialward. The head of the rib moves downward, outward and backward. From the costo-vertebral to the costo-transverse articulation is the short lever of the rib. From the costo-transverse to the costo-sternal articulation is the long lever. This movement causes an increase in the transverse diameter of the thoracic cavity and a decrease in the antero-posterior diameter unless associated with the pump handle movement. (See Gray's Anatomy Pg. 402 Fig. 4411-1-B.)

Combined Bucket Handle and Pump Handle Movement:- This movement is a combination of the pump handle and bucket handle movements with an increase in all diameters. The primary motion is a pump handle movement and this is followed by the bucket handle movement.

Enarthrodial Movement:- This refers to those ribs having free anterior extremities with corresponding slight movement in all directions, i.e. the 11th, and 12th floating ribs.

1. According to their attachments ribs are divided into three classes:

2. Vertebro-sternal or True Ribs (7 in number).

3. Vertebro-chondral; articulating with the ensiform (3 in number).

4. Vertebral or floating ribs (2 in number).

Vertebro-sternal Ribs:-
(a) First Rib. Forced inspiration results in a pump handle movement of the rib causing the sternum to be carried upward and forward. The head is very moveable and has no interarticular ligament. Movement of this rib results in an increase in the antero-poster diameter only.
(b) Second Rib. The sternal attachment is less rigid and the middle of the rib can also be drawn up allowing slight increase in the transverse as well as the antero-postero diameter.
(c) Third, Fourth, Fifth, Sixth Ribs. These ribs are elevated by a combined pump and bucket handle movement increasing all diameters. The primary motion is a pump handle movement and this is followed secondarily by a bucket handle movement.

Vertebro-chondral Ribs:-
(The 7th, Rib is included in this group.) Seventh, Eighth., Ninth, Tenth Ribs are elevated by a bucket handle movement only increasing the transverse and the lateral antero-postero diameters but decreasing the median antero-postero diameter.

Vertebral Ribs:- Eleventh and Twelfth, floating ribs. These ribs have enarthro-dial joints and ore capable of slight movement in all directions. They are depressed when others are elevated to form fixed points for action, of the diaphragm. Normally the tip of the twelfth rib lies two inches above the middle of the crest of the ilium.

Muscles of Respiration:-
These are divided into two classes, viz;

1. Muscles of ordinary respiration.

2. Muscles of forced respiration.

The muscles of ordinary inspiration are:

i. Scalenes Group, (Anticus, Posticus and Medius)

ii. Serratus Posticus, (Superior and Inferior)

iii. External Intercostals.

iv. Levatores Costorum.

v. Diaphragm.

vi. Quadratus Lumborum.

The muscles of ordinary expiration are: Internal Intercostals.

The muscles of forced inspiration are:

i. Pectoralis Major and Minor.

ii. Serratus Anticus.

iii. Sternocleido mastoideus.

vii. The muscles which extend the cervical region.

The muscles of forced expiration are: Abdominal

LESIONS OF THE RIBS.

Pump Handle Lesion:- (Elevated) A lesion wherein the rib is elevated anteriorly with downward backward rotation posteriorly on the transverse process of the first dorsal vertebra. Although theoretically- possible it is seldom if ever found.

Pump Handle Lesion:- (Depressed) A lesion wherein the rib is depressed anteriorly with upward and backward rotation posteriorly on the transverse process of the first dorsal vertebra. This lesion is more common than the above and is usually due to trauma, posture or forces of gravity.

Inspiration Lesion is any rib (2nd. to the 10th. inclusive) maintained in forced or exaggerated inspiration. The axis of rotation of the lesion depends upon the particular rib involved.

Lesions of the Second to Sixth Rib Inclusive: may be divided into:

1. Inspiration Lesions, may be one of the following;

1. Pump Handle.

2. Bucket Handle.

3. Combined Pump and Bucket Handle.

2. Expiration Lesions, the same lesions may occur in expiration in reverse form.

Lesions of the Seventh to Tenth Ribs Inclusive; are either inspirational or expirational. The axis of movement is bucket handle in character making the lesions of this area bucket handle lesions.

Lesions of the Eleventh and Twelfth Ribs may be in any direction as the above ribs have little movement in any direction. The most common lesions are:-

1. Depressed and rotated on long axis with the free and downward and the upper border outward, and the lower border inward.

2. Elevated and rotated on the long axis with the free end upward, the upper border inward and the lower border outward.

Inspiration Bucket Handle Lesion may occur in any rib second to the tenth inclusive, and is more common in the seventh, eighth, ninth and tenth ribs. The movement is on an axis drawn from the costo-transverse articulation thru the sternal junction. The rib bulges laterally, the outer surface moves upward and outward, the lower border turns outward and the upper border inward. There is a separation below with the adjacent rib above, and approximation with the rib above.

Expiration Bucket Handle Lesion occurs in the same ribs but the movement is the reverse of the above causing the outer surface to move downward and outward, the lower border to turn inward and the upper border to turn outward. There is a separation with the rib above and an approximation with the rib below.

Inspiration Pump Handle Lesion affects the first to the sixth rib inclusively. The movement is a rotation on a transverse axis drawn thru the costo-transverse and costo-vertebral articulations. The rib is elevated and slightly thrust forward anteriorly with a downward and backward rotation of the neck of the rib on its longer axis.

Expiration Pump Handle Lesion occurs in the same ribs with a reverse rotation causing the rib to be depressed anteriorly with upward and backward rotation of the neck of the rib on its long axis.

Combined Pump and Bucket Handle Lesions may occur in any rib the second to the sixth inclusive. The movement takes place on both axes (pump and bucket Handle) causing combined diagnostic features of pump handle and bucket handle lesions. Combined lesions may be inspirational or expirational the rotation and movements of one being the reverse of the other. (Note: The causes of inspirational rib lesions may broadly be considered as inherent dynamic forces of the body; i.e. muscular contractures etc. The cause of expirational lesions may broadly be considered as external dynamic forces i.e. trauma.) Vertebral lesions may or may not be associated with rib lesions.

Treatment. The operator should base his corrective treatment upon the following factors, whether the lesion is inspirational or expirational or whether it is bucket handle or pump handle.

First and Second Ribs (Forced Inspirational Lesion.)

Technic. Patient sitting on the stool and the operator on the table behind the patient. Hypothetical lesion of the right side. The operator should place his left foot on the stool and flex the knee at right angles. The patient should be instructed to lean toward the left side, the patient’s axilla over the operator's knee. The thumb of the operator’s right hand should be placed firmly against the posterior portion of the tubercle of the rib. The operator's left hand should be placed upon the vertex of patient's head.
Circumduction of the cervical spine should be made in the following order: - extension, left lateral extension, side bending to the left, left lateral flexion, flexion and right lateral flexion. With the patient's neck in this position rotate the head so that the chin points toward the patient's left shoulder. Adjust at the end of expiration, by approximating downward pressure on the vertex and upward forward thrust of the thumb.

First and Second Ribs Depressed. The same method is followed out except adjustment is made with the cervical spine in right lateral extension and the thrust of the thumb should be downward and forward. (Note: Inspirational and expirational pump handle lesions of the third can be corrected by the same method as explained above; Bucket handle lesions of the second and third ribs can be corrected by the same method excepting that the thrust of the thumb should be downward and forward against the angle of the rib in inspirational lesions and upward and forward in expirational lesions.

Swart's Strap Technic. Patient sitting. Strap is passed over shoulder on lesioned side and buckled under corner of table. "Patient is instructed to flex then fall forward and toward the side of the lesion. Operator should be careful to note that pressure comes directly against tubercle rib.

Expirational, Combined Bucket and Pump Handle Lesion. The operator may use the same technic.

Technic. The patient sitting on the stool, the operator behind the patient sitting on the table. Hypothetical lesion on the right side. The thumb of the operator's left hand should be placed against the posterior portion of the angle of the rib. The operator then grasps the patient's right arm with his right hand so that the point of the patient's elbow rests in the operator's palm and the forearm of the patient is held at right angles to the arm. The operator instructs the patient to inhale slowly and deeply, at the same time he raises the shoulder girdle by upward pressure against the patient's elbow thereby creating tension of the following muscles: Rhomboidii, Pectorales, Trapesius, Serratus Anticus, and Latissimus Dorsi. The operator then brings the elbow forward and medialward across the chest. (The lower the lesion the greater the circle of movement.) The arm is now raised above the patient's head and the right hand and forearm of the patient is allowed to drop behind his neck so that the fingers touch the opposite shoulder creating particular tension upon the Serratus Anticus and the Pectoralis Major and Minor. The patient is now instructed to exhale. At the end of expiration the arm is allowed to drop to the desired point. This varies greatly — if the third rib it should be on a level with the shoulder; if lower it should be allowed to fall posteriorly and inferiorly. The lower the rib the lower and more posterior the point desired and the greater the sweep. The forearm is allowed to fall forward to the limit of motion causing rotation of the shoulder joint. The thumb of the left hand during this manipulation should maintain upward, forward pressure against the lower border of the posterior portion of the angle of the rib.

Inspirational Combined Bucket and Pump Handle Lesions and Bucket Handle Lesions:

Technic: Same technic is used except that the manipulation is reversed. Inhalation is carried to a point where exhalation commenced in the former and exhalation commences where inhalation stopped, the reverse of the above. The pressure of the operator's thumb should be downward and forward against the upper border of the posterior portion of the angle of the rib.

Expirational Pump Handle Lesions. — Teet's Technic: Patient on side. Lesion side uppermost, facing the operator. A Hypothetical lesion on the right. The operator's thumb is placed against the posterior portion of the angle of the rib. The upper border of the right thumb is placed against the lower border of the rib as near the sterno-costal junction as possible. Instruct the patient to inhale and exhale deeply, consonant with which the operator should bring lateral pressure against the rib with his chest. Beginning of inspiration. Pressure is exerted downward and. forward with the left thumb and upward and forward with the right thumb. The pressure should be maintained throughout but accentuated during expiration.
Patient on back: Arms adducted across chest, forearm flexed so that the points of the elbows are brought together in the median line and the hands are in contact with the opposite shoulder. Instruct the patient to breathe deeply. At the completion of exhalation the operator should bring downward and forward pressure on the patient's elbow with the right hand and chest at the same time downward and upward pressure is brought to bear upon the posterior superior position of the costo-transverse articulation with the pisiform bone of the left hand.

Expirational Bucket Handle Lesion. Hypothetical lesion on the right side. The patient on left side. The fingers of the right hand are placed beneath the lower border of the angle of the rib. The operator's left hand is placed under the lower border of the rib on the sternal end. Simultaneously with deep inspiration bring the arm up and back (held between the right arm and the body of the operator in manipulation) and bring strong upward pressure against the rib with the fingers of both hands. Hold firmly in this position as the patient exhales.

Inspirational Pump Handle Lesion. The same technic as used in the correction of expirational pump handle lesions except with reverse pressure of the thumb.

Lesions of the Seventh, Eighth, Ninth, Tenth Ribs. Use the technic described under expirational and inspirational bucket handle and pump handle lesions. Lesions in this area are bucket handle. The circle of movement of the arm is the same but correspondingly greater..

Lesions of the Eleventh and Twelfth Ribs. (1) Elevated and Rotated upward:
Technic. The patient sitting on the stool, the operator standing. Hypothetical sight side. The operator’s left foot is placed on the stool and the leg flexed at right angles. The operator should pass his left arm under the patient's right arm and encircle the patient's body, his left hand grasping the left side of the patient. Lateral rotation is made with the patient over the operator's at the same time his thumb is brought to bear against the superior border of the rib in lesion.

Ribs Depressed and Rotated Downward. The same movement as above only upward pull should be made upon the rib in lesion. Patch for a posterior innominate lesion with a contracture of the Quadratus Lumborum as contributory cause.)

To Raise the Ribs. Use the same leverage as is used in the correction of expirational bucket handle lesions using the palm of the hand to maintain pressure upward and forward against the angles of the ribs, the patient inhaling deeply. Raising the ribs is of particular value in decreasing the intra-thoracic pressure in pneumonia. With the patient lying, sitting or standing the principle is the same.

Flat Dorsal. The patient on the side, the operator should apply lateral diagonal pressure to both sides of the thorax-upper side-pressure with chest; lower side with operator's hands consonant with deep inspiration on part of patient. It increases antero-posterior diameter of chest and tends to cause motility and uniform flexion in dorsal area. (Note: Increased mobility of the dorsal spines and ribs in costogenic anemia, diseases of the upper respiratory tract, bronchitis, asthma, laryngitis, rhinitis, etc. Relax the anterior chest muscles especially the Pectorales Major and Minor and the Serratus Anticus to promote lymphatic drainage and leucocytosis.

Dome Diaphragm. By upward and lateral pressure against the lower ribs, especially the eleventh and. twelfth simultaneous with forced expiration on the part of the patient, with abdomen pulled in. This movement is especially valuable in pneumonia. It decreases the intra-thoracic pressure and aids drainage. When used along with technic for raising ribs it is doubly valuable for relief of intra-thoracic circulatory disturbances.

CHAPTER 8

LESIONS OF THE LUMBAR VERTEBRAE.

Lumbar vertebrae are the largest movable segments of the spinal column. The bodies of the vertebrae are wider transversely than antero-posteriorly. The spinous processes are thick, broad, quadrilateral and project horizontally backward. The superior articular processes project upward and their facets are concave and face backward and medialward. The inferior articular processes project downward and their facets are convex, facing forward and lateralward. The former are wider apart than the latter. The twelfth thoracic vertebrae is classified under the lumbar vertebrae for purpose of convenience namely because of the fact that the inferior articular surfaces are similar to those of the typical lumbar vertebra.

The fifth lumbar vertebra is characterized by having a body much deeper anteriorly than posteriorly; a smaller spinous process and a wider interval between the inferior articular processes. The sacro-lumbar articulation is mechanically weak. The inferior articular facets face downward, forward and lateralward. A greater amount of rotation occurs in this joint than in the other lumbar articulations.

The normal lumbar curve is convex anteriorly, the convexity being greatest at the sacro-vertebral angle. The line of gravity or weight bearing passes in front of the core (nucleus pulposus) of the intervertebral disc. The pull of the muscles is behind. Some authorities sate that the line of gravity passes thru the center of the body of the second lumbar vertebra, other give it as the third.

Flexion: The core of the intervertebral disc acts as the fulcrum in this movement. Flexion is the most free of all movements in this area and can be carried just beyond straightening of the lumbar curve, the movement occurring in the vertical plane of the facets. It is greatest at the apex of the lumbar curve, in other words it increases from above downward and is greatest between the fifth lumbar and sacrum. There is compression of the disc in front and decompression behind. The inferior, articular processes slide upward and backward. Limitations to further movement are brought about by the tension of the posterior longitudinal ligaments, interspinous and capsular ligaments. Compression of the disc in front also plays a part. According to Tucker the ligaments lie longitudinally to the direction of tension and radially to the direction of motion so that they may remain tense at all times. The intervertebral foramina are enlarged during flexion.

Extreme flexion creates an anatomical locking of the lower thoracic and entire lumbar spine so that little or no rotation and slight sidebending are possible. Moderate flexion plus side bending may produce a combined side bending rotation lesion. This creates an articular locking of the inferior articular processes of the upper vertebrae passing beyond upper edge of lower, assuming an angle and a consequent indentation from its upper edge. The abnormal bony contact is maintained and increased by the tension of the interspinous and other ligaments. (Note: Instruct patient to recover from side bending rotation before assuming an erect position.)

The greater the flexion in the lumbar area the higher is the locking against rotation and sidebending. A considerable degree of flexion limits side bending rotation of the cervical and upper areas. The bodies of the thoracic vertebrae in flexion side bending rotation rotate toward the convexity. Flexion and side bending add compression upon the discs so that the forces of gravity cause the vertebrae to move in the path of least resistance to get out from under the super-incumbent weight. This applies only to the thoracic area except when the whole spine is in a position of flexion, under which circumstances the above rotation is to the convexity. It is possible to lock the lumbar articulations one by one from below upwards against sidebending rotation by a gradual increase in the amount of flexion.

Extension: The core (nucleus pulposus) of the intervertebral disc acts as the fulcrum. Movement occurs in the vertical plane of the articulations. Extension occurs almost wholly in the dorsal and upper two lumbar vertebrae. There is compression of the disc behind, decompression in front. The inferior articular facets slide downward and inward. Limitations of movement are the anterio longitudinal ligament, etc., compression of the disc, and bony contact, the inferior articular facets of each joint with laminae of vertebra below. Secondary movement occurs by sliding of bony contact and stretching ligaments. Intervertebral foramina are diminished in size. Hyperextension restricts rotation to the dorso-lumbar area locking upper and mid-dorsal areas. Hyperextension, sidebending is limited to lumbar area, the greater the extension the lower the movement occurs. Extension-sidebending is always accompanied by rotation of the bodies to the concavity.

Side bending: Side bending is a free movement in the lumbar area. It is greatest in the erect position, and least in flexion. It is limited by extension. It is always associated with rotation. Side bending rotation is highest in flexion, is lower in erect position and lowest in extension. The bodies of the vertebrae rotate toward the concavity, the opposite of which occurs in the thoracic region.

Rotation: Rotation in the lumbar area is extremely limited, is diminished in hyperextension and least in flexion. Rotation side bending is highest in flexion, lower in erect posture and lowest in extension. The bodies 02 the vertebrae rotate toward the concavity. Rotation in hyper-extension is confined to the dorso-lumbar area. The center of rotation is in the tips of the spinous processes.

Lesions:

1. Flexion Lesion.

2. Extension Lesion.

3. Rotation-Sidebending )

4. Sidebending-Rotation (Lateral Lumbar.

5. Combined Lesion.

THE FLEXION LESION: Bilaterally Posterior Lumbar.

The Flexion Lesion is a vertebrae immobilized in a position of flexion. The vertebrae en mass assumes greater prominence posteriorly and if a group lesion the concavity of the lumbar is decreased. It is commonly called a posterior lesion. The inferior articular processes of the vertebra in lesion move upward and slightly backward, the inferior articular facets passing beyond upper edge of superior of vertebra below. The fulcrum is the core of the intervertebral disc.

Etiology. Functional and postural abuse is the usual cause of the group lesion. It may be secondary to Bilaterally Anterior Innominate and the forerunner of the straight spine. There may be associated atonicity of the extensors from debilitated or toxic states. The individual lesion is usually due to reciprocal innervation. It may be the result of a strain. Extreme or forced flexion with injury of the ligaments i.e. heavy lifting, falls, wrenches, etc. It is sometimes found as a secondary or counterbalance lesion.

Diagnosis: Begin palpation with patient in flexion as this throws vertebrae into greater relief posteriorly.

1. Vertebra en mass posterior because of backward buckling of spine at this segment. (Compression in front decompression behind.)

2. There is approximation of the spinous process with the one above and separation below. The spinous process of the vertebra in lesion is also relatively more prominent posteriorly especially when the patient is in extension or the erect position.

3. Restricted motion is found between the vertebra in lesion and the one below. Movement is free between the one above and the one in lesion. Movement of flexion and extension cannot change the amount of separation between the spinous process of the vertebra in lesion and the one below. Extension is followed by no apparent approximation.

4. Concavity of the lumbar curve is decreased in group lesion.

5. The inferior margins of inferior articular processes assume greater prominence posteriorly.

Note: The fourth lumbar vertebra has a normally long spine process. The spinous process of the fifth is normally short.

Differential Diagnosis. Confusion may exist at times as to whether the lesion is a flexion lesion of a particular vertebra or an extension lesion of the one above. A safe rule to apply is: Restricted motion where there is separation indicates a flexion lesion. The fact that extension will produce no apparent approximation proves definitely the presence of a flexion lesion. Still more conclusive proof is the fact that there is free movement where there is approximation. In this particular instance it would be with the vertebra above the one in lesion.

The reverse of the above would indicate an extension lesion.

Treatment: The objective may be either the inferior articular process or the spinous process. The applied force should be directed inferiorly and forward.

Technic: Patient sitting crossways of table. Operator directly behind patient. Have patient fold arms. The objective should be the upper posterior aspect of the spinous process. The Operator's point of contact should be the hypothenar eminence. The applied force should be directed inferiorly and forward by bringing patient back into extension and giving thrust.

Technic: Patient prone. Place pillows under thighs to bring patient into position of extension. Direct action technic with bilateral application of the thrust against the inferior articular processes of the vertebra in lesion or against the spinous process in the latter case being careful to direct the force inferiorly as well as downward. An extension spring table is of value in this type of adjustment.

THE EXTENSION LESION: Bilaterally Anterior Lumbar

The extension Lesion is a vertebra immobilized in a position of extension. The vertebra en mass assumes a greater prominence anteriorly and if a group lesion the concavity of the lumbar curve is increased. It is commonly called an anterior lesion. The inferior articular processes of the vertebra in lesion move downward and slightly forward. The superior articular processes move downward and backward assuming greater prominence posteriorly. The spinous process becomes more oblique. The fulcrum is the core of the intervertebral disc.

Etiology. Functional and postural abuse may be the cause of the group lesion although this is less common than when associated with the flexion group lesion. It is usually secondary. It may be counterbalancing for Bilaterally Posterior In-nominates in which case it is the forerunner or the Dorso-Lumbar kyphotic spine (spine in which normal curves are accentuated). It may be secondary to pot belly, flat feet, high heels, etc.

Diagnosis: Begin the examination of the lumbar spine in a position of flexion.

1. Vertebra en mass is anterior because of the forward bending of the spine in this area. Compression of the intervertebral disc posteriorly, decompression anteriorly.

2. There is approximation of the spinous process with that of the vertebra below and separation from that of the vertebra above. The spinous process is more oblique and less prominent posteriorly particularly noticeable with patient in position of flexion.

3. Restricted motion is found between the vertebra in lesion and the one below. Movement is free between the one above and the lesion. Movement of flexion and extension cannot change the amount of approximation between the spinous process of the vertebra in lesion and the one below.

4. Concavity of the lumbar curve is increased in group lesion.

5. The superior articular processes assume greater prominence posteriorly.

6. Restricted motion where there is approximation (vertebra below): Free movement where there is extension. (vertebra above.)

Technic 1. Indirect Action Technic. Patient supine. The objective is the superior-articular process of the vertebra in lesion. Knees and thigh flexed on abdomen, bilateral fixation of the superior articular process with one hand. Extreme flexion of legs and thighs. Strong upward pressure against superior articular process with a quick forcible downward forward pressure of Operator’s chest against patient's knees.

Technic 2. Direct Action Technic. Patient prone in easy flexion. Thrust should be delivered bilaterally against superior articular process of vertebra in lesion being careful to direct force superiorly as well as downward.

Technic 3. Patient seated on stool in position of moderate flexion. Operator rests pectoral area on shoulder of patient and hand of same side on opposite shoulder of patient. Operator should grasp stool firmly with hand of some side. Strong approximation should be given. Graduate flexion to angle necessary to bring greatest leverage on vertebral articulation in lesion.

SIDEBENDING ROTATION LESION:

The sidebending rotation lesion is a vertebra immobilized in the position of sidebending. Rotation however is negligible. It is commonly called a sidebending lesion, occasionally a lateral lumbar. Both terms are synonymous. A right or left lateral lumbar inversely speaking is a sidebending lesion to right or left. If a group lesion a functional lateral curve will ensue. The bodies of the vertebrae rotate toward the concavity, the opposite of which occurs in the thoracic area. In sidebending the axis of movement is thru the intervertebral core and point of limitation. With rotation the axis of movement becomes a line drawn thru the intervertebral core and the articulation of the convex side.

Etiology. Functional or postural abuse may be the cause of the group lesion. The individual lesion is usually the result of strain produced with the patient in a position of flexion-sidebending. Many times the lesion is produced in the return to an upright position, particularly in lifting some heavy object. Reciprocal innervation may be the cause as also trauma, etc.

Ashmore states that there are two kinds of Lateral Lumbar lesions:
(1) a subluxation, an immobilization of a lumbar vertebral articulation in the position-of sidebending.
(2) A traumatic lesion, an immobilization of a lumbar articulation in the position of rotation. There is more torsion in a traumatic lesion therefore a greater percentage of rotation. However the distinction is not clear for the reason that there may be such a varied proportion of sidebending and rotation. The nearer the lesion approaches the mechanical possibilities of the lumbar spine the greater is the percentage of sidebending and the more is it typically a subluxation. This explains the classification by Ashmore. Effort to save oneself from falling, lifting heavy objects above the head, carrying heavy weights at the side are ether causes of lumbar lesions given by Ashmore.

Diagnosis: Diagnosis con best be made with the patient in position of flexion, as this threw the vertebrae into great relief posteriorly. Due to the thickened muscular mass in the lumbar area the transverse processes cannot be palpated with any great degree of certainty, moreover their irregularity prevents any accurate or positive diagnosis although a changed structural relationship may be suspected. According to Hallady the transverse process of the third lumbar are the most prominent. Gray's Anatomy states that the transverse processes are long and slender and horizontal in the upper three lumbar vertebrae and arise from the junction of the pedicles and laminae. The transverse processes of the lower two incline a little upward are set farther forward and arise from the pedicles and posterior parts of the body. They are situated in front of the articular processes instead of behind them as in the thoracic area and are homologous with the ribs.

(1) Lateral deviation en mass of the spinous processes of the vertebrae in lesion would be the main diagnostic factor.

(2) In lateral flexion the lower border of the spinous process of the vertebra in lesion will be relatively more palpable on the side of the convexity, the upper border may be relatively more prominent on the side of the concavity. The amount of rotation can be determined by relative comparison of the lateral borders of the vertebra in lesion, the greater the rotation the lass prominent the lateral border of the spinous process on the side of the convexity and the more prominent the lateral border on the side of the concavity. This is due to the greater deviation from the median line. In sidebending the vertical plane of the spinous bisects a line dividing the spinous process longitudinally. Normally these lines should be identical

In the lumbar area the spinous processes are in a horizontal plane with the articulation of the vertebra above and the vertebra below.

(3) Restriction of motion is found between the vertebra in lesion and the one below. Movement of sidebending-rotation in this area will produce no change in the relationship of these two vertebra to each other.

(4) Sensitiveness can be usually elicited on the concave side of the spinous process of the vertebra in lesion. The subjective symptomatology varies greatly subject to the particular enervation provoked.

Treatment: The general principles of adjustment proper are:

1. Sidebending to the side of convexity.

2. Adjustment with rotation toward side of convexity.

Technic 1. With the patient sitting the lesion can be adjusted with the spine in the erect position, or in varying degrees of flexion and extension. The objective should be in this case, the lateral aspect of the spinous process on the convex side. Considerable force and velocity are necessary to adjust in this position. Patient's trochanter on side of convexity should be off the table, so patient is out of balance and reflexly unable to contract at the time of adjustment. The patient can be maintained in such a position only a short time before automatically contracting. Therefore adjustment must immediately follow the moment he is in position of sidebending and off balance.

Technic 2. A very good method of adjustment with the patient sitting is for the operator to obtain the following hold. The fingers should be placed in front and against the anterior superior spine of the innominate on the concave side, the thumb of the same hand should be hooked firmly around the spinous process so that pressure is brought to bear on lateral aspect of convex side of process. This may be used on the three lower vertebrae. It demands a hand of considerable size and strength. After a hold is obtained sidebending and rotation toward the convex side should be made, at the same time firm fixation is maintained upon the innominate and firm pressure is exerted against spinous process.

Technic 3. The best and easiest method of adjusting sidebending rotation lesions is with the patient on the side as follows:

Hypothetical lesion Right Lateral Third Lumbar; patient on left (concave) side. Sidebending to convexity due to the fact that the only points of contact are the pelvis and shoulder. The unsupported area, the lumbar area must naturally assume a lateral flexion between the above support. The lumbar spine should be anatomically locked in flexion up as far as the articulation in lesion. The thoracic and lumbar spine should be locked by a combination extension-rotation down to the articulation in lesion. With the above locking complete the adjustment is carried out by rotation of the lower segment forward. The lumbar spine locked in flexion acts as a long handle lever. The upper segment should be maintained in firm backward extension-rotation. The rotation of the lower segment toward the concavity is better than an attempted rotation of the upper segment toward the convexity.

To correct lumbar lesions with this method the higher the lumbar area the lesion the greater the flexion from below upward and the shorter the extension from above downward. Lengthen the extension from above downward and shorten the flexion from below upward for lesions lower down in the lumbar area. Proper graduation of the above locking is absolutely essential if adjustment and not indiscriminate popping is expected. This method of adjustment can be used for all vertebrae in the lumbar area and also may be used in the dorso-lumbar area. It is not wise to attempt adjustment with it above the tenth dorsal. Upward digital pressure may be brought to bear upon the lateral aspect of the spinous process of vertebra below one in lesion (concave side). A finger should be placed directly over the articulation in lesion to be sure that locking falls above and below and not upon the articulation in lesion, also to ascertain amount of movement previous to and at the time adjustment is made.

The Rotation-Sidebending Lesion is usually of traumatic origin in which a greater percentage of rotation is found. Thera is usually greater deviation from the median line than is found in the side bending-rotation lesion; rotation at its best is more or less of a negligible factor therefore the clinical diagnosis places no particular emphasis upon this lesion. The same methods of adjustment would be used as in the correction of the sidebending-rotation lesion.

Combined Lesions: Combined lesions in order of frequency are:

1. Flexion-Sidebending-Rotation Lesion.

2. Extension-Sidebending-Rotation Lesion.

3. Flexion-Rotation-Sidebending Lesion.

4. Extension-Rotation-Sidebending Lesion.

Adjustment would be divided as follows:

1. Adjust sidebending-rotation or rotation-sidebending.

2. Adjust flexion or extension.

The methods for handling these conditions are discussed in full under the individual heads.


Notes re this restoration March 2016
In 2016 a friend loaned a decades old typewritten copy of the original, for this copy, to Western Australian osteopath Andre Gajek. Andre motivated David Beale to restore the book for preservation and for Internet compatibility. The old copy had been sold by the N.S.W. College of Natural Therapies Library; we don't know who wrote the Introduction — Explanation. Another stamp indicates the book was owned by Edward Boughen of the Wentworthville Chiropractic Centre (in N.S.W. Australia).
The restoration used Nuance PDF Converter Professional 8 and OCR by Nuance Omnipage Ultimate version 19 for a Microsoft Word 2010 docx and pdf.
Spelling correction used a medical dictionary addition to WordWeb Pro; and online resources. Proofing included some correction of typos in the typewritten copy of the original.

A pdf of the scans, some adjusted for easier reading, is here: http://dgbeale.com/Osteopathy/SCANS_of_Simplified_Spinal_Technique_by_Dr_Harrison_Downing_2016.pdf

A copy of the docx pdf is here: http://dgbeale.com/Osteopathy/Simplified_Spinal_Technique_by_Dr_C_Harrison_Downing _RESTORED_2016.pdf

 

N.S.W. College of Natural Therapies library stamp

Old Inside Cover