Thoracolumbar Junction Responsible for 40% of Low Back Pain

By Joseph D. Kurnik, DC

The thoracolumbar junction syndrome, also known as Maigne's syndrome, has been thought to be responsible for up to 40 percent of common low back pain. This percentage is based upon R. Maigne's personal statistical study of 500 cases. 
This may not represent a purely scientific study, but it is the observation of a respected practitioner. It is also a fairly awesome statement-when considered in relation to the emphasis chiropractors place upon lower lumbar and sacroiliac adjusting and segmental traction procedures.

I would consider the "40 percent" statement as being conservative. In my experience, I have seen the thoracolumbar region responsible or a contributor to well over half of sacroiliac dysfunction and/or common low back pain. As a result of these observations, I increasingly begin treatment of low back pain with thoracolumbar adjusting.

Volumes can be written and discussed concerning this subject. To keep matters brief, I would like to define the thoracolumbar region. Technically, it would be defined as the thoracolumbar junction. I have seen practitioners enlarge this to include T-10/11 throughout L-1/2, as we are dealing with an approximate region. The posterior rami of the T-12 and L-1 nerve roots innervate the superior gluteal regions and the inferior subcutaneous tissues. The anterior rami innervate the inferior abdomen and groin. A lateral cutaneous branch innervates the trochanteric region. Texts of anatomy, however, show many variations of innervation to these regions, which include roots from higher than T-12 and lower than L-1.

Aside from the subject of nerve roots, my most common finding of segmental fixations from T-10 through L-2 is the formation of bilateral or unilateral fixation of the sacroiliac joints. This can be evaluated and confirmed with seated and standing SI joint motion palpation. It is most common to find SI joint fixations released to some degree or completely with TLJ adjusting. This adjusting may partially or completely clear the subjective symptoms of discomfort. Other contributors to the low back complaints and SI joint dysfunction are: 

• lower lumbar dysfunction/problems;
• mid and upper thoracic dysfunction/problems;
• cervical dysfunction/problems;
• extremities dysfunction/problems;
• the SI joints dysfunction/problems; and
• soft tissue reactions dysfunction/problems.

The simplest visual test of the results of treatment to any of these regions is to utilize seated and standing motion palpation analysis of the SI joints. Understanding the principles of nutation and counternutation in relation to stabilization of the lumbar spine would help in understanding all of these relationships.

In previous articles for Dynamic Chiropractic I have presented the processes of SI joint dysfunction, leading to soft tissue reactions, contributing to: 

1. low back pain
2. gluteal complaints
3. groin complaints
4. hip complaints
5. ischial complaints
6. hamstring/quadricep complaints
7. knee complaints

The most common deficiency of all articles, tests, and seminars dealing with this subject is the treatment by adjusting to the thoracolumbar region. It is a difficult region to adjust. With low back and lower extremity complaints in the presence of SI joint dysfunction, I commonly initiate adjustive procedures by adjusting to the dysfunctions (fixations) at the thoracolumbar region. The method of locating the fixations is by utilizing seated and prone motion palpation. Prone motion analysis is the main key to locating these fixations.

The most successful and useful technique of adjusting for the TL region has been the incline adjustment. I can treat 80 percent or more of my patients most effectively with TL region adjusting by utilizing the incline bench. It solves the problem of tissue slack removal, rotational complaints, and painful prone adjusting in this region. It eliminates the problems with extension imbrication of the TL facet joints. The process involves utilization of a standard adjusting bench, where the caudal half elevates to 45-50.( The patient straddles the bench; buttocks against the incline; hands usually interclapsed behind the mid-to-lower neck; with elbows forward. The doctor flexes the torso forward mildly, places his or her fist or hand behind the back, over or under the TL fixation; then pushes the flexed patient back to the incline section and pushes the patient in the anterior to posterior direction, with the vector force directed at the contact point in back. This creates a P to A force upon the selected segment or a fixated intersegmental space. This adjustment can be applied to higher thoracic levels, and I have even reached the L-4 level on some. In order to emphasize rotation, I slightly rotate the patient's torso and position my fist slightly laterally to one side or other. I place a folded hand towel over my hand in order to soften the bony contact.

This adjustment works wonderfully with most patients, but other techniques also may need to be used instead. For example, people with too much flexibility or too little flexibility may not be suitable for this procedure.

It is exciting to use this type of adjustive procedure and pre-analysis and watch the results of mobilization to the TL region. If this procedure is used properly, you will see your treatment successes improve. It will decrease, also, your total or heavy reliance upon treating the low back and lower extremities exclusively with low back adjusting and traction. Very often, traction or specific low back adjusting may not be needed, or they must by supplemented with TL adjusting. This TL adjustive procedure also works very well in treating pregnant women who have TL or low back pain. As a classic '70s TV commercial said, "Try it, you'll like it!"

Manual Muscle Testing and Postural Imbalance

By Kim Christensen, DC, DACRB, CCSP, CSCS

The best posture is one in which the body segments are balanced in the position of optimal alignment and maximum support, with full mobility available. Optimal posture allows for pain-free movement with a minimum of energy expenditure, and is a sign of vigor and harmonious control of the body.¹ One of the most useful diagnostic procedures in chiropractic practice is the manual testing of the muscles responsible for maintaining postural alignment. 
This part of an examination provides valuable clinical information, which can be correlated with a patient's history and reported symptoms.

Postural patterns are maintained by a complex arrangement of proprioceptive input, modified by habits, somatotype, and even psychogenic factors, such as self-esteem. Deviations from the ideal, efficient alignment eventually result in the production of chronic pain symptoms, which have been shown to be predictable.² chiropractic adjustments can improve the segmental misalignments, but comprehensive and effective treatment requires that the muscle imbalances be addressed.

Postural Muscles and Alignment Problems

Persistent faulty postural alignment is almost always associated with an imbalance in the surrounding musculature. Sustained misalignments result in some muscles becoming shortened and others developing a constant overstretch. And, of course when certain muscles are used more frequently (at work, or during sports), they get stronger and tighter, while the underutilized opposing muscles are, by comparison, weaker. The eventual consequence is a malposition of the involved joint(s). Trying to determine which came first - the alignment problem or the muscle imbalance - may in some instances matter, however both will generally need to be addressed. In fact, they are usually bound together into neurological habit patterns that are imperceptible and unnoticed by the patient. The doctor must identify the structures and the muscles that are involved, so that the patient can begin to work on a corrective exercise program.

Common Muscle Imbalances

Many of us develop a similar, almost standardized configuration of muscle imbalance. While there are many individual variations, due to work habits and sport activities, there is a consistent pattern that is primarily the result of the way we customarily use our postural muscles. There also seems to be a neurological developmental component, since these patterns are very common and widespread.³

Upper Body Patterns

The postural muscles of the neck, upper and middle back, and shoulder girdle demonstrate this type of configuration, as discussed. It is very common to find tightness and trigger points in the neck extensor muscles, the upper trapezius, and the levator scapulae muscles. The opposing groups (longus colli and capitis and lower trapezius) are frequently lax, and in need of strengthening. In the shoulder, the muscles in the front (pectoralis major and minor) are usually tight and hypertonic, while the infraspinatus, teres minor, rhomboids, and thoracic erector spinae muscles are inhibited. These muscle imbalances develop into the very common postural pattern of forward shoulders and increased kyphosis, with a forward head and loss of the cervical lordosis.

Lower Body Patterns

Similar muscle imbalances are frequently found in the lumbar spine and pelvic region. The lumbar erector spinae muscles are often tight and hypertonic, while the abdominal muscles are lax. The hip flexor muscles get tight, while the gluteus maximus muscles become weak, thereby interfering with full hip extension during gait. This combination is suspected to be a contributing factor in hamstring muscle strains and tears.⁴ Tight hip flexors will inhibit the hamstrings, which are under more stress during strenuous hip extension, since the glutei are not being much help. The result is excessive stress on the hamstrings, causing a sudden tear injury. Tight hip adductor muscles are frequently found in conjunction with weakness of thegluteus medius and minimus muscles; this can develop into a chronic groin strain.

Manual Testing Procedures

Standard methods of muscle testing are well described in the textbooks by Kendall and Kendall, and by Walther.5 As is stated in Kendall and Kendall, "Muscle imbalance distorts alignment and sets the stage for undue stress and strain on joints, ligaments, and muscles. Manual muscle testing is the tool of choice to determine the extent of imbalance."6 One important key to be aware of is recruitment, also called substitution. This occurs when a patient has a weakened muscle and tries to use another muscle to pass the test. If a patient changes the angle of the joint or tries to rush the test, a careful repositioning will usually uncover a weak muscle. This is the reason that manual muscle testing requires practice and experience for accuracy. Otherwise, a patient can fool the unsuspecting tester.

Carefully performed manual testing procedures can help to identify the specific muscle groups that are weaker, and those that have become shortened in an individual patient, so that general patterns do not have to be assumed. This permits the doctor of chiropractic to develop an individualized plan to reestablish muscle balance, by combining stretches for shortened muscles and strengthening and neurological stimulating exercises for the inhibited groups. In some cases, the muscle imbalance may be caused by a distant malfunction, such as when the psoas muscle is inhibited by excessive pronation.

Successful treatment programs include individually determined exercises to regain postural muscle balance. Exercises to avoid include those that increase the strength of the tight, strong muscles or that stretch out the weakened, inhibited muscle groups. If pelvic unleveling has been identified during postural evaluation, effective treatment requires careful examination of the structures from the ground upward. Most commonly, the lower extremities are not providing the necessary support for the pelvis. In many cases, custom-made orthotic support for foot pronation may be needed. Manual testing of the postural muscles can provide much of the information needed to plan supportive care as the spine is adjusted.

References 

1. Panzer DM, et al. Postural complex. In: Gatterman MI. Chiropractic Management of Spine Related Disorders. Baltimore: Williams & Wilkins; 1990:256.
   
   
2. Griegel-Morris P et al. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Phys Ther 1992; 72:425-431.
   
   
3. Lewit K. Chain reactions in the locomotor system: coactivation patterns based on developmental neurology. J Orthop Med 1999; 22:52-57.
   
   
4. Geraci MC. Rehabilitation of the hip, pelvis, and thigh. In: Kibler WB, ed. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg;
   
   
5. Walther DS. Applied Kinesiology, Vol. 1: Basic Procedures and Muscle Testing. Pueblo: Systems DC; 1981.
   
   
6. Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function (4th ed.). Baltimore: Williams & Wilkins; 1993:270.

The Subluxation - More Than a Single Vertebral Misalignment

By William Shepherd

The concept of a subluxation as a single vertebra out of alignment with the vertebra above and below it is well-accepted within our profession. However, it is not accurate. When stress or injury occurs in one area of the spine, the whole spine becomes involved in the process of adaptation to that injury or stress.
Muscles-from the toes to the skull-are involved in this adaptive process. This has driven us into divisiveness that should not have happened, as most researchers have concentrated on one element in this adaptive process, and found conflict with other researchers who have concentrated on other elements. We have also developed a variety of techniques that have concentrated on adjusting according to the findings their research has yielded. Thus, we have multiple techniques, with everything from Basic to Grostic being used with effectiveness. These techniques all deal with some portion of this complex total-body adaptive mechanism, and would not be in conflict if we understood this process better. My attempt here is to shed some light on this process.

My particular area of inquiry has been in the study of motion in joints; the muscles involved in that motion; how motion varies from normal when a subluxation is present. That variation from normal is, in my opinion, the only way a subluxation may be properly assessed. Any technique that normalizes motion in joints and increases muscle tone throughout the body is an acceptable technique.

The next question is, "What is the definition of normal mechanical function, and how may it be assessed accurately?" Some have defined a normal spine as one that shows no misalignment on an x-ray and little, if any, curvature. This would be true if our spines had not had to adapt to strains so severe that self-correction did not occur in a short span of time after the trauma. Unhappily, most people ignore discomfort until it becomes too painful to tolerate. During this interval, adaptation can reshape the muscles, ligaments and disc tissues to better accommodate the distress. If accommodation has been successful and pain is decreased, and nothing is done to assess the cause of the prior discomfort, the body accepts the reshaping of the spine. Thus a misalignment shows up on the x-ray, which may be very difficult (if not impossible) for a return to normal alignment.

However, many techniques do use misalignment as the way to adjust a subluxation with too much success for me to argue that it is wrong. On the other hand, we cannot x-ray patients each time they come in, so an easier and more reliable method should be found to assess whether a subluxation is present in that person on that date, and the approximate location of the subluxation. I believe this can be done with motion palpation and muscle testing.

We use the reflex neuromuscular distortion, always accompanying a subluxation, to find that it exists. This neuromuscular distortion affects the movement of the sacroiliac joints very specifically. Normal motion, when the spine bends forward, when it bends side to side, and when one leg is raised and then the other leg is raised, was established 50 years ago by Dr. Henri Gillet.

In any flexion subluxation in any vertebra in the spine, the distorted movement in the sacroiliacs is a lateral flexion distortion in which the ilia follow the lumbar spine, indicating increased muscle tension in the flexors of the lumbar spine (the iliopsoas muscles). Normal movement of the ilia is away from the lumbar spine on lateral flexion of the trunk.

Any extension subluxation in any vertebra in the spine distorts movement in the sacroiliacs, by the ishium moving toward the sacrum when the knee is bent on that side. When the other knee is bent, the sacrum moves toward the ischium on that side. Normal movement is for the ischium to move away from the sacrum when that knee is bent. When the other knee is bent, the sacrum should move away from the ischium.

Rotational subluxation in any vertebra in the spine distorts movement in the sacroiliacs, by moving the ilium toward the sacrum when the torso bends forward. The normal movement is for the ilium to move away from the sacrum on forward bend of the torso.

These three directions of subluxations - flexion, extension and rotation - are the usual misalignments found. It is true that degrees of flexion or extension can vary 180 degrees rotationally, and rotation subluxations can have degrees of flexion and extension, but the major direction of distortion will follow the distorted sacroiliac movement I have just outlined.

Lack of specific breath motion is also an indicator of the presence of subluxation. Breath motion is measured by using a goniometer with at least seven-inch prongs. With this goniometer, one degree is equal to 3mm. If the goniometer prongs are placed with one on the ilium and the other on the scapulae, the measured motion on a deep breath should be 45mm. Anything less on either side indicates a subluxation somewhere in the spine is present. There should be 6mm of breath motion between vertebrae. No breath motion of this magnitude between vertebrae is also a prime indicator that a subluxation exists. This does not indicate the position of the subluxation, because there can be many breath motion locks in many different areas of the spine from a single subluxation.

Lack of breath motion between skull bones can also be prognosticative for a variety of directional misalignments. A lack of motion between occiput and temporal bones can indicate an extension subluxation somewhere in the spine.

A lack of breath motion between the occiput and parietal bones can also indicate a flexion subluxation somewhere in the spine.

A lack of breath motion between the sphenoid and the occiput bones can indicate a rotational subluxation.

After we have ascertained the direction of the subluxation from the sacroiliac tests, we move the spine in the direction opposite the indicated movement. Reluctance in movement is found to exist from the atlas down to near the subluxation, below which the spine seems to have free movement. In this area, a vertebra will be found in either flexion, extension or rotation, depending on the direction indicated on the x-ray.

Rotation subluxations, as indicated by the sacroiliac tests, exhibit rotary reluctant movement misalignment from the atlas down to an area in the spine, and normal rotary movement below. Since rotary subluxations involve from two to four vertebrae, exact positions of the vertebrae need the x-ray to be sure of the position needing release. Palpation may sometimes be quite close to the vertebra, since rotary muscles of the spine, when unbalanced in a subluxation, will be quite tender on the spastic tendon of the rotary muscle involved. A rotary subluxation will often have shoulder blades at varying levels, which can be easily observed by placing thumbs on the spine of the scapulae.

Flexion subluxations, as indicated by the sacroiliac tests, exhibit poor extension from the atlas down to the offending injury in the spine, and normal extension below the offending injury.

Extension subluxations, as indicated by the sacroiliac tests, exhibit poor flexion from the atlas down to the injury, and normal flexion below this point.

The Derefield leg-length tests have been used for the past 40 years to indicate that a subluxation is present in the spine. When present, it is a fine indicator. We have found that it is not present in a rotary subluxation; therefore, it should not be relied upon when a rotary subluxation is primary.

Muscle strength tests have been used to assess spinal subluxation as well. We have found that weakness in muscle strength follows exactly the scenario of being opposite the bend toward which the vetebra has moved: flexion subluxations have weak extensors; extension subluxations have weak flexors; and rotation subluxations have weak rotary muscles of shoulders, hips, forearms and knees.

I have used and advocated this method of spinal evaluation for the past 40 years. I have not found it in error.