Sunday, December 2, 2012

Inverted supinator reflex & its relevance to the manual therapist explained

Osteopaths like many other manual therapists such as chiropractors and physiotherapists have become known as specialists in back pain. For this reason, conditions such as spondylitis and spondylarthrosis are commonly seen by these practitioners, both of which can lead to compressive cervical myelopathy, compression of the spinal cord in the neck. Needless to say, osteopaths, physiotherapists and chiropractors must be familiar with the neurological tests that help differentially diagnose causes of neck and arm pain. In the upper limb it is less the sensory tests and more the motor tests and reflexes that help the osteopath to identify nerve root compression. The inverted supinator reflex is probably the the most important clinical sign that an osteopath, physiotherapist or chiropractor can illicit to decide whether there is spinal cord and spinal root compression. It is pathognomonic of cervical myelopathy at the level of C5/C6. In this article I will try and help the manual therapist; osteopath, physiotherapist and chiropractor the professions that use spinal manipulation, to understand the physiology of the inverted supinator reflex in order to appreciate its significance when treating patients.

One of the most common types of extra-dural cord compression (compression occurring outside of the dura matar) that an osteopath, physiotherapist or chiropractor is likely to come across is caused by spondylotic change, that is, spondylotic compressive myelopathy. Since the majority of movement in the cervical spine is focused between the levels of C5 and C6 vertebrae it is at this level that arthritic changes most frequently occur. At this level, On x-ray it is common to find a cervical bar due to disc degeneration, spondylosis, a posterior longitudinal ligament which is buckled, thickened and calcified and osteophytosis protruding into and narrowing the spinal canal. However, osteophytic changes narrowing the vertebral canal are unlikely to be limited to the spinal canal alone. It is likely that there will also be narrowing of the intervertebral foramen simultaneously due to thinning of the vertebral disc and thickening of the ligamentum flavum. The result of this is both compression of the spinal cord and compression of the nerve roots.

The osteopath must therefore be aware that any patient suffering with nerve root symptoms attributed to degeneration of the cervical spine, such as pain down the arm into the thumb, must be examined in order to exclude any long-track or spinal cord damage. It is for this reason that patients suffering with suspected cervical spine degeneration and nerve root symptoms in the upper limb must always be asked whether they also have leg symptoms such as heaviness, stiffness, difficulty climbing up stairs, tight band-like feelings (dorsal columns), a sensation of standing on a vibrating floor (dorsal columns), a sensation that water is running down the legs (spinothalamic tract) or pins and needles that don't conform to a nerve root pattern.

In addition to questioning the patient, the clearest indication of both nerve root and spinal cord compression in the cervical spine is displayed by the inverted supinator reflex. By tapping the brachioradialis tendon at the styloid process of the radius a force is sent down the bone, irritating the muscle spindles of all muscles at the front and back of the forearm, sending a message to the spinal cord, resulting in the reflex flexion of the forearm and fingers. The nerve roots responsible for elbow and finger flexion are C6 and C8 respectively. C7 however, responsible for elbow extension, is not activated despite its muscle spindles being irritated. This leads us to conclude that in a polysynaptic reflex, when a multitude of nerve roots are activated the reaction is for dominant nerve roots to react whilst others lie dormant.

Spondylosis, thinning of the disc between two vertebra causes compression of the nerve root between two vertebrae, deactivates its axons and gives other nerve roots, unaffected by compression, the opportunity to express themselves. In the event that there is also cord compression, an upper motor neuron lesion, above the level of the unaffected nerve roots, they will not only express themselves, they will be hyper-reactive. This explains the structural changes in the spine that result in an inverted supinator reflex. Bony changes of the intervertebral foramen between the vertebrae C5/C6 of the spinal column cause narrowing of the intervertebral foramen and compress the nerve root of C6 as it exits the spine causing a hypo-reflexive reaction from the nerve root C6. The bony changes in the form of a cervical bar, situated within the spinal canal at C5/C6 vertebrae, result in an upper motor lesion rendering everything below it hyper-reflexive. Therefore, C7, once dormant, now active, becomes hyper-reflexive as does C8. The result is an inverted supinator reflex, inverted because there is an absence of the C6 brachioradialis reflex and C7 is responsible for the elbow extension. One would also find a hyper-reflexive reaction at all reflexes on the same side of the body, that is, the knee jerk and ankle jerk reflex. One would also find clonus of the knee and ankle on the same side as well as an up-going planter response in-line with an upper motor neurons lesion.

This explains the pathophysiology of the the spinal column and the effect that altered structure can have on the nervous system. It should be clear why this sign is an important indicator for the osteopath, physiotherapist and chiropractor and GP as well as manual therapists using spinal manipulation Early identification of spondylotic compressive myelopathy can result in appropriate medical treatment being administered and avoids permanent neurological damage.

Danny Sher
Registered osteopath
Jerusalem: 14 Kaf Tet b'November Street
Modiin: Dimri Medical Center, 37 Yigal Yadin Street

Sunday, November 18, 2012

Sciatica and pregnancy - an osteopathic perspective

Osteopaths are not strangers to patients suffering with sciatica, however, when the patient suffering is pregnant a new set of conditions arise that may affect the sciatic nerve that need to be considered. The most obvious change affecting a pregnant woman is the increase in the size of the uterus.  As it expands the hip, pelvis and low back all have to adjust their position relative to one another in order to accommodate the increase in weight. This affects all the surrounding soft tissues. Since the sciatic nerve exits the lumber spine, enters the pelvis and continues its journey to the hip joint and into the  leg it is not surprising that osteopaths see pregnant women suffering with sciatica.  

The spinal cord and nerve roots are flexible neurological soft tissues and are normally able to stretch and curve around the bony structures of the spine and pelvis.  However, during the last 3 months of pregnancy as weight increases anteriorly for the pregnant woman, the lumber spine is pulled into extension narrowing the intervertebral foramen of the lumber spine and reducing the aperture through which the nerve roots of the sciatic nerve pass. Anyone who has a degree of stress through the sciatic nerve roots to begin with could start to feel leg pain as the pressure on the sciatic nerve increases. 

The glutei muscles are strong postural muscles that attach from the hips to the pelvis and sacrum. One of their functions is to keep the body upright, therefore as the center of gravity shifts anteriorly during pregnancy their workload increases and thus their tone. The sciatic nerve traverses the glutei muscles making it vulnerable to compression as it passes through the glutei muscles.  Once the hypertonia in the glutei muscles reaches a point where it compresses the sciatic nerve, there is hypoxia in the nerve and the pregnant patient may start to experience sciatic pain in the leg.

It is up to the osteopath to find out where along the path of the sciatic nerve, from the back to the leg, the sciatic nerve it is being compressed.  With some conservative osteopathic techniques the osteopath can take the stress off the spine, pelvis and surrounding muscles. The aim of the osteopath is to integrate the function of the muscles of the pelvis, hips and spine to encourage the body to make the transition smoothly.

The osteopathic treatment should be to allow the spine to shift according to changes in the center of gravity thus spreading out the weight equally and efficiently.  Furthermore the osteopath should aim to help the the hips and pelvis to anteriorly and posteriorly rotate dynamically and according to the changes in weight-bearing.

For more information:

Danny Sher B.Sc (Hons) Ost. Is a registered osteopath in the UK and Israel.
He works in his clinics in Jerusalem and Modiin.

Danny Sher
Registered osteopath
Jerusalem: 14 Kaf Tet b'November Street
Modiin: Dimri Medical Center, 37 Yigal Yadin Street

Thursday, November 8, 2012

Low pack, pelvic and pubic-symphysis pain during pregnancy - an osteopathic perspective

An osteopath treating the pregnant patient suffering with pelvic or low back pain must apply physiology and anatomy to a body in flux. Major weight increases, altered spinal curves and unique hormonal make up put a huge stress on the body over a short time. The inability to cope with these changes is often the cause of sacroiliac strains and pubic symphysis diastasis.

Unlike regular back pain, pregnant women have the extra consideration of an enlarged uterus whose strong uterosacral and round ligaments attach onto the sacrum and pubis putting extra stress through these structures.  Combined with the production of a hormone relaxin in preparation for the birth, the pelvis ironicallly has to increase its weight-bearing capabilities whilst accommodating for softer supportive ligaments. This makes the pelvic girdle a more relaxed, vulnerable piece of architecture during pregnancy.

Orthodox medicine tends to classify mechanical back and pelvic pain during pregnancy into roughly 3-5 categories according to the location of symptoms; low back pain due to either joint or disc dysfunction, sacroilliac dysfunction either unilaterally or bilaterally, pubic symphysis pain or pain in all 3 pelvic joints.

From an osteopathic perspective all these conditions are variations on a theme, that is, they are all the result of poor accommodation to the increased physical demands put on the body during pregnancy. Symptoms are likely to occur at the weakest most vulnerable joint in the kinetic chain. The job of the osteopath is to assess the patient and make a structural osteopathic analysis or "diagnosis" to determine why the body is not adapting well to the changes. Furthermore, the osteopath must decide which structures are central to treatment in order for the  body to adjust adequately and compensate during the transition.

Osteopathy does not encourage a protocol treatment and needless to say the osteopath should routinely check and treat each joint in the body, however, there are central structures that require extra attention. The sacrum, hips and perineum are the closest associated structures to the joints of the pelvis and they are expected to accommodate. Any excess tightness in any of these joints reduces their ability to absorb forces and strains the sacroiliac and pelvic joints.

The sacrum for example needs to nutate and counter-nutate (flex and extend) according to the movement of the spinal vertebrae superior to it. If the sacrum is unable to rock back and forth and twist on its vertical axis the illiolumber and pubic symphysis will be strained.  Similarly, any tightness in the hip adductors, external or internal hip rotators mean the femur and ischium tend to function as one unit. Movement of the leg results in traction and stress of the pubic symphysis.

The muscles must also be considered. Any tightness in psoas, abdominal muscles, lumber erector spinae, diaphragm and quadratus lumborum will result in further spinal and pelvic instability.

The osteopath must have an coordinated treatment approach directed at the hips, sacroiliac joints, spinal curves, lumber and abdominal muscles and uterine ligaments in order to treat the pregnant woman affectingly. If the osteopath manages to integrate these structures into a treatment plan the patient is likely to benefit in the long run from a thorough assessment that addresses the root of the problem.

Danny Sher qualified from the British School of Osteopathy (1996) and practices in Jerusalem and Modiin.

Monday, November 14, 2011

Wrist fractures and osteopathy

An osteopath needs to be aware of the consequences of a patient's fractured bones. A Colle's fracture, fracture of the distal end of the radius, is one of the commonest fractures and so it is likely to present at an osteopathic clinic.

Colle's fractures are normally the result of a fall on the outstretched arm. If the wrist is strong the impact of the fall is likely to reach the shoulder and may dislocate it. However, if the wrist is weak such as in people with osteoporosis then it can result in a fracture. For this reason it commonly occurs in women above the age of 40.

The fracture occurs transversely roughly 2 cm across the distal end of the radius. The fractured segment is displaced posteriorly and laterally resulting in the classic “dinner-fork” deformity. Colle's fractures usually recover rapidly but the functional results are often dissapointing. This suggests that the extent of the soft-tissue injury in Colle's fractures are an important consideration to acheiving a positive functional outcome.

The tendon of extensor-pollicis-longus curves around the dorsal radial tubercle and over the radial wrist extensors to the thumb so it is naturally a place of abrasion and wear and tear. Rupture of extensor-pollicus-longus can occur naturally but occurs more frequently between 4-8 weeks after a fracture of the radius. Rupture of extensor-pollicis-longus leads to the inability to extend the distal joint of the thumb.

Osteopathic treatment may be able to improve the recovery by helping to restore flexibility to the wrist and tendons which are likely to have scar tissue and tension after the fracture. Osteopathic soft tissue massage to the wrist extensors and flexors combined with articulation of the carpel and radio-ulnar joints could improve the blood supply, facilitate recovery of the soft tissues and help to restore good function and reduce abrasion.

For more information:

Wednesday, September 21, 2011

Pancoast tumor and its similarity to musculoskeletal conditions.

An osteopath must always be aware of medical conditions mimicking musculo-skeletal ones so as not to miss a problem requiring a referral to another discipline. Osteopaths regularly treat musculo-skeletal pain originating from the lower cervical or upper dorsal spine that radiates into the shoulder, scapula, arm and hand. This symptom picture could be the result of narrow zygo-apophyseal joints compressing the C7-C8 nerve roots. It could similarly be justified as thoracic outlet syndrome or a shoulder condition.

When a patient complains about these kind of symptoms the osteopath should consider the possibility of a Pancoast tumor. A Pancoast tumor is an extrathoracic tumor of the lung, plaque-like, located in the upper apex of either lung usually found in smokers. It is the location of the tumor and not the pathophysiological changes in the lung tissue that result in the symptom picture, and so one rarely sees respiratory symptoms with this condition. The symptoms that do present are the result of the tumor invading adjoining tissue in the confines of the thoracic inlet compressing intercostal nerves, the lower roots of the brachial plexus, the stellate ganglion and the sympathetic chain.

Patients with a Pancoast tumor will most likely complain to the osteopath about shoulder pain and pain radiating down the medial border of the scapula, not an uncommon complaint in any osteopathic clinic! The invasion of the tumor into the lower roots of the brachial plexus (C8) and upper thoracic trunk (T1, T2), may also result in pain radiating down the ulnar border of the arm from the elbow (T1) and ultimately to the ulnar surface of the forearm to the small and ring fingers of the hand (C8).

The osteopath should examine the patient's hand muscles checking for weakness and atrophy. Reflexes may show a reduced or absent triceps reflex on the affected side (C7). Since the tumor may also involve the cervical sympathetic ganglion and stellate ganglion, sympathetic involvement leads to ispilateral Horner's syndrome (hemianhydrosis, enophthalmos, ptosis and miosis) on the affected side of the face. If the tumor invades the recurrent laryngeal nerve there may be hoarsness and a bovine cough associated with the symptoms.

The patient is often in extreme pain with postural change creating little relief. The patient may tell the osteopath that supporting the elbow of the painful arm with the unaffected hand in order to take the tension off the painful area is the only position that brings relief. The patient will most likely be taking narcotics.

The overlap of symptoms between Pancoast tumor and musculo-skeletal symptoms should now be evident to the osteopath. However, unlike an ordinary neck-shoulder condition or nerve root compression the osteopath may discover on questioning that the patient also experiences malaise, fever, weight loss and fatigue emphasising the importance of a comprehensive osteopathic case history.

A Pancoast tumor is just one example of a life-threatening pathalogical condition that mimics a musculo-skeletal one. The osteopath needs to be fully aware of these conditions in order not to make the mistake of treating the condition and potentially delaying the appropriate treatment

Tuesday, September 6, 2011

The shoulder complex through the eyes of an osteopath

A unique quality of being an osteopath is the approach to biomechanics and the shoulder is no exception. The function of the shoulder is to guide the arm through space and hence it requires a considerable range of movement, in fact the shoulder is the joint with the largest range of movement in the body. It achieves the range of movement in a number of ways. The main factor is the incongruity between the head of the humerus and the glenoid fossa which allows the joint a massive range of movement due to its reduced bony apposition. This does however make the joint vulnerable due to lack of support. The shoulder compensates for this with a complex network of muscles and secondary joints and most importantly a tightly bound capsule that keeps the head of the humerus in apposition with the glenoid fossa.

The secondary joints are the acromioclavicular joint, the sternoclavicular joint and the scapulothoracic joint. The acromioclavicular joint keeps the scapula suspended away from the body and allows for changes in the position of the scapula and therefore the axis of movement of the glenohumeral joint. The scapulothoracic joint allows for a large degree of play by sweeping around the thorax and allowing the scapula a large degree of movement. The sternoclavicular joint attaches the scapula to the axial skeleton keep in the shoulder complex firmly attached to the body.

Finally the muscles involved in shoulder function can be divided in to three groups. The suspensory muscles, that is, the muscles from which the scapula and glenohumeral joint are suspended. The suspensory muscles are latisimus dorsi, trapezius, rhomdoid major and minor posteriorly and anteriorly, pectoralis major and minor. The extra-conal muscles or prime-movers of the shoulder joint are middle fibres of trapezius, deltoid, teres major, biceps and triceps whose job it is to move the shoulder in its anatomical directions. The final group is the periarticular muscles, the rotator cuff muscles, supraspinatus, infraspinatus, teres minor and subscapularis.

As osteopaths it is important that our examination and treatment incorporate the role of each of these areas to the patient's shoulder condition. Any alteration due to postural change or trauma can affect the different categories of muscle or joints listed above. As osteopaths it is our duty to view the all the structures and treat them accordingly. The osteopath needs to integrate his knowledge of biomechanics and apply them to the structure of the shoulder and of the body as a whole and treatment should be given accordingly.
For more information on osteopathy and the shoulder:

Friday, April 1, 2011

How an osteopath views knee mechanics.

A well known osteopathic principle developed by the founder of osteopathy Andrew Tailor Still is “structure governs function” and so as an osteopath my starting point is always the function of the joint. Evolution has adapted body structure according to its function and therefore once the osteopath understands the joint's function, structure is simply an adaption to meet the demands of the environment. Furthermore, as an osteopath I consider how the patient uses his body, that is, what kind of environment do the joints have to cope with and how pathophysiology may be developing under the circumstances. The knee joint is one of the most interesting joints in the body since it has two mutually exclusive functions which it has to perform; motility and stability. Unlike the shoulder, the king of joint mobility, the knee is a weight bearing joint. Unlike the hip, the king of stability, the knee needs to be highly mobile. Therefore there are structures unique to these 2 joints that we do not see in the knee. However, the knee is similar to the shoulder in that it requires a degree of mobility and it is similar to the hip in that it requires stability and it shares some of the structural features common to both. The knee like the shoulder lacks congruity and so has muscle and ligamentous strength to support it. Just like the hip the knee propels the body forward and therefore has structures that increase its congruity providing stability with mobility.

So, the knee has multiple function,  but probably the most obvious one is that of propelling the foot forward in order to make contact with the ground to allow the leg to propel the body forward.

If the knee were a regular hinge joint like the elbow, one can imagine how much trouble the leg would run into. Therefore unlike the elbow the knee allows for a degree of rotation in order to allow for uneven surfaces and pivoting.

If we appreciate for a moment the weight bearing function of the knee we will see that if all the ligaments and the muscles were removed from the knee joint it would essentially collapse in a medial direction. The reason for this is the q-angle. The femur which attaches to the pelvis extends laterally from the body in order to increase the range of movement of the hip. However, in order for the feet to face forwards the femoral condyles are more medial than the hip joint. The result of this is that most of the body weight is transferred to the medial aspect of the knee and therefore this has to be more stable than the lateral side.

The knee is split up into two compartments essentially. One compartment is designed for stability, that is the medial side of the bit – fem joint. It has a much wider surface area, it is much larger than the lateral side of the tibial plateau. The medial meniscus is much less mobile, it is deeper and the medial side is stabilised by the medial collateral ligaments, a structure which holds the medial side of the tib fem joint tightly together allowing only a small degree of valgus to occur. Furthermore, the medial meniscus is attached to the medial collateral ligament reducing its mobility further. The horns of the medial meniscus are attached further apart from one another resulting in a lot less mobility of the meniscus itself which in effect limits the mobility of the femoral condyle on the tibial plateau.

The stability of the knee joint is mainly contained on the medial aspect of the knee as mentioned above. The knee joint compared to the hip and to the shoulder has a complex latticework of ligaments which stabilize the knee in more than one direction and which support one another. In addition to the ligamentous support the muscles act as flexible elasticated ligaments with semitendinosis, gracilis and sartorius acting to support the medial collateral ligament and tensor fascia lata, biceps femoris and popliteus acting to support the weak lateral collateral ligament.
The bony structure of the lateral tibial side of the knee on the other hand is much smaller as is the femoral condyle. This smaller contact point does however have a greater range of movement than the medial femoral condyle. It not only flexes and extends but pivots and rocks around the tibial plateau under the guidance of the ligaments and meniscus.

So there we have it a medial condyle which is stable and a lateral one which is mobile. This allows the knee to perform its function of propelling the knee forward but at the same time supporting the body weight.

Before we move on to the menisci let us take a look at the centrally fixed cruciate ligaments which have the function of controlling the axis of movement of the knee. Most people are aware of the functions of the cruciate ligaments – preventing anterior and posterior shift but they are less aware of their function in limiting internal rotation of the tibia on the femur and guiding the femoral condyles smoothly into position on the tibial plateau during extension.

If we look at a graph of the tensility of the ligaments we tend to see that all the ligaments are at their most tensile during extension. Due to their origins and insertion around the femur and tibia all ligaments tend to become more taut the further into extension the knee goes. This results in a “tight-packing” of the knee which allows for no rotation of the tib-fem joint at all when locked in full extension. Therefore the knee is most stable, least mobile, during extension and least stable when the knee is flexed. The close packing is due to the increased tensility of ligaments and the squashing of the menisci whose job it is at this stage to increase the congruity of the knee joint.

The menisci have the primary task of providing increased congruity to the unstable tibial plateau. The differences between the 2 menisci related to the functions that we mentioned above, which is that the medial compartment maintains the stability whilst the lateral compartment creates mobility. The menisci are made of fibrocartilage which allows them to stretch and be squashed. The medial meniscus is less mobile than the lateral meniscus due to its shape, it is a C shape and less able to swing back and forth. It is tightly bound to the tibial plateau and reinforced by coronary ligaments and the medial collateral ligament. The lateral meniscus is O shaped, highly mobile, unrestrained due to loose coronary ligaments, unattached to the lateral collateral ligament and attached to the popliteus muscle which actively pulls it posteriorly out of danger when it contracts.  This allows for a much more mobile surface on which the lateral femoral condyle can rest.

Finally we consider the patella femoral joint which is a sesamoid bone designed to improve the efficiency of the quadriceps. It slides between the femoral condyles creating a much stronger force during flexion and extension. It is reinforced by retinacula tissue from medial and lateral muscles, a lateral femoral buttress and finally a thick layer of cartilage posteriorly to protect it from friction on the femur.

As osteopaths we are trained to build up a detailed picture of the way the patient uses the knees. What stresses does the patient's environment put on the various structures listed above? As osteopaths we must not be hasty to rush into the examination and treatment. The more information an osteopath gets from the patient the more focused will be the osteopathic examination and the better the treatment. The patient's work may influence the knee structure. Prolonged standing with a strong need for the illio-tibial band to contract causing an imbalance of the quadriceps, a history of a congenital hip displacement or Perthes that may influence the position of the hip and thus the q-angle, prolonged kneeling, repetative strains caused by regular rotatory forces.

In short, since ligaments are designed to support, most ligamentous injuries occur when the they are at their least flexible, in extension and the result is normally a force that stretches them beyond their physiological norm resulting in a partial tear. Menisci on the other hand are designed for movement and most meniscal injuries occur during movement, slightly out of sync with the movement of the femoral condyles becoming caught in between the femoral condyle and the tibial plateau and tearing partially.
To conclude, the knee is a classic case of function governing structure and for an osteopath to treat the joint effectively a deep understanding of the biomechanics makes the life of an osteopath much easier and more enjoyable.  The osteopath can develop a clearer osteopathic diagnosis, a clearer osteopathic treatment plan and a more effective treatment. 
For more info on knee pain:
More info in Hebrew: