Sunday, November 23, 2008

John Martin Littlejohn - Triangles of Force Made simple

THIS ARTICLE IS A WORK IN PROGRESS - IT WILL BE FINISHED IN THE COMING WEEKS

John Martin Littlejohn developed a theory on the mechanics of the spine and in the 1985 Yearbook of the Maidstone College of Osteopathy John Wernham explains the theory. This article is not meant as a substitute for the original text. The original contains a more detailed explanation of the theory and also provides very useful diagrams. I have tried to simplify the article which can be complicated and confusing as a springboard for others to go and return to the original.


Anterior- Posterior and Posterior-Anterior Gravity Lines:

John Wernham, for the sake of this study divides the "body" in to 2 parts - the vertebral column and the pelvis and finds the centre of gravity within them. To find the centre of gravity he draws 2 lines – the anterior-posterior gravity line and the posterior-anterior gravity line.

Anterior-Posterior Gravity line:
The anterior- posterior line is a line drawn from the upper to the lower limits of the body; that is, from the anterior margin of the foramen magnum to the end point of the coccyx. On its journey it crosses the posterior junction of L4/L5 and the body of S1 to get to the point of the coccyx.

Posterior Anterior Gravity line:
The second line is drawn from the posterior margin of the foramen margnum to the anterior most part of the spine – L2/L3 at which point the line splits to both femoral articulation in the acetabulae.

For reasons that are explained in the original article, the resultant ( a term used in physics) of these two lines passes through the body of L3 vertebrae and it marks the centre of gravity. The importance of this is that it means that the entire body above is supported on L3 and the remainder of the body is supported from L3. Therefore in standing or walking all movement passes through L3 and it is therefore it is most vulnerable to lesion.

The anterior-posterior line, which begins at the anterior foramen magnum and ends at the coccyx, is the foundation of spinal movement. The line crosses D11 and D12 which is the central point of the line. Therefore D11 and D12 are of great importance in lateral curvatures of the spine, postural conditions and of blood circulatory conditions involving the blood supply to the abdomen. Whilst being the strongest vertebra in the column D11 and D12 also have the weakest mechanical rib position as they are floating ribs.

As was mentioned earlier, the posterior-anterior line is a line of pressure (complimentary to the atlas-coccyx line) that begins at the posterior margin of the foramen magnum and splits at L2/L3 to both femoral acetabulae. It crosses rib 2 and D2 and therefore binds the occipito-atlantal joint with them (maintaining the integrity of the neck) and maintains the tension in the trunk and legs.

Some new tension lines – Anterior and Posterior Central Lines:

The anterior-posterior central line follows the same course as the anterior-posterior gravity lines. The anterior-posterior central line is balanced against the 2 posterior-anterior central lines that are drawn from the posterior margin of the posterior margin of the foramen magnum through the centre of the body D4 and on to the centre of femoral pressure on the acetabula. The anterior-posterior crosses posterior-anterior line in front of D4 and therefore form triangles above and below D4 and are associated with rib 3. Therefore, any torsion movements of the trunk tend to focus at the rib 3 and D3 and D4 (see original text for view of triangles).

Therefore, the articulation of the head sits on the base of the upper triangle (the foramen magnum) and is poised on the apex of the triangle (D4). Any alteration in the position of the triangle essentially is the alteration of the head in relation to the trunk and leads to strain at the apex of the triangle creating strain at D4 and rib 3 bilaterally. It is therefore logical to conclude that treatment of problems relating to headaches must include treatment of the base of the occiput and D4.

Saturday, November 8, 2008

Low back pain during pregnancy - an osteopathic approach

As has been mentioned earlier posts (coccyx pain and gastric reflux) pregnancy puts a great demand on the body as the increased weight leads to mechanical changes in the body and especially the spine. Areas which the osteopath may be unfamiliar with addressing in patients that are not pregnant are the uterosacral ligaments. As pregnancy develops and the size of the uterus increases the uterosacral ligaments have to adjust and become taught. Due to their mechanical attachments to the sacrum and the sacrum's mechanical attachments, the coccyx, pubic symphysis lumber spine and sacrum, all have to adjust accordingly. In some cases the mother may not be able to adapt well due to mechanical restrictions elsewhere in the body and this can put excess strain on the uterosacral ligaments causing back pain. A method for the osteopath to determine the role of the uterosacral ligaments is to ask the mother to stand whilst the osteopath gently lifts and supports the uterus. If the mother describes a relief from pain and ease of movement then the osteopath can start to build up a diagnosis.

As the pregnancy develops the weight of the mother increases anteriorly, the pelvis rotates and lumber spine gets pulled into extension. Ideally the extension should occur throughout the lumber spine, however if the upper lumber spine does not adapt well and most of the extension occurs at the lumbo-sacral junction then most of the weight bearing will occur on one set of facet joints (zygo-apophyseal joints) that are not designed for such a task. Eventually the facet joints will become irritated and inflammation and muscle spasm will develop leading to pain. The osteopath, by improving the function of the other lumber vertebrae can help to spread the weight bearing load that is now required of the back. The osteopath must of course pay due attention to the illiolumber ligaments which will be under strain due to the nutation and counter-nutation of the sacrum throughout pregnancy.

Disc herniations are also common due to the increases leverage applied to the back due to the increase in anterior weight. This can obviously be most uncomfortable for the mother who has to adapt to the regular pregnancy-related changes. The osteopath can significantly aid the pregnant mother by applying techniques to help the body accommodate the physical changes in her body. Soft-tissue massage to the muscles of the spine, articulation to the appropriate areas – especially the junctional vertebra – dorso-lumber junction, cervical-dorsal junction and the lumber sacral junction. Regular osteopathic treatment in this fashion can be very helpful in allowing the mother to adapt to the changes and hopefully to stop pain occurring.

Monday, November 3, 2008

Spondylosis: Disease or Natural Response to Stress


Structural changes in the vertebrae may be considered as features which are related to disease. Changes which occur in the intervertebral disc are described as spondylosis. Changes in the facet joints are described as osteoarthritis.

When an osteopath examines an X-ray of a neck that has spondylosis the osteopath will notice osteophytes or bony spurs along the perimeter of the vertebral body i.e. at the junction between the two vertebral bodies and the disc. The osteopath could be forgiven for perceiving these osteophytic changes as part of an aggressive disease attacking the body, however, on closer examination the osteopath begins to understand that it is in fact part of the body's natural response to the mechanical stresses that are applied to the spine throughout life. In other words, it is an active purposeful process in the body, used to compensate for the natural, physiological changes occurring with age.

In a young healthy adult the vertebral disc in between each vertebrae adapts according to the stresses placed on the spine. It is able to do this due to its high water content. With age the disc loses water and hence flexibility – essentially it dries out, becomes less flexible and as a result the surrounding cartilage, the annulus, bears most of the weight.

Eventually, in cases of excess compression along the annulus, ossification starts to develop and can occur around the entire margin of a vertebral body. This can be viewed as if the vertebral body is trying to expand the surface area for articulation in order to distribute the load.

The osteopath must remember that spondylosis and osteoarthritis are not necessarily associated with pain; in fact spondylosis is just as common with people who have symptoms as those who do not have symptoms. Similarly, patients with pain may not have a single trace of spondylosis.

We could therefore conclude that there must be another cause for the pain in people with spondylosis and osteoarthritis and not necessarily the bony changes. As osteopaths this fact supports much of the work that we do. Osteopathy claims to help the body accommodate to changes. Osteopaths are regularly asked whether they treat arthritis. Well, osteopaths don't so much as treat arthritis as they do the patient's whole body – helping it to compensate for any changes that may put stress on the soft tissues.