The Biomechanical Basis for Spinal Correction in Treatment of Tennis Elbow and Various Wrist Dysfunctions

By Jesse Jutkowitz

Reading a chiropractic publication this past week, I noted an article on the correction of tennis elbow. The emphasis of the article was to correct the problem with stroke changes. Lip service was paid to adjusting as a temporary solution, but the article then states, "But to produce long-term change, the correction of the underlying faulty techniques that led to the condition's onset must be addressed." Sounds good, but it does not work out in real life experience. 
The faulty stroke technique of the patient is often a compensation for poor body mechanics elsewhere. A few examples from my experience:

Patient #1 was a stranger I met on the golf course wearing a tennis elbow brace. After the round, I asked him about the condition. The history was insidious onset of elbow pain several months previous, which was worse during sporting activities. Medical treatment including rest and steroid injection yielded no improvement. Chiropractic treatment offered temporary relief after the first adjustment, but he said the pain was much worse after the second visit. The chiropractor had adjusted only his elbow and neck. After discussing the problem with several other people that had not gotten relief with any type of treatment except the elbow brace, he had given up on doctors and bought a brace at the drug store. He said he only had relief while wearing the brace but still had some pain while wearing it. He had arm and hand weakness without the brace, but it was the most effective thing he found.

Further questioning for other problems not related to the elbow elicited a history of a mild back sprain lifting something during yard work about a week before the onset of the elbow problem. I made a brief check of the man's body mechanics, tested the insertion of the latissimus dorsi on the ipsilateral humerus (pain on palpation with flinch of patient), and tested the elbow for pain on wrist extension against resistance with no spinal support (positive to the point of eliciting a yelp and the person pulling away his arm). I then tested the elbow pain again in the same manner after wrapping a shirt tightly around the person's trunk at the T10 level. The test elicited the comment from the patient that the elbow was still very sore but much stronger. This was while he continued to extend his wrist against resistance without flinching. Testing the insertion of the latissimus again elicited no flinch and a subjective report of no pain. After removing the support, all tests were again positive. I told him the problem was in his spinal mechanics and might be correctable.

On intake to the office a complete history and physical examination was done along with full spine radiographs, in both the sitting and standing positions, for comparative biomechanics. The findings were altered spinal biomechanics with focal problems (primary subluxation, fixations, whatever nomenclature you use) at L4, T10, C7, and a marked resistance to flexion of the head and neck (standing) when the coccyx was held anterior, which indicates fixation in the meninges. Not unusual, all the primary vertebral problem areas were subluxated and fixed anterior.

To successfully adjust the lumbars and lower thoracics, A to P, without using a lot of force, hurting the patient, you also need some information from the sitting full spine film. Where is the apex of the person's kyphosis while sitting relaxed?

When adjusting the anterior upper thoracics, you put your hand under the vertebra to be adjusted. This puts the adjusting fulcrum (your hand) between the vertebra to be adjusted and the apex of the person's thoracic kyphosis. To adjust lower thoracics and lumbars, A to P, your adjusting fulcrum must also be between the vertebra to be adjusted and the apex of the kyphosis, which means above the vertebra to be adjusted. The person also needs to be bent forward quite a bit imitating a sitting type position.

In many people (about 80 percent in my office), especially those with biomechanical pathology, the lumbar lordosis and thoracic kyphosis degenerate in undefensed positions. An undefensed position is any position where the pelvis and femurs are flexed, which removes some or all of the stabilizing effect of the large muscles attaching the femur to the pelvis and the pelvis to the column, forcing the column to hold itself (defend itself) against gravity without the benefit of its primary large stabilizers. This biomechanical degeneration leads to a change in the position of the kyphosis, most often downward. With the kyphotic curve moving caudad, the position of the apex also changes in the same direction making the placement of the adjusting fulcrum a little more difficult to determine in the L3 to T7 region. Remember, stretch the meninges, fulcrum position, and patient flexion, making A to P adjusting much easier, even in the lumbars.

After stretching the meninges to loosen any internal soft tissue fixations in the column, adjustment of T10 (A to P) was done first. After the adjustment testing, the elbow revealed a return of strength but some continuing pain. After adjustment (A to P) of C7, elbow testing revealed some improvement subjectively. The patient also noted he could breath better which had been a problem since the strain, but nothing significant objectively. After adjustment of L5 (also A to P, the ease of which, when I demonstrate, brings me many questions) testing of the elbow revealed a greater increase in strength and a subjective report of a little soreness with no pain at all. At that point, I had the patient stretch his arm vertically to full extension of the elbow. There was an audible pop. Testing the elbow again yielded a subjective report of normal but no notable objective change since it seemed normal at the previous test. I should mention here that there is a large difference between A to P and P to A adjusting, especially since these types of cases are usually anterior fixations.

Many people think adjusting the lumbars A to P is difficult to impossible. It's easy. First, you must note that when the lumbars go anterior there is often meningeal fixation which must be released before the lumbars will release. This is easily accomplished with the patient side-lying, by flexing and extending the knees and hips with the person's head in lateral flexion to both sides (not at the same time, ha ha), then in extension, and lastly in flexion. sometimes the coccyx is fixed anterior and must be adjusted A to P.

After a short course of treatment consisting of twice a week for five weeks, this patient has no pain in the right elbow except if he falls asleep sitting in a chair with his head down and plays tennis the following day. The reason is easily seen on the sitting full spine film. When he relaxes the apex of the thoracic, kyphosis moves down from T7 to T10 fixing that vertebra anterior to setting a pathological (abnormal) defense which affects the biomechanics of the latissimus dorsi, which affects upper extremity biomechanics adversely.

This local biomechanical mechanism for tennis elbow and other biomechanical pathologies of the arm and wrist are often set up by normal mechanics in the thoracolumbar region of the spine that cause abnormal mechanical action (changes in the vector of force) of the latissimus dorsi muscle, which changes the mechanics of the entire shoulder-arm-elbow-wrist-hand mechanical unit. I have found quite a few cases of carpal tunnel that did not respond to any treatment until the thoracolumbar mechanics were corrected, after which there was excellent response to adjustive treatment to the elbow and wrist with various PT to the wrist.

A similar case involves a long-time tennis player with slight but significant lateral wedging of the T11, T10, and T9 vertebrae. His original reason for visiting a chiropractor was back pain. Upon moving to the area he was referred to me by a neighbor for a minor strain in the lumbosacral region, which had been a recurrent problem for several years following a rear-end auto collision. The tennis elbow complaint was elicited in the history.

Examination and x-rays gave me the necessary information for treatment. As an aside, before treating him I tested the wrist dorsiflexion against resistance eliciting pain at the lateral epicondyle of the elbow. Postadjustment (A to P of the anterior fixations at L4, T11, T6, and C7) treating of wrist dorsiflexion against resistance elicited slight pain and greater strength. The patient was then instructed to force extend his elbow with the arm vertical. An audible pop was produced. Repeating the test there was "no pain, just a little soreness" in the elbow.

Playing tennis brought the pain in the elbow back within a set until I recommended this patient use a rib belt while playing to compensate for the lateral flexion effect of the vertebral compression when he moved his trunk. Not only have his elbow complaints been reduced by 90 percent, but "with this chest brace for my elbow" the man now has a very effective backhand.

My main point is for chiropractors to continue to look at the body as a single functioning unit with all parts interconnected. Not every problem involving subluxation is nerve related and most problems with extremities are not local. When subluxation is defined to include nerve interference, it narrows the thought processes so we become like medical doctors in our thinking: Treat neck subluxations for carpal tunnel, tennis elbow, and shoulder problems because that is where the nerves originate. No wonder the "old time guys" got and get better results than the younger guys. The "old timers" were educated more broadly in full spine effects than students are today. They, "old guys," are more often than not full spine adjusters who solved and solve many conditions by fixing biomechanics, not just relieving nerve pressure, whether they know it or not.

These case studies are anecdotal. They provide a basis for doctors to institute more effective chiropractic treatment of these upper extremity conditions and a basis for research study by a formal researcher. Let's get back to full spine work. I am not a straight, and I think those guys miss a great deal by not employing therapy at the appropriate times, but the rest of you are missing a lot when you do not diagnose or analyze the spine as a single functioning unit. Full spine films, standing and sitting, will give you more appropriate information than just standing. Do them by section if you do not have a large buckey. You will be amazed at the changes in biomechanics from one minute to the next as the person sits. Many biomechanical pathologies will become apparent sitting that are unseen in standing or recumbent films.

As I finished this paper, a chiropractor friend called me and asked if I could see his friend, a chiropractor, who had not been able to get relief from back and leg pain for six weeks. This doctor said, "I told him he would have to listen to you lecture about full spine sitting and standing radiography, but he would be much better when you finished." This turned out to be the case, but more interesting was my friend. He came in with his left arm in a sling due to a painful calcification of the forearm extensor tendons.

He could not extend his elbow past 95 degrees or his wrist more than five degrees, and that caused pain that buckled his knees. He had received a cortisone injection which was not helping. I examined his spinal mechanics and adjusted (A to P) at T7, 10, 12, and L4. Immediately he could extend his wrist 30 degrees and elbow 25 degrees although with pain. After adjusting C7 (also A to P), the wrist extension increased to 45 degrees and the elbow to 150 degrees. The next morning the wrist had full range in extension and was pain free; the elbow had the same 150 degrees extension but was not pain free.

He continued to improve until sitting for days at a chiropractic seminar brought a return of the pain. He was afraid to be adjusted (P to A) because a previous adjustment of this type brought instant return of pain to his arm and wrist. Upon his return, two adjustments had him back to pain free with full range of motion.

This is a sad state of affairs. Either of these people should have been cake for any chiropractor to successfully treat. When I read about DACBRs saying meaningful biomechanical measurements cannot be made from x-rays, and hear neurologists saying that the chiropractors in their town are just glorified physical therapists because, by their own admission, they don't do much manipulation, I know why chiropractic is having so much trouble.

The Pronated Foot and the Lumbo-pelvic Area

By Keith Innes

One of the most common foot disorders is the pronated foot. It can be used as an example to illustrate how alterations in its function can be followed by a series of biomechanical changes that produce a wide variety of signs and symptoms through the interrelated structures and systems of the body.

The pronated foot presents with multiple site fixations that could include the posterior subtalar joint, the calcaneotalonavicular complex, the cuboid, mortice joint and the first ray. Weight will be borne on the medial structures and there will be an internal rotation of the entire lower extremity accompanied by an increase of the normal anterior pelvic inclination. With internal rotation of the femur, the greater trochanter moves anterior and the lesser trochanter moves posterior. These two bony processes are traction processes, the former for attachment of gluteal muscles, and the latter for the tendon of the iliopsoas. In the case of the internally rotated lower extremity, the tendon of the iliopsoas is tensed as it passes to the tractionation. It is worth noting that this increased tension may cause pain over the anterior aspect of the hip joint from which the tendon is separated by a bursa.

If the anterior pelvic inclination is increased, the posterior portion will be elevated, accompanied by an abnormal stretching and tension of the hamstring muscles. In this group the biceps femorus holds the greatest clinical interest. Although the long head originates from the ischium many of its fibers are directly continuous with the sacrotuberous ligament. Traction of this muscle makes tense the entire ligament and the coccyx is therefore made to move on the sacrum. Clinical importance of this relationship is significant. Just anterior to the coccyx is the ganglion impar of the sympathetic trunk and the anorectal region with its visceral branches to the hypogastric and pelvic plexuses. Tensions of this ligament should be kept in mind when coccygodinia and the wide variety of perinopelvic disorders that may well be associated with pelvic imbalance are encountered.

Elevation of the posterior part of the pelvis, coupled with the forward position of the greater trochanter, is accompanied by increased tonicity of the piriformus muscle, upon which the sacral plexus of nerves lies within the pelvis. The above situations of pelvic dysfunction may give rise to a sciatic pain that is secondary to the postural change. At this point, I would like to remind the reader that the cause of this scenario is the subtalar joint pronation; it is this that must be adjusted to fix the postural abnormalities and structural compensations.

Increased lumbosacral junction angle is a common finding in those patients with pronation of the foot and associated internal rotation of the lower extremity. The center of gravity falls anterior to its normal position and a shearing force takes place at the L-S junction. Strain of the iliolumbar ligament usually results and a lumbosacral junction subluxation is produced.

Unleveling of the sacral base must be followed by other changes since it is the body's nature to compensate for structural imbalance. The groundwork has now been laid for extensive spinal pathology from sacrum to occiput.

The pelvis has been mentioned as the junction between the mobile spinal segments and the moveable lower extremities. It is therefore important to remember that not only are the somatic structures involved but also the genitourinary and gastrointestinal systems as well.

The soft tissues, the muscles, fascia, and ligaments functioning under abnormal stress and strain, in an effort to keep the body in as near normal a position as is possible, are usually contracted, sometimes stretched, and sometimes shortened. Generally speaking, the muscles, the origins of which have been brought closer to the insertions due to the postural change, are the ones that will undergo shortening. The opposite relations produce stretching: both may be painful upon palpation. These areas are found in relation to the postural groups concerned. The principal ones are: (1) the plantar fascia and muscles; (2) the gastrocnemius and soleus forming the calf of the leg, where the most tender point is at the site of injunction of the tendinous portions of the two muscles at the middle of the calf; (3) the iliotibial band of the fascia lata on the lateral aspect of the thigh where the tensor fascia lata and the gluteus maximus enter about its middle, the origin of the satorius at and below the anterior superior iliac spine, a muscle that undergoes shortening in this condition and which helps to maintain the anterior inclination of the pelvis; (4) the fleshy origin of the gluteal muscles associated with the dorsum illi; and (5) the area over the extrapelvic portion of the piriformis muscle. The last named point requires definite location which can be reached midway on a line drawn from the tuberosity of the ischium to the greater trochanter of the femur. At this point where the sciatic nerve passes downward into the thigh and immediately above it, the painful piriformis spasm can be elicited.

So what do you treat? Obviously the foot, but more specifically the subtalar joint. The subtalar joint must be examined for joint play motions in both a closed kinetic chain and an open kinetic chain as talar motion is ONLY a function of the weight bearing foot. MPI's new E1 Lower Extremity seminar details many new examination and adjustment procedures that will enable you to become a more proficient doctor when it comes to locating the CAUSE of your patient's low back pain.

Capsulitis and Synovitis: Two Very Common Problems of the TMJ

By Darryl Curl

If you are like many of our readers you've often wanted to get your hands on a clinical article specifically describing the benefits of chiropractic. I know because I get a number of phone calls asking for articles regarding various aspects of head or neck pain. 
Well, good news is here. In regards to the temporomandibular joint we have just published an article about the chiropractic management of two very common disorders: synovitis and capsulitis. Herewith is a brief summary of the article.¹ The original article can be obtained by calling the Los Angeles College of Chiropractic library, or try your local chiropractic library.

Clinical Conditions Which May Present Similarly to Capsulitis or Synovitis.

Localized inflammatory conditions (e.g., synovitis and capsulitis) of the temporomandibular joint are commonly seen in clinical practice and typically occur following trauma, such as an auto accident. Regardless of their frequency of occurrence, these conditions must be differentially diagnosed from conditions which also may cause pain in the region of the temporomandibular joint. If local pain in the temporomandibular joint is present, and historical, physical and laboratory findings do not indicate a referred pain phenomena, systemic, tumorous or infectious involvement, local causes such as capsulitis or synovitis should be considered.

For the sake of thoroughness, here are some other things to consider: inflammation of the pre-auricular lymph node, otitis media or externa, referred pain from a trigger point, and tendonosynovitis of the temporalis tendon as it passes behind the zygomatic arch -- all may cause pain that is experienced in the region of the temporomandibular joint. Certain facial or dental pains, such as trigeminal neuralgia or dental caries, may initially present as pain over the temporomandibular joint. Bony tumors, both benign and malignant (primary and metastatic) that lie in the temporomandibular joint region, have been reported to initially present as temporomandibular joint pain. The inflammatory arthritides (i.e., ankylosing spondylitis, rheumatoid arthritis, juvenile arthritis and psoriatic arthritis, etc.) may initially present as temporomandibular joint pain and not uncommonly the initial presentation is of isolated temporomandibular joint involvement. In the case of chronic pain, the practitioner must first differentiate between whether the complaints are due to organic changes or psychosocial factors.²

Synovitis -- Chief Characteristics

Synovitis (also known as retrodiscitis) follows a typical course of events and thus makes it easy to recognize: a) the posterior attachment becomes edematous; b) intracapsular pressure increases; c) the condyle becomes displaced anteriorly in the rest position causing a barely perceptible midline shift to the opposite side; d) ipsilateral disocclusion; and e) joint pain that is aggravated when the patient attempts to fully occlude the ipsilateral teeth and, thus, forcing the condyle backward against the inflamed posterior attachment.

Capsulitis

Capsular pain is provoked when the inflamed capsule is stretched (e.g., by translatory movement of the capsule). The pain, therefore, is exacerbated by protrusion or lateral excursion of the mandible, contralateral chewing, and wide mouth opening. Capsulitis is further characterized by palpable tenderness or pain directly over the condyle and minor swelling over the joint may be detected.

Etiology

It is commonly believed that various factors which alter joint dynamics contribute to the formation of synovitis or capsulitis. Factors such as changes in occlusion, occlusal interferences, loss of posterior support, iatrogenic malocclusion, abusive oral habits, occupational conditions (e.g., holding the telephone receiver between the shoulder and ear), bruxism, microtrauma and some of the conditions mentioned at the beginning of this article can cause muscular imbalance and lead to increased loading of the temporomandibular joint.

Treatment

Management goals for patients with capsulitis or synovitis are similar to those for patients with other joint related disorders namely, decrease pain and tenderness, decrease adverse loading, restore normal function and the resumption of activities of daily living. Factors found to be etiologically important must be managed during treatment because those etiologies that initiate capsulitis or synovitis may also perpetuate them.

The initial management of noninfectious capsulitis or synovitis is similar to that prescribed for most any inflamed joint. If the condition is severe, aspirin (I prefer Bromelaine -- a pineapple extract), nonsteroidal anti-inflammatory medication, mild heat or cold, a soft diet and/or instructions to limit mandibular movement should be quickly applied. In the case of synovitis, a stabilization appliance may prove useful as it tends to disengage the condyle from the inflamed posterior attachment. A stabilization appliance may also be used for either capsulitis or synovitis if it has been determined that relaxation of the elevator muscles is needed.

Current knowledge strongly states that adjustment of the occlusal surfaces of the teeth is absolutely contraindicated for the management of synovitis or capsulitis.

Generally, treatment of capsulitis or synovitis includes mild cryotherapy to the area for 10 to 20 minute periods followed by ultrasound or other physiotherapy. As the acute stage resolves, 20 minute applications of moist heat can be used to further reduce inflammation and associated muscle complaints. Instructions to the patient routinely include resting of the jaw, soft diet and the taking of a mild analgesic (e.g., aspirin). In the final stages of healing mobilization and manipulation of the joint has been reported to be useful in accelerating tissue repair.

Prognosis

The resolution of synovitis and capsulitis is usually uneventful. The clinical outcome and course of symptoms depends upon the etiology, but generally is as short as a few days when the cause is uncomplicated or related to a single stressful event.

Complications of capsulitis or synovitis are well known. The possibility of hemarthrosis or deterioration in the quality of the synovial fluid presents the chance for adhesion formation between the disc and its bony compliment. Those of you who have attended my TM seminars may remember the use of the translatory manipulation as a measure to prevent adhesion formation.

Capsular fibrosis or capsular contracture is another complication of capsulitis or synovitis. Long axis distraction with a lateral vector added to maintain or regain the length of the capsule is recommended.

References 

1. Curl DD, Stanwood G. The Chiropractic Management of Capsulitis and Synovitis of the temporomandibular joint. J Orofacial Pain 7(3):283-293, Summer 1993.
   
   
2. Curl DD, Shapiro CS. Head/neck pain: the need to identify the patient with acute versus chronic pain. J Chiro Technique 1(3):101-105, 1989.

Management of Osteoarthritis of the Spine: a Conservative Approach

By R. Vincent Davis, DC, PT, DNBPM

Cartilage in the spine is subject to degenerative changes with advancing age, just as it is elsewhere in the human body. This process involves the loss of cartilagenous resiliency with disintegration which varies in degree from one individual to another. 
Some factors which influence this degenerative process include, but are not limited to, concomitant constitutional conditions which may involve infection, menopause and metabolic disorder. The primary pathological change which takes place involves intradiscal dessication.

Clinicopathologically, the fibrocartilage of the intervertebral discs degenerates and is replaced by fibrous tissue components. This results in the loss of a shock absorbing effect between segmental pairs leading to increase pressures upon opposing surfaces of the vertebral bodies. This pressure/opposing surface factor results in a biodefensive increase in bone formation at the respective sites. Accordingly, spondylitic hypertrophy results in the formation of peripheral osteophytes which may totally bridge the intersegmental space and become united forming an ankylotic juncture. Due to the increased pressure/stresses on apophyseal joints, the articular cartilage of the facets is gradually denuded. Also, the apophyseal joint interval is narrowed with bony surfaces becoming sclerosed and irregular. These biomechanical changes result in articular process displacement and subluxation with overlap. As a result, neurothlipsis takes place with encroachment upon the nerve root which exits at that respective level. Rheumatoid (atrophic) arthritis may coexist with this osteoarthritic process and means that the atrophic changes have been reduced in speed of progress in the presence of osteoarthritic pathology, although it may still be active. Since these degenerative changes affect the annular ligaments, these individuals have a diathesis to disc protrusion with the consequence of need for differentiation of radiculoneuralgia of foraminal encroachment.

Pain in this clinicopathological circumstances may be a product of sprain, acute synovitis of the apophyseal joints, radiculitis, discal rupture, and bilateral spinal muscle spasm. Occupational demands which include the carrying of excessively heavy loads with frequent and repeated bending and lifting predispose to deterioration of the joints in the lumbar spine. Also, hypertrophic arthritis is an inevitable consequence of poor postural habits involving adverse biomechanics.

Symptoms typical of degenerative arthritis involve pain and stiffness when resting which are reduced in intensity upon becoming physically active. This physical activity must be performed in moderation because excessive bending and lifting tend to exacerbate the symptoms, as does cold, damp weather. When there is referred pain it tends to indicate the presence of nerve root pain and may include muscle spasm and paresthesias with chest and abdominal pain which may simulate visceral disease. The entire spine may be flattened and stiff with limited motion, especially in the lumbar region, where forward bending may be performed primarily by hip motion. Radiographic findings present with loss of articular cartilage from the facets posteriorly and fibrocartilage from the disc anteriorly with secondary bony hypertrophy of the articular cortex.

Maintenance of muscle power, within physiological limits, appears to be the key to retarding degeneration of the spine. A conservative therapeutic regimen in degenerative arthritis includes relief of pain, increased mobility of the spine, with strengthening of the paraspinal musculature. Bed rest includes the use of a firm mattress and may be improved by placing a board between the mattress and box springs to reduce the lumbar lordosis and relieve tension on the articular ligaments. Moist heat may be applied as hot infrared packs, either hydrocollator packs or silicone gel packs, for 15 to 20 minutes, b.i.d., or p.r.n. for pain and/or local spasm. Erythema ab igne must be avoided and the patient must not be allowed to place the heat source under the weight of the body part to avoid capillary compression. Interferential current therapy may be used to reduce pain level and to enhance interstitial fluid transfer serving as a form of massage. Recommended parameters include a 120 Hz beat frequency, with a low grade surging effect if desired, for about 15 to 20 minutes per application, b.i.d., or p.r.n. for pain and/or reduction of edema. Discontinue IFC if the patient finds it intolerable due to sensitivity. Traction may be applied to the cervical, or lumbar, spine and may be used concomitantly. Cervical traction should be applied at an angle of 20 to 30 degrees anterior to the angle of pull in order to enhance IVF patency. Traction may be applied p.r.n. to assist with pain and to enhance mobility. Therapeutic exercise is advisable as soon as acute pain has been controlled, to begin strengthening paraspinal muscles. These exercises must be initiated on a gradual basis beginning with passive effort and gradually building to active exercise without approaching fatigue.

Treatment of spinal degenerative arthritis is ameliorative, rather than curative.

References

Davis, RV: Therapeutic Modalities for the Clinical Health Sciences, 1st ed., 1983. Copyright -- Library of Congress Card # TXU-389-661.

Griffin JE, Karselis TC: Physical Agents for Physical Therapists, 2nd ed. Springfield: Charles C. Thomas 1982.

Hoppenfield: Physical Examination of the Spine & Extremities, 2nd ed. New York: Appleton/Century/Craft.

Krusen, Kottke, Ellwood: Handbook of Physical Medicine & Rehabilitation, 2nd ed. Philadelphia: W.B. Saunders Company, 1971.

Schriber WA: A Manual of Electrotherapy, 4th ed. Philadelphia: Lea & Feibiger, 1975.

Turek: Orthopedics -- Their Principles and Applications, 3rd ed. Lippincott Publishers.

Repetitive Posture Stress Patterns (RPSP)

By Raffael Siclare, DC

The RPSP is a pattern of muscle dominance resulting from the habitual, repetitive use of the same muscles every time we engage in any posture. It is rare that we will use the same muscles on both sides of our body in the same manner.

Thus, we create a pattern of muscle use on each side that is different than the pattern of use on the other side (Figure 1). We refer to the overall pattern of habitual, repetitive use as the RPSP. We call the overall pattern of infrequent use the contra pattern (mirror image of RPSP). 

Figure 1
One of 32 known Repetitive Posture Stress Patterns (posterior view).

Which Postures Create the RPSP?

All postures contribute to the RPSP. The four postures all people engage in are the primary postures of reclining (sleeping), sitting, standing, and walking. We sleep with one arm and one leg positioned differently than the others. We prefer to cross one leg more than the other when we sit. We stand on one leg differently than we stand on the other. We walk on one leg differently than we walk on the other. During work and play we unconsciously use those muscles made dominant from habitual use in the primary postures.

Our postural idiosyncrasies begin to develop in utero. During this time we develop a preference for positioning one arm and leg differently than the others. By the time we reach the age of 12 to 18 months, we have developed our own specific primary postures, i.e., dominant limbs, which continue, with certain modifications for growth, virtually unchanged throughout life.

Since the RPSP Is Caused by Normal Activities, Why the Concern?

Whenever muscles are activated in dynamic use, static positioning, or therapeutic release, the entire skeletal system moves in response to the change in length of the muscle fibers, i.e., any action, such as the active lifting of a leg or the passive stroke of a muscle, as in reflex testing, produces changed in the entire kinematic chain. If the activated muscles increase the strength differential from one side to the other, as in the use of the RPSP, the skeletal system moves away from balance. If the activated muscles decrease the strength differential from one side to the other, as in the use of the contra pattern, the skeletal system moves toward balance. The direction of movement can be observed by monitoring various skeletal checkpoints before and after activation.

There would be no cause for concern if the RPSP was used only slightly more than the contra pattern. However, the RPSP is used in most instances because it is comfortable to use and the contra pattern is not. For example, a person will cross one leg (RPSP) comfortably when sitting, but the other leg will feel tighter and less comfortable when it is crossed. Therefore, the uncomfortable leg (contra pattern) will be crossed much less often. Similar tendencies can also be found in sleeping, standing, walking, working, and playing. Day after day, the skeletal system is being postured deeper and deeper into misalignment patterns, and will eventually have a negative effect, particularly on the nervous system.

The depth of the misalignment is usually not apparent when using one of our most common analytical tests -- leg length inequality. This is because unbalanced postural activities both shorten and lengthen each leg. The net result may manifest as one-quarter inch leg length inequality because the apparent long leg happened to lengthen one inch and shorten three-quarters of an inch during unbalanced postural activity, while the apparent short leg lengthened and shortened half inch in each direction. The net effect would be a quarter inch short leg and varying degrees of misalignment throughout the skeletal system. The apparent short leg frequently becomes the apparent long leg during the RPSP release procedure, before returning to an equal length. It is my experience that more trigger points and areas of myofascitis are found in the RPSP than in the contra pattern, contributing to the depth of the skeletal misalignment pattern.

The most important unbalanced structures are the extremities, because of the time spent in unbalanced use and their relative power. An example of the influence unbalanced extremities can have on the spine is illustrated by the consistent alleviation of certain types of torticolis seen following the release of the RPSP, without adjusting the cervical spine. They can also be made worse by releasing the contra pattern of the extremities. Just as the RPSP is little understood and universally common, so are pain syndromes and many other health problems.

What Can Be Done to Stop Using the RPSP and Begin Using the Contra Pattern?

I have been investigating the RPSP for 12 years, and have devised an analytical method to determine an individual's specific RPSP. Once the RPSP is known, the data can be used for three distinct approaches, all contributing to the same goal -- movement of the skeletal system toward alignment along the same path it traveled in its migration toward misalignment, and correction of the vertebral subluxations: 

• release of the RPSP
  
  
• adjusting in opposition to the RPSP
  
  
• strengthening of the contra pattern

Many chiropractors view absolute skeletal balance as unattainable. I share the same view. Note that the use of the word balance is always preceded by "toward" and/or "away from" to indicate direction of movement only. Muscle use, soft tissue therapy, or osseous adjustments will cause movement of the entire skeletal system either away from or toward balance. The objective, when working with the RPSP, is always to avoid the former and promote the latter.

Release of the RPSP consists of applying a muscle releasing modality to the individual's specific pattern. Release of the shortened muscle fibers allows the skeletal system to move toward balance, equalizing bilateral skeletal checkpoints (leg deficiency, crests of the ilia, inferior scapular angles, arm deficiency, and mastoid processes). At the same time, many subluxations are automatically reduced, improving the nerve deficit, and relieving many symptoms.

The direction of spinal misalignment is generally, but not specifically, the same in individuals that have the same RPSP. Variations can be attributed to the degree of the particular individual's posture imbalances, as well as the genetically determined quantity and quality of muscle distribution peculiar to that particular race, nationality, or individual. However, certain known directional tendencies, plus reflex testing, makes it possible to adjust the spinal column using a line of correction that reinforces the skeletal position achieved by the release of the RPSP.

To maintain the new skeletal position, the patient must stop using the RPSP and begin using, and strengthening, the contra pattern. This is done by reverse posturing which must be taught to the patient. The effects of reverse posturing are manifested by the continued elimination of apparent leg and arm deficiency, and continued maintenance of level crests of ilia, inferior scapular angles, and mastoid processes.

The most popular prescription for musculoskeletal rehabilitation is exercise. However, exercise has positive and negative effects on the musculoskeletal system. The positive effect can be increased muscle strength or endurance. The negative can be increased skeletal misalignment due to our habit of using the RPSP more than the contra pattern. Completing each exercise routine with unilateral exercises of the contra pattern will minimize skeletal misalignment.

How Does this Hypothesis Contrast to Current Chiropractic Thinking?

The dichotomy within the chiropractic profession has one group focusing on the vertebral subluxation and totally excluding soft tissue work in their effort to correct it. The other group includes soft tissue work using the allopathic model, i.e., treatment of the symptomatic area. These preoccupations have prevented us from making even a minimal effort to understand the cause of what we are trying to correct (Figure 2). Neither group has directed its thinking toward the dynamic aspects of the myofascialskeletal system as a functional unit in its function of relating the organism to gravity.

Figure 2

The RPSP hypothesis indicates that you cannot separate the myofascialskeletal system anatomically or functionally. When myofascia is contracted or released, by use or therapy, the entire skeletal system moves toward or away from balance. The same phenomenon results from adjusting any major articulation, including those of the spinal column. Following is an important premise that is a constant when working with the myofascial system: The direction of movement of the skeletal system seen when a muscle is activated (contracted or released) will be the opposite of that seen when the same contralateral muscle is activated in the same way. The direction of movement of the skeletal system seen when a muscle is activated will be the same as that seen when the same contralateral muscle is activated in the opposite way. Movement of the skeletal system may not be detected following activation of muscle if the same contralateral muscle as that being activated is of equal strength.

Assume any posture using muscles that are stronger than their contralateral partners and the entire skeletal system will move away from balance. Assume any posture using muscles that are weaker than their contralateral partners and the entire skeletal system will move toward balance.

Apply soft tissue releasing therapy (ultrasound, electrotherapy, massage, trigger point therapy, acupressure, etc.) to muscles that are stronger (RPSP) than their contralateral partners and the entire skeletal system will move toward balance. Apply soft tissue therapy to muscles that are weaker (contra pattern) than their contralateral partners and the entire skeletal system will move away from balance.

Adjust any articulation in the proper direction and the entire skeletal system will move toward balance. Adjust any articulation in the wrong direction and the entire skeletal system will move away from balance.

Movement toward balance corrects subluxations and/or impedes their development. Movement away from balance creates subluxations and/or furthers their development. This innovative approach, used exclusively by RPSP to correct subluxations and maximize movement of the skeletal system toward balance, yields fast and consistent structural and symptomatic changes and teaches the patient a unique way to minimize recurrences.

Muscle use, soft tissue therapy, and osseous adjustments are the methods of choice commonly used by the various disciplines for musculoskeletal conditions. Could it be that all disciplines are intentionally or unintentionally removing and/or creating nerve interference by modifying the relationship of the skeletal system to the nerve system and, in doing so, removing and/or creating subluxations?