Blocking (Manual Medicine)

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In manual medicine, a blockage (also reversible segmental dysfunction ) is the temporary restriction of the mobility of one or more joints . Blockages at the joints of the spine are believed to be an important cause of back pain in otherwise healthy people. Scientific research results are hardly available, so that the theories so far put forward on this topic are unsecured.

Restrictions in the mobility of a joint due to detectable or visible changes such as inflammation , fluid accumulation ( effusion ), meniscus entrapment or cartilage damage are not blockages in the sense of manual medicine. Blockages suddenly arise for a variety of reasons and usually resolve spontaneously a short time later during everyday movements, often with a cracking noise. In the event of a blockage, joint mobility is never completely eliminated, but is free in at least one direction (e.g. flexion). A pathological reflex happening is discussed as the cause .

In extreme cases, blockages should also be the starting point for chronic pain. They are of particular clinical importance in the spine . Attempts to explain this phenomenon as such and its effects and - in the event that blockages do not resolve spontaneously - to intervene therapeutically have a long tradition.

Basics

The term “blocking” in the sense described here is a key term in manual medicine (syn. Chirotherapy) . In other specialist areas such as orthopedics , sports medicine or general medicine , the term is partly also used in this sense, or (especially in orthopedics) in the sense of the general meaning of the word "blocking" (here according to Duden (joint) lock) used.

Typical of blockages are the intensity of pain perception, depending on the direction of movement, and the increase in muscle tone . When moving, for example turning, in a blocked direction, in contrast to the unrestricted, free direction, both the extent of the movement is reduced and the tone of the segmentally associated muscles is increased.

Blockage is a minor and common clinical finding in manual medicine; its cause and its mechanism of development could not yet be adequately explained. According to current ideas, this is not, as was often assumed in the past, a mechanical joint lock, but a pain-related (nozireactive) reflex event.

Functional anatomy

Movement possibilities of the spine

A joint is a movable connection between two or more bones. Movements in a joint always occur, regardless of its special type and shape, by changing the position of the joint-forming bones relative to one another. There are basically six different types possible. These are the three axes around which rotations can take place, i.e. flexion and extension as well as rotation to the left and right and lateral inclination also to the left and right. There are also three levels on which a shift can take place, i.e. forwards and backwards, to the left and right as well as upwards and downwards. The extent and direction of movement are joint-specific and were also measured in the area of ​​the spine.

Ultimately, with each movement, there are sections of different tension states in the assigned ligament structures and relative movements of the respective joint surfaces to one another. The degree of mobility is an important criterion in diagnostics , but viewed in isolation there is no evidence of a blockage, because it must be reduced in one or more directions, but unrestricted in at least one direction.

Neurophysiological explanatory approach

Schematic representation of a blockage of the spine
- the muscle symbolizes both extremities and autochthonous back muscles

From a neurophysiological point of view, painful disorders of the postural and musculoskeletal system can be divided into "directed receptor pain" (classic blocking) and primary and secondary increased sensitivity to pain ( hyperalgesia ).

The current conception of the pathogenesis mechanism of a blockage is as follows: Nerve cells that are specialized in processing pain stimuli ( Aδ and C pain fibers ) are electrically excited by pain stimuli and pass this excitation on to another nerve cell in the spinal cord . The excitation of the second nerve cell, WDR Neuron ( wide dynamic range neuron , multirezeptives neuron in the spinal cord), called by the release of the neurotransmitter glutamate and substance P mediated. The further neural processing of the pain stimulus is carried out on two paths: one enters the information on the nerve cell train of the spinothalamic tract to the brain , where the conscious perception of pain takes place. On the other hand takes place via axon collaterals energization of motor neurons (α- and γ-motor neurons) on the same level in the spinal cord.

The muscles supplied by these motor nerve cells are divided into agonists and antagonists according to their respective effect on a joint, for example in the sense of flexion or extension . The excitation of the motor nerve cells leads to an activation of the agonists and a simultaneous inhibition of the antagonists ( Renshaw interneuron ) in the sense of the classical defense against pain. The activation of the muscles manifests itself in an increase in the tone of the muscle. In addition to the limb muscles (muscles of the arms and legs), the tone of the autochthonous back muscles (functional: deep spinal rotators ) is increased as a result of this reflex arc. The autochthonous back muscles are also counted among the agonists in this context. Your changes in tone can be felt as "irritation points".

Causes and course

The assumptions about the causes of blockages are based on experience, but have not been scientifically proven. Blockages are partially (eg. As a result of a unique "wrong" movement, as a result of static incorrect loading of a joint due to structural fluidized asymmetry or foot deformity ) or functional (for. Example, muscular disorders or band insufficiency) deficits and / or as a disturbance in the nervous-reflex control circuit of the associated segment (e.g. myotome , dermatome ). Often they occur spontaneously (without recognizable cause) and asymptomatically (without recognizable complaints) and often resolve themselves with everyday movements. They can also simulate life-threatening internal diseases. In sports medicine, they are to be clarified in the differential diagnosis of pain.

Diagnosis

The diagnosis is based on the 3-step diagnosis. In the first step, it is determined by palpation whether a joint is free or less mobile (so-called hypomobility ). In the second, the segmental irritation point (i.e. the palpable changes in tone of the autochthonous back muscles described above) is sought. This is also present in primary and secondary hyperalgesia as the cause of a dysfunction in the associated segment, i.e. also in changes that are not counted among the reversible hypomobilities. Therefore, only in the third step, through the palpatory detection of the “free” direction (muscle tone reduction when moving the joint in the painless direction) , the diagnosis “blockage” and thus the indication for the corresponding treatment, e.g. B. releasing the blockage. The diagnosis of blocking requires a positive result in each of the three steps of the examination.

The diagnostic methods used to detect blockages are not reliable . Different examiners come to different results in the same patient. Since there are no reliable tests to diagnose blockages, their existence is hypothetical.

The documentation of a blockage on the spine, prescribed by the KBV for statutory health insurance physicians in Germany, includes information on its segment height, blockage direction, muscular reflex fixation and the vegetative and neurological accompanying symptoms.

Imaging procedures

The necessary clarification is required to prevent adverse events. The spondylolisthesis shown is a relative contraindication and must be known in advance

To date, a hypomobile movement segment of the spine can only be recorded using manual medicine (by palpation) and not by imaging. So far there are only a few studies that deal with this topic.

Before any manipulation , an X-ray of the spinal column to be treated is necessary. This z. B. bony injuries, misalignments and malformations such as a spondylolisthesis or tumors , for which manipulation treatment is fundamentally contraindicated , because in these cases it can lead to serious complications.

treatment

Since a blockage is a reversible, segmental movement disorder, the aim of treatment is to completely restore the mobility of the affected joint. This action is known as unblocking . There are basically different approaches, mostly hand grip techniques or guided movements that are actively performed by the patient himself. Successful treatment immediately releases the blockage and thus immediately restores the physiological mobility of the affected joint. The same effect can also set in spontaneously (without therapeutic measures) or after the administration of pain relieving or muscle relaxing medication. Targeted, regular physical training (training therapy) can be helpful as a preventive measure .

The therapeutic effectiveness of manipulations to dissolve blockages on the spine has repeatedly been scientifically investigated. Overall, compared to conventional treatments (such as drug pain management, physiotherapy) and sham treatments, there were minimal benefits for some types of back pain and conflicting results for headaches. This is offset by the radiation exposure from the necessary X-ray examinations, frequent slight undesirable effects and the risk of (presumably) rare serious complications. Therefore, the recommendations derived from the available studies are different.

Historical aspects

Attempts to explain the occurrence of blockages have a long history. Hippocrates already described a kind of functional "adjustment" of joints in the spine and referred to them as parathremata . Various theories and working hypotheses were developed to explain the pathogenesis of blockage well into the 20th century . In 1908 Andrew Taylor Still postulated a disturbance in the circulation of tissue fluid and in 1933 Daniel David Palmer postulated a subluxation or nerve entrapment. Ludwig Zukschwerdt (1960) and Wilhelm Doerr (1962) assumed meniscus entrapment , James Cyriax (1969) and James Waddingham Fisk (1977), however , assumed that the intervertebral disc tissue was jammed and Wolf J. (1969) assumed that the gliding ability of the joint surface was impaired.

Irvin Korr (1975) and Jiří Dvořák (1983) introduced the fundamentally new aspect that the blockage is not primarily due to a disturbance of the joint itself, but rather arises from the nervous-reflex control of the joint.

Different hypotheses have been put forward over the years to explain common accompanying phenomena. A swelling of the connective tissue that surrounds the joints (periarticular connective tissue) was assumed to be an organic correlate of irritation points . Alternatively, points of irritation were viewed as a result of painful protrusions in the joint capsules. The crackling accompanying noise that often occurs when a blockage is released was understood to be the result of a negative pressure phenomenon in the joint space or the release of joint cartilage adhesion .

literature

  • HP Bischoff: Chirodiagnostic and chirotherapeutic technology. ISBN 3-88429-290-0 , pp. 9-23.
  • W. v. Heymann: Basic research meets manual medicine. In: Manual Medicine. Verlag Springer, Berlin / Heidelberg 2005, pp. 385-394, ISSN  0025-2514 (print), 1433-0466 (online).

Individual evidence

  1. ↑ Further training regulations of the Bavarian State Medical Association (PDF; 442 kB)
  2. ↑ a) K.-B. Baller: Standards of sports medicine: The examination of the spine in sports medicine - Part 3. In: German magazine for sports medicine. 2000, pp. 213-214, ISSN  0344-5925 . (online)
    b) AWMF guidelines (orthopedics): Muscular torticollis. (online)
    c) AWMF guidelines: Low back pain. (on-line)
  3. ↑ a) AWMF guidelines (orthopedics): Osteochondrosis dissecans of the knee joint. (online)
    b) AWMF guidelines (orthopedics): Gonarthrosis. (online)
    c) AWMF guidelines (orthopedics): Patellar luxation. (on-line)
  4. ↑ LE Koch et al.: Measurement method for representing the isolated head joint mobility in children and adults. In: Manual Medicine. 2003, pp. 30-32, Verlag Springer, Berlin / Heidelberg, ISSN  0025-2514 (print), 1433-0466 (online).
  5. ↑ a b c d H. D. Neumann: Manual medicine. Springer-Verlag, New York / Berlin / Heidelberg 1989, ISBN 0-387-50511-3 , pp. 5-10.
  6. ↑ E.-J. Speckmann, W. Wittkowski: The substrate of "blocking" - neurophysiological foundations of manual medicine. In: Manual Medicine. 1997, pp. 176-183, Verlag Springer, Berlin / Heidelberg, ISSN  0025-2514 (print), 1433-0466 (online).
  7. ^ A. Fischer et al.: Differential diagnosis of thoracic pain in internal medicine. In: Manual Medicine. 2006, pp. 530-532, Verlag Springer, Berlin / Heidelberg, ISSN  0025-2514 (print), 1433-0466 (online).
  8. ↑ F. Mayer: Injuries and complaints in running: conclusion. In: Deutsches Ärzteblatt. 2001; 98 (44) (online) .
  9. ↑ MJ Stochkendahl et al .: Manual examination of the spine - a systematic, critical review of reproducibility. In: Manual Medicine. 2007, pp. 301-308, Verlag Springer, Berlin / Heidelberg, ISSN  0025-2514 (print), 1433-0466 (online).
  10. ↑ L. Hestbaek, C. Leboeuf-Yde: Are chiropractic tests for the lumbo-pelvic spine reliable and valid? In: J Manipulative Physiol Ther. 2000; 23 (4), pp. 258-275. PMID 10820299
  11. ^ S. French, S. Green, A. Forbes: Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low-back pain. In: J Manipulative Physiol Ther. 2000; 23 (4), pp. 231-238. PMID 10820295
  12. ^ National Association of Statutory Health Insurance Physicians : Announcements: Resolutions and findings of the Doctors / Substitute Funds Working Group of the 191st meeting on March 26, 1997. In: Deutsches Ärzteblatt. 1997; 94 (21), pp. A-1452 / B-1234 / C-1107 (online) .
  13. ↑ z. BU Wolf, M. Brockmann, A. Wilke: Imaging of blocks in the spine with bone scintigraphy (SPECT). In: Biomed Tech (Berl). 2000; 45 (7-8), pp. 206-210. PMID 10975149 .
  14. ^ H. Lohse-Busch: Pitfalls for doctor and patient. In: Manual Medicine. Springer, Berlin / Heidelberg 2004, pp. 427-434, ISSN  0025-2514 (print), 1433-0466 (online).
  15. ↑ R. Kittel et al.: Blockage of the cervical spine in segments C3 to C5. In: Manual Medicine. Springer, Berlin / Heidelberg 2002, pp. 325-329, ISSN  0025-2514 (print), 1433-0466 (online).
  16. ↑ G. Müller: Training therapy in the context of manual medicine. In: Manual Medicine. Springer, Berlin / Heidelberg 1997, pp. 210-219, ISSN  0025-2514 (print), 1433-0466 (online).
  17. ^ E. Ernst, PH Canter: A systematic review of systematic reviews of spinal manipulation. In: JR Soc Med. 2006; 99, pp. 192–196, doi: 10.1258 / jrsm.99.4.192 (online) ( Memento of the original from May 11, 2008 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / jrsm.rsmjournals.com
  18. ↑ See K. Lewit: Manual medicine for functional disorders of the musculoskeletal system. Elsevier, 2006, ISBN 3-437-57190-7 , p. 1 (online) ; KA Ligeros: How Ancient Healing Governs Modern Therapeutics. Kessinger Publishing, 2003, ISBN 0-7661-3266-8 , p. 420 (online) .
  19. ↑ J. Wolf: The chondrosynovial membrane as a uniform lining skin of the joint cavity with a sliding and barrier function. In: Manual Medicine. Springer-Verlag, New York / Berlin / Heidelberg 1969, p. 25, ISSN  0025-2514 (print).
This version was added to the list of articles worth reading on July 15, 2008 .