AJCC October 2000
- The Biomechanical Rationale for Ambulatory
- Translation Traction of the Thoraco-Lumbar Spine
- By Donald W. Meyer, D.C.
A
skeleton named “Lucy” was found in 1974 and estimated to be
approximately three million years old. The finders of this ancient human
specimen noticed that the pelvic and lumbar regions were remarkably
similar to those of a modern female. This fact suggests that lumbar
lordosis and an inclined pelvis was most likely acquired a very, very
long time ago and has continued to be a stable acquisition for the past
few million years. The authors of this article go on to state that it
is, therefore, unreasonable to argue that features such as lumbar
lordosis and pelvic inclination are basic weaknesses due to our
evolution toward a more stable form of erect stance.l
In this paper, I will demonstrate why a normally aligned lateral
thoraco-lumbar spine is a pain-free, stable structure that has lasted
millions of years in its present form. I will also explain the effect
altered postural translations of the thorax has on the lumbar spine and
the pelvic girdle and the production of chronic pain. Finally, I will
describe a corrective ambulatory treatment for anterior or posterior
translations of the thoraco-lumbar spine with pre/post radiographic
results.
EXAMINING
THORACIC TRANSLATION
Radiographic studies have shown that the amount of a person’s
sacral inclination correlated strongly with the amount of one’s Ll -L5
lordosis and thoracic kyphosis and that pelvic tilting also correlated
strongly with Ll-L5 lordosis .2 It has also been noted that with age,
especially in the sixth decade of life, that the lumbar lordosis tends
to decrease as the thoracic kyphosis increases.2,6 Other studies have
found that lumbo-pelvic lordosis and pelvic balance over the hips are
strongly correlative.3,4 All of these studies point to the fact that
there is a postural interaction of the thoracic, lumbar and pelvic
spinal regions in their quest to allow us to fully function while still
contending with the forces of gravity. Anterior or posterior thoracic
translation is coming into light as a major aberrant posture that can
affect the thoracic kyphosis, lumbar lordosis, pelvic tilting and sacral
inclination. Translation, for the purpose of this paper, is defined as a
horizontal anterior or posterior movement along the Z-axis of the body.
Anterior or posterior thoracic translation is written as +Tz or -Tz
because of its movement along the body’s Z-axis. (See Figure 1)
The aberrant mechanical loading that the spinal joint tissues are
subjected to because of these structural and postural changes is now
being found to be a major cause of chronic and acute spinal related
pain. Numerous studies have all shown that chronic low back pain
subjects demonstrate decreased lumbar lordosis and sacral inclination
with increased thoracic kyphosis and L5-S 1 segmental lordosis.5,6,7,8
This structural alteration is associated with the posterior thoracic
translation posture. (See Figure 2) Acute low back pain subjects showed
a hyperlordotic tendency with an increased pelvic tilt and sacral
inclination.8 This structural alteration is associated with an anterior
thoracic translation posture. (See Figure 2) This posture is also
generally associated with a decrease of the thoracic kyphosis.
The normal lumbar lordosis for asymptomatic people is now being
defined as approximating an ellipse.9 The average segmental rotation
angles for 552 pain-free subjects for T12-Ll was 0 degrees, Ll-L2 was
2.9 degrees, L2-L3 was 7.4 degrees, L3-L4 was 11.9 degrees and L4-L5 was
16.6 degrees, L5-Sl was 32.4 degrees, Sl to horizontal was 39.7 degrees
and the average posterior translation of T12-Sl was six millimeters with
zero millimeters being the ideal.l0 (See Figure 3)
CORRECTION
OF THORACIC TRANSLATION
A recent article on “Functional Re-Training and Spinal
Support” described the concept of specific adaptation of imposed
demands (SAID) as one of the basic tenets of the strength and
conditioning field. This SAID concept encourages exercises that mimic as
closely as possible the real conditions under which the spine must
function day after day. This includes the specific stress of gravity in
the upright position or functional posture. The spine is part of a
closed kinetic chain when it is weight bearing and performing most daily
activities. Open-chain exercises for the spine are done non-weight
bearing either lying on the ground or immersed in water. While this type
of exercise is useful during the acute stage, its value in improving
functional end results is limited. A recent study on back pain published
in Spine listed six popular low back exercises considered “sham”
treatments, because if they are the only ones performed, no improvement
will be seen. They included: knee-to-chest stretches, partial sit-ups,
pelvic tilts, hamstring stretches, and “cat,” “camel,” and side
leg lifts. They are all open-chain, non-weight bearing exercises.11
Weight bearing activities require the co-contraction of accessory
and stabilizing muscles. They also stimulate proprioceptive input from
receptors in the muscles, connective tissues, and joint capsules. This
is why it is so important to perform neck and back rehabilitative
exercises in a closed-chain, weight bearing posture that is closer to
real life positions. The SAID concept tells us to expect that closed
chain, weight bearing exercises generally will be more effective.11
So now that we know that an effective rehabilitation program
should include weight bearing exercise, what if this ambulatory
treatment could be performed while the patient’s normal lateral spinal
alignment was in traction and held into place? Could we expect to see a
more rapid and effectual means of spinal postural remodeling take place?
One reason to expect a more effective change is because spinal tissues
that are undergoing rapid movement will elongate and remodel faster than
static or slow moving spinal tissues.12 With each step of the ambulatory
patient, the pelvis rotates 40 degrees forward. The opposite hip joint
acts as a fulcrum for this rotation. Also with each step, the pelvis and
trunk shift laterally approximately one inch, inducing a lateral flexion
motion into the thoraco-lumbar spine.13 All this motion stimulates
viscoelastic changes within the spinal supporting tissues as well as
accelerating postural muscular and neurological re-balancing.
With these considerations in mind, I created the Lumbar
Remodeling Brace™. This adjustable, padded steel device is worn by the
patient and can pre-stress the patient’s thoraco lumbo-pelvic posture
back to a normal lateral alignment (eliminating either anterior or
posterior thoracic translation) while also applying an anterior traction
force into the mid-lumbar spine to restore its normal elliptical
configuration. (See Picture 1A & B)
I have been using this posture corrective brace in conjunction
with a treadmill or a low impact elliptical exerciser. I have found
these devices to be a cost and time effective means of applying
ambulatory corrective traction treatments that we bill out as either
therapeutic exercise or neuro-muscular re-education. Besides spinal
adjustments and eight to ten minute ambulatory traction sessions, most
of these patients also received seated abdominal rotational crutches
with tubing progressive resistance to strengthen the abdominal obliques,
if they manually tested weak.
Muscles
attaching onto the rib cage have been found to be important for control
of the overall spinal posture and maintenance of equilibrium.14
Stretching of the hamstrings and strengthening of the back extensor
musculature has also been found to encourage a more normal lumbar
lordosis and thoracic kyphosis.l5,16,17,18 These two benefits occur
naturally during ambulatory exercise.
The table below lists the radiographic results I have recorded so
far. I hope to provide a more complete report of the LRBrace’s
effectiveness once I have been able to gather at least 30 radiographic
pre/post measurements. I have also listed the reduction in forward head
posture that was also noted in the patients that simultaneously wore one
of our Cervical Remodeling Collarstm during their ambulatory exercise
with the Lumbar Remodeling Brace.
CONCLUSION
Studies have shown that hyperextension of the lumbar spine helps
to re-hydrate and increase the height of the intervertebral discs in a
prone subject with the optimal traction time being 20 minutes.l9,20
Another study has demonstrated that aerobic and training devices (like a
treadmill) showed a greater response than physiotherapy in the reduction
of chronic low back pain.21 This last paper was the 1999 Volvo Award
Winner in Clinical Studies. Unlike in the past, excellent spinal
research is now being conducted, tirelessly, by many individuals who
hope we grasp the information they prove and utilize it. With this in
mind, I also want to remind doctors that, “Many chronic spinal
problems develop secondary to an imbalance in the weight bearing
alignment of the lower extremities. In fact, lower extremity
misalignments such as leg length discrepancies and pronation problems
are frequently associated with chronic pelvis and low back
symptoms.”11 If you presently provide or now plan to provide an
ambulatory treatment, it is essentially important that you also
correctly prescribe heel lifts and arch supports to address your
patient’s frequent pronation and anatomical leg length deficiencies.
The effects of gravity on weight bearing and the alignment of the
kinetic chain in both the anterior/ posterior and lateral dimension
should always be considered.
In closing, I would like to leave you with this quote I
especially like: “The use of passive treatment modalities as the sole
means of chiropractic intervention for the management of patients
suffering with neuromusculoskeletal dysfunction no longer has a place in
modern chiropractic practice after the acute phase of healing has
passed.”22 This statement
comes from an excellent research paper that treating doctors can use to
justify to third party payors the necessity of your active posture
corrective work after the patient’s resolution of symptoms.
Figures:
- REFERENCES
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CONTENTS
Biomechanical & Neuro responses to Adjustment
Communicating From the Inside Out
Normal Values in Anatomy, Physiology, Disease and Chiropractic
Ambulatory Translational Traction
Percutaneous Radiofrequency Neurotomy...