Neurodynamic of spinal segmental dysfunctions in clinical practice. A neurodinâmica disfunção espinhal na prática clínica

Revista Brasileira de Quiropraxia - Brazilian Journal of Chiropractic

Endereço:
Rua Columbus 82-A - Vila Leopoldina - São Paulo
São Paulo / SP
5304010
Site: http://www.quiropraxia.org.br
Telefone: (11) 3641 7819
ISSN: 2179 7676
Editor Chefe: Djalma José Fagundes
Início Publicação: 31/05/2010
Periodicidade: Semestral
Área de Estudo: Saúde coletiva

Neurodynamic of spinal segmental dysfunctions in clinical practice. A neurodinâmica disfunção espinhal na prática clínica

Ano: 2014 | Volume: 5 | Número: 2
Autores: Francio VT
Autor Correspondente: Vinícius Tieppo Francio | [email protected]

Resumos Cadastrados

Resumo Inglês:

The principles, art and science behind the chiropractic profession have always been and will continually be a topic of discussion within the chiropractic and other health care disciplines. The theoretical process, mechanisms, clinical applications and effects behind segmental spinal dysfunctions, or segmental artrokinesiopathologies of the spine, traditionally and historically defined as “Vertebral Subluxation Complex (VSC)”, are considered extremely multifarious, and requires a greater understanding of the intricacy of the neuro-musculo-skeletal spinal system. Each portion of this process is complex and interconnected, expressing the biological response of the body in relationship to a structural dis-relation, brought by stressors from the external or internal environment, or by a combination of both. The traditional term ‘subluxation’ has its ambiguous definition with other professions and, does not clearly define the current functional and structural dis-relation in question. Rather, currently definitions describe it as a disturbance of normal functional movement within spinal segments, better expressed as spinal motion unit dysfunctions, or spinal fixations, or even more so as, ‘spinal articular kinetic aberration’ – stated as disturbances of spinal kinematics with reflective significant effect in the neural and mechanical function. The general effects of spinal kinematics dysfunctions results in alterations within the adjacent structures of the neuromusculoskeletal systems, therefore the purpose of this short commentary is to describe contemporary clinical applications of this theoretical process, in clinical practice.
In reference to the skin, subcutaneous tissues and associated musculature, alterations can vary from a thin, glossy texture to a thick, rough, discolored patch, resembling a callus formation. Clinically in the past, infrared thermography has been utilized to determine its specific locations, as indicated by vascular changes in the dermatome. Usually, palpatory findings may range from a “slimy” feeling to a “skin-slip” granular feel. The surrounding musculature demonstrates natural resiliency, to a contracted ‘cord-like’ or ‘stringy’ band according to its chronicity. Subjectively, the most convincing evidence for the patient is the acute ‘sore-spot’ and the tenderness experienced upon posterior-to-anterior palpation of spinal segments with mutual translation.
The process of ongoing spinal kinematic dysfunction is complex and comprehensive within the neuromusculoskeletal arrangement. Any stressor from external or internal environment can disturb the receptor endings in the joint capsules, ligaments, intervertebral discs, musculo-tendinous junctions, etc. Such dis-relation evokes an abnormal flow of afferent impulses into the reciprocal neurological bed, which is no longer equivalent to the opposite side, as it would be in a physiological homeostatic balance. The excessive persistent stimulation alters the function within the respective neuronal pool and those adjacent to the main structure, for a variable distance. Such sensorial neurological disruption, succeed in making synaptic connections with the motor pool in the anterior gray horn, through either collateral branches, or intercommunicated neurons, therefore motor response to an aberrant sensorial stimulus is perpetuated. Clinically, the most noticeable muscular contraction putatively associated with spinal kinematic dysfunctions is to be found within segmental spinal muscles, such as the rotators, stabilizers and the deep layer of multifidus.
Due to the intermingling and intricacy of the fiber arrangements, those fibers supplied by the same neuronal bed may experience a degree of hyper tonicity, although not readily detected by spinal palpation. However, in addition to the time factor, there may be evident changes in muscle texture on the long postvertebral chain, such as paraspinal groups, as fibrosis develops. Minimal loss of active range of motion is one of the first appreciable alterations of major muscles fibrosis and, focal non-specific myalgia without evoked contraction on elevated compressive stress may be an earlier indication of a smaller muscle groups involvement.
Nevertheless, the musculature supplied by the anterior primary ramus of the associated nerve trunk does not escape from alterations in tone either. Those muscles, whose action is antagonist to the prime movers, are inhibited by a decrease in tonus of the respective myofibrils due to a decrease in nerve supply from the aberrant neuronal pool. Afferent impulses will also involve the lateral horn cells for the control of the vascular tone of the corresponding musculature, experiencing hyperactivity and an increase in arterial blood supply. The vascular bed undergo dilation, upon a decrease of adequate neuronal flow to their tunica intima, strongly evoking a central state of preganglionic sympathetic inhibition of the lateral horn. The hypothalamus may play a role with the cerebral motor cortex and the sub-collicular area stimulating the postganglionic sympathetic fibers to these vessels by the secretion of acetylcholine, resulting in vasodilation. Therefore, the vascularity of the corresponding area of spinal kinematic dysfunction is greatly decreased, as may be detectable by thermocouple heat measuring instruments, commonly used in clinical practice. Associated with the vascular activity, the sudoriferous glands are activated by stimulation of other preganglionic sympathetic fibers of the lateral gray horn, which in turn, activate postganglionic fibers via the posterior primary ramus at the corresponding level of segmental dysfunction. This enhanced activity of sudoriferous gland may be clinically perceived by sensitive instruments measuring skin resistance, or by trained hands of the manual medicine providers.
Noxious afferent impulses may arise form any of the contributory elements injured by chemical stressors or mechanical trauma, which may be the causative factor in the process of the spinal dysfunctions. Such impulses take precedent over the proprioceptive impulses and result in the cascade effect of muscular ‘splinting’, a natural response of the musculoskeletal system to prevent further damage to the area of the injured joint, thereby preventing further motion that might aggravate the injured tissues, and release more chemical mediators of an inflammatory and painful response – such as histamine-like, and bradykinin-like factors. In general, these chemicals cause a greatly increase in capillary permeability, permitting extravasation of blood plasma in to interstitial space, with protein and fibrinogen-like substances. This interaction promotes coagulation and in conjunction with necrosin-like chemicals, may generate a ‘brawny-edema’ appearance surrounding the joint and damaging more cells. This swelling can produce pressure upon receptor nerve endings in the area, perpetuating the flow of centripetal noxious impulses to the neuronal pool at the spinal cord, in a vicious-cycle arrangement to the similar neuronal pathways arc or to higher neural center.
Incontestably enough, the mechanisms from which vertebral kinematic dysfunctions may disturb physiological functions are quite unique and comprehensive, as the distinctiveness of the neuromusculoskeletal system. Researchers are far from the absolute true regarding this concept, but progress has been made through the past hundred years, and evidence-based care has been validating these new models. As any other field of study, chiropractic shouldn’t be stationary to new discoveries. Evolution and growth of a profession is a process, and incorporating new ideas is a part of this development. It is important to focus major efforts to overcome current difficulties and barriers within, and out of our profession. In addition, it is fundamental to integrate this contemporary model within the application of our traditional principles, science, and art – without losing our professional identity, for the benefit of the chiropractic profession, and future generations.

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