Diagnosis and choice of subsequent treatment

The construction of pathobiomechanical diagnosis and choice of tactics of manual therapy

• The detection of diagnosis begins from the moment of meeting with the patient, continue during the all examination and have several stages:
•  Diagnosis of biomechanical failure of statistics and dynamics and elements that constitute it;
• Determination of  localization of statically and dynamically overloaded elements in musculoskeletal apparatus ( in localization of pain);
• Determination of localization of pathogenic significance of pathobiomechanical  changes, that requires static and dynamic compensation;
• Construction of pathobiomechanical chains, where different detected changes in muscle biomechanics, ligaments, spinal-motion segments are connected together and support existence of each other.

PATHOBIOMECHANICAL CHAINS

Vertebrate – vertebrate:

Associative – acquired ties between spinal-motion segments, that has muscle functional blocks by the rule ”up-down, left side – right side”. For example, functional block L5-S1 towards flexion, lateroflexion to the left side, rotation to the left side – functional block C0-1 towards extension, lateroflexion to the left side, rotation to the right side.

Vertebrate – muscular:

Innervation – functional block of spinal-motion segments has a disturbance of innervation of the dorsal spine muscles that come out at this stage with the formation of its functional weakness. For example, functional block C6-7 – has a disturbance of functions of nerve root C6  - functional weakness of big pectoral muscle (front pectoral nerves);

Associative – acquires ties between spinal – motional segments of the neck that has functional blocks and muscles of extremities that are formed at the stage from 4 weeks to six month age. It is connected to simultaneous movement of the baby’s head and movement in the extremities. For example, functional block C2-3 — functional weakness of big gluteal muscles;

The spatial – approachment of shorted muscle ends — functional muscle blocks in the places of its attachment. For example, contraction of lumbal-iliac muscle – functional block of hip joints and thoracolumbartransition.

Muscular – muscular:

There are tone-forced correlation between five muscle groups and participating in a motor pattern. For example, relaxed antagonist – big gluteus muscle, shorted antagonist – is lumbar-iliac muscle. 

Vertebrates- ligamentous:

Spatial – contraction of ligaments leads to statics overloads at their places of attachment and formation of functional block. For example, functional block L5-S1 towards flexion, lateroflexion and rotation to the left — are contraction of lumbal-iliac ligament to the right;

Ligamentous – ligamentous:

Formation of ligamentous chains by the rules “up-down, left – right sides”. For example, contractions of   lumbal-iliac ligament to the right – is contraction of spine- pulmonary ligament  at the right.

Knowledge of the law of construction of pathobiomechanics chains helps us to formulate pathobiomechanics diagnosis after some minutes of visual and palpatory diagnosis

A. Visual diagnosis of nonoptimality statics

1. The determining of direction of displacement of common center of gravity.

2. The determining of region, pathogenic significance in the appearing of displacement of common center of gravity projection.

3. The determining of the region, that compensate displacement of common center of gravity projection (“stopping falling” of the patients’ body)

4. The diagnosis of variant of postural imbalance in pathobiomechanics significance region.

5. The diagnosis of postural imbalance of muscles in compensatory overload region.

B. Visual diagnosis of optimality of dynamic stereotype

Innervation – functional block of spinal-motion segments has a disturbance of innervation of the dorsal spine muscles that come out at this stage with the formation of its functional weakness. For example, functional block C6-7 – has a disturbance of functions of nerve root C6  - functional weakness of big pectoral muscle (front pectoral nerves);

There are some stages of diagnosis:
1. In comparing the horizontal lines that held through the boards of shoulder, scapula, lumbar, pelvic, hip and tibial regions;
2. The diagnosis of contractive muscles in compensatory overloaded regions;
3. Comparing of the clinic syndrome and pathobiomechanics changes in musculoskeletal system.

C. The identification of pathogenic significance gypoexcitability of relaxed antagonist and formation of secondary compensatory hyperactivity of contractived muscle.

D.In expressed pain syndrome there are radiography of certain part of the  spine in statics (in two projections) and in functional try – movement in the direction that provoke pain.  The final radiological diagnosis.

1.Analysis of the statics as all;
2.Analysis of the spatial interposition vertebrae in the individual vertebrae spinal-motion segments in static;
3.Analysis of the statics disturbances in the sagittal plane;
4.Analysis of the dynamic;

E.The construction of the pathobiomechanics diagnosis

All pathobiomachanics changes that were found after visual and radiological diagnosis , are line up into pathobiomechanics pathogenesis chain links.

THE PATHOBIOMECHANICS CHAINS

Spinal-spinal:
Associative:

- Functional block L5—S1 – functional block C0-1 ;
- Functional block Th12—L1 – functional block C5-6;

Spinal – muscular:
Innervations:

- Functional block C6-7 – disturbance of function of spinal root C6 – functional weakness of muscles of deltoid (subscapular nerve) and big pectoral muscle (front pectoral nerve);
- Functional block L5—S1, disturbance of the function L4 – functional weakness of big gluteal muscles;

Associative:
- Functional block С2-3 – functional weakness of big gluteal muscles;

Surround:
- Contraction of the lumbar-iliac muscles – functional block of hip join;
- Contraction of the upper part of the trapezius muscle on the left – functional blocks at the stage C0-1  and scapular- clavicular joint;
- Contraction of short neck’ extensors;
- Contraction of square lumbar muscle – functional block L5—S1 towards to flexion, lateroflexion and rotation to the left;

Muscular – muscular:
- Relaxed antagonist (big gluteal muscle) – shortened antagonist (lumbar- iliac muscle)
- Relaxed antagonist (big pectoral muscle) – shortened synergist

Spinal – ligamentous:
Spatial:
- Functional block L5—S1 toward to flexion, lateroflexion and rotation to the left – contraction of lumbar-iliac muscle at right;

Ligamentous – ligamentous:
- Contraction of lumbar-iliac ligament – contraction of sacro-tuberal and spinal – pulmonary ligament on the opposite side.

THE PATHOGENETIC LINKS

Dynamic

The big relaxed gluteal muscle at the left that is an antagonist of motor pattern of hip extension and didn’t do its dynamic function because of its gypoexcitability , it required compensatory inclusion of the square lower back muscle at the right (muscle – fixator of such motor pattern) and has contraction of its antagonists – lumbar-iliac muscle , causing gypoexcitability of both muscles and outrunning its inclusion in motor pattern.
The big relaxed pectoral muscle is the antagonists of motor pattern of shoulder’ flexion, didn’t do its dynamic function because of its gypoexcitability, it required compensatory inclusion of small pectoral muscle (synergist of such motor pattern), leads it to gypoexcitability and contraction.

Statics

-It is contraction of lumbar-iliac muscle – hyperlordosis in thoracolumbar transition – displacement of center of gravity in lumbar region and “falling” of patients’ body forward and to the left – compensatory displacement of center of the gravity in pectoral region back and to the right – statics overloading of muscles of the right shoulder girdle, convergence of right parts of its borders – contraction of the upper part of trapezius muscle at the right, statics overloading of the upper part (displacement of center of the gravity in the cervical region forward  – contraction of short extensors – functional block of joints of upper and cervicothoracic parts);
- Functional block C5-6  towards flexion, lateroflexion to the right, rotation to the left – static overloading of cervical region – compensatory formation at the stage С2-3 of functional block toward extensions, lateroflexion to the left, rotation  to the right;
- Shortened upper part of the left trapezius muscle – is statics overloading of place of its attachment and compensatory formation of functional blocks at the stage C0-1 and scapuloclavicular joint;
- Contraction of lumbar-iliac muscle – approaching of places of its attachment – approaching the femoral head and acetabulum – functional muscle block of hip joint and thoracolumbar junction – twisted pelvis of muscle genesis;
- Contraction of square lumborum – functional block L5—S1  — contraction of lumbar-iliac ligament at same side – twisted pelvis of ligamentous genesis;

CAUSES OF THE DIFFERENT LOCALIZATION OF THE PAIN SYNDROME

Static or dynamic overloading of joints and muscles causes its contractions and formation of functional blocks in the places of its attachments:

1. Pain at the left in lumbar spine during the walking – dynamic overloading of square lumborum at the left, contraction of lumbar-iliac ligament;
2. Pain in the right shoulder girdle – static overloading of the upper part of trapezius muscle at the right, contraction of spinal – pulmonary ligament;
3. Pain in the left shoulder joint during the walking – dynamic overloading of the small pectoral muscle;
4. Pain in the back of the head – is static overloading of short neck extensors , functional block at the stage С0-1;
5. Pain in the lower-cervical spine – functional block C6-7;
6. Overloading of lumbar-iliac muscle, contraction of sacrotuberal ligament.

THE  PATHOBIOMECHANICAL CHAINS AND ITS INTERACTIONS

1.The contraction of spinal-pectoral ligament is as a reaction to contraction sacrotuberal ligament and lumbar-iliac ligament, maybe, traumatic genesis – during the falling of patient at the beginning of disease – functional block C6-7 – functional block С2-3 – relaxing of  the big gluteal muscle – contraction of square lumborum –functional block L5-S1 – contraction of lumbar-iliac ligament – contraction of spinal-pectoral ligament.

2. Functional block C6-7 – functional block С2-3 – relaxing of the big gluteal muscle.

3.Relaxing of the big gluteal muscle – contraction of lumbar-iliac muscle (dysfunction of pelvis muscle genesis) – is hyperlordosis in the thoracolumbar transition. Such chain can have two variants of further development:

a)functional block Th12-L1 – functional block C6-7;
b)contraction of upper part of trapezius muscle – contraction of short neck extensors – functional block C0-1 – functional block L5—S1 – relaxing of the big gluteal muscle – functional block C6-7

Influence of pathobiomechanics chains at formation of pain symptom shows on scheme.

Ignatyev G.V. :

- And now thinks about what consequences can be if layman does only one wrong movement in manipulations. The human organism – it is complicated biological machine, where everything is interconnected. If you break the chain, you will disturbance grow in anyway, as like unscrew the bolt in mechanical watch. That’s why that “specialists” makes many knowing only 2-3 maneuvers of manipulation, and don’t know elementary knowledge about human anatomy.   He cause of his activity develops instability in joints, including in spinal-motor.

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