The practice of osteopathy

Spinal Curvatures

Any deviation of two or more consecutive vertebræ from the normal curves of the spinal column is usually termed by the osteopath a pathological curvature. Of the common pathological curvatures of the spinal column there are found: (1) scoliosis or lateral curvature, (2) kyphosis, or excurvation, an antero-posterior curve with the convexity backward, and, (3) lordosis, or incurvation, an antero-posterior curve with the convexity forward.

Osteopathic Etiology.—Of primary importance in the causation of pathological curvatures of the spinal column, are injuries to the spine, such as strains, falls, blows, and various physical forces, acting directly or indirectly, as injuries to the chest, pelvis and limbs. The osteopath in his daily work finds more curvatures, as well as acute and chronic diseases, resulting from some simple injury to the spine, as a slip, strain or twist, than from any other cause. The dire effects of any violence to the spinal column cannot be overestimated.

Among predisposing causes may be mentioned, continued ill health, general weakness, rapid growth, rachitis, tuberculosis, etc. Any habitual one-sided position may result in a curvature. An injury to the chest, adhesions from pleuritis, chronic liver disease, obliquity of the pelvis producing unequal length of the legs, carrying heavy weights on one side, and various morbid growths of the chest and abdomen, may all produce curvatures. Many cases are found in school children who are growing rapidly, and whose muscular strength and development do not keep pace with their growth. Unilateral atrophy of the muscles, due to central changes or overuse, may be the cause of deviations of the spinal column. Sacro-iliac disease in some instances is a potent factor. Thus there may be a great variety of causes productive of the incipiency, and the spine being strained or irritated at a single point and in a certain way gradually develops a curvature. Every spinal and innominate lesion should be considered as a potential cause for a curvature.

Scoliosis.—This is the most common spinal deformity and is characterized by lateral deviation from the median line. In most cases the curve is to the right in the upper dorsal region, with a compensatory curve in the opposite direction in the lumbar region. The curve being to the right in the majority of cases, is probably due to the fact that most people are right-handed.

Morbid Anatomy.—The vertebræ in the region involved are rotated so that their spinous processes point toward the concavity of the lateral curve. The bodies of the vertebræ on the side next to the concavity are thinner, due to absorption; the intervertebral discs are made thin on the same side by pressure and absorption. The ribs are considerably distorted, depressed on the concave side and prominent on the convex side. The ligaments on the concave side are contracted, and stretched on the convex side. The muscles on the concave side are more or less contracted, and on the convex side they are stretched, causing atrophy and fatty infiltration of their tissues.

Kyphosis.—This may be a slight posterior curve really amounting to nothing, or it may be a very grave pathological condition as in Pott’s disease. Therefore it is very necessary that one should make a most careful diagnosis (see Pott’s disease).

The most common causes of kyphosis are Pott’s disease, rachitis, occupation, general weakness, rheumatism and old age.

In Pott’s disease, the posterior curve is characterized by a sharp angle, and by the spine being very rigid. This, taken in conjunction with the history and other symptoms should be sufficient to enable one to make a diagnosis. Radiographic examination should be made.

The condition of round shoulders, which in time produces marked kyphosis, is rarely a habit as it is usually termed. In nearly every case it indicates either a weakness of the back muscles or, what is more apt to be the cause, a strained posterior condition of the dorsal vertebræ, commonly of the lower dorsal region.

Morbid Anatomy.—In mild cases there is simply a relaxation of the ligaments of the vertebræ and a separation of the laminæ and spinous processes. In severe forms there may be absorption of the anterior portion of the intervertebral discs and the bodies of the vertebræ (Pott’s disease).

Lordosis.—This may be a congenital condition, especially when occurring in the lumbar region. Anterior curves of the spine are generally found in the lumbar or cervical regions, but occasionally occur in the dorsal region, causing the spinal column to be more or less straight, and thus weakening the individual. This curve is commonly compensatory to kyphosis, hip-joint disease and congenital dislocations of the hip.

Treatment of Spinal Curvatures.—The treatment of pathological curves of the spinal column, by osteopathic methods, has been highly satisfactory to both osteopath and patient. The success of the osteopath in these cases has been due to his comprehensive and exact knowledge of each vertebra, and of the spinal column in general. He recognizes curvatures that the ordinary practitioner, and it is safe to say the orthopaedic specialist, would not even notice or recognize. On account of the highly developed sense of touch of the osteopath, he is capable of detecting the slightest deviation of one vertebra from another, and of the spine in general from the normal. Thus by the uniqueness and peculiarity of his work he is capable, not only of discovering a curvature, but also of reducing a curve when found.

The work consists of, first, relaxing any muscles that may have become rigid over the seat of the curve. Then follows a treatment to each vertebra involved, by attempting to replace it, and treatment to the curve in general by springing it toward its normal position. At each treatment effort should be made to accomplish something toward correcting the spine; too many treatments are given in a “general” way, and being unspecialized amount to nothing. One must become familiar with the exact location of each vertebra involved, to attempt a correction of a curvature intelligently. Upon this one point it is impossible to speak too strongly, for a great many treatments have been wasted and improvement of cases retarded by not paying enough attention to the details of the diagnosis, either from pure slothfulness or from an imperfect conception of osteopathy. Corrective exercises are always of value in addition to treatment.

These remarks refer to incipient and certain moderate curvatures. In other cases radical measures (Abbott) should be employed if age and conditions permit. Remember, however, that the practitioner in his daily work of adjusting the many combinations of rotation and sidebending lesions corrects innumerable actual and impending curves.

Lateral curvature in the dorsal region is undoubtedly the hardest to correct on account of the ribs, which complicate the condition. A marked curve in the dorsal region is sure to be accompanied by a dislocation of the vertebral end of one or more ribs. Treat each distinct lesion separately, follow by general stretching, replacing and molding of the tissues. A good method to stretch tissues and adjust a moderate lateral curve is to utilize the swing, or in lieu of this have the patient stand just at arm’s length from the wall with concave side toward the wall with straight arm at right angles and palm resting against the wall. Stand in front of patient whose feet are firmly on the floor and reach around with both hands upon the spine. As the patient sidebends toward the wall it tends to correct the deformity, so if the operator coordinates his adjustment with that lateral movement of the patient, precise fulcra can be obtained and a certain, definite correction secured. The significance rests with the stretching of tissues and the definite fulcra obtained, thereby securing a maximum sidebending and rotation toward correction.

The dislocation of an innominate sometimes complicates matters, but is a simple point to remedy, and should not be overlooked.

The correction of a curvature presents a special study to the osteopath, whether it be scoliosis, kyphosis or lordosis, and special rules cannot be laid down for treatment. Cases of rare occurrence are what might be termed “symmetrical” curves; i. e., no vertebra presents separately a marked lesion, the column on the whole being simply bowed. Such cases can be treated by springing back the spinal column, and by the use of methodical exercises. Unfortunately most curvatures are characterized by various lesions between the vertebræ, and thus each lesion requires special work.

In simple curves the use of braces, jackets, and the various mechanical appliances are of very little use to the osteopath, in fact, more harmful on the whole, than beneficial. Naturally they would apply to a “symmetrical” curve, or where the patient is too weak to sit or walk, but they can be of very little use to the average patient, in place of correct osteopathic treatment. Mechanical appliances confine the movements of the patient, interfere with the development of the muscles, and impinge to a greater or less extent the spinal nerves. Due attention to hygienic surroundings and diet are certainly of aid. Proper exercises and occupation for the sufferer should be advised. Special care should be taken in examining (radiographic) for infectious lesions (arthritis).

Straight Spine is a term used particularly by osteopaths for a condition seldom recognized by orthopedic surgeons. The following is from H. W. Forbes[40]: Straight spine is “a departure from the normal in the conformation of the chest; characterized anatomically by bilateral diminution in size, decrease in the antero-posterior diameter, relative increase in the transverse diameter and flattening of the anterior and posterior walls; characterized clinically by diminution of respiratory capacity, lowered lung and heart resistance, impaired general nutrition and predisposition to neurosis.

“Of the many possible manipulations that may be used to lift and overcome the morbid bend of the ribs I will attempt the description of but one.

“Relax the musculature of the back and chest. Rotate, flex and extend the dorsal spine. Examine all the ribs on each side and loosen any that do not move freely. Having done this, the patient is prepared for the specific treatment. Have the patient sit on a stool and lean forward on a table. Have him separate the elbows, flex the forearms, place one hand over the other and his forehead on the hands. Tell him to relax all the muscles of the shoulders and arms and to breathe deeply without using the muscles. After a few trials he is able to fully expand his chest without contracting the muscles connecting the upper extremity with the trunk. The physician then takes a position at side (either side) of the patient and places the weight of his trunk on the ribs of the side he is on, a little external to their angles. He passes his arms around the patient’s body; the arms passing across the front of the chest are carried around far enough to allow the hand to be placed on the ribs just external to their angles. The other hand is placed on the top of this one. In this position the physician’s body on one side, and his hands on the opposite, occupy similar positions. The patient is now told to inspire deeply and at the same time to relax the shoulder muscles, as before instructed. As the chest expands drop the weight of the trunk on one side and make pressure forward (forward meaning toward the anterior surface of patient’s body) with the hands on the other side. This lifts the ribs to a greater extent than the patient unassisted could lift them. At the end of inspiration and during the first third of expiration the chest is compressed laterally. The compressing force, if applied correctly, will fix the ribs in a position of less obliquity and will also correct the increased lateral bending of them. The dorsal spine becomes more convex posteriorly at the moment of lateral compression of the thorax, if correctly made. Great force should not be used at the beginning. Repeat the manipulation five to twenty times each treatment. Give treatment three times a week. A similar movement may be given on the table.

“The greater number of flat chests in patients under thirty years of age may be corrected. If the patient is above thirty, although complete correction may not always be accomplished, the results are satisfactory. Two to six months treatment is required.”

A “typhoid spine” comes as a sequel to typhoid fever. There is constant pain, tenderness along the lumbar region and rise of temperature. The pain is generally increased when the spine is moved forward or sidewise. Such a condition is clearly understood by the osteopath. There are always found distinct vertebral lesions along the region that is tender on pressure. In fact these very lesions may have been the predisposing cause of the attack of typhoid fever. The treatment is rest and the indicated manipulation to correct the derangements. It is of great interest to note that where the typhoid patient is treated osteopathically the condition just described seldom results. Observations by C. M. T. Hulett confirm this statement.

The Neurotic Spine may be the result of injury but the subject is usually of a nervous, neurasthenic type. It occurs from the age of puberty to adult, much more often in females than males.

The patient has dull pain in the back of the neck or in the lumbar or sacral region, complains of a constant tired feeling and often of a sharp neuralgic pain in certain parts of the spine. Generally there is a drooping posture in the upper dorsal with shoulders thrown forward, which is a sign of weakness. There is extreme tenderness along the spine and usually the pain is confined to the sensitive places.

Treatment consists of a constitutional toning up, and increasing muscular strength through judicious exercise. The posterior curve may be pushed toward the median line by laying the patient on the face; also with the knee in the back and the flat of both hands on the sternal ends raise the ribs; or by the arms making use of the pectoral muscles accomplish the same result. Deep breathing is also effective. Relief can usually be given and a cure will depend upon the patient’s general condition.

The Hysterical Spine is usually considered the same as the neurotic spine, but there are many cases which have the sensitive spine without being hysterical. There is more deformity usually present, particularly in the lumbar region. Probably there will be a history of some injury.

The treatment is to correct the curvature and build up the general health. These conditions are stubborn and progress is slow. In both the neurotic and hysterical spines the ligaments of certain areas will be found atonied and relaxed. This is especially noticed upon attempting to spring a group of vertebræ when all of a sudden the section relaxes. In either of these spines the lesions will irritate or obstruct nervous courses, produce venous stagnation or arterial starvation, and disturb lymph channels. H. F. Goetz has observed that in functional nervous diseases the dorsal spine is flat, while in visceral displacement the dorso-lumbar spine is posterior.

The Spine of the Aged wherein is found stooped shoulders and a rigid spinal structure, can be distinctly improved by slow, cautious traction. This tones weakened muscles, releases contractures, separates the compressed intervertebral discs, and definitely tones the viscera. Careful work is imperative.