I asked the organizer, Audry Vleeming, Ph.D., of Rotterdam and Berlin if many chiropractors attended. His answer, "Disappointingly low."
On the faculty brochure, J. David Cassidy D.C., M.Sc., FCCS, was listed with only a DC degree; James Wooley, D.C., was mistakenly listed as an MD. The majority of attendees appeared to be physiatrists and physical therapists. European orthopedists were also in attendance and seemed very interested in manual medicine.
The following are some brief highlights from my observations of the conference.
Anthropologist C. Owen Lovejoy, Ph.D., spoke about the gluteus maximus and the piriformis as efficient muscles for energy dissipation. He said the calcaneus, a thin cortical shell bone, was also more efficient at dissipating energy on heel strike.
Dr. Cassidy spoke of autopsying 180 joints, then showed slides demonstrating the sacroiliac joint's unique features. The joint develops in the first trimester, the ilium ossifies early, and is prone to early senescence later, while the sacrum develops more cartilage and withstands stress better. The joint is a synovial joint of both disarthrosis and anarthrosis, while the iliac joint is a pseudoarthrosis. When asked what was the clinical relevance, he said there was a "gap."
Radiologist Piet F. Dijkstra, M.D., of Amsterdam, Netherlands, said he had several patients with sacroiliac subluxation undetected on CT. He had a physical therapist manipulate these patients and they improved. He also stated that tuberculosis develops in three months as a large hole in the ilium.
Orthopedist Thomas N. Bernard Jr., M.D., of Columbus, Georgia, showed interesting slides of the sacroiliac joint moving with fluoroscopic dye. The Patrick test yielded a 1-2 mm difference, opening and closing; the Yeoman test yielded 1 mm difference; and the Shear motion, cross stretching the joint showed a closing motion in the joint. Dr. Bernard mentioned chiropractic as part of the First World Congress.
Physical therapist Diane Lee of Delta, Canada, said that she manipulated T11 to change the pelvic height. She cited a case study of a man with hamstring bleeding that referred pain to the sacroiliac joint. She used neuromobilization to release adhesions of scar tissue around the sciatic nerve.
Richard L. DonTigny, P.T., from Montana, theorizes that L3 and C7 dysfunction causes the pelvis to lock anteriorly, causing false ovary groin pain, and pseudoepididymitis, and that sacroiliac joint problems uncorrected, lead to degenerative discs at L4, L5. He stated that if a compression test is done on the SI joint while having the patient cough, and if the patient feels no pain, then the SI joint was at fault.
Jan Mens, M.D., of Rotterdam, the Netherlands, sent a questionnaire to over 600 patients (postpartum women with pelvic pain) and selected 262 of the 394 responses according to certain criteria, and monitored their progress. Their conclusion was that the increased weight played only a small part in the development of pelvic pain. Exercise and pelvic belts were useful. "It is hypothesized that peripartum pelvic pain is caused by strain of pelvic ligaments and that the ligaments are overloaded by a combination of traumatic and hormonal effects."1
Jon Helge Hansen, P.T., of Tromso, Norway, did a study of 160 women with no other factor causing pain other than parturition. He reported that children with larger head circumference influenced pain, and recommended crutches and tape to relieve the lumbosacral area. He said 93 percent had pain in the pubic symphysis during sexual intercourse, and 46 percent in the lumbosacral area; 50 percent had pain after sexual intercourse. He theorizes that increased intra-abdominal pressure is related to increased incontinence.
Andy Vleeming, Ph.D., from the Department of Anatomy, Rotterdam, Netherlands, said the many ridges in the sacroiliac joint, called "form closure," could look blurred on plain x-ray, leading to the misdiagnosis of arthritis. He stressed the importance of the shoulder muscles' strength on the contralateral side of the sacroiliac joint, whose stability affected dorsal ligaments and muscles, leading to flattened lordosis and increasing dorsal pressure on the lumbar disc.
Serge Gracovetsky, Ph.D., of Montreal, Canada, tested the audience with an x-ray of a cadaver, asking if the "patient" was ready to return to work. He stressed the importance on focusing on function. He showed a clip of a 20-year-old man, armless and legless, using his spine to walk, swinging from side to side like a fish (or a snake upright). He said, "We are the only species with lordosis and kyphosis," giving us the axial torque when we do lateral bending. He said that if the spine was meant to be a supporting column, then surgical fusion made sense. His view was that the spine is an engine, and it is the lumbar dorsal fascia that is supporting up to two tons pressure. He noted that a person with low back pain often had higher EMG activity than a normal person. He used the principle in physics where if something is working less (nerves, joints), then muscles have to work more. He felt that reduction of lumbar lordosis did not mean disaster, that forces could be transmitted safely through the erector spinae.2 His view was that muscles only transmit 20 percent of the force, intra-abdominal pressure less than one-tenth of a percent (good news for all the pot bellies), and fascia could transmit 80 percent of the forces. He said range of motion tests depended, in part, on patient collaboration.
James Wooley, D.C., from Irvine, California, talked about the effect of the skull's position, or orthogonality on the sacroiliac joint. He uses a neurocalometer as well as the Gaenslen test. He adjusts the PI ilium side down, and the AS ilium up to restore the occiput sacroiliac axis vertical. He mentioned nutrition of alkaline diet, chlorophyll, kelp, and vitamins. He also uses prolotherapy as Robert Klein, M.D., next explained.
Robert G. Klein, M.D., of Santa Barbara, California, favors the use of prolotherapy, injections of dextrose, glycerin and phenol in back pain. He theorizes that collagen is the key to back pain.
Dr. Klein, an orthopedist, said the nucleus of the disc consisted of phospholipase which can inflame without the presence of nerves, resulting in a nonmechanical pain.4,5,6 Within 24-48 hours and up to a week, the tendon diameter increases in water content, amino acids, and sugar, while hydroxyproline content decreases. With local anesthetic, he treats patients with six weekly injections into the ligaments, fascia, and joint capsules. Sacroiliac manipulations can be performed after the injections. Control groups in his experiments got xylocaine. He found that groups that do not respond are heavy cigarette smokers (whose collagen does not form properly), hypersensitive patients, and diabetics, whose collagen is limited and don't usually herniate their discs.3
When asked about cortisone, he said he did not favor it because it was lytic of collagen and could even provoke inflammation, as in arachnoiditis, which does not occur with prolotherapy injections. When asked why it seemed more women were subjects of pain, he theorized that androgen deficiency was a cause. He had injected 1.2 mg of testosterone to women resulting in less sensitivity. He acknowledged that lumbar punctures did result in headaches sometimes.
References
- Low Back Pain and Its Relation to the Sacroiliac Joint, Ed. Andry Vleeming, Vert Mooney, Chris Snijders, Thomas Dorman, First Interdisciplinary World Congress on Low Back Pain and Its Relation to the Sacroiliac Joint. San Diego, November 5 & 6, 1992, Rotterdam: ECO. pp 532.
- Ibid, pp 555.
- Ibid, pp 569.
- Connective Tissue Research, Liu, et al. 11:95-102, 1983.
- Orthopedic Research, Maynard, 3:236-248, 1985.
- Journal of Neuro-orthopedics, Klein, February 1993.
Amy Wong, D.C., Ph.D.
East Meadow, New York