Application of Spinal Segmental Physiology to Evaluating Chronic Pain
We all can agree that chronic pain (CP) occurs in a multitude of forms that extend to every branch of healthcare and that there are probably as many causes for these challenging disorders as there are patients seeking relief. Numerous cures have been proposed at one time or another, indicating that no one specialty has a universal solution. Truth be told, CP encompasses a wide diversity of causes that demand a multi-specialty approach. A great deal of time and money is wasted by the chronic pain patient wandering from office to office in search of a cure. The dilemma confronting the pain clinician is to determine which specialist is best suited for each patient.
In the interest of trying to resolve this problem, a new diagnostic algorithm for the evaluation of the chronic pain patient is being presented in this series of articles in Practical Pain Management.1-3 It is called the P.A.N.E. Process and stands for ‘Practical Applications of Neuropostural Evaluations.’ Although the P.A.N.E. Process is derived entirely from Western science, it differs in a significant number of ways from the familiar symptom-directed, anatomic approach of current Western Medicine.
This article presents the second stage of the P.A.N.E. Process: evaluation for spinal segmental dysfunction as a cause of altered neuroposture and chronic pain. These tests are called the “R” Tests. The exam process is quite simple, requiring only a few moments, but can help the clinician identify when spinal segmental dysfunction is the primary cause of a chronic pain condition—even when the patient does not have spinal pain. It is the author’s opinion that we have come to rely too much on radiological and electro-diagnostic technology, and not enough on functional testing. Chronic pain is usually a functional condition. The novice physician entering practice quickly learns that back pain encompasses far more problems than answers from the standard methods.
Overview of the P.A.N.E. Process
First, the same sequence of tests are performed initially on every patient, regardless of the anatomic area of complaint. In this way, nothing will be missed. Chronic pain conditions are usually compensatory disorders. Frequently the actual problem is hidden beneath these compensatory mechanisms such that the symptoms are not helpful in locating the true cause of the pain. Secondly, the sequence of these tests are organized along developmental and biological priorities.1,4,5 By following this algorithm, the priorities of treatment are established. Thirdly, most chronic pain disorders have an underlying neurological cause, even if they look like “tendonitis.” Therefore, comprehensive neurological diagnosis is essential. The P.A.N.E. Process addresses this problem by using manual postural motor reflex tests (PMRT), which reflect all levels of neurological control in the human nervous system. These tests are derived from standard motor evaluation procedures used in orthopedics, gait, physical therapy, and pediatrics.6-9
Human balance requires the integrated function of all parts of the nervous system. The gait definition of “normal posture” has nothing to do with appearing “straight,” but rather normal posture is actually when the patient demonstrates equal strength on both sides of the body in resisting a displacing force (perturbation) in symmetrical muscle pairs.10 Normal neuroposture, in other words, is a state of symmetrical motor functions that require symmetrical neurologic controls. Posture is the strength that resists movement not creates it. This is a clinically easy determination to make because the examiner does not have to quantify the strength, but simply compare the left and right sides of the body.
Therefore, neuropostural testing is the window to observe the entire spectrum of neurological levels. In contrast, standard neurological tests are limited to measuring less than thirty percent (30%) of the nervous system1 and so functional testing makes more sense for a comprehensive evaluation.
Finally, neuropostural reflex tests used in the P.A.N.E. Process are referenced to the constant of gravity. These tests provide a straight-forward “yes” or “no” answer to the question “is the patient’s neurological state balanced?”
As a brief review, the first stage of the P.A.N.E. Process, presented in the July/August 2008 issue of this journal, assesses the stability of brain processing by identifying if developmentally-early motor reflexes are present in the neuroposture. If they are present, then, this is a sign of regression in the central motor hierarchy.1 We have found that such regression is highly associated with degraded homeostatic capability, including pain processing. The closest previous description of this phenomenon was called “deafferentation,” but, to my knowledge, the concept of deafferentation does not provide a diagnostic benefit. Rather, the diagnosis of certain early developmental reflexes in the neuroposture alerts the clinician to the possibility of unreliable symptomalogy, poor response to exercise challenge, and even altered healing capability after surgery because of degraded biological homeostasis.3 Furthermore, the author has been able to associate specific early reflexes with clinical pathologies so that the cause can be treated and the regression corrected using the “P Tests” described in the third article of this series in the November/December 2008 issue. The author believes that establishing a stable biology is critical in any medical endeavor. This is why the “P Tests” are the first priority in the P.A.N.E. Process.
Clarification of The Concept ‘Neuroposture’
Let us diverge for a moment to be certain that the reader is perfectly clear about our use of ‘neuroposture’ since this concept is critical to the proper application of the tests being described. The P.A.N.E. Process, like every other diagnostic process in medicine, demands a proper application of the underlying physiology. Traditional concepts of “posture” are completely misguided in a physiological sense and are therefore therapeutically irrelevant. That is why “posture” as a health issue has been discarded in our Western culture. This turns out to be a big mistake in the management of chronic pain.
Human bipedal stance requires an incredibly complex integration of millions of neuromuscular reflexes per second, based on even more complex proprioceptive functions in the afferent nervous system. Neuroposture is not a choice, any more than blood pressure or body temperature. There is a shocking paucity of knowledge in both the medical profession and the general public surrounding the significance of bipedal posture and the human body’s homeostatic relationship with gravity. Posture is rarely mentioned in chronic pain evaluations, and never in the proper physiological context.2,11-13 The most common cause of functional low back pain has been, and always will be, a faulty relationship with gravity—namely, poor posture. This is particularly true when the cause of the poor posture is an involuntary neurological injury.1 After all, posture is a reflexive motor process, not a choice.