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10 Articles in Volume 9, Issue #4
Application of Spinal Segmental Physiology to Evaluating Chronic Pain
Dental Consequences of Pain Management
Facility Profile: Casa Palmera
Intellectual and Moral Tasks in Intersection—Part 2
Milnacipran: A New Treatment Option for Fibromyalgia
Neuroma Pain of the Foot Successfully Managed with Laser Therapy
Opioid Treatment Longevity Study: Interim Report
Pain Management in a Palliative Care Setting
Precursor Amino Acid Therapy
Prolotherapy for Sacroiliac Joint Laxity

Application of Spinal Segmental Physiology to Evaluating Chronic Pain

A simple dermatomal screening process is used to help isolate the location of an offending segment when spinal ‘segmental facilitation’ is the cause of a chronic pain disorder.

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.

Sometimes the terms ‘balance’ and ‘posture’ are used interchangeably, but this is a misuse. Balance, as used in these articles, refers specifically to the location of the body center of mass relative to the axis of gravity.9 Neuroposture, on the other hand, incorporates survival-related behaviors into the concept of balance. ‘Posture’ is ‘balance’ with an attitude.

Osteopathic medicine, chiropractic, and manual physical therapy have stepped into the void left by ineffective medical treatments for spine pain. Physicians, in general, have no explanation for concepts such as “the facilitated segment” or “vertebral subluxation” or “segmental sensitization.” What do these specialists know that we don’t know in allopathic medicine? Physicians become skeptical when the chiropractor addresses cardiac problems with spinal manipulation. Are we missing something here? Is there logic in these concepts to help the physician make sense of all of this?

Figure 1. Classic neurospinal segmental anatomy. Adapted from Purves et al. (2008).7

Spinal Segmental Theories and Chronic Pain

This article addresses how to use sensory-motor integration phenomena—taking place at the spinal cord level—as a diagnostic tool to determine possible causes of chronic pain conditions. This second stage of the P.A.N.E. Process is for the patient who fails the “Wall Test” for postural imbalance, but does not exhibit central regression in the motor hierarchy (i.e., primitive reflexes).3 The next priority of conditions that can cause this combination of findings is “spinal segmental dysfunction.” Herein lies the answers to some of the questions concerning alternative healthcare.

All Physicians are trained in physical segmental anatomy and neuroanatomy of the human spine (see Figure 1). Indeed, much of our diagnostic efforts in evaluating the patient with chronic back pain are directed at locating pathoanatomic and compressive neurological pathology.15 The AMA Guides, 5th Edition, defines a motion segment of the spine as two adjacent vertebrae, the intervertebral disk, the apophyseal or facet joints, and the ligamentuous structures between the vertebrae.16 Unfortunately, this definition is limited in encompassing the diverse range of possibilities of causes of chronic pain.

It is agreed in neurophysiology that the spine is far more than a simple conduit of neurological flow between the brain and the body.17 Significant active sensory motor integration (processing) takes place at the spinal level, hence functional pathology is possible without visible anatomic changes (see Figure 2#). Furthermore, the flow of information is not only up and down the cord, but also transversely such that one side of the body affects the other side in certain circumstances.12 Thus, segmental relationships are complex and variable from a dynamic neurological standpoint.

A brief review of the developmental biology of the spine is necessary to understand what the author believes is the central issue in Allopathic Medicine concerning limited diagnosis of spinal pain: failure to recognize the extent of involvement of the autonomic nervous system in spinal physiology. At four (4) weeks of gestation, there are identifiable neurocytes gathering around the primitive notochord, migrating from the neural crest of the embryo in a process known as neurulation (see Figure 3). This migration ultimately forms the sympathetic chains running along either side of the vertebral column. Further, progression of autonomic development extends the spinal ganglia to the viscera (see Figure 4). Thus, the early spinal development of the spine, the autonomic nervous system, and organ functioning are all closely interrelated.

Korr has defined the ‘facilitated segment’ of the spinal cord as a segment with a low-motor reflex threshold, i.e. it represents a hyper-excitable segment of the cord.21 It is the author’s opinion, based on his experience with neuropostural motor reflex testing, that the basis for the “facilitated segment” of osteopathy is derived from autonomic segmental influences. Certainly the role of adrenergic physiology related to “fight or flight” functions in the brain are well known and so it would seem logical that similar physiology would extend to spinal processing. Thus, relationships between spinal segmental physiology and survival functions in the somatic body are neurologically likely. The issue here is not whether the clinician can treat heart disorders with spinal manipulation, but whether this is a better way. In consideration of the established physiological fact that sympathetics control blood flow distribution throughout the periphery, it is likely that disturbance of spinal autonomic regulation can have far- reaching effects on organ functions. We contend that allopathic neurology’s continued blindness to autonomic physiology is a major reason for difficulties in the management of chronic pain.21

In this physiological debate, osteopathy and chiropractic are not free of criticism either. The author contends that the autonomic nervous system is a reflexive system. All reflexes have to have a beginning, middle, and end to be a reflex. Concerning segmental physiology, the spinal components presumably are the “middle” of the autonomic reflex arc (where are the afferent limbs?). All of us have experienced the patient who goes to his chiropractor for endless manipulations, has a brief improvement, and then lapses back into the old chronic pain problems. The author attributes this to the failure to identify and treat the beginning of the reflex loop. The P.A.N.E. Process, on the other hand, can help the clinician locate the “beginning” of the reflex loop so as to change unwanted reflex processes resulting in chronic pain. Chronic pain is a reflex22 and is always best treated at its source.

Figure 2. Sensory motor integration at the spinal level. Adapted from Shepherd (1994).18 Figure 3. Development of autonomic ganglia in early development. Adapted from Rao and Jacobson (2005).19

Still pending in this series is an article describing a new concept called “postural injuries.” These are conditions that invoke unwanted changes in the body’s homeostasis—far beyond the local extent of the disorder—by affecting inherent “survival” mechanisms. Examples of common postural injuries that cause this systemic effect are peripheral nerve entrapments, certain gastro-intestinal disorders, headaches, dizziness, upper respiratory obstruction, allergies, TMJ/TMD, etc.

Figure 4. Distribution of autonomic innervation to the body. Adapted from Pansky and Allen (1980).6

Examination For Spinal Segmental Disorders

Examining the spine for segmental facilitation is the second stage in the P.A.N.E. Process protocol and is only done if the first stage is normal. Keep in mind that this protocol is arranged along biological and survival priorities and is not directed by the location of the patient’s pain complaints. The patient may or may not even have back pain. The method of segmental spinal evaluation being presented here utilizes several techniques derived from spinal surgery, physical therapy, and neurobiology. These tests are based on dermatomal sensitization of the involved spinal segments combined with “Scratch-Collapse Tests.”23 Knowledge of the anatomic dermatomes is necessary (see Figure 5). Note that all of the dermatomes are centered in numerical order over the spine whereas, in the extremities, they are widely scattered. It has been reported that light, scratching over an area of sensitized nerves will trigger a flexion withdrawal reflex.23 While this is normal in an infant, adults normally perceive scratching as “pleasant” and do not withdraw from it.2 However, with facilitated spinal segments, the associated dermatomes become sensitized. Scratching the activated dermatome causes adults to assume this infantile pattern. The author considers this further evidence that the central changes being described are mediated by the autonomic nervous system and represent a form of regression.3 Please note that the withdrawal response only lasts for three to four seconds after the stimulus.2

The examiner must recall the principles of neuropostural motor reflex testing described in the PPM July/August 2008 and September 2008 issues.1,2 Posture resists movement, it does not create movement. If the patient begins wrestling with you, the test is invalid for neuroposture evaluation because the patient’s movement has become voluntary movement (corticospinal, not postural). If the patient is aggressive, repeat the instruction “the statue does not chase the pigeon” to help the patient grasp this concept and simply try to “hold still” or maintain position. The examiner applies increasing equal push with both hands in a gentle crescendo while the patient simply resists the examiner’s pressure.

In accordance with the P.A.N.E. Process protocol, the first test—“The Wall Test”—is a postural screening test for basic balance.2 This test is performed with a patient standing, facing the examiner with his elbows at his sides, forearms parallel with the floor, and palms facing each other (see Figure 6). If positive—i.e. there is asymmetrical weakness free-standing, but normal strength leaning against the wall—we then proceed to the sitting balance tests.

The first sitting balance test is “The Light/Dark” sequence (see Figure 7). If the patient demonstrates asymmetrical weakness only with her eyes closed, she is demonstrating a regressive pediatric reflex pattern-sensitivity to darkness. The examiner should then proceed to perform “the PCSD Tests” also called “the P-Tests” to find the specific cause of the dystrophy.3

Only if the “Light/Dark Test” is negative, do we then proceed to the second stage of the protocol: the “Neurospinal Scratch Tests” for spinal segmental conditions. We call these the “R Tests.” For this part of the exam, the patient is seated (not slouching) on the side of the exam table, with elbows flexed to 90 degrees at their sides and forearms parallel with the floor. The wrists are at neutral extension with his palms facing each other. The first step is to scratch the bare skin directly over the spine in an up and down motion (see Figure 8). It is easiest to divide the spine into three areas: cervical, thoracic, and lumbar. Within three to four seconds of scratching, the examiner returns his attention to the patient’s hands and tries to push his hands towards each other. If the patient is unable to easily match the push and maintain position, the arms and hands will collapse. This is interpreted as a “positive” response. Note whether the left or the right side is the weaker. Do not “arm wrestle” the patient or it will activate a corticospinal (voluntary) motor response from the patient. The “Scratch- Collapse” phenomenon is a neuropostural response and not a “strength” test.

Figure 5. Segmental dermatomal sensory distributions. Illustration adapted from Gray’s Anatomy. Figure 6a. The Wall Test. Subject is free-standing. Figure 6b. The Wall Test. Subject is against the wall. Figure 7a. The Light/Dark Test. Subject’s eyes closed. Figure 7b. . The Light/Dark Test. Subject’s eyes open. Figure 7a. The Light/Dark Test. Subject’s eyes closed. Figure 7b. . The Light/Dark Test. Subject’s eyes open.

If the ”Spinal Scratch Test” is positive in the lumbar region, then the technique shifts to the lower extremities (see Figure 9). For the lower extremities, the patient is seated with legs extended, mildly abducted at the hips, and the scratch is applied to the lateral aspect of the legs. The examiner’s push is then applied to the side of each ankle.

In this stage of testing, each of the dermatomes are stimulated by scratching directly over the spine. The neuro-anatomic basis for the “Scratch-Collapse” tests over the spine is seen in (see Figure 10). Note the dorsal sensory branch innervates the skin over the tip of the spinous process and represents a direct dermatomal connection to the underlying spinal segment.25 The spinal scratch tests are convenient screening tests to save time.

A brief explanation is warranted regarding the “Basic Sitting Postural Test.” In the “P.A.N.E. Protocol,” we typically apply a stimulus and then confirm the effect of the stimulus with this test which must be done within three to four seconds (see Figure 11).

If the screening scratch test for the cervical spine is positive, then proceed to test the upper extremities—dermatome by dermatome—to localize the affected segment (see Figure 12). If there is a “positive” response in the lumbar region, then the lower leg dermatomes are scratched one by one. The “Scratch-Collapse Test” is then applied within three to four seconds.

Summary of the Second Stage of the P.A.N.E. Process

The simple dermatomal screening process presented in this article is just that—a screening process. When spinal segmental facilitation is the cause of a chronic pain disorder, these tests can help isolate the location of the offending segment. Conventional examinations are still necessary (e.g., X-rays, MRIs, etc). However, many times a patient presenting with knee pain, heel pain, shoulder pain, etc., will show that the real cause is in his spine. Conversely, we frequently encounter patients with back or neck pain that actually have an occult peripheral nerve entrapment as the real cause. Their “Spinal Scratch-Collapse Tests” are “negative” in spite of the locus of pain. For these patients, I frequently administer a xylocaine nerve block to the area of suspected nerve entrapment. Imagine the surprise on the patient’s face when I inject a nerve in his foot and his back pain miraculously disappears! These issues are admittedly not always this simple, and many patients have multiple areas causing them chronic pain. The P.A.N.E. Process can be used to peel away these layers like peeling away the layers of an onion. Referred pain phenomena and double crush issues always have to be considered. This is why hand surgeons must know about the spine and vice versa. Most of all, chronic pain has a multitude of causes. Each of our healthcare professions has a piece of the truth, but in the arena of chronic pain, we truly need each other.

Figure 8b. Neurospinal scratch tests— lumbar region of spine. Figure 9a. Neuropostural tests of lower extremities: scratch applied to lateral aspect of leg. Figure 9b. Neuropostural tests of lower extremities: examiner’s push is then applied to the side of each ankle. Figure 10. Dorsal ramus of the spinal sensory nerve. Adapted from Dvorak and Dvorak (1984).25 Figure 12a. Dermatomal scratch tests: If screening cervical scratch test is positive—perform scratch tests on upper extremities, dermatome-by-dermatome.

In my next article, I will explain how the P.A.N.E. Process can be applied to simplify testing for peripheral nerve entrapments and is the third stage in our algorithm.

Last updated on: January 6, 2012
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