THE CONCEPT OF PAINFUL MINORINTERVERTEBRAL DYSFUNCTION

Robert MAIGNE (PARIS)

Current theory on spinalmanipulation:Current theory on spinalmanipulation:

� The aim of manipulation is to restore normalmobility to a hypomobile vertebral segment (orjoint)

� The diagnosis of hypo or hypermobility is basedsolely on palpation

Assessment of segmental mobility isgenerally regarded as the keystone of manualmedicine for diagnosis and treatment

This theory is open tocriticismThis theory is open tocriticism

� Clinical assessment of hypomobility is not areliable and reproductible test

� Hypomobility is frequent in osteoarthriticcadaveric vertebral joints

– There is no evidence that it may be a source of pain– Hypomobility could be regarded as a protective mechanism

against overuse of a degenerated joint

The R. Maigne School IThe R. Maigne School I

� If any component of the vertebral motionsegment originates pain...

� ...It is likely that stressing this motion segment byspecific maneuvers will elicit pain

� The tests we use depend solely upon elicitingtenderness or pain of the segment

� No particular attention is paid to hypomobilityper se

The R. Maigne School IIThe R. Maigne School II

� This does not mean that hypomobility does notexist

� It means that hypomobility is not the major orprimary element regarding vertebral pain

� Hypomobility may be– a casual consequence of pain– or without relationship with the pain

SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION

TheThe fourfour specific maneuversspecific maneuvers ofof thethe segmentalsegmentalexaminationexamination are:are:

1 - Pressure on the spinous process2 - Transverse pressure against the spinous

process3 - Longitudinal friction on the facet joints4 - Pressure on the interspinous ligament

SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION

� Pressure on thespinous process

� Transverse pressureagainst the spinousprocess

� Longitudinal frictionon the facets joints

� Pressure on theinterspinous ligament

SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION

� Pressure on thespinous process

� Transversepressure againstthe spinousprocess

� Longitudinal frictionon the facets joints

� Pressure on theinterspinous ligament

SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION

� Pressure on thespinous process

� Transverse pressureagainst the spinousprocess

� Longitudinal frictionon the facets joints

� Pressure on theinterspinous ligament

SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION

� Pressure on thespinous process

� Transverse pressureagainst the spinousprocess

� Longitudinal frictionon the facets joints

� Pressure on theinterspinousligament

SEGMENTAL EXAMINATIONSource of errorsSEGMENTAL EXAMINATIONSource of errors

� Superficial tenderness ofthe spinous process

� Interspinous acute bursitis

SEGMENTAL EXAMINATIONSource of errorsSEGMENTAL EXAMINATIONSource of errors

� Pressure of a sensitive orcellulalgic skin over thespinous process

SEGMENTAL EXAMINATIONSource of errorsSEGMENTAL EXAMINATIONSource of errors

� Pressure of a cellulalgic skinor tender taut muscularbands against the z-joints

Pain Originating from a VertebralMotion Segment Can Be Due ToMany Causes (benign or not)

Pain Originating from a VertebralMotion Segment Can Be Due ToMany Causes (benign or not)

� Some are more or less easily recognizable– Disc herniation– Acute synovitis of the Z-joints

� Others would be only recognizable with sophisticatedinvestigations

– Facet blocks– Discography + MRI

These tests– Are positive in less than 50% of the cases (Schwarzer et al, 1995)– Are not applicable in routine daily practice

Pain from a Motion Segment Can Be DueTo Many CausesPain from a Motion Segment Can Be DueTo Many Causes

� Segmental examination focuses the intereston the painful segment

� Special attention must be paid on thissegment

� Depending on the clinical and the radiologicalcontext, further investigations may benecessary

Painful Minor IntervertebralDysfunction (MID, R. Maigne)Painful Minor IntervertebralDysfunction (MID, R. Maigne)

TheThe diagnosisdiagnosis ofof PainfulPainful MIDMID is evokedis evoked

1 - When the segmental examination is positive2 - When the pain is considered as common3 - Whether the X-Rays films are normal or show

non significant degenerative changes

PAINFUL MINOR INTERVERTEBRALDYSFUNCTION (R. Maigne)PAINFUL MINOR INTERVERTEBRALDYSFUNCTION (R. Maigne)

MID :MID :

� Is the result of trauma, efforts, bad postures,repeated micro-traumas...

� Is not linked to any neurological deficit or X-Rayabnormality

� The diagnosis of MID is purely clinical� It is based on segmental examination

Painful Minor IntervertebralDysfunction (R. Maigne)Painful Minor IntervertebralDysfunction (R. Maigne)

InIn thethe frameworkframework ofof commoncommon painpainsyndromes,syndromes, thethe most frequentmost frequent causescausesof segmentalof segmental dysfunctiondysfunction are:are:

– "Painful Minor Intervertebral Dysfunction"(MID)

– Disc lesions– Synovitis of zygapophyseal joints

Painful Minor IntervertebralDysfunctionPainful Minor IntervertebralDysfunction

� Painful minor intervertebral dysfunction may beconsidered as a selfself--sustaining sprainsustaining sprain of thevertebral segment

� The Painful MID can be active or latentactive or latent. Thesigns of MID are permanent in chronic caseseven between attacks

Painful Minor IntervertebralDysfunctionPainful Minor IntervertebralDysfunction

Painful minor intervetebral dysfunction appears tobe the common denominator of a great numberof vertebral pain

– directly– or by intermediary of reflex manifestationsreflex manifestations

that may be determined in the correspondingmetamere : SegmentalSegmental Vertebral CelluloVertebral Cellulo --TenoTeno--PeriosteoPeriosteo--MyalgicMyalgic SyndromeSyndrome

(R. Maigne)