Increased Multiaxial Lumbar Motion Responses During Multiple-Impulse Mechanical Force Manually Assisted Spinal Manipulation

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

FROM:   Chiropractic & Osteopathy 2006 (Apr 6);   14 (1):   6 ~ FULL TEXT

Tony S Keller Ph.D., Christopher J Colloca D.C., Robert J Moore Ph.D., Robert Gunzburg M.D., Ph.D., and Deed E Harrison D.C.

BACKGROUND:   Spinal manipulation has been found to create demonstrable segmental and intersegmental spinal motions thought to be biomechanically related to its mechanisms. In the case of impulsive-type instrument device comparisons, significant differences in the force-time characteristics and concomitant motion responses of spinal manipulative instruments have been reported, but studies investigating the response to multiple thrusts (multiple impulse trains) have not been conducted. The purpose of this study was to determine multiaxial segmental and intersegmental motion responses of ovine lumbar vertebrae to single impulse and multiple impulse spinal manipulative thrusts (SMTs).

METHODS:   Fifteen adolescent Merino sheep were examined. Tri-axial accelerometers were attached to intraosseous pins rigidly fixed to the L1 and L2 lumbar spinous processes under fluoroscopic guidance while the animals were anesthetized. A hand-held electromechanical chiropractic adjusting instrument (Impulse) was used to apply single and repeated force impulses (13 total over a 2.5 second time interval) at three different force settings (low, medium, and high) along the posteroanterior (PA) axis of the T12 spinous process. Axial (AX), posteroanterior (PA), and medial-lateral (ML) acceleration responses in adjacent segments (L1, L2) were recorded at a rate of 5000 samples per second. Peak-peak segmental accelerations (L1, L2) and intersegmental acceleration transfer (L1-L2) for each axis and each force setting were computed from the acceleration-time recordings. The initial acceleration response for a single thrust and the maximum acceleration response observed during the 12 multiple impulse trains were compared using a paired observations t-test (POTT, alpha = .05).

RESULTS:   Segmental and intersegmental acceleration responses mirrored the peak force magnitude produced by the Impulse Adjusting Instrument. Accelerations were greatest for AX and PA measurement axes. Compared to the initial impulse acceleration response, subsequent multiple SMT impulses were found to produce significantly greater (3% to 25%, P<0.005) AX, PA and ML segmental and intersegmental acceleration responses. Increases in segmental motion responses were greatest for the low force setting (18%-26%), followed by the medium (5%-26%) and high (3%-26%) settings. Adjacent segment (L1) motion responses were maximized following the application of several multiple SMT impulses.

CONCLUSION:   Knowledge of the vertebral motion responses produced by impulse-type, instrument-based adjusting instruments provide biomechanical benchmarks that support the clinical rationale for patient treatment. Our results indicate that impulse-type adjusting instruments that deliver multiple impulse SMTs significantly increase multi-axial spinal motion.

KEYWORDS:   Biomechanics, Chiropractic, Impulse, Instrument, Manipulation, Mechanical Force, Spine


From the Full-Text Article:

Discussion

Increased segmental and intersegmental acceleration responses were observed when multiple force impulses were applied to the ovine lumbar spine. The increased motion response most likely reflects the dynamic nature of the Impulse Adjusting Instrument®, which has a short force-time pulse duration (approximately 2 milliseconds) and causes the ovine spine to oscillate or vibrate for up to 150 ms following the application of the force impulse. The haversine wave shape of the Impulse Adjusting Instrument ® creates an efficient mechanical excitation and energy transfer to the spine, which in turn excites a broad range of vibration frequencies (0–200 Hz) in the contacted and adjacent vertebral segments [6]. This frequency range encompassing the resonant frequency (4 Hz) of the ovine spine [18] which, when coupled with the repeated (multiple impulse) mechanical excitation of the spine, amplifies the spinal motion response. Increasing vertebral motions via tuning the frequency and speed of the mechanical inputs during SMT has long been an objective of chiropractic delivery, especially in the development of chiropractic adjusting instruments [16-20].

A number of studies have quantified the applied forces and concomitant mechanical response of the spine during SMT [9,19-24]. In previous work, we have demonstrated that the stiffness and therefore motion response of different regions of the human [20,25] and animal [18] lumbar spine varied with the mechanical stimulus frequency. Knowledge of the frequency-dependent stiffness characteristics of the spine aids chiropractors in determining the manner in which forces are transmitted to the spine during chiropractic adjustment/spinal manipulation. Such information is important in assessing the biomechanical characteristics of chiropractic treatments, spinal modeling, treatment efficacy, and assessment of risk in the medicolegal arena. To our knowledge, this is the first study to quantify the motion response of the lumbar spine during repeated impulse loading. Our findings indicate that application of multiple short-duration impulses to the spine can increase the magnitude of ensuing vertebral oscillations.

The chiropractic adjusting instrument examined in this study (Impulse Adjusting Instrument®) produces a forcetime profile with a very short pulse duration (2 ms). Forces that are relatively large in magnitude, but act for a very short time (much less than the natural period of oscillation of the structure), are called impulsive [19]. Impulsive forces acting on a mass will result in a sudden change in velocity, but are typically associated with smaller amplitude displacements in comparison to longer duration forces. However, the sudden change in velocity associated with impulsive forces causes the spine to oscillate or vibrate for long periods of time. In the current study we observed that the ovine spine oscillated for a period of time roughly equal to the time interval between impulses (e.g. 160 ms). This corresponds to an impulse loading frequency of 6.25 Hertz, and the application of repeated mechanical excitation resulted in a continuous chain of oscillations in the sheep spine.

The motion response of the spine is closely coupled to the frequency or the time history of the applied force [16]. When external mechanical forces are applied at or near the natural frequency of the spine, greater segmental and intersegmental displacements result (over 2-fold) in comparison to external forces that are static or quasi-static [16]. Thus, it is possible to achieve comparable segmental and intersegmental motion responses for lower applied forces during spinal manipulation, provided that the forces are delivered over time intervals at or near the period corresponding to the natural frequency. Based on the findings of this study, application of repeated mechanical excitation at 6.25 Hertz produces a significantly increased segmental and intersegmental motion response – up to 26% increase in adjacent segment acceleration following the application of several consecutive SMT impulses. Since the oscillations induced in the spine are mostly damped out prior to the onset of the next pulse train, the increased acceleration response is most likely due to mechanical conditioning of the spinal tissues, a desired feature in accomplishing chiropractic adjustment. Noteworthy, axial and medial-lateral accelerations were observed that represent a coupled response to the PA (dorsoventral) forces applied to the ovine spine. We have previously shown that PA thrusts induce coupled motions in both the ML and AX axes [4]. Coupled motions are dependent on a number of factors, including spinal geometry and material properties as well as the force vector applied [16]. As noted in the aforementioned paper, the motion response and coupling are dependent on the intrinsic material properties and geometry, which vary from segment to segment, producing complicated patterns load transmission within the spinal column. Indeed, the decreased axial acceleration response (6–10%) observed for the segment closest to the thrust most likely reflects underlying spinal geometry and material properties. Further research is needed to improve the mechanical excitation characteristics of chiropractic adjustment/spinal manipulation devices and treatment regimes, including force vector, force amplitude, force duration, forcetime profile and number of oscillations or impulses applied. We hypothesize that optimization of the mechanical excitation delivered to the spine will enhance neuromechanical and clinical responses in patients.

There are inherent limitations of this study. First and foremost, an animal model was used to study the motion response of the spine. The sheep spine is comprised of structures (ligaments, bone, intervertebral discs) that have qualitatively similar properties as the human spine [26,27], but differ in a number of respects, most notably geometry or morphology. Sheep lumbar vertebrae, and vertebrae of other ungulates (hoofed animals) are more slender and smaller in size compared to human lumbar vertebrae. As a result, the PA stiffness of the ovine lumbar spine is substantially lower (approximately 4-fold) than the human lumbar spine [18]. However, using an animal model we were able to perform invasive measurements of bone movement, which are otherwise difficult to perform in humans [3-5]. Measurement of bone movement using intra-osseous pins equipped with accelerometers [3-5] and other invasive motion measurement devices [28,29] has been previously shown to be a very precise measure of spine segmental motion. Moreover, the short duration (impulsive) mechanical excitation produced very small displacements in the T12 and adjacent vertebrae so the coordinate axes of the vertebrae and accelerometers did not change appreciably. Hence, intersegmental acceleration transfer could be estimated directly from the acceleration- time recordings of the adjacent sensors. However, subtraction of the L1 and L2 time-domain signals to obtain the intersegmental motion response does not take into account the inherent phase differences in the acceleration- time signals. A more comprehensive frequency domain analysis of the acceleration data could be performed [3,16], but this was beyond the scope of this paper.

In addition, testing was performed on anesthetized sheep, so muscle tone was deficient during the tests. The presence of normal or hyper-normal muscle tone may modulate the vibration response of the spine, so we are currently conducting impulsive force measurements while the animals are undergoing muscle stimulation. Finally, vertebral bone acceleration measurements were obtained for vertebrae (L1, L2) adjacent to the point of force application, but we did not quantify the acceleration response of the segment under test (T12) as the accelerometer pin mount and force vector applied precluded contacting the instrumented segment. As a result, the motion amplification response that we observed in adjacent segments following repeated loading may not be representative of the response of the segment under test, which is deemed by most practitioners to be of primary importance. Adjacent segment motion responses, however, are important as it is our belief that the putative effects of MFMA procedures are due to intersegmental motions, which are more similar to intersegmental motions predicted for manual thrusts, as opposed to segmental motions, which are very dissimilar in comparison to manual thrusts [4,5,16,17]. Additional work is needed to quantify both the thrust segment and adjacent segment motion responses to repeated mechanical excitation.

Conclusion

Our results indicate that repeated multiple-impulse mechanical excitation using an impulsive-type adjusting instrument significantly increases spine motion during the application of multiple impulse SMTs. In principle, mechanical interventions could be tuned to provide specific force delivery for desired biomechanical outcomes including vertebral motion.

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