Ip

UJ x

Unmodified tenderness

Increased tenderness

Fig. 5.8 'Opposed thumbs technique' of Maigne for the diagnosis of 'minor intervertebral derangement' (MID). The application of thumbs on spinal processes B and C is represented in the upper part; tenderness is elicited in (I); tenderness in (II) is unmodified with opposed thumbs on A and B; tenderness in (III) is increased with opposed thumbs on B and C (with permission of Robert Maigne).

an increase in pain, the involvement of the two vertebrae was diagnosed by Maigne as a 'minor intervertebral derangement' (MID). In the group of 138 patients with TLJS mentioned above, 59.4% presented one MID, 26.1% two MID and 14.5% three MID. The first group showed MID at various levels, but in 75.6% the vertebrae involved were T11-T12 and T12-L1 (Table 5.1).

It has to be remembered that an MID with a chronic irritation of the anterior branch of the 12th thoracic and 1st lumbar spinal nerves may also provoke referred pain in the abdomen which may be erroneously attributed to ovary, appendix or kidney.

When considering how to contribute to the issue of the 'short' lumbar spine I realized that the only possible way was to check the tenderness of the auricle before and after manipulation. Therefore I

Table 5.1 Location of the 'minor intervertebral

derangement' (MID) according to Maigne in 82

patients with thoracol

umbar junction syndrome

(TLJS)

MID

Level

%

MID (1 level)

T9-T10

4.9%

T10-T11

12.2%

T11-T12

41.5%

T12-L1

34.1%

L1-L2

7.3%

Total

100%

identified the MID with the opposed thumbs technique proposed by Maigne in a series of consecutive patients with possible TLJS. To ascertain the exact level of MID I placed in some patients a small

metal disc 5 mm in diameter on the most painful spinal process before performing X-ray, as in the following case:

CASE STUDY

A 34-year-old male patient had been suffering for a few days from lumbago without pain radiating to his legs; the pain manifested abruptly after he lifted a weight. The most tender spot at pressure was on the right side corresponding to the spinal process of Til (see the metallic disc in Figure 5.9). On the auricle of the same side I found one tender point on the anthelix and a second aligned on the helix (Fig. 5.10). After manipulations of the spine, as recommended by Maigne in rotation and extension for the relief of thoracolumbar disorders, the point on the anthelix lost its tenderness whereas the point on the helix remained partially sensitive.

Fig. 5.9 A metal reference marker indicates the identified MID, before spinal manipulation of the thoracolumbar junction, in a 34-year-old male with lumbago without sciatic pain.

Fig. 5.10 Tender points of the helix and the anthelix, aligned with Nogier's point zero, in the same patient before manipulation.

Fig. 5.9 A metal reference marker indicates the identified MID, before spinal manipulation of the thoracolumbar junction, in a 34-year-old male with lumbago without sciatic pain.

Fig. 5.10 Tender points of the helix and the anthelix, aligned with Nogier's point zero, in the same patient before manipulation.

This experience permitted me to study a consecutive series of 10 male patients (average age 36.2 years) with lumbago and MID at the level of T11-T12, detecting the tender points before and after the manipulations described in the case study. Before manipulation two-thirds of the points were concentrated on sectors 18 and 19, especially on the anthelix (on the left of Fig. 5.11). After manipulation the total number of points decreased to 44.5% and only sector 19 maintained a higher concentration of points with respect to the other sectors (on the right of Fig. 5.11).

As a control group for my observations I examined 10 male patients (average age 47.6 years) with sciatic pain due to a disk lesion in L5-S1. The tender points were concentrated before the manipulation on sectors 21 and 22 (on the left of Fig. 5.12); after manipulation only sector 22 maintained a higher concentration of points (on the right of Fig. 5.12).

My results appear therefore to support Nogier's hypothesis regarding the representation of the thoracic and lumbar tract, but support also the importance of the Chinese gluteus area on which several tender points overlap, related to either TLJS or sciatic syndrome.

THE REPRESENTATION OF THE CERVICAL SPINE

A minor issue concerns the cervical tract of the spine which seems, like the lumbar tract, to be 'shorter' both on Nogier's and the Chinese map.

Fig. 5.11 Tender points in 10 male patients, average age 36.2 years, with lumbago associated with an MID in T11-T12, before manipulation (left) and after manipulation (right). Dots = lateral surface; circles = medial surface.
Fig. 5.12 Tender points in 10 male patients, average age 47.6 years, with sciatic pain associated with a L5-S1 disk lesion, before manipulation (left) and after manipulation (right). Dots = lateral surface; circles = medial surface; crosses = internal (hidden) border.

It is possible that the cervicothoracic junction could be represented higher up on the anthelix and the scapha.

My deductions regarding this subject derive from both inspection and pain pressure testing. The former helps us to be aware of the presence of a greater level of telangiectasia, incisures and cartilaginous hypertrophic areas, as expected. For example, in Plate XIVB we have the case of a 60-year-old female who had been suffering from chronic neck pain for many years: a large part of the anthelix showed a thickening of the cartilage and a swelling of the subcutaneous tissues. The affected part of the anthelix was very sensitive to palpation and several points were identified on its surface with the pressure-probe.

The more cranial representation of the lower cervical vertebrae may be appreciated in Figure 5.13 which relates to five female patients with a mean age of 58.2 years suffering from cervical syndrome and radiation of pain consistent with a disk lesion at C6-C7. The distribution of tender points was mainly on sectors 12 and 13 (on the left of Fig. 5.13). In the case of a disk lesion at C7-T1 related points would probably be found above the horizontal line on sectors 14 and 15.

Regarding the cervical spine, for diagnostic and therapeutic purposes we must not forget the points on the internal border of the anthelix related to whiplash syndrome (on the right of Fig. 5.13). Depending on the modalities and strength of impact we may find one or more tender points in this area (representing the cervical sympathetic plexus according to Nogier and Bourdiol) which are very effective on accompanying symptoms such as headache and dizziness (Fig. 5.14).

THE ETIOLOGICAL PUZZLE OF FIBROMYALGIA

The diagnostic criteria of the American College of Rheumatology (ACR) for fibromyalgia syndrome include widespread musculoskeletal pain, morning stiffness and muscle fatigue for at least 3 months,

Fig. 5.13 Tender points in five female patients, average age 58.2 years, suffering with cervicobrachial pain associated with a disk lesion in C6-C7 (left); and tender points in a patient with whiplash syndrome (right). Dots = lateral surface; circles = medial surface; crosses = internal (hidden) border.

Fig. 5.13 Tender points in five female patients, average age 58.2 years, suffering with cervicobrachial pain associated with a disk lesion in C6-C7 (left); and tender points in a patient with whiplash syndrome (right). Dots = lateral surface; circles = medial surface; crosses = internal (hidden) border.

Sacral sympathetic ganglia

Lumbar ganglia

Cervicothoracic (stellatum) ganglion

Middle cervical ganglion (marvelous point)

Superior cervical ganglion

Vertebral body

Paravertebral sympathetic ganglionic chain

Claustrum

Concha

Fig. 5.14 Representation of the sympathetic ganglionic chain according to Bourdiol (with permission).

accompanied by pain on palpation in at least 11 of 18 anatomically defined painful tender points.10 Other well known symptoms commonly observed are non-restorative sleep, depressive/anxious mood, fatigue and headache. The National Arthritis Data Workgroup11 reviewed published analyses from available national surveys and provided a prevalence estimate for the US of 5.0 million adults suffering with fibromyalgia. The etiology of fibro-myalgia is as yet unclear and a co-morbidity has been described with irritable bowel syndrome

(IBS), depression, chronic fatigue syndrome and tension-type headache.

Current hypotheses center on atypical sensory and pain processing in the CNS and dysfunction both of skeletal muscle nociception and autonomic nervous system.12 Seemingly therapies targeting central pain mechanism should give the best results; this is the reason why the US Food and Drug Administration recently approved pregabalin as the first specific medication for fibromyalgia syndrome.

As regards acupuncture, the systematic review of Mayhew and Ernst13 concluded cautiously that 'the notion that acupuncture is an effective systematic treatment for fibromyalgia is not supported by the results from rigorous clinical trials. On the basis of this evidence, acupuncture cannot be recommended for fibromyalgia'.

As regards ear acupuncture and fibromyalgia, however, an interesting experiment is currently being carried out by my assistant Dr Riccardo Maz-zoni on a group of patients who are members of Scudo Amico (Association for Fibromyalgia) in our city. In a still ongoing pilot study he included 16 selected patients for observation, according to the diagnostic criteria of the ACR (15 females and 1 male with an average age of 49.1 years), and treated them with ear acupuncture. Three patients dropped out of the study: one became pregnant during the therapeutic course and two others had an increase of the severity of pain during the first sessions. The remaining 13 patients received 10 weekly sessions of ear acupuncture. Figure 5.15 shows the distribution of tender points at the first treatment (on the left) and at the last treatment (on the right).

As is visually appreciable, 70% of the points lost their tenderness during the course of the therapy and this variation was accompanied by an evident improvement of scoring in the two scales adopted: the Psychological General Well-Being index (PGWB), a specific function and symptom questionnaire, and the Regional Pain Score (RPS).14

Two aspects are interesting in Mazzoni's preliminary observations and are worthy of further exploration: the first is that most points are located on the scapha and particularly on the internal border of the helix. Nogier made the hypothesis that this part of the auricle could be the representation of the intermediolateral nuclei of the lateral horn, the cells of which give rise to the preganglionic sympathetic outflow.

Sacral sympathetic ganglia

Lumbar ganglia

Cervicothoracic (stellatum) ganglion

Middle cervical ganglion (marvelous point)

Superior cervical ganglion

Vertebral ligaments Paraspinal muscles

Vertebral ligaments Paraspinal muscles

Vertebral body

Paravertebral sympathetic ganglionic chain

Concha

Fig. 5.14 Representation of the sympathetic ganglionic chain according to Bourdiol (with permission).

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Fig. 5.15 Representation of the tender points in 13 patients with fibromyalgia, at the beginning (A) and at end (B) of a therapeutic course. (Unpublished data, with permission of Mazzoni). Dots = lateral surface; crosses = internal (hidden) border.

This line of points, very close to the helix, has been defined by Lange15 as the 'vegetative groove' and was supposed by the author to be essential for regulating the functions of a disturbed segment of the body according to Nogier's principle of alignment.

The second interesting aspect is that while routinely examining some immunological parameters, high titers (between fifteen- and a hundredfold normal levels) of IgG of cytomegalovirus were found in 14 of the 16 patients. In addition, in two patients a high IgG level of the Epstein-Barr virus was documented. These findings may be fortuitous or may represent a further factor in the etiological puzzle of fibromyalgia. Some authors16 have indeed reported the possibility that viral infection or vaccination may be associated with this syndrome: the symptoms of fibromyalgia, such as myalgia and fatigue, would therefore appear to overlap considerably with those of a viral or atypical infection.

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