9
Volume 69 March 1976
177
Section of Orthopiedics President F C Dwyer Mch (orth) FRCS
Meeting 7 June 1975 at Liverpool
Short Papers The Intercostal Muscles and Conditioned Reflexes in the Control of Spinal Posture by Professor Robert RoafMch (orth) FRCS (Department ofOrthopwdic Surgery, University ofLiverpool, PO Box 147, Liverpool, L69 3BX)
electromyographically the activity of my intercostal muscles by needle and surface electrodes. We found that arm movements were a powerful cause of reflex contraction of the intercostal muscles. Following this we have tried to create a series of conditioned reflexes in patients with scoliosis, linking arm movements, contraction of the ipsilateral trunk muscles and external corrective
Spinal posture involves the concept of mobility and adjustment to limb movement. A decerebrate cat can stand but is easily pushed over. It cannot adjust to its environment. The human spine is mobile, curved, polyarticular and asymmetrical in the sagittal plane. The intervertebral discs are seldom horizontal. Basically the upright spine is in unstable equilibrium held upright by a number of trunk muscles which exert tension on levers. The longer the lever the greater the turning moment. An inclined beam is maintained in equilibrium by a smaller force if this acts either at the end of a long lever or is directed horizontally. The Milwaukee brace works on this principle. The ribs are the most important levers which control spinal movements. If the ribs on one side are removed, as used to be done for tuberculosis of the lungs, the spine becomes deformed. Conversely if the ribs are fused, an opposite deformity occurs. If the rib posture fails as in poliomyelitis the ribs assume a vertical position and scoliosis develops. The distance between the point of insertion of the trunk muscles and the axis of rotation is diminished and the turning moment of the trunk muscles on that side is lessened. In order to investigate some of the factors which control rib posture Dr I Calma of the Physiology Department of Liverpool University recorded
Fig 1 Correction of deformity by a combination of fixed weight and pulley traction supplemented by the patient also lifting himself up by the use ofhis arm muscles, thus ensuring periods offull body weight traction
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Proc. roy. Soc. Med. Volume 69 March 1976
X
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....
. .......... X
X
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'Fig 2 .ong-term result ofcostodesis combined with exercises pressure on the trunk. The aim is to correct the spine and maintain postural control by conditioned reflex action.
The patient initiates a corrective force with the convex side arm and simultaneously contracts the ipsilateral trunk muscles. The use of the patient's leg muscles to apply a corrective force is of course very old. The use of the ipsilateral arm muscles is more physiological. The corrective force can be horizontal or vertical, exerted by an occipitomental sling, or a halo splint (Fig 1). The combination of a powerful external force and contraction of the patient's own ipsilateral trunk muscles is very effective. After initial correction the patient wears a removable brace embodying the same principle until the corrective reflexes are well established and automatic.
Physiotherapy which relies on voluntary exercises is seldom effective in the control of spinal deformities; the corrective muscle contractions must become automatic, frequent and the result of conditioned reflexes.
In more severe deformities initial mobilizing operations, e.g. division of muscles, ligaments and bone may be required. If the rib deformity is severe, rib fusion or costodesis to restore their efficiency as levers is also used (Fig 2).
Finally, if the spinal deformity cannot be controlled by the patient's own muscles, fixation preferably using a horizontally directed derotatory force - is necessary. REFERENCE Calma I & Roaf R (1973) Journal of Bone and Joint Surgery 55B, 653
Lobster-claw Deformities of the Feet by F C Dwyer Mch (orth) FRCS and D 0 Maisels FRCS (Alder Hey Children's Hospital, Liverpool) Lobster-claw deformity, which tends to affect feet and hands in the same individual, though relatively uncommon, has attracted attention in the literature because of the unsightly appearance and the associated functional disability (Fig 1). The clinical and genetic features of the deformity have been fully reviewed by Birch-Jensen (1949), Barsky (1964), Phillips (1971), David (1974) and others. This paper describes the experience gained from treating 4 children with bilateral
Volume 69 March 1976
177
Section of Orthopiedics President F C Dwyer Mch (orth) FRCS
Meeting 7 June 1975 at Liverpool
Short Papers The Intercostal Muscles and Conditioned Reflexes in the Control of Spinal Posture by Professor Robert RoafMch (orth) FRCS (Department ofOrthopwdic Surgery, University ofLiverpool, PO Box 147, Liverpool, L69 3BX)
electromyographically the activity of my intercostal muscles by needle and surface electrodes. We found that arm movements were a powerful cause of reflex contraction of the intercostal muscles. Following this we have tried to create a series of conditioned reflexes in patients with scoliosis, linking arm movements, contraction of the ipsilateral trunk muscles and external corrective
Spinal posture involves the concept of mobility and adjustment to limb movement. A decerebrate cat can stand but is easily pushed over. It cannot adjust to its environment. The human spine is mobile, curved, polyarticular and asymmetrical in the sagittal plane. The intervertebral discs are seldom horizontal. Basically the upright spine is in unstable equilibrium held upright by a number of trunk muscles which exert tension on levers. The longer the lever the greater the turning moment. An inclined beam is maintained in equilibrium by a smaller force if this acts either at the end of a long lever or is directed horizontally. The Milwaukee brace works on this principle. The ribs are the most important levers which control spinal movements. If the ribs on one side are removed, as used to be done for tuberculosis of the lungs, the spine becomes deformed. Conversely if the ribs are fused, an opposite deformity occurs. If the rib posture fails as in poliomyelitis the ribs assume a vertical position and scoliosis develops. The distance between the point of insertion of the trunk muscles and the axis of rotation is diminished and the turning moment of the trunk muscles on that side is lessened. In order to investigate some of the factors which control rib posture Dr I Calma of the Physiology Department of Liverpool University recorded
Fig 1 Correction of deformity by a combination of fixed weight and pulley traction supplemented by the patient also lifting himself up by the use ofhis arm muscles, thus ensuring periods offull body weight traction
178
10
Proc. roy. Soc. Med. Volume 69 March 1976
X
........... ....
....
. .......... X
X
XX
'Fig 2 .ong-term result ofcostodesis combined with exercises pressure on the trunk. The aim is to correct the spine and maintain postural control by conditioned reflex action.
The patient initiates a corrective force with the convex side arm and simultaneously contracts the ipsilateral trunk muscles. The use of the patient's leg muscles to apply a corrective force is of course very old. The use of the ipsilateral arm muscles is more physiological. The corrective force can be horizontal or vertical, exerted by an occipitomental sling, or a halo splint (Fig 1). The combination of a powerful external force and contraction of the patient's own ipsilateral trunk muscles is very effective. After initial correction the patient wears a removable brace embodying the same principle until the corrective reflexes are well established and automatic.
Physiotherapy which relies on voluntary exercises is seldom effective in the control of spinal deformities; the corrective muscle contractions must become automatic, frequent and the result of conditioned reflexes.
In more severe deformities initial mobilizing operations, e.g. division of muscles, ligaments and bone may be required. If the rib deformity is severe, rib fusion or costodesis to restore their efficiency as levers is also used (Fig 2).
Finally, if the spinal deformity cannot be controlled by the patient's own muscles, fixation preferably using a horizontally directed derotatory force - is necessary. REFERENCE Calma I & Roaf R (1973) Journal of Bone and Joint Surgery 55B, 653
Lobster-claw Deformities of the Feet by F C Dwyer Mch (orth) FRCS and D 0 Maisels FRCS (Alder Hey Children's Hospital, Liverpool) Lobster-claw deformity, which tends to affect feet and hands in the same individual, though relatively uncommon, has attracted attention in the literature because of the unsightly appearance and the associated functional disability (Fig 1). The clinical and genetic features of the deformity have been fully reviewed by Birch-Jensen (1949), Barsky (1964), Phillips (1971), David (1974) and others. This paper describes the experience gained from treating 4 children with bilateral
