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Immobilization
New Evidence, New Problems
A. Introduction

1. New evidence of considerable interest to chiropractors comes from Videman and his fellow researchers at Institute of Occupational Health, Helsinki, Finland. It shows that rest and immobilization of joints not only delays healing but causes osteoarthritis-with first degenerative changes measurable within one week.l This has brought further criticism of various traditional forms of immobilization following joint injury and pain. Bed rest, which has no valid evidence of effectiveness in the treatment of musculoskeletal pain and has been proved ineffective in two recent trials2. S is now seen by leading researchers as positively harmful.4. & Troup, a British orthopaedic specialist highly respected in the field of occupational health, says: "It is no longer reasonable to look upon back pain as a benign self-limiting condition. . .more than 2 days in bed may be dangerous. . .rest may be equated with immobilization and (this) is now known to rate significantly as an actiological factor in osteoarthritis. . .the need for active management of acute musculoskeletal symptoms at the earliest possible stage is therefore clear".4 2. The chiropractic approach to active management of biomechanical problems goes further than this. It is based upon two premises: a) Where there are symptoms-such as neck pain, back pain, referred pain in the limbs, headache-there should be early active management directed at correcting dysfunction (the cause) and maintaining normal lifestyle rather than passive management to remove pain (the symptom). (This proposition is now accepted worldwide hv leading medical researchers-but not yet widely re cted in general medical practice). b) beyond this there should be active management of - biochelnical problems before the arrival of pain or other . symptprns. and after symptoms have subsided. The health problem begins with loss of range of motion in a joint and/or associated neuromusculoskeletal changes, not the later symptom of pain. Similarly dental problems begin before toothache, and marital difficulties require attention prior to separation or divorce. From chiropractic perspective the prime significance of the recently published book 'The Back Power Approach'6 by Imrie MD and Barbuto DC is that this is the first extended work by medical and chiropractic co-authors which explains fully the extension of active management ofmuscu1oskeletal problems to prevention as well as treat ment. (For a full review of the book see this Report May1988, Vol. 2, No.4). . 3. This preventive aspect of chiropractic practice results in emphasis upon periodical biomechanical check ups to monitor range of movement of joints and correct any altered mechanics or subluxation. This has support from some specialists in manual medicine, such as Lewie and Stoddard8, but is often criticized and misunderstood. Inappropriate actions by some chiropractors leading to over-treatment and patient dependency have undoubtedly fuelled this misunderstanding. 4. Chiropractors have also felt, though with little objective scientific evidence, that subluxation or joint dysfunction is not only a precursor of pain but a cause of early joint degeneration leading to permanent changes in Spinal function that have a range of health effects mediated by the spine and the nervous system. The work of Videman and his colleagues speaks to this issue. In this Report we look at their evidence. We also review other recent studies that support the importance of early active management and the mechanisms involved. B. Osteoarthritis 5. For the past 15 years Videman has been conducting animal experience with rabbits seeking to understand what role. if any, immobilization of a joint has in the pathogenesis of osteoarthritis. Leading researchers9,4 agree that animal experience have excellent human relevance in this area, far more so than producing degeneration in animals by chemical means where osteoarthritis is not typical of that found in humans. Equivalent human experiments would take many years to complete and inevitably would be more subjective and therefore less valid.l 6. In a number of experiments during the last 10 years Videman has splinted the knees of rabbits in extension. In his most recently published paper reviewing these experience he reports these results of such immobilization: a) "An early, and the most obvious, change is reduc tion in mobility". Initially lost mobility is "at least parT tially reversible". However some range of movement is lost permanently. b) The level ofoompression between o areasofcartilege in the joint "increases sharply during the first week" to 200% above normal oompression. It stays at that level for the following four weeks before beginning to decline. c) Coincident effects include: (i) Increased blood supply to the cartilage (measurable after 1 day). (ii) Increased formation of collagen (seen after 3 days) and glycosaminoglycan (7 days) in joint tissues. (iii) Increased periarticular fibrosis. (iv) Cartilage proliferation on the joint surfaces. (v) Fibrillation (degenerative softening 8;11d formation of clefts and atrophy of joint cartilage. . (vi) After 2 weeks of immobilization, first signs of burnation in the subchondral bone-that is exposure, wearing and hardening of bone because of extended fragmentation of the protective layer of cartilage in the joint. "Such changes are ot reve l tand) are identifiable radiologically as narrowing the joint space, osteophyte formation and subchondral sclerosis". d) These osteoarthritic changes and the loss of joint mobility can be produced either by a single period of immobilization (a few weeks) or repeated short periods of immobilization (several days each). e) When the knee is immobilized "the range of motion at the hip is necessarily restricted" also. Accordingly secondary loss of mobility and degeneration was measured by Videman at the hip-including glycosaminoglycan synthesis and capsular thickening. f) Follow-up was equally interesting. Videman induced osteoarthritis by knee immobilization in one group of rabbits for 5 weeks, then removed the splints. Over the next 18 months some were released to "normal cage activity" others forced to take up jogging on the treadmill (3 times 5 days per week-about 2,250 meters weekly). During this follow-up "radiographically there was no clear increase in the level of osteoarthritis" for either group of rabbits. Two points of obvious significance here are: i) Degeneration occurred during rest ofthe joint, but was largely arrested by resumption of normal activity. ii) Normal activity (normal lifestyle) was just as healthy for the joint as a specific exercise regime. g) Videman is now beginning to look at the lumbar spine in his experiments with rabbits. In one recent study 10 lumbar joints were restricted in motion (by neural arch fusion) or e-stabilized .(unilateral f cet resecti n) with the result: i) In both Instances disc narrowing and marginal osteophyt:es appeared "within a few mon hs".

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