SPINAL LESION ANALYSIS AND LOCATION

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GRAVITATIONAL ANALYSIS, COMBINED VISUALIZATION WITH STATIC AND MOTION PALPATION-MOTION EXAMINATION

 CLASSIFICATION DEFINED 

    Over the centuries manipulative historians have had tremendous difficulty correlating a modern diagnosis (no matter the century) with the area of altered joint dynamics.  For this reason areas of altered joint dynamic can be divided into two common sense classifications; The Physiological Condition” of the joint and the “Motion Condition” of the Joint.  The manipulable lesion has of these both properties or motions which assist in differentially diagnosis and treating the condition.  For example the “Physiological Condition” of the joint is divided into disorders which yield rationale for diagnosis based upon the anatomy, physiology, and known pathologies associated with degenerative changes f articulations and associated processes and structures. 

     The “Physiological Condition” of the joint tells us where on the joint the injury occurred, why there is pain and dysfunction, and combined with a good history of the injury or incident, tells us how the mechanics of injury occurred as we diagnosis and decide medical treatment. 

     The “Motion Condition” of the joint is divided into the possible motions the particular joint will exhibit.  For example, we do not expect a Diarthrosis joint to exhibit all the motions of an Ampharthrosis Joint.  Thus, when examining the spinal joints with a motion examination we bring the joint through at least five (5) ranges of motion, which are forward flexion, extension, lateral flexion-rotation rotation-lateral flexion, and circumduction (which is a combination of forward bending and lateral bending motions (combined motion) to the right and left.  While bringing the spinal joints through the five ranges of motion, the physician holds or will ‘fix” the vertebral joint under examination.  If the patient report pain/or the physician feels “joint splitting” or “joint excursion”, we have found the “motion condition” of the joint.  When we find the “motion condition” of the joint, it indicates the restricted motion, in what direction the joint restriction exhibits splinting, thus indicating the direction or vector of correction.  The “motion Condition” assists in the differential diagnoses between the physiological conditions, and indicates in what direction the joint must be adjusted.   

    Location of the painful joint restrictions and resultant areas of compensatory Pathomechanics described, is the chiropractic diagnostic procedure known as Motion Palpation.  Motion Palpation involves biomechanics in practice clinical application.  Awareness of the facet facings and of how each vertebral joint of a given area moves is mandatory.  Inducing the motion specifically in the correct joint area, feeling for the correct data and correlating correctly with degree of altered joint dynamics indicates where and why and how often the joint splint or excursion must receive treatment.  Of course, you would write what joints are to be adjusted.  Further, the examination indicates whether a correction of the altered joint dynamics occurred with manual medicine. 

      Throughout this section, you will study lesion consistent for palpation, gravitational analysis for body mechanics during weight bearing situations, motion palpation and end feel analysis.

MOTION RESTRICTIONS

      The cause of a muscular joint split or restriction is usually due to a contracting head of a muscle, a contracting muscular fasciculation within a muscle or an entire muscle pulling the vertebra into joint splinting dynamics represented by the joint restricted in rotation, lateral flexion extension, flexion, or a combination of planes.  Of course, there is regional general spasticity.  Note these findings if they are present.  This denotes and early acute phased of injury, or chronic condition with Upper and/or Lower Motor Neuron Disease.  Generally, if an entire muscle contracts into spasticity neighboring and even distant vertebrae are affected.  Influences which cause muscular spasticity are numerous and some follow:  Atmospheric changes of heat and cold (Bells palsy, Torticollis etc) vasomotor spasm, visceral reflexes, toxic metabolites in the blood and tissues, fatigue, postural stresses and strains, postural defects (Kyphosis, Lordosis) lateral curvatures (scoliosis), infections, inflammation, pathologic changes in nervous system or somatic tissues. Stretch/strain/sprain or overexertion and poor diet are causes of muscular spasticity. 

     The cause of a ligamentous restriction is usually due to ligamentous thickening or thinning of the fibrous tissue.  The etiology is usually mechanical irritation and or inflammation and congestion.  The result is a restricted  (joint splint) joint or relaxed (hypermobile) joint.  The restricted joint is characterized by an approximation of all the bony parts with a thinning of the intervertebral disc and a thickening of the ligament about the joint.  Later, when you review the Huston Conference Listings these conditions are known as Kinetic Intersegmental alterations. 

     Conversely, great elasticity of the interarticular fibrocartilage and a thinning of the ligaments about the joint characterize the hypermobile joint.  In order for a joint to translate into excursion dynamics the ligamentous, holding structures would have had to undergo deformation and creep.  Thus, the joint is lessened and its integrity has been compromised and is in jeopardy.  Etiologies for deformation of ligamentous holding structures are trauma but also rheumatoid arthritis, and various diseases.

FUNCTIONAL PROPERTIES OF TENDON ORGANS 

     Tendon organs are relatively insensitive to passive “stretch” because they lie in series with a compliant, contractile element that absorbs most of the stretch and prevents elongation of the tendinous region.  Changes in the muscle length then affect tendon organs very little, and their receptors provide no information about length.  When a muscle contracts as in isotonic exercise, the tendon organs within it discharge in proportion o the tension that is developed.  If the contraction merely shortens the muscle without developing very much tension, the tendon organs are weakly excited.  If contraction would occur when the muscle is lengthened and the ends are “fixed”, the shortening of the contractile part of the muscle necessarily lengthens the noncontractile area where tendon organs are located and vigorous firing will occur.  Sometimes a particular tension may be developed at various muscle lengths.  Because of their location, tendon organs measure this tension regardless of length.

      When a stimulus is appropriate the tendon organ is an extremely sensitive receptor.  Systematic testing of all the motor units in the Soleus muscle was performed and it was found that about 15 different units will each cause firing of a single tendon organ.  Histological studies have shown that 3 to 25 muscle fibers insert on each tendon organ.  Thus, a motor unit in the Soleus that has averaged 180 fibers contributes only one or two of them to a tendon organ.  A tendon organ samples the local tensions in a muscle by monitoring a small faction of the muscle fibers of a large number of functional motor units.  Response of a tendon organ is determined by the number of active motor units inserting on it and the tension developed by each of the contributing fibers.  It is known that a single muscle fiber producing 0.1 gm of tension is sufficient to cause the receptor to fire at 25/sec.  Thus, tendon organs have great sensitivity and must be active whenever muscle are contracting and doing (important reference in hyper flexion/hyperextension injuries as well as overexertion) work.

FUNCTIONAL PROPERTIES OF LIGAMENTS

        Ligaments act as the holding structures of the somatic tissues.  Often times it is their task to hold vital structures from being touched by bony processes during movement, and often times they may guide and/or assist in the motions of osseous tissues.

      When ligaments are damaged may things can occur.  They can elongate and thin with subsequent atrophy and necrosis generally associated with deformation of the ligament and subsequent creeps due to elongation with improper healing.  Ligaments can also thicken and swell due to irritation and edematous processes. 

     Even the juxtaarticular epiphyseal or apophysial insertions of ligaments can be damaged in extension injuries.  However, the body has provided excellent protection for the insertions of ligaments into the osseous tissues.  There is an interposition of cartilage tissue between the ligament and the bone.  This subsequently reduces the chances of mechanical strain on the zone of ligamentous insertions by preventing the ligamentous insertions from being able to kink and twist.  Thus, the fibrous interposition of cartilage acts as an anchor to the ligamentous insertions.

      If an excessive extension injury occurs and the ligamentous juxtaarticular epiphyseal or apophysial insertions are stretched and strained, than there may be the process of deformation due to necrosis.  This occurs in the following steps.  First, there is a deposition of lipids, and calcium salts by hyalinization.  This is usually followed by necroses and degeneration and thinning.  Often times an altered healing process also occurs.  Multipontential connective tissue cells degrade the degenerated portions of the ligamentous tissues and scar formation of the tissues occurs.  The finale to this form of repair is generally a transformation of cells to osteoblasts and bone formation occurs.  This explains how traction spur occur at insertions of ligaments and even tendons and how osteoarthrotic Osteophytosis in the articular cartilage forms.  This fibroostosis or fibrous tissue becoming osseous tissue is noted upon the radiograph a horizontal process if osteophytes, or a spur or pin or bulge.

      This fibroostosis is of primary concern to the Chiropractic physician because complete ligamentous ossifications can occur secondary to some traumatic incidents, permanent overloading as in the obsess or patients who repetitively lift weights in excess of their physical conditions.  If these ligaments are not stretched with corrective manual medicine than the mechanical impairment can again cause regressive pathological changes in neighboring soft tissues and contiguous bursa.  Repetitive irritation may then cause friction and reactive inflammation, infection, edema and congestion.  This may irritate nervous tissues and cause radicular complaints.  When ever a fibroostosis is found than it must be assumed that their may other etiologies other than trauma.  Thus, referral to a medical physician or a battery of lab test would be in order to rule out bacterial or viral invasions of the tissues.

    However often times the fibroostosis is due to aging or trauma and may manifest itself with calcium deposits in the ligaments, tendons, and ever bursas.  Notorious is the calcium deposits in the shoulders of the aged after some traumatic incident.  Various names for these deposits have been noted in the medical literature such as calcareous tendonitis, calcareous peritendinitis, calcareous bursitis, periarthritis and periarthropathy where the calcium deposits occur not only in the ligaments, tendons, tendon sheaths and tendon bursa but as well as the fibrous joint capsules.  Often ties these conditions are asymptomatic.  However may times they cause extreme limitation of joint motion, swelling, and even severe pain.  These calcium deposits may cause an inflammation and reaction, which may spread down the course of the tissues.  As in the case of the shoulder, immediate shoulder adjustive procedures to break up the fibrous adhesions and calcific densities will assure a return to normal motion.  These procedures should always be preceded by specific physiologic therapeutics such as interferential and ultrasound for hyperemic, antispasmodic, analgesic and nerve root sedation effects.  During acute stages of secondary reaction due to trauma use cryotherapy.

      Many Physicians have written about Motion Palpation over the years and it is this examiners opinion that absent a combined Gravitational Analysis, combined with Static and Motion Palpation and then Joint End Feel Analysis, Motion Palpation alone yields equivocal results.  However, an Examination, which is a complete series of progressive joint analysis through joint weight barring, static palpation and motion palpation, forms the motion examination.  Finally, the lesions discovered during the motion examinations are consistent with lesions reviewed radiographically or through imaging, consistent with the lesions noted upon active motion palpation and finally consistent with the lesions treated by modern scientific manual medicine.

GRAVITATIONAL ANALYSIS

   It has been established that the spinal column offers an intricate lever system associated with the prime movers or the muscles as well as the primary and secondary stabilizers the ligaments, tendons and other bones.  This biomechanical system allows the biped to move about efficiently under the force of gravity.  As the earth’s gravitational field tries to accelerate the biped toward the center of the earth, our somatic structures apply the correct force for the erect plantigrade posture or a greater force for sustained motion.

      Often times if the body is unable to balance the centers of gravity with the force of gravity, postural stresses, or strains with associated reflex tensions may occur.  If these manifestations are not corrected by homeostasis or other means a vicious cycle of pain and discomfort may result.  One method of determining which joins have altered dynamics is through the Motion Examination.  This begins with a Gravitational analysis obtained by comparing the biped with the gravity line either visualized or conceptualized.  A superiorly anchored cord that is fixed inferiorly, called a plumb line, represents the gravity line.  When the patient is placed against the plumb line in the lateral position the line should intersect the following anatomical landmarks: 

1.     A point which is slightly posterior to the apex of the coronal suture

2.     A point, which intersects the external auditory meatus.

3.     A point, which intersects most of the bodies of the cervical vertebrae.

4.     A point, which intersects the shoulder joint.

5.     A point, which intersects the bodies of the lumbar vertebrae.

6.     A point, which is slightly posterior to the axis of the Acetabulum.

7.     A point, which is slightly anterior to the axis of the knee joint.

8.     A point, which is slightly anterior to the lateral malleolus. 

     When the biped is compared in the anterior-posterior position, the line should project at the mid-line of the body.

IN-DEPTH COMBINED GRAVITATIONAL VISUALIZATION AND PALPATION 

     After the physician has compared the eight gravity intersect points he may begin his in-depth gravitational analysis.  This is done in the following manner;

1.     The physician will observe the alignment of the occiput.  This is done by digital palpation of the inferior edge of each mastoid process, and comparing them to one of your palpation hands which is pivoted to a horizontal position.  It has been determined with palpation and visual observation whether the occiput is level with the horizontal or if one mastoid is high.  For example if the right is elevated note the mastoid is high on the right.

2.     The physician will note if one side of the face shows more than the other.  This may indicate a rotational malposition.  If the occiput palpated high on the right and the left side of the face showed more than the contralateral side the notation would be listed as RIGHT POSTERIOR SUPERIOR OCCIPUT.

3.     Palpate down the upper trapezius for a difference in muscle tonus, temperature differential, skin texture, differential in oiliness or dryness and note the findings.  Compare your findings with your knowledge of Myotome, dermatome and neurological relationships for determination of which vertebral segments would theoretically be in a state of altered joint dynamics.

4.     Once you have palpated the Acromion processes, pivot your hands out laterally.  Observe the shoulder height.  Make sure to note if one shoulder is elevated.

5.     Observe and palpate the scapulae.  Indicate your finding sin the following manner

a.      Right (left or negative) downward rotation with concomitant shoulder change.

b.     Unilateral scapulae elevation or depression with concomitant shoulder change.

c.     Right (left or negative) upper scapula rotation with concomitant shoulder change.

d.     Unilateral abduction or bilateral abduction of scapulae.

e.      Unilateral or bilateral scapulae adduction.

f.       Vertebral winging or protrusion of medial border of either scapulae.

6.     Contact the i9liac crest bilaterally, beginning at the inferior and pressing the soft tissues as your hands translate superiorly and laterally and observe heights.  Indicate right or left iliac crest elevation.

7.     To contact the inferior border of the Posterior superior iliac spine come from the inferior and move superiorly.  Determine if one has moved posteriorly, inferiorly and medialward.  If the PSIS palpates more prominent make a note of it.  If the PSIS palpates anterior, superior and laterally (or medialward) make a note of it.  For the Chiropractic Physician, communication between Biomechanical Experts or DC’s is mandatory and code your notes a RPIN, LPIN,LPEX, LAIN, RAIN, LAEX, RAEX.  For example the RPIN equates to the right PSI moving posteriorly and inferiorly.  LAEX equates to the left PSIS moving anteriorly and externally.

THE VETEBRAL COLUMN

      This procedure is best accomplished with a skin pencil for the novas with these procedures.  Compare the patient’s spine with the gravity line.  Observe the following: 

a.      Scoliotic deviations in the neutral plantigrade posture.  Next have the patient flex forward in Adams position and note if the scoliosis diminishes (determine functional from structural scoliosis).

b.     Palpate for differences in the patients paravertebral musculature.  Check for any prominent areas and/or differences in texture or temperature.  Also feel for prominent AP’s, SP’s. Tp’s or MP’s.

THE EXTREMITIES 

1.      The brachium and antebrachium

a.      Compare lengths bilaterally.

b.      Note relative abduction or adduction and the carrying angle.

c.      Note the hands for medial or lateral rotation, which may indicate shoulder rotation and/or Pronation-Supination of the forearm.

2.       The Lower Extremities

a.      Observe the patient for translation through the coronal plane.  If one limb appears abducted, the other often times appears adducted.

b.     Observe the Gluteal masses for symmetry and compare bilaterally for muscle tone.

c.      Observe the patients knees for genu valgum (knock knee), or genu varum (Bow legged).

d.     Observe the legs for differences in muscle mass or symmetry.

e.      Observe the ankles for inversion or Eversion as well as Pronation and Supination.

f.       Observe for loss of arch of foot as well as deformation of the greater toe.

STATIC DIAGNOSTIC PALPATION 

     B.J. Palmer DC stated “Palpation is the method of feeling, pressing or exploring with the fingers.  Vertebral palpation is the application of the principles of palpation to the vertebral region; or it is a method of feeling, pressing upon or exploring the region over the vertebrae or the purpose of detecting irregularities or abnormalities in the form of subluxation, curvatures….” Dorland’s dictionary states “Palpation is the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the consistency of the parts beneath in physical diagnosis.”  Actually palpation is limited by the knowledge of the physicians and physicians limited in palpation must never attempt to correct altered joint dynamics. 

     Historians point out that the middle finger of each hand has been distinguished with the title the “Chiropractic Index Finger” distinguishing it from the first finger.   This finger has the greatest strength it is manly utilized for gripping action and not that of tactile application.  However with training this finger develops great sensitivity due to the fact that brain centers have been previously untrained and are impressionable.  In the 1970’s when I matriculated through the Los Angeles College of Chiropractic one method of palpation training was to place a hair on a peace of paper.  Next they took another piece of paper and placed it upon the first.  The hair was palpated.  Once this level was mastered another peace of paper was placed upon the first.  Some have palpated a strand of human hair under no less than 30 pieces of typing paper.  I was one of many. 

     Very light touch, light touch; touch, and pressure are the taxonomy for communicating relative tissue depths reached.  In very light touch, or in fact passing the hand a few millimeters above the skins surface may provide information on surface temperature.  Light touch may reveal skin humidity, and the sebaceous and sudorific condition and activity of the skin.  Mild pressure may reveal the tone, plasticity and turgor of the skin.  Slight pressure reveals the superficial muscle groups and at times determines their tone, turgor, and metabolic (Toxic metabolites) status.  Moderate pressure may also be utilized for abdominal exploration and determination of organ size, shape, and correct location.  Deeper penetration pressures may allow firm, easy and gentle contact with bone.  Knowledgeable palpation assures purposeful palpation, which will reveal vital information. 

     Actual palpation is conducted with the bulb of the finger and not the tips.  When palpating a patient’s spine take the index and middle fingers and slide one at a time downward not jumping or losing Cutaneous contact between finger and skin.  The following are landmarks for palpating the spine. 

1.     External Occipital Protuberance – EOP

2.     Cervical second vertebra is the first big posterior bone, and is bifid.  Upon motion examination in flexion of the head the spine moves posterior.

3.     Cervical third vertebra has the smallest spinous process of the spine, and also moves posterior upon head flexion.  Cervical fourth and fifth also move posteriorly upon head flexion.

4.     Cervical sixth vertebra is found by motion examination.  Flex the head and neck forward.  Find cervical six by counting down from cervical two.  Once found note at extending the head upon the neck and upon the shoulders allows cervical six to disappear.  In clinical practice the contact finger would be placed approximately upon cervical six and the head extended to define cervical six.

5.     Thoracic first vertebra is known as vertebra prominence in 40% of the population.  On X-ray examination thoracic first spinous process points caudad more caudad than the cervical spinous process.

6.     Thoracic third is found at the level of the scapular spine.

7.     Thoracic fourth is the widest and longest spinous process and the last to have an oblique angle.

8.     Thoracic fifth is the first spinous generally to angle inferiorly.

9.     Thoracic sixth found in the prone position, is at the level of the infrascapular line.

10. Thoracic seven is found at the level of the infrascapular line in the plantigrade posture, ad thoracic eight is found at the infrascapular line in the seated position.

11. Thoracic nine and ten are parallel in configuration and generally palpate as one.  Their angulations are more perpendicular to the axis of the spine.

12. Thoracic eleven is a motion vertebrae exhibiting great joint flexibility.

13. Thoracic twelve is known as a transitional vertebra because it appears as if it is a lumbar vertebra.  It also forms attachment bigger but shorter than a thoracic.  However is a little smaller but longer than a lumbar spinous.

14. Lumbar third is considered the apex of a lumbar curvature whose curve is within normal biomechanical limits.

15. Lumbar fourth spinous is at the level of a line drawn from the superior crest of the Ilium.

16. Lumbar fifth is the last movable segment of the spinal vertebrae.

17. Sacral two’s tubercle is at the level of the posterior superior spine.

18. The coccyx is the last moveable segment of the spine.

19. The body of a vertebra can be found by palpating the spinous and moving the finger cephalad and around.

20. Transverse process of the cervical spine can be palpated by feeling just lateral t the spinous a finger girth or on the side of the neck.

21. The thoracic first body is at the level of the Interspinous space above thoracic first spinous.

22. Thoracic fifth through eight palpate two Interspinous spaces above and move lateral.

23. Thoracic nine through twelve palpate one Interspinous space above and lateral.

24. Mamillary processes are best interpreted in the prone position.  Palpate one Interspinous space above and lateral, and about the width of two fingers.  Lumbar fifth is an exception to this rule.

25. The facets of Michaelis should be noted.  These are the soft tissue indentations in the lumbar region.

26. Visualize the foramen magnum correlating its level with the hard palate.

27. Palpate cervical third vertebra and the hyoid bone at the same approximate level.

28. Palpate cervical fourth and fifth and the thyroid cartilage at the same level.

29. Correlate cervical sixth with palpation and visualization of topographical landmarks such as the beginning of the trachea, end of the larynx, beginning of esophagus, end of pharynx, and cricoid cartilage.

30. Cervical seven correlated with the level of the isthmus of the thyroid gland, and the highest pint of the thoracic duct.

31. Thoracic first is correlated with the level of the apex of the lungs.

32. Thoracic fourth is correlated with the sternal angle, 2^nd costal cartilage, end of ascending aorta, end of trachea, and limits of superior mediastium from inferior mediastium.

33. Thoracic fifth to the thoracic seventh are correlated with the thoracic duct as it crosses posterior to the esophagus from the right below to the left above.

34. Thoracic seven is also at the level of the inferior angle of the scapula in the standing posture.

35. Thoracic eight is correlated with the inferior vena cava as it passes through the diaphragm.

36. Thoracic nine is correlated with the xiphosternal angle.

37. Thoracic ten is correlated with the level of the esophageal hiatus in the diaphragm.

38. Transverse process of atlas of cervical one inferior and slightly anterior to the mastoid process.

39. Cervical seven is the second most prominent spinous process in this region of the spine.

40. Thoracic second opposite jugular notch.

41. Thoracic fifth opposite the angle of Louis (sternal angel)

42. Thoracic ten opposite the xiphoid process.

43. Lumbar thi8rd disc correlated with the level of the umbilicus.

44. Sciatic notch is correlated as two inches inferior and one-inch lateral to the PSIS also known as the PSS.

45. Ischial tuberosity is correlated as two inches inferior to the apex of the coccyx and on a vertical line through the PSIS. 

     The most important of the latter would be used as ready references due to their nature.  These again follow:  To find C6 it disappears upon extension.  Thoracic seven in the plantigrade posture can be found by palpating the tips of the scapulae.  To verify a thoracic or lumbar location palpate the 12^th rib to the 12 thoracic vertebrae and count to vertebra in question.  Crests of the Ilium across from the L4 spinous. 

     To palpate the sacroiliac joints slide the thumbs caudad until you feel a slight notch or hook on the Ilium in the sacral area.  Visualize the fossae of Michanelis where the depressions of the skin are due to the bony prominences.  Motions of the SI joint are related by the PSIS.  The PSIS can go in a postero-inferior motion, an antero-superior motion, an internal motion, and an external motion.  Postero-inferior is coded PI.  Antero-superior as AS.  Internal deviation as IN.  External deviation as EX.  When you static palpate this area note if the PIS are relatively PI, AS, IN, EX, PIIN, PIEX, ASIN, or ASEX re within normal limits of symmetry.  However many physicians assume that it is understood that when the PSIS moves posteriorly it moves inferiorly and when it moves Anteriorly it moves superiorly.  Chiropractic Physicians code the motion to denote which PSIS is under discussion.  This diversified coding would be as follows:  RPI, LPI, RAS, LAS, RIN, LIN, REX, LEX, RPIN, LPIN, RPEX, LPEX, RAIN, LAIN, RAEX, LAEX. 

     Palpation for the Greater Trochanter of the femur begins by palpating the lateral aspect of the iliac crests.  Palpate caudally about 5 or 6 inches to locate the greater Trochanter.  In chapter 11 you will correlate this location with sciatic distribution manifestations.  This is due to the fact that the Piriformis muscle originates from the anterior aspect of the sacrum (see Chapter on Origins and insertions) through the sciatic notch and inserts on the greater Trochanter.  Its function is external rotation of the thigh.  It lies over the sciatic nerve and the nerve pierces it in many cases. 

     Palpation of the Transverse process of the Atlas begins by palpating the mastoid process.  Palpate caudally by coming off the mastoid and moving inferiorly along the sternocleidomastoidius muscle to its belly.  The transverse process palpates as a tight area in the muscle as if it felt dull and abut twice the size of the eraser end of a pencil. 

     Finally palpation of the lamina pedicle junction of the cervical spines is located one finger width lateral to the spinous process. 

THE MOTION EXAMINATION LESIONS

      For many generation’s various health care practitioners have utilized some form of manual manipulative medicine to alleviate the joint related ailments of mankind.  Hypocrites in 490 BX utilized a crude form of traction as described in “On Setting Joints By Leverage” and “Manipulation and Its Importance to Good Health, “ just two of the many books he wrote.1 

     Doctors of Chiropractic, the primary proponent of manipulative procedures used today, introduced for the first time in the written scientific literature a “short leveraged manipulation of joints using the spinous, transverse and other vertebral processes as levers” to relieve ailments of their patients.  Today, manipulative medicine is being utilized and investigated by scientific bodies worldwide. 

     The question remains, once a quality examination has been performed, and it has been determined manipulative medicine may be the prudent choice of treatments, how can we figure out where to manipulate, and whether any correction has occurred?  Of primary importance to physicians interested in manual manipulative medicine are the “Motion Examinations”.  As noted the Motion Examination combines all moving forms of palpation including Motion Palpation.  The Motion Examination is the system of modern biomechanical based methods used in determining when and where a spinal adjustment (Short radius manipulation to a joint) is indicated, or a mobilization is indicated.   

     Often times if the biped is unable to balance body centers of gravity with the force of gravity and external loads, postural stresses, or strains with associated reflex tensions, pains and suffering may occur.  Further, many conditions presented for manipulative medicine are due to some incident where the joints of the body may have been overworked, jammed or stretched, strained, and/or sprained and possibly deformed.  This “jamming’ (Joint Compression), overexertion (injury to the joint during or within its physiological range of motion), or extension (injury to the joints beyond their physiological range of normal motion) may produce an “area of altered joint dynamics” via altered mechanics.2 

     This may be represented upon examination by a “restricted joint or ‘joint splint” (hypomobile, fixed translation, subluxation, restricted somatic dysfunction) or an area of excessive joint play or motion known a hypermobile (hypermobile somatic joint dysfunction, hypermobility, vertebral translation, subluxation, or vertebral excursion). 

     A “joint restriction” is defined as an isolated joint complex that demonstrated restricted movement upon motion examinations and may have pain that can be minimal to severe in nature, and is the consequence of a biomechanical or pathomechanical change.  The joint restriction palpates upon motion palpation for example as a living, rubber like resistance increasing during the continuum and upon reaching end motion comes to an abrupt stop with some reflex or rebound to reduce physiological contracting/pain.2, 6 

     Generally the joint restriction phenomena is a component of a musculoligamentous stretch/strain or sprain injury or a component of a reflex arch from internal organ disease or even psychosomatic sequelae.1 

     A “hypermobile joint” is defined as an isolated joint complex that demonstrates excessive motion upon a motion examination, and again may have pain that is minimal, slight, moderate, or severe, and is due to a biomechanical or pathomechanical physiological change.  The “hypermobile joint” (spinal or extremity) palpates upon motion palpation as too much palpable motion with a lack of restriction that seems to lose normal resistance prior to end motion.  End motion has been described as n empty feeling stopped by a pain/discomfort response.2, 6 This is generally a component of a severe sprain with musculoligamentous or tendinous tears, severe deformation of ligaments with subsequent osseous creep or even a sequelae of chronic improper manipulation. 

     When we are recording range of motion findings looking for restrictions of motion with pain responses we are assessing osteokinematic motion which is the movement that occurs between bones.5  While assessing arthrokinematic movements you will note joint play motion.  Joint play movements are those accessory movements that can be produced passively at a joint but cannot be produced actively.  When you perform a motion examination you will note those restrictions to your applied motion noting the joint is in a closed packed position also know as maximal congruence.  When a joint is restricted in a closed packed position and a subsequent trauma occurs to the joint conditions such as fractures, dislocations, capsular tears and so forth can occur.5,6,7   

     Conversely if a joint is in a loose-packed position, which is less stable and has more joint play, trauma could perhaps induce strains and sprains to the associated tissues about the joint.5,7  Thus the motion examination of a joint will denote whether the joint is closed packed or in maximal congruence, restricted, hypermobile or with a normal limit for motion, tension and absence of pain. 

     Often times these areas of altered joint dynamics are not demonstrable on radiological imaging.  Here we say we have a joint restriction, or subluxation without radiological imaging evidence and describe the change in body mechanics by palpable pain responses, diminished range of motion with or without pain responses, positive orthopedic tests, measurement for atrophy, inability to perform a squat, note positive heal or toe walking and normal and customary history, limited physical, orthopedic examination of the area of complaint and neurological examination noting consistencies and abnormalities related to your special testing such as MRI.  Then a diagnosis is rendered such as a strain, sprain, and traumatic acceleration deceleration musculoligamentous injury.  Examples of radiological utility for alterations in joint dynamics would include the Lines of symmetry such as Jackson’s, Chaberline’s, Ferguson’s, Ulman’s, George’s and the like.     

     Specific alterations in joint dynamics were organized into the Houston Conference Listings, which are considered investigative, valuable and follow: 

RADIOLOGICAL NOTATION OF ALTERATIONS IN JOINT (CHIROPRACTIC LESIONS) DYNAMICS: 

A.     Static Intersegmental Displacement:

1.     Flexion Malposition

2.     Extension Malposition

3.     Lateral Flexion Malposition

4.     Rotation Malposition

5.     Anterolisthesis

6.     Retrolisthesis

7.     Laterolisthesis

8.     Altered Interosseous spacing

9.     Osseous foraminal encroachments

10. Discopathy

B.      Kinetic Intersegmental Alterations in Joint Dynamics

1.     Hypomobility

2.     Hypermobility

3.     Aberrant motion

C.     Sectional or Block Alterations in Joint Dynamics

1.     Scoliosis secondary to muscular imbalance.

2.     Scoliosis secondary to structural asymmetries.

3.     Decompensation of adaptational curves

4.     Abnormalities of motion examination.

D.     Paravertebral Displacements

1.     Costovertebral and costotransverse disrelationships

2.     Sacroiliac disrelationships

E.      Extremity Alterations in Joint Dynamics: Lesions

1.     Osteoarticular (Pure).

RADIOGRAPHIC ALTERATIONS IN JOINT DYNAMICS DEFINED: 

     The Academy does not believe that Radiographic Examination is necessary to locate and treat Manipulable lesions.  It is not necessary to irradiate each patient with a biomechanical condition unless the study is to rule out pathology and thus focus the care specifically.  

Joint Restricted in Flexion Motion or the Flexion Malposition.

      A flexion joint “splint” or restriction of a vertebral articulation in the position of flexion.  When a vertebra is restricted in a relative position of flexion it has been designated a code of “FR” (flexion restriction), or “AR” (anterior restriction) by the American Academy for Justice Through Science.  In the coordinate system, the vertebra has moved into the z-plane about the x-axis in an anterior cylindrical motion. 

Anatomical theories of the FR joint restriction.

a.      The spinous process of the vertebral joint has separated from the one below, thus approximated to the one above.  Generally the spinous would be palpated more easily then it would be normally

b.     Parts of the articular surfaces are in apposition.

c.     The body presents anteriorly at the anterior inferior margin.

d.     The disc may be compressed anteriorly and stretched posteriorly.

e.      The following ligaments are thought to have been stretched, thinned, and possibly atrophied in a worse case scenario; Posterior longitudinal, ligamentum flava, Supraspinatous, Interspinous and intertransverse.  The anterior longitudinal ligament is relaxed and perhaps thickened.

f.       Due to the separation of the pedicles of the vertebral joint splint with one below, the intervertebral foramina are increased in size above and decreased below.  Often times inflammatory changes occurs at the foramen with a resulting deposition of connective tissue, edema and congestion, which may alter the size of the foramen.

g.     Fasciculi of extensor muscles of the area may be stretched, strained and possibly deformed or atrophied.  Corresponding muscles of the flexor muscles may be contracted.

JOINT RESTRICTION IN EXTENSION MOTION 

     An extension joint splint is a restriction of a vertebral articulation in the position of extension or hyperextension.  When a vertebra is restricted in a relative position of extension or hyperextension, it is designated as “ER” (extension restriction) or “PR” (posterior restriction).  In the coordinate system, the vertebra is moving out of the z-plane about the x-axis in a posterior cylindrical motion. 

Anatomical theories of the “ER” splint: 

a.      The spinous process of the vertebral joint has approximated to the one below and separated from the one above.

b.     Parts of the articular surfaces have glided posterior and inferior.

c.     The body presents a slight posteriority at the anterior inferior margin.

d.     The disc is thought to perhaps be compressed posteriorly and stretched somewhat anteriorly.

e.      All the posterior ligaments are relaxed and perhaps thickened where the anterior longitudinal ligament is stretched perhaps thinned and possibly atrophied if a chronic restriction.

f.       The intervertebral foramina are generally narrowed vertically.  When inflammation occurs connective tissue may lessen in caliber.

g.     Fasciculi of the extensor muscles of the area are contracted while corresponding flexor muscles are stretched and possibly atrophied if the condition is chronic or untreated.  The fifth lumbar vertebra, and the T3-T7 thoracic, vertebrae present extension joint dynamics most commonly.   

JOINT RESTRICTION IN ROTATION AND LATERAL FLEXION 

     A rotational joint splint is a restriction of a vertebral articulation in the relative position of rotation.  When a vertebra is restricted in a right rotation it is designated a “RR” (rotational restriction right) or “LP” (left transverse process has moved posterior) or “PR” (spinous process has moved posterior and to the right). 

Anatomic theories of “RR” joints follow:

A.     Spinous process to the right.

B.      Left transverse process is posterior and approximated to the one below.

C.     Right transverse process is anterior and approximated to the one above.

D.     Vertebral body relatively rotated left posteriorly and right anteriorly.

E.      The intervertebral disc may be compressed on the left and spread on the right.

F.      The IVF is narrowed vertically on the left and widened vertically on the right.

G.     The third right rib is slightly anterior to adjacent ribs, separated from the fourth rib and approximated to the second rib.

H.     The third left rib is posterior to the adjacent ribs, approximated top the fourth, and perhaps separated form the second.

I.         On the right the ligamentum flava, capsular, lateral spinal and anterior longitudinal ligaments may be stretched, thinned and possibly atrophied. On the right, the latter ligaments are perhaps shortened and thickened if the condition remains untreated.

J.        On the right, the fasciculi of the multifidus, semispinalis, and rotatores are contracted on the right, stretched and atrophied on the left. 

Rotational joint splints occurrence in relation to spinal area is governed by the patients age.  Generally, they are most commonly found in the cervicothoracic spine.  As one reaches their fifties they are most common in the cervical spine proper.

Rotational misalignments generally have a property of lateral flexion in their dynamic position. 

LATERAL FLEXION RESTRICTION 

     A lateral flexion joint splint is a vertebral articulation restricted in the position of lateral flexion.  When a vertebra is restricted in right lateral flexion (lateral flexion has a component of rotational dynamics-coupling motions) it is designated as a “LR” (Lateral flexion restriction).  In the coordinate system as the vertebral jot and vertebrae tilts into the x-plane about the z-axis in a right lateral cylindrical motion. 

Anatomical theories of “LR” joint splints.

a.      The intervertebral disc is thought by some authorities to be compressed on the left, widened on the right.

b.     A perpendicular line projected upward from the superior vertebral end plates is inclined to the left.

c.     Intervertebral foramen on the left narrowed infero-posteriorly, and widened vertically on the right.

d.     The right anterior longitudinal lateral spinal, capsular, and ligamentum flava are stretched and possibly atrophied.  The latter ligaments on the left are perhaps shortened and thickened absent care.

e.      Fasciculi of the intertransverse multifidus and rotatores are stretched and possibly atrophied on the right.  The latter fasciculi of muscles on the left perhaps become shortened and thickened if the condition remains. 

Oftentimes if a lateral flexion joint, restriction occurs alone and not in a group or lateral sweeping complex of vertebrae the etiology is discopathy, or degenerative joint disease or some other arthritis o disease. 

ANTERO, RETRO AND LATEROLISTHESIS EXCURSIONS

A.   Antero or Spondylolisthesis

     A defect in the pars interarticularis allows anterior translation of the involved vertebra in relation to the sub adjacent one.  This “Anterolisthesis” of a vertebra is known as a vertebral anterior excursion or more commonly Spondylolisthesis.  The true etiology is unknown.  The foremost theory suggests that anterior excursion is due to a fatigue fracture superimposed on a hereditary defect or predisposition.  The following list demonstrates the wide view on the mechanism of Anterolisthesis.

1.     Separate ossification centers (The lateral masses, which normally have one ossification center, have two which fail to fuse

2.     A fracture which occurs at the time of birth

3.     An ordinary fracture of the region.

4.     A stress or fatigue fracture.

5.     Excursion secondary t increased lumbar Lordosis.

6.     Displacement secondary to breaching of superior and inferior articular processes.

7.     Weakness of regional ligamentous and support structures.

8.     Aseptic necroses of the pars interarticularis.

9.     Dysphasia of the pars interarticularis. 

     It is interesting to note that Anterolisthesis have a high incidence below the age of six and a half.  Yet, fatigue fracture occurs after the age of six and a half.  The radiographic details of the pars are not typical of fatigue fractures elsewhere in the body.  These issues detail how incongruous a typical fatigue fracture appears an opposed to a pars “break” or separation. 

     One logical explanation is due to the fact that the lumbar spine has a different configuration of loading dynamics than the rest of the spine.  The lumbar spine must resist powerfully loaded shearing fore pressures while acting in its normal function.  Thus, these powerfully loaded shearing force pressures cause a break in some cases. 

RETROLISTHESIS (False Spondylolisthesis due to discopathy) 

     Retrolisthesis akin to lateral listhesis are illusive to traditional medical literature.  Whether the etiology is flexion-extension strain, discopathy or disease the retrolisthesis is a posterior excursion of the upper of two vertebras except in the case of the sacrum.  Generally, it is accompanied by some degree of extension of a motion unit and possible approximation of vertebral bodies due to disc narrowing.   The vertebral excursion remains restricted in posterior dynamics the body of the vertebra is thought to cause friction and irritation of the structures surrounding the nerve root.  This may cause the reported Radiculopathies reported by clinicians. 

LATEROLISTHESIS 

     The Laterolisthesis follows a multiplane alteration of joint dynamics.  Generally a lateral excursion is characterized by a lateral translation and excursion accompanied by considerable vertebral rotation.  Radiologic imaging demonstrates an overreaching of the lateral margin of the vertebral body of the superior vertebra relative to the subadjacent one.  These areas of Laterolisthesis are rare to the medical and scientific literature and rare to clinicians.

ALTERED INTEROSSEOUS SPACING 

     Altered Interosseous Spacing refers to a decrease or increase in the interosseous space.  This condition is considered the most common of all the alterations in vertebral joint dynamics commonly demonstrated by the Geriatric populations. 

     The main features of a decreased interosseous spacing are a narrowing of the vertical intervertebral foraminal space and inferior excursion of the facets.  This narrowing is generally due to degeneration of the disc, which thus yields an approximation of the vertebral bodies and facet articulations.  This may cause a degeneration of the intervertebral disc resulting in increased intra discal pressures with possibility of prolapse of the nucleus, herniation of the disc into the end plate, into the intervertebral foramen yielding compression of the contents within the intervertebral foramina, increased shearing force pressures upon the posterior vertebra joints resulting in facetal imbrications and sclerosis, in chronic cases yielding facetal degenerative arthrosis with ebernation an even hypertrophy, resulting in alterations in vertebral joint motion dynamics which can lead to compensation in biomechanics’ in neighboring or even distant motor units which make up the spinal curves. 

     Conversely, the main features of an increase in interosseous spacing is a excursion of the superior vertebra body and facets from the inferior, traction stress forces to the annulus and the synovia of the inferior facet articulations and jamming of the superior joint capsules, stretching of the ligament associated with the motor units involved.  This situation is generally due to a pathological process or inflammatory swelling of the disc. 

FORAMINAL OCCLUSION    

     The features of foraminal occlusion are compressive friction and irritation to the structures within the intervertebral foramen which ay lead to nerve root swelling and congestion within the foramen.  Generally, foraminal occlusion is due to any or a combination of the above listed static alterations in joint dynamics, degenerative joint or disc diseases, foraminal stenosis either acquired or idiopathic, Osteophytosis and so forth.  If nerve root irritation occurs than a radicular condition may occur.

KINETIC INTERSEGMENTAL ALTERATIONS IN JOINT DYNAMICS

JOINT RESTRICTIONS AND HYPOMOBILITY 

     The main features of the joint splint are a motor unit, which demonstrates restricted motion.  Joint restriction may be due to muscular spasticity, thickening of the intervertebral fibrocartilage, thickening of the ligamentous holding structures, discogenic disease, Osteoarthritis and so forth.  Patients generally report these as a severely painful catch in the back.  If the joint is restricted in a position of altered joint dynamics, held in this conformation, and foraminal diameters are reduced than a repetitive stress and friction will be applied to structures within the intervertebral foramen.  This can cause swelling of the nerve root with edema and congestion.  Should this situation go untreated than a radicular syndrome may occur.  These joint restrictions can occur at single motor units with ah hypermobile segment above, below, or in groups of splinted segments with a hypermobile segment being distal to the injured motor unit.  Motion palpation will easily detect these aberrations in joint mobility. 

LOSE JOINT OR HYPERMOBILE JOINTS 

     The Lose joint is a motor unit, which demonstrates excessive motion.  It is often found as a compensatory mechanism accompanying a joint restriction at one or more various spinal levels.  It generally means that there has been deformation with associated creep of the ligamentous, and tendinous attachments.  These hypermobile joints may cause repetitive irritation with excessive motion of the motor unit resulting in micro or macro trauma to the intervertebral discs and other holding elements of the motor unit, Periosteum, neurological root insult as well as irritation to the musculature and blood supply.  Again, motion examination will easily detect these alterations in joint mobility and dynamics. 

ABERRANT MOTION JOINT 

     The aberrant motion joint has been defined to occur when one or several vertebrae move in a manner, which is no n phase with neighboring segments during spinal movement.  In other words, the aberrant motion joint is out of phase with the segments above and below where two motor units are involved.  Aberrant motion joints indicate that some injury either accidental or unplanned has damaged the spinal unit above and below as well as direct deformation and creep of the aberrant joints and their associated holding structures yielding unstable multiple spinal units.  The affects can be encroachment of the intervertebral foramina above and below the aberrant vertebra, increased shearing force pressures to the capsules of both spinal units, irritation to the intervertebral disc and continuous repetitive micro trauma to the ligamentous attachments of both motor units with eventual degenerative joint and perhaps disc disease with Osteophytosis, sclerosis, and ligamentous traction spur production. 

SECTIONAL OR BLOCK ALTERATIONS IN JOINT DYNAMICS 

     A scoliosis is a condition in which there is a lateral deviation with torsion of a series of vertebral bodies from the y’ plane.  The scoliotic curvature is constant in the erect position and is distinguished as functional when it disappears in “Adams Orthopedic Position” and as structural when it remains in Adams position. 

     Hypocrites in the fourth century BC first used the term “scoliosis” to imply abnormal curvature of the spine.  He derived the term from the Greek word meaning to twist or bend. 

     Inspection of any type of scoliotic spine demonstrates lateral deviation with torsion in a series of vertebral bodies.  As each vertebra varied from normal equilibrium position to one varied in multiple planes and multiple area of altered joint dynamics with restrictions and excursions noted. 

Categories of scoliosis are Functional, Compensatory and Structural. 

1.     Functional Scoliosis.  Usually due to unbalanced muscular loading of the spine resulting in ipsilateral contraction of muscles.  These types of patients respond remarkably to Osteoarticular technique (manual medicine). 

2.  Compensatory Scoliosis:  This classification is divided into:

a.      A compensation for an opposite scoliosis forming an S-shaped curve.

b.     A compensation for a short leg-pelvic obliquity.

These scoliotic patients respond excellently to manual medicine. 

2.     Structural Scoliosis.  This scoliosis takes its shape from a change in the vertebral bodies assuring a wedge shape.  In mild cases Osteoarticular, care is indicated in the form of manual distraction techniques and adjustive procedures.  In severe structural scoliosis, the thoracic spine curvature with associated rib cage deformity causes respiratory impairment with possible secondary cardiac complication.  Here manual distraction is the treatment of choice (relative to manual medicines) to decrease intradiscal, intra-abdominal, and intrathoracic pressure as well as opening posterior disc space, opening foramina and decompressing nerve root structures.  However, surgical intervention may cure the patient’s ills.  Differential selection of procedures is indicated with these patients and generally will occur only with complete cooperation between the medical forensic chiropractors and orthodox medical (see corsets and applications; Calliet) physicians.

PARAVERTEBRAL ALTERATIONS IN JOINT DYNAMICS

     This last classification generally refers to the Costovertebral, costo-transverse and extra spinal structures.  The main features of these alterations in joint dynamics are misalignments of the costal processes in relation to the transverse processes and vertebral bodies.  These displacements occur independently of alterations in the vertebral motor unit.  However, these costal displacements have also been found in some cases to be secondary to a spinal unit alteration in normal dynamics.  Patients will complain of pain upon breathing or rib excursion and the pain may radiate along the course of the Intercostal muscles beginning at the posterior Costovertebral joints.

These paravertebral alteration in joint dynamics may cause repetitive stress on the capsule ligaments and synovia with subsequent production of alterations in local spinal unit dynamics or even affect blocks of spinal units thus changing the spinal curves yielding irritations to the nerve roots, sympathetic ganglia and Rami communicantes.  Patients also have reported the pain being present at the costochondral junctions at the sternum when in fact the altered joints responsible are in the posterior articulations. 

     In some cases, this last classification may refer to alterations in sacroiliac joint dynamics.  The man features of these alterations in joint dynamics are misalignments of the sacrum in relation to the iliac bones, which are ipsilateral in nature.  When a sacral misalignment is associated with bilateral iliac distortions it is know as a secondary displacement.  Generally, the effects of these types of displacements are a repetitive friction and irritation to the interarticular structures as well as extra-articular holding structures.  In severe cases this may cause a functional scoliotic pattern in the vertebra piled, a pelvic obliquity and a short o long leg syndrome.  If the displacement is severe, there may also be a repetitive traction and irritation to the nerve roots, which issue the intervertebral foramina of the sacrum or lumbar spine.

 MOTION PALPATION                                      

     Dr. Henry Gillet of Belgium originally introduced motion palpation.  His primary concern was with the physiological ranges of motion of spinal articulations.  He motion palpated for fixations which he divided in partial and complete.  He subdivided them into muscular, ligamentous, and interarticular which actually involved the capsule.  Today we know of numerous causes for restricted vertebra such as discopathy, arthritis, contractures, adhesions etc.  Today the basis for motion palpation revolves around nine integral notions. 

1.     Motion palpation is considered an instrument of biomechanics in practical clinical settings.  Gillet stressed that awareness of facet facings and how a particular vertebrae of a region move.

2.     Motion was to be induced specifically (in accordance with the specificity set forth by DD Palmer) in the area where the physician desires to test.

3.     Relaxation of both the physician and the patient were stressed as crucial.  The patients will relax by perceiving the physicians firm but gentle control with his/her indifferent hand designated IH.

4.     The indifferent hand contact may be modified to the physician’s abilities and build.

5.     If the patient is seated support the patient on the doctor’s thigh.  In the supine position the patient’s head is cradled in the physicians fingers.

6.     Learn to feel the motion on yourself as a priorii to attempting it on another student or patient, or study in quality didactic and empirical course work taught by specialists in the motion examination.

7.     Motion palpation should be conducted unilaterally except where bilateral palpation is specifically indicated.

8.     The active hand is designated AH and feels for motions.

9.     While palpating feel for joint restrictions, loose or hypermobile joints or denote aberrant motion. 

     Motion palpation is continually being refined by the various practitioners and is practiced in many ways.  Broad radius motion palpation for feeling restriction is occasionally utilized (as it is the easiest to master, i.e. Doctors of Physical Therapy, MD’s, DO’s) as well as short radius motion palpation for feeling joint restriction due to ligamentous stretch/sprain/strain or deformation with concomitant muscular spasticity and so forth.  Further an instrument has been used to assist the physicians in the detection of lumbosacral alterations in joint dynamics known as the Osteopathic Mc Mannis instrument, the Chiropractic Cox Table, and others.  Motion palpation on these instruments is known as Distraction-motion palpation which some feel is effective when lumbar discogenic diseases is suspected.  Finally the definition of motion palpation or the motion examination is a diagnostic procedure utilized to locate areas of normal and altered joint dynamics or subluxation.  The test is also used to decide when, where, and in what plane and adjustment is to be delivered.  This test also suggests if a vertebral correction has occurred and gives the practitioner an indication of the anticipated duration of further manipulative care. 

     The following is one method of short radius motion palpation used for the detection of aberrant joint motions, such as a restricted joints or hypermobile joints when examining the vertebral column.  This examiner has implemented these diagnostic procedures on over 45,000 patients successfully, with 99% patient approval judged by actual patient satisfaction, no stroke victims and patient end status as clinically helpful indicated by successful clinical trials of 25 years. 

1.     Examination of the Atlanto-Occipital Articulation:

a.      Examination of flexion and extension motions: 

Please place the calcaneal and digital portion of your indifferent hand on the forehead of the patient or more superior on the head with the thumb, palmar and digital contact (either position is deemed appropriate).  Place a broad digital one-finger contact, upon the superior aspect of the transverse process of the atlas and the Ramus of the mandible.  Flex the patient’s Atlanto-occipital joint while feeling the ramus approximate with the transverse process of the atlas.  Next extend the patient’s Atlanto-occipital joint while feeling the transver3s process separate fro the ramus.  If you cannot feel the separation motion, relax and try again gently.  Have another physician place their finger next to your contact finger and have them place pressure.  Feel the pseudo-restriction.  It is imperative that you learn to feel normal limit motion before detecting aberrant motion.  Feel for a loss in resistance before en motion.  Feel for a almost rubber-like resistance increasing during the testing continuum.  The latter will equate to a joint restriction. 

b.     Rotation Examination

Please place the calcaneal and digital portion of your indifferent hand on the forehead of the patient or more superior on the head with thumb, palmar and digital contact.  Place a broad digital one-finger contact, upon the anterior aspect of the transverse process of the atlas and the ramus of the mandible.  Rotate the patient’s head with the indifferent hand.  At the end of the motion learn to feel the separation of the ramus and the transverse process and feel the mastoid glide over the transverse process.  This takes practice as there is minimal (0-4 degrees) motion, which may occur at the end of cervical rotation.

 c.     Lateral Flexion 

Please place the calcaneal and digital portion of your indifferent hand on the forehead of the patient or more superior on the head with thumb, palmar and digital contact.  Place a specific digital contact superior to the transverse process of the atlas, jut inferior to the mastoid.  Next laterally flex the head gently to one side and then the other.  Feel the transverse process and mastoid separate and then approximate.  Reproduce this finding until you have confidence.  However, remember the test is conducted gently in a relaxed manner. 

d.     Antero-posterior Translation 

Please take a palmar digital contact on the vertex of the patient’s skull.  Place a broad digital one-finger contact (active hand) upon the anterior aspect of the transverse process of the atlas and the ramus of the mandible.  Exert pressure on the head (while the chin goes anterior) approaching a position known as the anterior inferior occiput.  It is important to remember that it is the occiput in motion and not the atlas.  Feel the ramus separate from the atlas, and the mastoid come anterior and inferior to meet the atlas. 

2.     The Motion Examination of Possible Occipito-Axial Restriction: 

It has been the experience of motion examiners that often

spasticity of the retus capitis posterior major and the longus capitis will splint the Occipito-Axial region causing a painful restriction.  Please palpate within the space between the occiput and the axis spinous  Flex the head forward and “feel” the occiput move away from the spinous process.  If there is regional splinting due to longus capitis spasticity the occiput will remain restricted in motion. 

3.     The Motion Examination of the Atlanto-Axial Articulation: 

a.      Rotation Examination of the Atlanto-Axial joint is an extremely important procedure since rotation is a primary motion  is joint.  Remember that the motion occurs around the odontoid or dens.  In this examination the contact is still the original as designated by Dr. Gillet; the three finger contact of the Atlanto-Axial articulation.  Please place the first, second and third digits on the occipital notch, posterior tubercle of the atlas (if palpable) and the spinous of the axis.  Fix your fingers firmly but gently on the contact points and rotate the patient’s Atlanto-Axial articulation feeling for restriction to motion.  Further if the spinous is carried or dragged with the occiput and atlas joint restriction is definitely suspected.  Gently reproduce the test after a minute to confirm results.  Always note the direction of splinting (joint rotates well to the left but is restricted form right rotation indicating the vector of correction). 

b.     Lateral Flexion motion examination is performed

many ways.  The following is known as the preferred method of lateral flexion of the Atlanto-Axial articulation.  Please place the index fingers of “both” hands together and spinous process area between the index fingers.  Place extended thumbs upon the neck.  Laterally flex the joint and then return to neutral and feel the spinous move away fro your contact (the spinous process is moving in an arc motion) on the contralateral side and follow your ipsilateral index finger.  With joint splinting you will note the restriction to the spinous motion.  In a hypermobile joint you will note joint instability in the articulation. 

c.     The Flexion and Extension Motion Examination: 

Please place the index fingers of both hands together about the spinous process area actually contracting the lamina pedicle junction, with the spinous process area between the index fingers.  Place extended thumbs upon the neck.  Flex and then extend the head upon the neck feeling the C1 spinous move from C2.  When both move congruently consider joint restriction.  Note the motion relationship between the C1 and C2 motion considering restricted motions or excessive motions. 

4.     The Motion Examination of Cervical Vertebra two through Seven (This procedure can be used with the patient in the seated or supine position.  When the patient is supine the physician will sit or stand facing the patient’s head with your hands comfortably under the neck.)

a.      The Flexion and Extension Motion Examination 

In the cervical spine, flexion motion and extension motion occur concomitant with changes in facet orientation or facet gliding if you will.  In flexion motion the superior articular process glides forward on top of the inferior one and the spinous processes separate posteriorly.  The bodies approximate anteriorly, causing an approximate wedging of the intervertebral disc and a shift of intradiscal pressures.   

Please place the laymen’s index fingers of both hands together and spinous process area and lamina pedicle junction area, under your extended fingers.  Then place extended thumbs upon the neck.  Flex and extend the cervical vertebra level under examination and feel for the separations and approximations of the spinous processes.  Expect a larger range of motion in the lower cervicals than the upper cervical vertebrae.  With this method of motion examination also known as the angel wing technique, one can palpate for spinous separation and cephalad-caudad lamina-pedicle junction separation as well as articular processes separation.  If separation is inhibited or restricted spasticity of the musculature is suspected.  Please remember that you must know how a normal non-restricted spine palpates before you make an educated didactic and empirically trained decision.  Absent proper clinical training, physicians tend to derive erroneous information.  Thus practice on normals first. 

Normal Lovett negative motion is noted in the cervical spine where rotation and lateral flexion are coupled motions or motions, which occur concomitantly.  As the vertebrae are laterally flexed, the bodies rotate to the same side and the spinous processes move into the convexity or to the contralateral side. 

b.     Rotational Examination

Please place the laymen’s index fingers of both hands together and the spinous process area between the distal interphalangeal joint and the lamina pedicle junction area just before the distal interphalangeal joint.  Gently rotate the head and feel the stair case effect, with the articular process going superior and anterior contralateral to the side of rotation.  A restriction will palpate as if there are more steps on one side than the other or will present as complete restriction splinting with no motion.  To complete the rotation portion of the lower cervical spine and isolate inter and intra motion unit restriction, you must perform three distinct gentle motions.  Please gently extend the cervical spine.  Net gently lateral flex the neck until you feel limitation of motion.  These first two motion actions will specifically restrict motion to the motion units under examination.  Last rotate the neck feeling for the restriction.  Please note vertebral motion unit level of restriction and direction that the splint limits motion. 

To complete rotation examination of the lower cervical spine and isolate inter and intra motion unit restriction, you must perform three distinct gentle motions.  Please gently extend the cervical spine.  Next gently lateral flex the neck until you feel limitation of motion.  These first two motion actions will specifically restrict motion to the motion units under examination.  Last rotate the neck feeling for the restriction.  Please note vertebral motion unit level of restriction and direction that the splint limits motion. 

c.     Lateral Flexion Motion Examination

The contact points are the same as in the rotation examination just presented.  Please laterally flex the cervical spine, feeling the articular process on the ipsilateral side moving inferior and posterior and feeling the articular process area on the contralateral side move superior and anterior.  As one laterally flexes the cervical spine move your contact down the spine contacting each lamina pedicle junction and articular areas one segment at a time.  Feel the spinous process move into the convexity. 

5.     Thoracic and Lumbar Spinal Motion Examinations: 

     These procedures must be performed with the patient seated and the physician either standing or sitting behind the patient.  Standing is the preferred method unless you are tall.  The thoracic spine, mainly due to its rib attachments, is essentially an immobile structure, particularly in the mid to upper thoracic.  As we age calcifications and ossifications of rib attachments may occur.  The lower thoracic spine will demonstrate increases in motion as you move down it, due to the floating ribs on the last two segments. 

     The thoracic vertebrae and the lumbar vertebrae are basically palpated in a similar manner.  The contact points differ as well as ranges of motion. 

a.      The Flexion and Extension Motion Examination 

     During forward flexion of the thoracic spine there is an upward gliding of the superior facet on the inferior facet.  Feel as the superior spinous approximates with the inferior spinous when the patient is brought up from a full flexion position.  The head is utilized as a lever to move the upper thoracics during motion examination.  From the thoracic fourth vertebrae and below the arms of the patient are crossed and utilized as a lever to progressively induce the range of motion desired.  Place your contact digit between the spinous processes and later over the transverse processes.  From T1-T3 with the cervical spine fully flexed, please place your contact finger at the distal aspect of the spinous and proximal interspaces.  Flex the head a little further palpating the spinous processes as they approximate.  From T4 down flex and extend the patient with your indifferent arm (flex the thoracic cage generally performed in the seated position) and feel the spinous processes approximate as the patient is brought up from flexion.  At the end of extension movement you should expect to feel the spinous processes go slightly anterior.  Descend down the spine and repeat with transverse processes contact.  Feel for restricted motion unit complexes with or without neighboring joint restriction. 

b.      The Lateral Flexion Motion Examination for the Dorsolumbar Spine. 

It is essential to remember that when the thoracic spine laterally flexes, there is a concomitant rotation to the contralateral side known as coupling motion.  The patient should be seated with their arms crossed in front.  Please have the patient laterally flex their thoracic spine with your palpating fingers on the spinous.  Feel the spinous processes move into the concavity.  This is known as the Lovett positive motion.  Keep all lateral motion in the coronal plane, as the lower shoulder must not go posterior ward.  If it appears to biomechanical move posteriorly feel for spinal joint restriction and note the side of restriction.  Exert pressure with your active contact thumb onto the spinous process from the ipsilateral side in the thoracolumbar lateral flexion motion examination.  The indifferent hand can be around front upon the crossed arms or upon the contralateral shoulder.  As you laterally flex the thorax on the contralateral side you will feel the spinous process move into your thumb on the ipsilateral side.  Note any joint splinting or excessive motion. 

c.     The Rotational Motion Examination for the Thoracolumbar Spine.

Again please have the patient in a seated position with their arms crossed.  The indifferent hand of the physician reaches around the contralateral side of the patient and holds the proximal forearm area.  The contact point is the thumb onto the ipsilateral side of the spinous process associated with the vertebral level in question.  Rotate the patient’s body contralaterally to the physician and feel the spinous processes come into your hand.  Feel for restrictions to normal motion or excessive motion. 

3.       The Sacrum 

The patient remains in the seated position with the contact point being the sacral base at the lateral aspect (posterior superior iliac spine).  Flex, Extend, laterally flex and rotate the patient comparing them bilaterally.  Feel for restricted base motion. 

4.       Sacro-Iliac Motion Examination. 

The prudent physician will begin the examination with the patient in the plantigrade position (standing).  Have the patient flex the thigh toward the chest while the knee is bent.  When the patient has the leg-raised place the ipsilateral thumb upon the exposed superior portion of the PSIS.  Have them drop the leg down.  Hold the contact.  Have the patient then repeat the procedure for the left sacroiliac joint motion.  Feel for aberrant motion and not whether one thumb is higher than the other or equal.  Then while holding the contact have the patients sit down on the examination table with you behind (start behind the table to begin with) it.  Then have the patient forward flex in the seated position observing the motion of your thumbs while feeling for restriction to motion or hypermobility (loose joint).  If the PSIS have moved inferiorly and posteriorly again it is called a PI Ilium by Doctors of Chiropractic.  If the PSIS has moved anteriorly and superiorly and is splinted in the position it is called an AS Ilium. 

Next have the patient lie prone on the examination table.  With your ipsilateral thumb on the same-sided PSIS grasp the ankle of the ipsilateral leg and with the le flexed at the knee move the leg externally and internally.  Feel the PSIS joint move internally and externally.  If either joint palpates as restricted in the internal or external configuration as compared to the opposite side or your experienced knowledge of normals, note the joint as IN for internal restriction or EX for external splinting. 

DISCUSSION 

     Over the centuries manipulative medicine historians have been divided on the priori of importance between definitions, basic medical taxonomy and basic communication.  This has continued even though experts in manipulative medicine achieved tremendous success reversing patients conditions a well as achieving patient satisfaction. 

    Is it not a mistake for health care practitioners with two points of view, one oriented toward medicine which can be injested or injected and medicine applied externally, and blindly assume neither has valid medicine absent scientific scrutiny and investigation?  Further, once interprofessional scientific investigation and scrutiny occurs, would this not foster cooperation through the principals of openness, and shared knowledge.  Only through a team effort of interprofessional cooperation will the total health needs of all our citizens be fostered.  “Health care is a team effort and must not remain divided.”1 

    The motion condition of a joint is divided into the possible motions the particular joint will exhibit.  For example we do not expect an Ampharthrosis joint to exhibit all the motions of a Diarthrosis.  Thus, when examining the spinal joints, the physician will bring the joints through their possible motion actions, which are generally forward flexion, Extension, lateral flexion-rotation, rotation –lateral flexion, and circumduction motion which is a combination of forward bending and lateral bending motions (combined coupled motion) to the left and right.  In other words you are testing all planes of motion possible for the joint.  If the patient reports pain and or stiffness and/or the physician feels joint restriction or joint translation or excursion, they have found the motion condition of the joint.  When we find the motion condition of the joint, it indicates the restricted motion, in what direction the joint restriction exhibits splinting, thus indicating the direction or vector of correction needed for the adjustment (knowledgeable, purposeful short radius manipulation).

     In fact sophisticates in the motion examination will denote expediently spondylolisthetic excursions, from asymmetrical facets of the lower lumbar spine, from facet syndrome and capsulitis (hindered entrance into extension with pain) and so forth. 

     The “Motion Examination” presented involves spinal biomechanics in practical clinical application.  Awareness of the facings of vertebral arch articular junctures and of how each vertebral joint of a given area moved was deemed mandatory.  Inducing motion specifically in the correct joint area, feeling for the correct data and correlating correctly with the degree of altered joint dynamics indicates where, why and how often the joint restriction or hypermobility must receive treatment.  Further, a quality motion examination indicates whether or not a condition of altered joint dynamics has been reversed or improved.  This combination of biomechanical testing determines candidates for manual medicine, which manipulations to utilize to correct the AJD (e.g. Area of Altered Joint Dyanmics-Neff), the location to be manipulated, and the vector of correction, the depth of the maneuver and the velocity of the maneuver.  This biomechanical testing will indicate if a correction in vertebral dynamics has occurred, how many more treatments the patient may need, or if a more radical procedure is indicated.   

     If we combine the knowledge of the motion examination with the history of injury, a quality orthopedic, neurological and physical examination as well as special testing procedures, modern adjustment procedures an indications for rehabilitative physiological therapeutics as well as pharmaceuticals or surgery, (MD’s/DO's working with DC’s within the same offices) you will gain insight into the world of modern spinal manipulative specialties.

REFERENES:

1.     Neff Scott D., “Neuroanatomy of Vertebral Joint Subluxations” Journal for the American Chiropractic Association, S-55-S57, Vol 17, Number 4, 1980.

2.     Neff S D, “Evolution of Forensic Science in Manipulative Medicine”, Lecture for American Back Society, 1985.

3.     Port C, “Ports Notes in Spinal Diagnosis”, Published by Dr. Carol Port, Ass. Prof, LACC, pp. 39-65, 1978.

4.     Friel John p, Dorland’s Medical Dictionary, Twenty-fifth Edition, WB Saunders Co., p. 1122, 1974.

5.     Warwick and Williams, Gray’s Anatomy, 35^th British Edition, WB Saunders Company pp. 400-407

6.     Kessler RM, Hertling D, Management of Common Musculoskeletal Disorders.  Harper & Row P. 88, 1983.

by Scott D. Neff, DC DABCO MPS-BT CFE DABFE FFABS FFAAJTS as a dedication to the people of Minnesota and to the "Fountain Head" of learning for Science and Medicine, the University of Minnesota. - 08-30-04

"Why does this magnificent applied science which saves work and makes life easier, bring us little happiness? The simple answer runs, because we have not yet learned to make sensible use of it." Albert Einstein 1931

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