As the chiropractic profession has evolved, it has developed vari- ous abbreviated descriptions for designating abnormal joint posi- tion or movement. The result is a profession laden with redundant nomenclatures (listing systems) that describe spinal subluxations and fixations. As new descriptive terms are introduced, old ones are not replaced. It is not uncommon for each technique to have its own unique listing system. Unique listing methods may be effi- cient for those performing the associated technique, but many are not commonly understood.
As part of the process to include chiropractic in Medicare, there was an attempt to standardize listing systems at the 1977 American Chiropractic Association (ACA) conference in Houston. Although the parties did succeed in developing a common nomenclature for Medicare claims based on standard kinesiologic terms, it unfortu- nately did not form a basis for larger professional consensus. There is still significant variation among chiropractors and on national board examinations as to the preferred listing systems.
To their students’ continual frustration, colleges are left in a position of teaching repetitive and often contradictory methods of describing joint malpositions and fixations. Presently, the common systems used to describe abnormal position are Medicare, Palmer- Gonstead, and National–Diversified systems. In an attempt to reduce the confusion and redundancy, this book emphasizes standard kine- siologic terms and the Medicare listing system. When deviations in position are described, the term malposition is used, and when limita- tions to movement are described, the term restriction is used.
Spinal joint listing systems should be incorporated only in con- junction with a diagnosis of spinal JSDS. They describe character- istics of subluxation and dysfunction syndromes, but they are not expected to be stand-alone diagnostic terms. Spinal listings should be viewed only as a short-hand method of recording which joint changes were subjected to manipulation (Figure 3-10).
All motion segment malpositions are described with the posi- tion of the upper vertebra compared with the lower vertebra. For example, a flexion malposition describes a vertebra that has devi- ated into a position of flexion relative to the vertebra below, and a flexion restriction describes a limitation or loss of joint flexion between the two vertebrae.
Trunk and neck movements are described in kinesiologic terms. They are based on vertebral body movement, not spinous process movement. Left rotation of the trunk is defined by left posterior
vertebral body rotation, not by right rotation of the spinous process.
CliniCAl eVAluAtiOn OF JOint
SuBluXAtiOn/DYSFunCtiOn
SYnDROMe
Before adjustive treatments are applied, the chiropractor must evaluate the patient’s complaint and determine if the patient is suffering from a condition (manipulable lesion) that is amenable to chiropractic care. As mentioned previously, therapeutic deci- sions on where and how to apply adjustive therapy are based pri- marily on the evaluation of the NMS system and a determination that injury, derangement, or disease has led to altered function.
Although the diagnosis of joint dysfunction identifies a painful clinical syndrome that may respond to manual therapy, the nature of the dysfunction must be evaluated before therapy is adminis- tered. The mere presence of joint subluxation or dysfunction does not determine the need for adjustive therapy. Joint dysfunction
may result from diseases or disorders that contraindicate treat- ment or result from disorders that do not respond to adjustive treatments. The ability to thoroughly evaluate and triage disor- ders of the NMS system and distinguish those conditions that are appropriate for chiropractic care is critical. Differentiating
Figure 3-10 Comparative chart of static listing systems. (Modified from ACA Council on Technic: J Am Chiropr Assoc 25[10]:46, 1988.)
Medicare
(Vertebral body reference) (Spinous process reference)Palmer-Gonstead (Vertebral body reference)National-Diversified
Flexion malposition None Anterior inferior
Extension malposition Posterior Posterior inferior
Right lateral
flexion malposition None Right inferior
Left lateral
flexion malposition None Left inferior
Left rotational malposition Posterior spinous right Left posterior
Right rotational malposition Posterior spinous left Right posterior
Anterolisthesis None Anterior
Retrolisthesis Posterior Posterior
mechanical from nonmechanical conditions, assessing the source of the presenting complaint, and understanding the potential pathomechanics and pathophysiology of the disorders being con- sidered for chiropractic care are crucial elements for successful treatment. Therefore, before instituting treatment, the clinician must perform a thorough case history, physical examination,
and any other appropriate imaging or laboratory procedures to rule out any disorders that contraindicate adjustive treatments. The evaluation should assess whether the dysfunction is associ- ated with joint hypermobility or hypomobility and the site, side, and potential directions of immobility, aberrant movement, or hypermobility.
Medicare
(Vertebral body reference) (Spinous process reference)Palmer-Gonstead (Vertebral body reference)National-Diversified
Left rotational malposition Left lateral flexion malposition
Posterior right
Superior spinous Left posterior inferior
Left rotational malposition Right lateral flexion malposition
Posterior right
Inferior spinous Left posterior superior
Right rotational malposition Right lateral flexion malposition
Posterior left
Superior spinous Right posterior inferior
Right rotational malposition Left lateral flexion malposition
Extension
restriction restrictionFlexion Right rotationalrestriction Left rotationalrestriction flexion restrictionRight lateral flexion restrictionLeft lateral Posterior left
Inferior spinous Right posterior superior
Dynamic (motion) listing: designation of abnormal joint movement Restriction: direction of limited
movement in subluxated dysfunctional joints
Dynamic listing nomenclature 1. Flexion restriction 2. Extension restriction
3. Lateral flexion restriction (right or left) 4. Rotational restriction (right or left)
eXAMinAtiOn PROCeDuReS AnD
DiAGnOStiC CRiteRiA
Uncomplicated JSDS is a clinical diagnosis identified by a collec- tion of presenting symptoms and physical findings. It is not inde- pendently detectable by laboratory procedures, and a single gold standard for detecting primary joint subluxation or dysfunction does not currently exist. Often it is suspected after the possibilities of other conditions with a similar presentation have been elimi- nated. A favorable patient response to manipulation or mobili- zation (decreased pain or improved function) and reduction or normalization of abnormal physical findings indicates the original working diagnosis and application of manual therapy was a clini- cally sensible and effective approach.
History
JSDS is commonly symptomatic but the diagnosis does not depend on the patient being symptomatic. However, in asymp- tomatic JSDS, one would expect the physical findings support- ing the diagnosis to be pronounced. In the spine, patients with JSDS commonly complain of pain located in the midline to paraspinal region with or without pain referral into the extremi- ties. Although the somatic referred pain does not usually extend below the knee or upper arm, pain may radiate as far as the foot or hand. However, the location, quality, and referral patterns of the patient’s pain complaints are not unique to this diag- nosis. These symptoms overlap with a number of other axial spine complaints and do not differentiate JSDS from other mechanical spine disorders. The patient’s history is also crucial in identifying possible red flags and differentiating nonspecific mechanical back pain from nonmusculoskeletal or nonmechan- ical NMS disorders. It is also helpful in implicating neurologic involvement and identifying mechanisms of possible injury and load sensitivities pertinent to JSDS.
Physical Examination
With the exception of radiographic evaluation, the major- ity of the commonly used examination procedures devoted to assessing joint structural and functional integrity are physi- cal examination procedures. They include standard ortho- pedic, neurologic, and physical examination procedures and a wide array of unique “system technique” diagnostic proce- dures. Observation and palpation are the most commonly used physical examination procedures and include postural and gait evaluation, soft tissue and bony palpation, global ROM, and segmental ROM testing or what is also referred to as passive
intervertebral motion tests.55,74,234-239 Manual palpation is the
primary evaluative tool, necessitating many hours of practice and concentration to develop adequate skill. The application of joint manipulation relies heavily on the clinician’s ability to locate and identify landmarks, painful musculoskeletal tissue, painful joint movements, contracted muscles, restrictions of motion, and hard EP resistance.240
Specialized laboratory procedures, such as thermography and electromyography (EMG), are presently not in common clini- cal use for detection of JSDS. Further research is necessary before their role in clinical practice can be fully ascertained. The classic
physical signs indicative of JSDS are provocation of pain, abnor- malities in alignment, abnormal resistance to joint movement, and altered tissue texture. Bergmann,241 modifying the acronym PARTS from Bourdillon and Day,242 identifies the five diagnos-
tic categories commonly applied by chiropractors for the iden- tification of joint dysfunction: pain and tenderness; asymmetry;
ROM abnormality; tone, texture, and temperature abnormality;
and special tests. Various investigators have suggested that detec- tion of the spinal manipulative lesion should not rely on a single assessment method.
During spinal evaluation, the physical examination should focus on identifying the source of the patient’s complaints and dif- ferentiating segmental from nonsegmental sources. The examina- tion findings supportive of a spinal JSDS diagnosis can be divided into primary and secondary categories and are listed in Box 3-3. It is recommended that the physical assessment of JSDS focus on reproducing the patient’s joint pain with palpation and joint prov- ocation and challenge procedures. Although a number of manual examination findings have historically purported to confirm this disorder, bony and paraspinal soft tissue tenderness or pain repro- duced with JP or EP are the most reliable and potentially valid diagnostic tools.243-246
It has been suggested that tests should be considered in group- ings leading to a multidimensional approach.247-251 A 2006 lit-
erature review by Stochkendahl and associates concluded that a “global assessment” (i.e., segmental static and motion tender- ness, palpatory altered joint motion, and palpable tissue changes) demonstrates reproducible intraexaminer reliability (0.44 kappa). However, there was not enough evidence to calculate pooled results for interexaminer reliability. The significance of a multi- dimensional approach is further illustrated by the Health Care Financing Administration requirement that the manipulable lesion be supported by physical examination.252 From the ini-
tial coverage of chiropractic care in the Medicare program in 1974–1999, Medicare required x-rays to demonstrate subluxation of the spine and therefore the clinical necessity for chiropractic care. Beginning in 2000, Medicare allowed physical examination findings (the pain and tenderness, asymmetry or misalignment, ROM abnormality, and tissue or tone changes [PARTs] multi- dimensional approach) for the demonstration of subluxation in place of x-rays: To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under “physical examination” are required, one of which must be asymmetry/mis- alignment or ROM abnormality.252
Pain and Tenderness
The perception of pain and tenderness is evaluated in terms of loca-
tion, quality, and intensity. Most primary musculoskeletal disorders
manifest by a painful response. The patient’s description of the pain and its location is obtained. Furthermore, the location and intensity of tenderness produced by palpation of osseous and soft tissue are noted. Pain and tenderness findings are identified through obser- vation, percussion, palpation, and provocative orthopedic testing. The patient’s description and location of pain is obtained verbally, physically, or by a pain drawing. The location and intensity of tenderness produced by palpation of osseous and soft tissues is identified and noted. Changes in pain intensity can be objectified
using visual analog scales, algometers, and pain questionnaires. The production of palpatory pain over osseous and soft tissues has been found to have good levels of interexaminer and intraexam- iner reliability.244,246,253-256 The validity of motion palpation or pain
reproduction with palpation to identify painful spinal joints or direct effective treatment is limited. The results have been mixed but encouraging in a few studies.257-262 Although assessment of
segmental motion has generally scored poorly in terms of reliabil- ity, in several studies lumbar P-A mobility assessment did succeed in achieving acceptable predictor scores (likelihood ratios) for clas- sifying and directing various types of therapies (e.g., manual ther- apy vs exercise).263,264 In these studies P-A mobility testing was
only one of several presentations or physical findings used to cat- egorize patients, and P-A mobility testing may not be a materially contributing factor in predicting outcome.
Asymmetry
Asymmetric qualities are noted on a sectional or segmental level. This includes observation of posture and gait, as well as palpation for misalignment of vertebral segments and extremity joint structures. Asymmetry is identified through observation (posture and gait anal- ysis), static palpation for misalignment of vertebral segments, and evaluation of static plain-film radiographs for malposition of verte- bral segments. The complex structure of the human body, and espe- cially its frame, is never completely or perfectly symmetric. Therefore, focal changes in symmetry may or may not be clinically significant. They must be judged by the degree of deviation and placed within the context of the overall clinical presentation and examination.
Range-of-Motion Abnormality
Changes in active, passive, and accessory joint motions on a seg- mental and sectional basis are noted. These changes may be reflected
by increased, decreased, or aberrant motion. It is thought that a decrease in motion is a common component of joint dysfunction. Global ROM changes are measured with inclinometers or goni- ometers. Segmental ROM abnormalities are identified through the procedures of motion palpation and stress x-ray examination.
Tone, Texture, and Temperature Abnormality
Changes in the characteristics of contiguous and associated soft tissues, including skin, fascia, muscle, and ligaments, are noted. Tissue tone, texture, and temperature (vasomotor skin response) changes are identified through observation, palpation, instrumen- tation, and tests for length and strength.
Special Tests
The category of special tests includes two major subsets. One group incorporates testing procedures that are specific to chiropractic tech- nique systems, such as specific leg length tests (e.g., Derifield) and mus- cle tests (e.g., arm fossa test). The other group encompasses laboratory procedures such as x-ray examination, EMG, and thermography.
System technique assessment procedures are typically man- ual examination procedures. They are commonly the products of individual innovation. They are distinguished from other physical examination procedures by their unique use and association with brand- name techniques. Most of these procedures have not been subjected to testing, and their reliability and validity have not been evaluated.
Many of the laboratory procedures that are promoted as poten- tial detectors of JSDS have substantiated value in evaluating disor- ders of the NMS system. However, most have not been subjected to in-depth evaluation relative to their ability to detect segmental joint dysfunction. In addition, visceral relationships are considered (e.g., evaluation of the upper thoracic spine in cases of asthma) in localiz- ing the spinal segment or segments that might be dysfunctional.
BOX 3-3
Physical Examination Findings Supportive of Spinal Joint Subluxation/Dysfunction Syndrome Diagnosis PRIMARY FINDINgSPalpable segmental bony or soft tissue tenderness/ dysesthesia
Painful or altered segmental mobility testing
Joint motion is traditionally assessed in its open packed posi- tion with joint play (JP) procedures, through its segmental range of motion, and with end play (EP) at the end range of motion. All three components of joint motion are evaluated for quantity, quality, and pain response. Clinical studies indi- cate that JP and EP are more reliable for pain response than range of motion assessment.
Palpable alterations in paraspinal tissue texture or tone
Tissues texture changes are represented by a loss of paraspinal tissue symmetry at the segmental level or between adjacent segments. These changes are characterized by palpable alter- ations in muscle resting tone (hypo or hypertonicity or spasm) and textural changes characterized by a palpable sense of tis- sue induration or fibrosis often described as a hardening or thickening of tissue.
SECONDARY FINDINgS
Palpable malposition (e.g., spinous deviation)
Note: Because of individual variation and the high preva- lence of asymmetry many manual therapists do not consider this an indicator of joint dysfunction
Repetitive loading in direction of EP restriction may improve symptoms
Alterations in sectional or global range of motion:
Decreased and painful global active range of motion and various positive pain-provoking orthopedic tests are not primary features of a joint dysfunction diagnosis because of their commonality with multiple painful musculoskeletal disorders. Note: active range of motion may be normal with joint dysfunction syndrome because of the spine’s ability to compensate at other segmental levels.
CliniCAl uSeFulneSS OF JOint
ASSeSSMent PROCeDuReS
Although the effectiveness and appropriateness of chiropractic adjustive therapy for treating mechanical neck and back pain has been demonstrated (see Chapter 4), the clinical value and useful- ness of many of the diagnostic procedures used to detect JSDS have not been thoroughly or properly evaluated.236,244,253,256,265-272
The clinical usefulness of a diagnostic procedure is measured by its ability to provide accurate information that leads to appropri- ate and effective management of health care problems. These attri- butes can be evaluated by assessing a given procedure’s reliability, validity, responsiveness, and utility.
Chiropractic is not alone in its need to advance the critical appraisal of its diagnostic and therapeutic procedures.273-277 Other
health disciplines also suffer from significant variations in the use of diagnostic tests, and many lack experimental evaluation and confirmation.278 The prudent practitioner should remain skep-
tical of unsubstantiated and biologically unfeasible claims, but supportive of and open-minded toward investigation of untested procedures. Untested procedures are not necessarily invalid proce- dures. It is just as wrong to reject a therapeutic procedure because it is untested as it is to accept the same procedure in the absence of supporting evidence.
It is likely, however, that examination procedures that depend on human evaluation will always carry the potential for some error. Furthermore, quantifying a manual art is difficult because of the lack of a standard for comparison.240 The chiropractic doctor must
be aware of these limits, yet constructively use the physical evalua- tion to help gain the patient’s confidence and compliance. Physical examination procedures placed within proper clinical perspective still provide a significant cost-effective contribution to the forma- tion of a clinical impression. Within this context, it is important not to rely excessively on any one procedure, but rather to use a combination of diagnostic procedures and allow the weight of evi- dence to build a clinical impression of the patient’s problem.
Reliability
“Reliability is the reproducibility or consistency of measurement or diagnosis. It is the extent to which a test can produce the same result on repeated evaluation of an unchanged characteristic.”271
Reliability estimates the contribution a given test makes to the clinical decision-making process beyond what would be expected by chance. Reliability measures include evaluation for interexam- iner and intraexaminer consistency, and test-retest evaluation to determine if measurements are reproducible and consistent over time. Fortunately, the profession has witnessed a significantly increased interest in evaluating its diagnostic procedures. It is now possible to make some generalizations about the reliability of com- mon chiropractic diagnostic procedures.
In 1991, Haas265 reviewed the literature on the reliability of
chiropractic joint assessment procedures and concluded that many of the studies had questionable design and statistical anal- yses. These same conclusions have been echoed repeatedly since then.243,244,256,279-284 In addition, most of the studies evaluated the
reliability of only one procedure at a time. This leaves the ques- tion of combined reliability in need of further evaluation; the
procedures may demonstrate higher reliability when used in con- junction with each other.244,245,253,285,286 Furthermore, combin-
ing different assessment methods in a multitest regimen more closely parallels actual clinical practice.262,286 There are a number