Principles and Practice of Chiropractic, 3E (2005) (PDF) (UnitedVRG)

PRINCIPLES
AND PRACTICE
OF CHIROPRACTIC
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PRINCIPLES
AND PRACTICE
OF CHIROPRACTIC
Third Edition
Editor in Chief Section Editors

Scott Haldeman, DC, MD, PhD, Brian Budgell, DC, MSc
FCCS(C), FRCP(C) Associate Professor
School of Health Sciences, Faculty of Medicine
Clinical Professor, Department of Neurology Kyoto University
University of California, Irvine Kyoto, Japan
Adjunct Professor, Department of Epidemiology
University of California, Los Angeles
Adjunct Professor, Research Division Niels Grunnet-Nilsson, DC, MD, PhD
Southern California University of Health Sciences Director of Studies for Clinical Biomechanics
Whittier, California Faculty of Health Science
University of Southern Denmark,
Odense, Denmark
Associate Editor Paul D. Hooper, DC, MPH, Dipl Erg

Simon Dagenais, DC Chair, Department of Principles and Practice
Southern California University of Health Sciences
Department of Environmental Health, Science, and Policy
Whittier, California
University of California, Irvine
Clinical Research Manager, CAM Research Institute
Irvine, California William C. Meeker, DC, MPH
Director, Palmer Center for Chiropractic Research
Vice President for Research
Palmer Chiropractic University Foundation
Davenport, Iowa
John Triano, DC, PhD

Director, Chiropractic Division
Co-Director, Conservative Medicine
Texas Back Institute
Plano, Texas
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Contents
Contributors xi
Preface xvii
Acknowledgments xxi
I. INTRODUCTION TO CHIROPRACTIC PRINCIPLES / 1

William C. Meeker, DC, MPH
1. History of Spinal Manipulation 5

Glenda Wiese, MA
Alana Callender, MS
2. A Brief History of the Chiropractic Profession 23

Joseph C. Keating, Jr., PhD
3. The Evolution of Vitalism and Materialism and its Impact on Philosophy

in Chiropractic 65
Reed B. Phillips, DC, PhD
4. Philosophy in Chiropractic 77
Joseph C. Keating, Jr., PhD
5. Communication in the Chiropractic Health Encounter:

Sociological and Anthropological Approaches 99
Ian D. Coulter, PhD
6. International Status, Standards, and Education of the Chiropractic Profession 111

David A. Chapman-Smith, LL.B (Hons)
Carl S. Cleveland III, DC
7. Integration of Chiropractic in Health Care 135

William C. Meeker, DC, MPH
Robert D. Mootz, DC
8. The Clinical Effectiveness of Spinal Manipulation for Musculoskeletal Conditions 147

Gert Brønfort, DC, PhD
Mitchel Haas, DC, MA
Roni Evans, DC, MS
9. The Treatment of Headache, Neurologic, and Non-Musculoskeletal Disorders

by Spinal Manipulation 167
Howard Vernon, DC, FCCS, FCCRS, FICC
vi CONTENTS
10. Public Health Responsibilities for Chiropractic 183

Michael G. Perillo, DC, MPH
11. Professionalism and Ethics in Chiropractic 201

Robert D. Mootz, DC
Ian Coulter, PhD
Gary D. Schultz, DC, DACBR
II. INTRODUCTION TO CHIROPRACTIC THEORY / 221

Brian Budgell, DC, MSc
12. Sensory Innervation of the Spine 225

Joel G. Pickar, DC, PhD
13. Muscle Spindles and Spinal Proprioception 249

Barbara I. Polus, BAppSc(Chiropractic), MSc (UNE, Australia), PhD (Monash, Australia)
14. Central Projections of Spinal Receptors 269

Xue-Jun Song, MD, PhD
Ronald R. Rupert, DC, MS
15. Peripheral Nerve Biology and Concepts of Nerve Pathophysiology 289

Geoffrey Bove, DC, PhD
16. Somatoautonomic Reflexes 301

Akio Sato, MD, PhD
17. Clinical Biomechanics and Pathomechanics of the Cervical Spine 315

Gary Greenstein, DC
18. Clinical Biomechanics and Pathomechanics of the Lumbar Spine 335

Partap S. Khalsa, DC, PhD, FACO
19. The Theoretical Basis for Spinal Manipulation 361

20. Pathophysiology of Disc Degeneration 383

Michael A. Adams, BSc, PhD
21. Pathophysiology of the Posterior Zygapophysial (FACET) Joints 401

Lynton G.F. Giles, DC, MSc, PhD
22. The Influence of Muscles in Spinal Pain Syndromes 419

Mark T. Finneran, MD
23. Biomechanics and Pathophysiology of the Sacroiliac Joint 433

Dale Mierau, DC, MSc
24. Headaches of Spinal Origin 447

Simon Dagenais, DC
Scott Haldeman, DC, MD, PhD, FCCS(C), FRCP(C)
CONTENTS vii
25. Risk Factors for Low Back and Neck Pain: An Introduction to Clinical Epidemiology
and Review of Commonly Suspected Risk Factors 465
Jan Hartvigsen, DC, PhD
III. INTRODUCTION TO THE CLINICAL EXAMINATION / 485

Niels Grunnet-Nilsson, DC, MD, PhD
26. The Clinical History 487

Palle Pedersen, DC, MPhil, DPMSA
27. The Physical Examination 509

B. Kim Humphreys, DC, PhD
Lisa Caputo, BSc, DC, FCCS(C)
28. Neurologic Examination 537

Rand S. Swenson, DC, MD, PhD
29. Orthopedic Examination 561

Edward Rothman, DC, FACO(US), FCC(UK)
Haymo Thiel, DC, MSc(Ortho), FCCS(C), FCC(Orth)
30. Manual Examination of the Patient 593

Donald R. Murphy, DC, DACAN
Craig Morris, DC, DACRB
31. The Clinical Application of Selected Examination

and Diagnostic Instruments in Chiropractic 611
Keith Wells, DC, MA
32. The Use of Measurement Instruments in Chiropractic Practice 629

Christopher J. Colloca, DC
Tony S. Keller, PhD
Gregory J. Lehman, MSc, DC
Donald D. Harrison, DC, PhD, MSE
33. Indications for and Use of X-Rays 661

Cynthia Peterson, RN, DC, DACBR, MMEd, FCCR(C)
William Hsu, BSc, DC, DACBR, FCCR(C)
34. Indications for and Use of Advanced Imaging Studies 683

Dennis R. Skogsbergh, DC, DABCO, DACBR
35. Indications for and Use of Laboratory Tests 705

Robert W. Ward, DC
36. Documentation and Record Keeping 725

Louis Sportelli, DC
Gary Tarola, DC, DABCO
viii CONTENTS
IV. INTRODUCTION TO SPECIFIC TREATMENT METHODS / 743

Paul D. Hooper, DC, MPH, Dipl Erg
37. Evolution and Basic Principles of the Chiropractic Adjustment and Manipulation 745
38. High-Velocity Low-Amplitude Manipulative Techniques 755

Thomas F. Bergmann, DC, FICC
39. Mobilization Techniques 767

John Scaringe, DC, DACBSP
Craig Kawaoka, DC, DACBSP, CSCS
40. Low-Force and Instrument Technique 787

Arlan W. Fuhr, DC
41. Soft Tissue Manual Techniques 805

Stephen M. Perle, DC, MS
42. Traction and Distraction Techniques 821

James M. Cox, DC, DACBR
M.R. Gudavalli, PhD
43. Medication-Assisted Spinal Manipulation 841

Frank J. Kohlbeck, DC
44. The Use of Physical Modalities 861

45. Acupuncture, Acupressure, and Trigger Point Techniques 875

John A. Amaro, DC, FACC, FIAMA, DiplAc
46. The Role of Rehabilitation and Exercise in Chiropractic Practice 887

Craig Liebenson, DC
Clayton Skaggs, DC
V. INTRODUCTION TO MANAGEMENT OF SPECIFIC DISORDERS / 907

47. The Management of Low Back Pain and Radiculopathy 911

Dennis R. Skogsbergh, DC, DACBO, DACBR
Robert Cooperstein, MA, DC
48. Thoracic Spinal Pain Syndromes 951

W. Mark Erwin, DC
49. Management of Neck Pain and Related Disorders 969

Donald R. Murphy, DC, DACAN
Michael Freeman, DC, PhD, MPH
50. The Management of Headache 999

Rand Swenson, DC, MD, PhD
CONTENTS ix
51. Disorders of the Peripheral Nerves 1013

Rand S. Swenson, MD, DC, PhD
P. Thomas Davis, MUP, DC
52. Management of Non-Musculoskeletal Disorders 1037

Richard L. Sarnat, MD
53. Issues Specific in Pediatric Practice 1049

Jesper M. M. Wiberg, DC
Niels Klougart, DC
54. Issues Specific to Geriatric Practice 1079

Jacqueline D. Bougie, DC, MS
55. Clinical Nutrition 1099

G. Douglas Andersen, DC, DACBSP, CCN
56. Musculoskeletal Complications of Chiropractic Practice 1137

Marion McGregor, DC, FCCS(C), MSc
57. Neurological Complications of Spinal Manipulation Therapy 1149

Allan G.J. Terrett, DipAppSc(HumBiol), BAppSc(Chiro), MAppSc(Chiro), FACCS, FICC
58. Integration Of Chiropractic Into Multidisciplinary and Hospital-Based Settings 1165

Deborah Kopansky-Giles, BPHE, DC, FCCS(C)
Bruce Walker, DC, MPH, DrPH Scholar
Sira Borges, DC, MD
Index 1181
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Contributors
Michael A. Adams, BSc, PhD Alana K. Callender, MS

Senior Research Fellow, Department of Anatomy, Director, Palmer Foundation for Chiropractic History, Davenport,
University of Bristol, United Kingdom Iowa
Pathophysiology of Disc Degeneration History of Spinal Manipulation
John A. Amaro, DC, FACC, FIAMA, DiplAc Lisa Caputo, BSc, DC, MEd, FCCS (C)
Chiropractic Physician, Licensed Acupuncturist, International Coordinator, Clinical Education (Acting) Division of Chiropractic,
Academy of Medical Acupuncture, Inc, Carefree, Arizona School of Health Sciences, RMIT University, Melbourne,
Acupuncture, Acupressure, and Trigger Point Techniques Australia
The Physical Examination
G. Douglas Andersen, DC, DACBSP, CCN
Postgraduate Faculty, Southern California University of
Health Sciences, Whittier, California; Certified Clinical
David A. Chapman-Smith, LLB (Hons)
Nutritionist; Private Practice of Chiropractic Nutrition, Attorney at Law, The Chiropractic Report, Toronto, Ontario,
Brea, California Canada
Clinical Nutrition International Status, Standards and Education of the
Chiropractic Profession
Thomas F. Bergmann, DC, FICC
Professor, Methods Department, Faculty Clinician, Carl S. Cleveland, III, DC
Northwestern Health Sciences University, Bloomington, President, Cleveland Chiropractic College, Kansas City and Los
Minnesota Angeles
High Velocity Low Amplitude Manipulative Techniques International Status, Standards and Education of the
Chiropractic Profession
Sira Borges, DC, MD
Clinic Director, Clinica Internacional da Coluna, Christopher J. Colloca, DC
Salvador, Brazil
Graduate Student, Department of Kinesiology, Arizona State
Integration of Chiropractic Into Multidisciplinary and University, Tempe, Arizona; Postgraduate and Continuing
Hospital-Based Settings Education Department Faculty, New York Chiropractic
College, Seneca Falls, New York; Clinic Director, Owner,
Jacqueline D. Bougie, DC, MS State of the Art Chiropractic Center, PC, Phoenix,
Associate Professor and Chair, Department of Integrative Arizona
Procedures, Southern California University of Health Sciences, The Use of Measurement Instruments in Chiropractic Practice
Faculty of Los Angeles College of Chiropractic, Whittier,
California
Robert Cooperstein, MA, DC
Issues Specific to Geriatric Practice
Professor and Director of Technique and Research, Palmer College
of Chiropractic West, San Jose, California
Geoffrey M. Bove, DC, PhD
The Management of Low Back Pain and Radiculopathy
Assistant Professor, Department of Anesthesia Harvard Medical
School and Beth Israel Deaconess Medical Center, Boston,
Massachusetts Ian D. Coulter, PhD
Peripheral Nerve Biology and Concepts of Nerve Professor, School of Dentistry, University of California, Los
Pathophysiology Angeles; Research Professor, Southern California University of
Health Sciences, Faculty of Los Angeles College of
Gert Brønfort, DC, PhD Chiropractic, Whittier, California; Senior Behavioral Scientist,
Research Professor, Director of the Neck and Back Research RAND Corporation, Santa Monica, California
Program Northwestern Health Sciences University, Communication in the Chiropractic Health Encounter:
Bloomington, Minnesota Sociological and Anthropological Approaches;
The Clinical Effectiveness of Spinal Manipulation for Professionalism and Ethics in Chiropractic
Musculoskeletal Conditions
James M. Cox, DC, DACBR
Brian Budgell, DC, MSc Chiropractic Physician, Chiropractic Radiologist, Post Graduate
Associate Professor, School of Health Sciences, Faculty of Faculty, National University of Health Sciences; Private
Medicine, Kyoto University, Kyoto, Japan Clinical and Radiological Practice, Chiropractic Associates,
Introduction; Somatoautonomic Reflexes; Management of Non- Inc, Fort Wayne, Indiana
Musculoskeletal Disorders Traction and Distraction Techniques
xii CONTRIBUTORS
Simon Dagenais, DC M.R. Gudavalli, PhD

Department of Environmental Health, Science, and Policy, Associate Professor, Palmer Center for Chiropractic Research,
University of California, Irvine; Clinical Research Manager, Davenport, Iowa; Adjunct Associate Professor, National
CAM Research Institute, Irvine, California University of Health Sciences, Lombard, Illinois
Headaches of Spinal Origin Traction and Distraction Techniques
P. Thomas Davis, MUP, DC Mitchel Haas, DC, MA

Associate Professor, Northwestern Health Sciences University, Professor and Dean of Research, Western States Chiropractic
Bloomington, Minnesota College, Portland, Oregon
Disorders of the Peripheral Nerves The Clinical Effectiveness of Spinal Manipulation for
W. Mark Erwin, DC
Clinician and Clinic Director, Osgoode Health Centre, Toronto, Scott Haldeman, DC, MD, PhD, FCCS(C),
Ontario, Canada FRCP(C)
Thoracic Spinal Pain Syndromes Clinical Professor, Department of Neurology, University of
California, Irvine; Adjunct Professor, Department of
Roni Evans, DC, MS Epidemiology, University of California, Los Angeles; Adjunct
Associate Professor and Director, Wolfe-Harris Center for Clinical Professor, Research Division, Southern California University of
Studies, Northwestern Health Sciences University, Health Sciences, Faculty of Los Angeles College of
Bloomington, Minnesota Chiropractic, Whittier, California
The Clinical Effectiveness of Spinal Manipulation for Headaches of Spinal Origin
Donald D. Harrison, DC, PhD, MSE
Mark T. Finneran, MD President of CBP Nonprofit, Inc., Evanston, Wyoming; Affiliated
Medical Director, Ashland Industrial Medicine Services Professor, Biomechanics Lab, University of Quebec
Wooster, Ohio Three Rivers, Canada
The Influence of Muscles in Spinal Pain Syndromes The Use of Measurement Instruments in Chiropractic
Practice
Michael Freeman, DC, PhD, MPH
Clinical Assistant Professor and Forensic Trauma Epidemiologist,
Jan Hartvigsen, DC, PhD
Department of Public Health and Preventive Medicine, Senior Researcher, Nordic Institute of Chiropractic and Clinical
Oregon Health Sciences University, Salem, Oregon Biomechanics; Associate Professor, Institute of Sports Science
and Clinical Biomechanics, University of Southern Denmark
Management of Neck Pain and Related Disorders
Odense, Denmark
Risk Factors for Low Back and Neck Pain: An Introduction to
Arlan W. Fuhr, DC
Clinical Epidemiology and Review of Commonly Suspected
President and Co-Founder, Activator Methods Risk Factors
Phoenix, Arizona
Low Force and Instrument Technique
Paul D. Hooper, DC, MPH, MSc
Chair, Department of Principles and Practice, Southern California
Lynton G.F. Giles, DC, MSc, PhD University of Health Sciences, Faculty of Los Angeles College
Director, National Unit for Multidisciplinary Studies of of Chiropractic, Whittier, California
Spinal Pain, The University of Queensland, Townsville
Introduction; The Evolution and Basic Principles of the
Hospital, Townsville, Queensland, Australia; Adjunct
Chiropractic Adjustments and Manipulation; The Use of
Associate Professor, School of Public Health and
Physical Modalities
Tropical Medicine, James Cook University
Townsville, Australia
Pathophysiology of the Posterior Zygapophysial (FACET)
William Hsu, BSc, DC, DACBR, FCCR(C)
Joints Associate Professor, Canadian Memorial Chiropractic College
Toronto, Ontario, Canada
Gary Greenstein, DC The Indication and Use of X-Rays
Associate Professor of Clinical Sciences, University of Bridgeport
College of Chiropractic, Bridgeport, Connecticut B. Kim Humphreys, DC, PhD
Clinical Biomechanics and Pathomechanics of the Cervical Dean, Graduate Education and Research Programmes, Canadian
Spine Memorial Chiropractic College, Toronto, Ontario, Canada
The Clinical Examination
Director of Studies in Clinical Biomechanics, Professor, Faculty of Craig Kawaoka, DC, DACBSP, CSCS
Health Science, University of Southern Denmark Assistant Professor, Southern California University of Health
Odense, Denmark Sciences, Faculty of Los Angeles College of Chiropractic
Introduction: The Clinical Examination; The Management of Whittier, California
Headache Mobilization Techniques
CONTRIBUTORS xiii
Joseph C. Keating, Jr., PhD Robert D. Mootz, DC

Secretary and Historian, National Institute of Chiropractic Associate Medical Director for Chiropractic, State of Washington
Research; Member, Board of Directors, Association for the Department of Labor and Industries, Olympia, Washington
History of Chiropractic, Phoenix, Arizona Integration of Chiropractic in Health Care; Professionalism and
A Brief History of the Chiropractic Profession; Philosophy in Ethics in Chiropractic
Chiropractic
Craig Morris, DC, DACRB
Tony S. Keller, PhD Associate Clinical Professor, Cleveland Chiropractic College, Los
Professor and Chair, Department of Mechanical Engineering, Angeles, California; Post Graduate Faculty, Southern
The University of Vermont, Burlington, Vermont California University of Health Sciences, Faculty of Los
The Use of Measurement Instruments in Chiropractic Practice Angeles College of Chiropractic, Whittier, California; Post
Graduate Faculty, Canadian Memorial Chiropractic College,
Partap S. Khalsa, DC, PhD, DABCO Toronto, Ontario, Canada; Clinic Director, F.I.R.S.T. Health,
Torrance, California
Associate Professor of Biomedical Engineering, Neurobiology, and
Orthopaedics; Vice-Chair and Graduate Program Director, Manual Manual Examination of the Patient
Department of Biomedical Engineering, State University of
New York (SUNY), Stony Brook, New York Donald R. Murphy, DC, DACAN
Clinical Biomechanics and Pathomechanics of the Lumbar Spine Department of Community Health, Brown University School of
Medicine; Postgraduate Faculty, University of Bridgeport
Niels Klougart, DC College of Chiropractic, New York Chiropractic College,
Southern California University of Health Sciences,
Private Practice, Denmark
Anglo-European College of Chiropractic; Clinical Director,
Issues Specific in Pediatric Practice Rhode Island Spine Center, Providence, Rhode Island
Manual Examination of the Patient; Management of Neck Pain
Frank J. Kohlbeck, DC and Related Disorders
Associated Research Faculty, Southern California University of
Health Sciences, Faculty of Los Angeles College of Palle Pedersen, DC, MPhil, DPMSA
Chiropractic, Whittier, California
Senior Lecturer in Clinical Sciences (Chiropractic), The Welsh
Medication Assisted Spinal Manipulation Institute of Chiropractic, University of Glamorgan
Pontypridd, United Kingdom
Deborah Kopansky-Giles, BPHE, DC, FCCS(C) The Clinical History
Associate Professor, Canadian Memorial Chiropractic College,
Toronto, Ontario, Canada Michael G. Perillo, DC, MPH
Integration of Chiropractic Into Multidisciplinary and Hospital- Adjunct Professor in Public Health, University of Bridgeport
Based Settings College of Chiropractic, Bridgeport, Connecticut
Public Health Responsibilities for Chiropractic
Gregory J. Lehman, MSc, DC
Assistant Professor of Biomechanics, Canadian Memorial Stephen M. Perle, DC, MS
Chiropractic College, Toronto, Ontario, Canada Associate Professor of Clinical Sciences, University of Bridgeport
The Use of Measurement Instruments in Chiropractic Practice College of Chiropractic, Bridgeport, Connecticut; Private
Practice, Connecticut Chiropractic Specialists, L.L.C.
Craig Liebenson, DC Milford, Connecticut
Post Graduate Faculty, Southern California University of Health Soft Tissue Manual Techniques
Sciences, Director, L.A. Sports and Spine; Adjunct Professor,
School of Chiropractic, Division of Health Sciences, Murdoch Cynthia Peterson, RN, DC, DACBR, MMedEd,
University; Private Practice, Los Angeles, California FCCR(C)
The Role of Rehabilitation and Exercise in Chiropractic Practice Professor and Chairperson, Department of Radiology and Chief of
Clinical Radiology, Canadian Memorial Chiropractic College,
Marion McGregor, DC, FCCS(C), MSc Toronto, Ontario, Canada
Associate Professor, Texas Chiropractic College, Pasadena, Texas The Indication and Use of X-Rays
Musculoskeletal Complications of Chiropractic Practice
Reed B. Phillips, DC, PhD
William C. Meeker, DC, MPH President, Southern California University of Health Sciences,
Director, Palmer Center for Chiropractic Research; Vice President Faculty of Los Angeles College of Chiropractic
for Research, Palmer Chiropractic University Foundation Whittier, California
Davenport, Iowa The Evolution of Vitalism and Materialism and its Impact on
Introduction; Integration of Chiropractic in Health Care Philosophy in Chiropractic
Dale Mierau, DC, MSc Joel G. Pickar, DC, PhD

Chiropractor, Saskatoon Musculoskeletal Rehabilitation Center Professor, Palmer Center for Chiropractic Research
Saskatoon, Saskatchewan, Canada Davenport, Iowa
Biomechanics and Pathophysiology of the Sacroiliac Joint Sensory Innervation of the Spine
xiv CONTRIBUTORS
Barbara I. Polus, BAppSci, MSc, PhD Louis Sportelli, DC

Senior Lecturer and Coordinator of Research (Acting) Division of Past President, World Federation of Chiropractic; Private Practice,
Chiropractic, School of Health Sciences, RMIT University, Palmerton, Pennsylvania
Melbourne, Australia Documentation and Record Keeping
Muscle Spindles and Spinal Proprioception
Edward Rothman, DC, FACO(US), FCC(UK) Rand S. Swenson, DC, MD, PhD
Senior Clinical Tutor, Anglo European College of Chiropractic, Associate Professor of Anatomy and Neurology, Departments of
Bournemouth, Dorset, England Anatomy and Medicine, Section of Neurology, Dartmouth
Medical School, Hanover, New Hampshire
The Orthopedic Examination
Neurological Examination; The Management of Headache;
Disorders of the Peripheral Nerves
Ronald R. Rupert, DC, MS
Director of Research, Research Institute, Parker College of
Chiropractic, Dallas, Texas Gary Tarola, DC, DABCO
Central Projections of Spinal Receptors Postgraduate Faculty of Southern California University of Health
Sciences, Faculty of Los Angeles College of Chiropractic, and
Richard L. Sarnat, MD National University of Health Sciences, Whittier, California;
Alternative Medicine Integration, Highland Park, Illinois Clinic Director/Owner, Chiropractic Associates
Fogelsville, Pennsylvania
Management of Non-Musculoskeletal Disorders
Documentation and Record Keeping
Akio Sato, MD, PhD
Professor, University of Human Arts and Sciences Allan G.J. Terrett, DipAppSc(Hum Biol),
Iwatsuki-City, Japan BAppSc(Chiro), MAppSc(Chiro), FACCS,
Somatoautonomic Reflexes FICC
Associate Professor, RMIT University, Bundoora, Australia
John Scaringe, DC, DACBSP Neurological Complications of Spinal Manipulation
Dean of Clinical Education, Chief of Staff, and Clinical Professor, Therapy
Faculty of Los Angeles College of Chiropractic
Whittier, California Haymo Thiel, DC, MSc(Ortho), FCCS(C),
Mobilization Techniques FCC(Ortho)
Associate Professor and Head of Clinic, Anglo-European College
Gary D. Schultz, DC, DACBR of Chiropractic, Bournemouth, Dorset, England
Vice President of Academic Affairs and Professor of Radiology, The Orthopedic Examination
Faculty of Los Angeles College of Chiropractic
Whittier, California John J. Triano, DC, PhD, FCCS
Professionalism and Ethics in Chiropractic Director, Chiropractic Division, Co-Director, Conservative
Medicine, Texas Back Institute, Plano, Texas; Research
Clayton Skaggs, DC Professor, University of Texas, Arlington Biomedical
Engineering, Arlington, Texas
Research Associate, Logan College of Chiropractic; Adjunct
Instructor, Department of Obstetrics, Washington University The Theoretical Basis for Spinal Manipulation;
School of Medicine; Director, Clayton Physical Medicine, Introduction
St. Louis, Missouri
The Role of Rehabilitation and Exercise in Chiropractic
Howard Vernon, DC, FCCS, FCCRS, FICC,
Practice
PhD
Professor, Canadian Memorial Chiropractic College, Toronto,
Dennis R. Skogsbergh, DC, DABCO, DACBR
Ontario, Canada
Chiropractic Practice, Texas Back Institute, Plano Texas;
The Treatment of Headache, Neurologic and
Musculoskeletal Radiology, Quantum Diagnostic Imaging,
Non-Musculoskeletal Disorders By Spinal Manipulation
Richardson, Texas
Indications and Use of Advanced Imaging Studies; The
Management of Low Back Pain and Radiculopathy Bruce Walker, DC, MPH, DrPH Scholar
Doctor of Public Health Scholar, School of Public Health and
Xue-Jun Song, MD, PhD Tropical Medicine, James Cook University, Townsville,
Associate Professor and Associate Director of Basic Science Queensland, Australia; Townsville Back Clinic, Townsville,
Research, Parker College of Chiropractic Research Institute, Queensland, Australia
Dallas, Texas Integration of Chiropractic Into Multidisciplinary and Hospital-
Central Projections of Spinal Receptors Based Settings
CONTRIBUTORS xv
Robert W. Ward, DC Jesper M. M. Wiberg, DC

Associate Professor of Diagnosis, Southern California University Chiropractor, Private Practice, Kiropraktisk Klinik
of Health Sciences, Faculty of Los Angeles College of Ballerup, Denmark
Chiropractic, Whittier, California Issues Specific in Pediatric Practice
The Indication and Use of Laboratory Tests
Glenda C. Wiese, PhD
Keith Wells, DC, MA Professor, Palmer College of Chiropractic
Professor, Southern California University of Health Sciences, Davenport, Iowa
Faculty of Los Angeles College of Chiropractic History of Spinal Manipulation
Whittier, California
The Clinical Application of Selected Examination and Diagnostic
Instruments in Chiropractic
Preface
The evolution of this text, Principles and Practice of retrospect it must be admitted that there were exten-
Chiropractic over the last 20 years represents, to a large sive gaps in the material presented and that the text
extent, the evolution of the chiropractic profession did not cover the field adequately. Nonetheless, the
during this period. Over this relatively short period text did provide some insight into chiropractic and
of two decades, chiropractic has seen rapid changes provided a reference for students, practitioners, and
in its acceptance by the other health care professions. scientists with an interest in the field. It also estab-
Interest in chiropractic on the part of clinical and basic lished that there was a lucrative market for textbooks
science researchers has also grown exponentially dur- on the topic of chiropractic and paved the way for the
ing this time. This may be in part due to the growing publication of future chiropractic textbooks by major
interest in all complementary and alternative treat- medical publishers.
ment approaches but is primarily the result of in- The second edition of this text, published in 1992,
creasing research directly related to the theories and was much more ambitious than the first, perhaps be-
practice of chiropractic. cause the era was much more favorable to chiroprac-
The first edition of this text was the first time tic than the early 1980s had been. Following the land-
that a chiropractic textbook was published by a ma- mark 1987 Superior Court ruling against the American
jor medical textbook publishing company, and there- Medical Association, it became acceptable for medi-
fore marked the beginning of a new era for the sci- cal physicians to communicate and interact with chi-
ences related to chiropractic and for the education of ropractors. This cooperation marked the beginning
chiropractors. At the time the first edition was pub- of several important cross-disciplinary and joint re-
lished, several medical associations around the world search efforts, culminating with the publication of
affirmed that it was unethical for medical physicians multidisciplinary guidelines for the management of
to cooperate with chiropractors. Chiropractors were, back and neck pain that included input from chiro-
for the most part, excluded from major academic in- practic scientists and researchers.
stitutions and research facilities, and interdisciplinary During this period there was a progressive in-
practice was almost unheard of. Within this context, crease in the number of chiropractors with advanced
it was extremely difficult to convince the major pub- and graduate degrees in a variety of subjects, includ-
lishing companies that not only did a market exist for ing the basic sciences, who could be called upon to
chiropractic textbooks, but also that publishing such a write chapters on their fields of expertise. It was there-
text would not tarnish the reputation of the company fore possible to rely to a much lesser extent on authors
considering such a venture. without formal chiropractic training to write chapters.
Despite these obstacles, the first edition of this text The second edition attempted to be much more com-
was eventually published in 1980. When developing prehensive than the first by doubling the number of
the content of the text it was necessary to recruit a chapters to 32 and increasing the number of pages to
number of scientists and clinicians without any chi- 641. Again, retrospection allows us to appreciate the
ropractic background to write many of the chapters. many aspects of chiropractic theory and practice that
There were simply too few chiropractors at that time were not included in that text.
with the advanced scientific and academic qualifica- With the publication of this, the third edition of
tions and experience necessary to write quality trea- Principles and Practice of Chiropractic, it is again time
tises in the basic and clinical sciences. Although the to reflect upon the position gained by the chiroprac-
first edition was intended to be fairly comprehensive, tic profession over the past decade. Bolstered by the
it consisted of only 16 chapters and was 390 pages endorsement of spinal manipulation for low back
long. There were sections on social aspects of chiro- and neck pain by several interdisciplinary guidelines
practic and a number of scientific principles on which both in the US and worldwide, chiropractic has de-
the practice of chiropractic was based at that time. In veloped a significant presence in the musculoskeletal
xviii PREFACE
literature of the 1990s. During this period, the focus understand the theories on which chiropractic is based
slowly shifted from defending the practice of chiro- without understanding both spinal neurophysiology
practic to studying its appropriateness for a number and biomechanics and how these two sciences inter-
of specific conditions. Helping this effort is a grow- act with each other. It is not, however, sufficient to re-
ing number of chiropractors who have gone on to view normal physiology to understand the etiology of
obtain Masters and Ph.D. degrees in various fields symptoms coming from the spinal structures. Abnor-
of research related to chiropractic. Their efforts have mal physiology or pathology within these structures
served to greatly increase the quality of the science also impacts the manner in which treatment might
on which chiropractic theory and practice are based have an effect. It is for this reason that a series of
and to develop new and increasingly interesting the- chapters on the pathophysiology of the intervertebral
ories to explain the results observed in chiropractic disc, the posterior zygapophysial joints, the muscles
clinical studies. The number of scientists with a chi- and the sacroiliac joint have been included. The in-
ropractic background is now such that all but 6 of the clusion of chapters on headaches related to the spine
58 chapters contained in this edition were written by and risk factors for low back pain and neck pain con-
chiropractors with graduate degrees in such subjects clude this section by introducing come basic epidemi-
as biomechanics, epidemiology, neurophysiology, and ological principles and illustrating how clinical and
public health, to mention just a few. This shift of ex- theoretical principles can be integrated.
pertise to individuals with training and expertise in Section III is an introduction to the clinical skills a
both the clinical aspects of chiropractic and the ba- chiropractor needs to evaluate a patient and develop
sic sciences has resulted in a more comprehensive, a treatment plan. The process of reaching a diagnosis
critical, and practical discussion to the topics in each is dependent on a complex integration of the clinical
chapter. history, basic physical examination, the neurological
This text is divided into five sections. Section I and orthopedic examinations, and the use of a variety
presents the history of spinal manipulation and chi- of diagnostic tests. There is an increasing incorpora-
ropractic followed by a discussion of some of the tration of advanced diagnostic tools including imaging
ditional and modern philosophical issues that have and electrodiagnostic tests that are becoming part of
dominated much of the discussion of chiropractic such the chiropractic diagnostic armamentarium and are
as the relationship of vitalism and science. This is fol- included in chapters on these topic. The final chapter
lowed by a series of chapters that discusses some of in this section is devoted to documentation and record
the more important sociological factors that have in- keeping and gives some of the principles necessary to
fluenced and continue to influence the growth and build a practice that can integrate with other health-
behavior of chiropractic as a profession. The expan- care professionals, as is increasingly being required by
sion of chiropractic legislation and educational facil- governmental and insurance agencies.
ities outside of the North American continent is se- Section IV is devoted to the most common treat-
riously impacting chiropractors within its traditional ment approaches used by chiropractors for their pa-
strongholds of Canada and the United States. This has tients. It is not possible to discuss each of the over
been brought about by the publication of clinical tri- 100 manipulation and adjustive techniques that are
als that are described in Chapters 8 and 9. The last currently used and taught within chiropractic institu-
two chapters in this section focus on the public health tions. Instead, the chapters in this section have focused
responsibilities and the importance of professionalism on differentiating specific subgroups of manipulative
and ethics in the practice of chiropractic. This section techniques such as mobilization, high velocity low
aims to provide a background from which chiroprac- amplitude, low force, instrument, traction, and dis-
tic as a discipline can be evaluated and appreciated for traction techniques. There are also specific chapters on
what it has accomplished in its century of existence. treatment approaches that are gaining increasing in-
Section II is devoted to reviewing the basic sci- terest within chiropractic such as medication- assisted
ences that increasingly influence chiropractic theory manipulation, physical modalities, acupuncture, and
and practice. The innervation of spinal structures and rehabilitation.
manner in which neuronal input to and from spinal Section V is an attempt to integrate the prior chap-
tissues can impact spinal function have been of grow- ters into a logical clinical approach to the most com-
ing interest to all clinicians who treat patients with mon conditions seen by chiropractors in practice. The
spinal disorders. The neurophysiological processes majority of patients who seek chiropractic care do
that are the source of much of this research have been so for low back pain, thoracic pain, neck pain and
reviewed in some depth in the first five chapters of headaches. There are also, however, a small percent-
this section. The neurophysiology chapters are then age of patients who seek care for non-musculoskeletal
followed by the second component of chiropractic the- symptoms and a discussion of some of the research on
ory, namely spinal biomechanics. It is not possible to these conditions is necessary to put recommendations
PREFACE xix
on these conditions in context. There are also others as a stand-alone reference on the topic. Due
unique characteristics in the pediatric and geriatric to constraints on volume length, it remains impossi-
patient populations that can impact management that ble to include chapters on every important aspect of
warrant specific chapters on these topics. There is chiropractic theory and practice. What we have pre-
no treatment approach that is without some risk. Al- sented here is a comprehensive overview of the topics
though the risk of the most commonly used chiroprac- deemed most relevant to chiropractic clinicians and
tic treatment approaches is very small, it is nonetheless students at this time. Although specific objectives are
important that those rare complications be discussed. listed in each chapter, the general purpose of a chapter
It is for this reason that two chapters were devoted to is to present a condensed review on a particular topic.
these issues. The final chapter in this test is devoted For those wishing to gain deeper understanding in a
to the integration of chiropractic into interdisciplinary field, these chapters are simply a starting point for fur-
spinal clinics. It is probable that a fourth edition of this ther learning and discussion. Key references are pro-
text will devote considerable more time on the inte- vided in each chapter to help guide the reader through
gration of chiropractic into mainstream healthcare. the literature.
Although a more thorough understanding of chi- We hope that readers will enjoy this text and use
ropractic may be achieved by reading the book in the it as an opportunity to learn more about the very
order it is presented, each chapter is in fact nonse- interesting and rapidly evolving discipline that is
quential and may thus be read independently of the chiropractic.
SCOTT HALDEMAN
SIMON DAGENAIS
Acknowledgments
This book is a team effort and has become too complex I would like to thank Frank Kohlbeck for his input on
to be written or edited by one person. The wide scope a number of chapters.
of knowledge and understanding that is necessary to This text, however, could not have been completed
write and edit a book that adequately covers this topic without the intense effort of Simon Dagenais, the as-
requires people with qualifications and experience in sociate editor, who personally reread and edited every
a number of backgrounds that include the social and chapter after it had passed through my hands and that
basic sciences, as well as clinical practice. For this rea- of the section editors to ensure that the final product
son, multiple authors from around the world were was legible, accurate, and of high quality.
recruited to impart their knowledge and expertise on A text of this scope that requires several years of
a particular topic, and I wish to thank them for their intense work cannot take place without the sacrifice of
efforts. the families of the authors and editors. In particular
The task of corresponding with authors and ensur- I want to thank my wife Joan for her support and
ing that a quality manuscript was written that would understanding of the weekends and evenings spent
contribute to the each of the sections fell on the shoul- in the preparation of this text.
ders of the section editors. All five of these individu- Finally, there is always considerable amount of
als are amongst the most respected and experienced work that has to be done once the text is submitted
scientists and clinicians within the field of chiroprac- to the publisher. The energy and skill of the edito-
tic. I count each of them amongst the closest of my rial staff at McGraw-Hill, including Michael Brown,
friends and wish to thank them for accepting this Barbara Holton, and Andrew Hall, who transformed
challenge. our manuscript into the book you now see today.
This text also received input from a number of To everyone who played a part in the production
other individuals who contributed to reading, edit- of this book, whether or not I remembered to include
ing, and correcting individual chapters. In particular, your name here, thank you.
SCOTT HALDEMAN
S E C T I O N
INTRODUCTION TO
I
CHIROPRACTIC PRINCIPLES
The profession of chiropractic has a unique history and manipulation. The historical context, especially during
evolution. It is not possible to understand the factors the formative years of chiropractic, is particularly impor-
that are currently driving the scientific and clinical de- tant for understanding the current competition for emi-
velopments within chiropractic and to place the profes- nence in the field of manual therapies. It is also impor-
sion in the broader perspective of the health care com- tant to understand the reasons behind the development
munity without describing its historical context. Thus, of chiropractic.
the first section of this text is devoted to a brief review The history of spinal manipulation is picked up in the
of the history of spinal manipulation and chiropractic. It second chapter when it intersects with the dramatic
would be inappropriate not to discuss some of the more birth of the profession of chiropractic. Joe Keating, a
controversial components of the theory of chiropractic, well-known and highly published chiropractic historian,
especially its earlier reliance on vitalistic concepts, and provides the reader with an image-filled narrative about
its philosophical principles, as is done in Chapters 3 and the strong-willed pioneers of chiropractic, most notably
4. The chapters on history are followed by an important the Palmer family and their many important contempo-
look at the current state of the profession, its organiza- raries, and the profound and durable effect they had on
tions, and its educational systems from an international the future of the profession. Starting with a section de-
perspective. This flows naturally into an examination of scribing the intellectual milieu surrounding the founder
the extent to which chiropractic has managed to “inte- of chiropractic, D. D. Palmer, the story unfolds with a
grate” with the overall health services system, especially chronological look at the various forces and personal-
in the United States. These quantitatively focused chap- ities at work in a turbulent time. Readers will well ap-
ters give way to a qualitative discussion of the nuances preciate the challenges chiropractic had to overcome
and importance of the chiropractic patient “encounter,” to reach its current state of development.
in Chapter 5. Chapters 8 and 9 change tone to describe After this introduction to chiropractic philosophy in
the most important randomized clinical trial evidence the historical context, the chapter by Reed Phillips pro-
regarding spinal manipulation for both musculoskeletal vides a more detailed discussion of the underlying con-
and nonmusculoskeletal conditions. The last two chap- cepts and propositions of vitalism, which was a dom-
ters of this section provide important information about inant component of chiropractic theory in the first
the role of chiropractic in the wider domains of public 50 years of the profession, and which has been a
health and social and personal ethics. Together, this set source of much of the controversy surrounding the in-
of introductory chapters gives the reader a thoughtful corporation of chiropractic into the mainstream health
context within which to understand the more detailed care system. Beginning with an examination of the an-
and clinically focused information that follows. cient giants of formal philosophy, the chapter then deals
The first chapter is written by Glenda Wiese and with the progression of intellectual thinking on vitalism
Alana Callender, both eminently qualified by virtue of that came before the term chiropractic was coined and
their long professional involvement in historical schol- influenced chiropractic philosophy.
arship to present a precise history of spinal manipula- This is followed by a discussion by Joe Keating in
tion through the ages. Beginning with prehistorical ev- Chapter 4 of the various philosophical positions that
idence, the authors describe early theories underlying have been taken by chiropractors over the years and
manipulation and go on to emphasize the role that many the role of philosophy in the development of chiroprac-
professions have played in adopting and adapting spinal tic theory. He points out that much of the controversy
1
2 CHIROPRACTIC PRINCIPLES
surrounding chiropractors has come from the histori- two models of integration are presented in Chapter 7.
cal isolation of the profession and the legal necessity to One deals with the complex and overlapping levels within
differentiate chiropractic from the practice of medicine. the overall health system and society where integration
He points out, however, the potential pitfalls of main- is occurring. The other model is a useful breakdown of
taining untenable theoretical or philosophical positions clinical behavior and relationships that practitioners can
to the future of chiropractic and points out the short- use to describe their own situation. The authors go on to
comings of some traditional chiropractic concepts. place the current position of chiropractic in each model,
Chapter 5 contains a discussion of the interaction drawing the potential implications for each reality. Read-
between chiropractors and their patients. Ian Coulter ers will be able to appreciate the context as they con-
has a long and influential career in chiropractic scholar- template their own clinical and professional goals.
ship. With expertise in many areas, Dr. Coulter brings Gert Bronfort, Roni Evans, and Mitch Haas are
his years of experience, research, and training in sociol- among the preeminent clinical scientists of the profes-
ogy to an important discussion regarding the chiroprac- sion; in Chapter 8 they describe the current state of the
tic encounter. Along with several social scientists who scientific evidence for spinal manipulation for the treat-
study health care, Dr. Coulter believes that there is a ment of several common and important musculoskeletal
unique communicative power in the chiropractic style of conditions. Back pain, neck pain, and extremity condi-
case management. He applies the concepts, analytical tions comprise the overwhelming majority of complaints
tools, and models developed through medical sociology that bring patients to chiropractic, and there is more
and anthropology to provide a compelling argument sup- evidence for the effectiveness of spinal manipulation for
porting the unique chiropractic approach to health care. these conditions than there is for many other treatment
Rather than the dry and limited picture of chiropractic approaches. Yet, despite several decades of scientific
that might emerge from the quantitative studies on ma- effort, there are still many clinical questions left unan-
nipulation, the social sciences provide a much richer swered. The reader will gain an understanding for the
palette from which to view chiropractic. The patient– complexity and difficulty of conducting clinical trials, as
practitioner relationship is an area of intense interest well as an appreciation for study designs and different
from a scientific point of view, and one that will likely levels of evidence.
bear much fruit down the road. In Chapter 9, Howard Vernon tackles a similar
David Chapman-Smith is in a unique position to pro- evidence base regarding the effectiveness of spinal
vide in Chapter 6 an overview of chiropractic worldwide. manipulation for headache and nonmusculoskeletal
As the chief executive of the World Federation of Chi- conditions. Dr. Vernon has had an influential career as
ropractic, he has been directly involved in the rapidly a chiropractic scientist and is well qualified to articulate
evolving international spread of chiropractic. The most the state of the evidence in this area. Starting with a
important professional organizations are described as brief overview of some of the proposed mechanisms
well as the various laws governing the right to practice by which spinal manipulation could affect visceral, or
chiropractic. The recent evolution of chiropractic edu- nonsomatic, functions of the body, the chapter quickly
cation worldwide is a fascinating movement to observe. moves into a succinct recitation of the results of a
In the last two decades, enormous strides have been review of the scientific literature. There are sections on
made in research, professional literature, and in the de- headache and vertigo, and one on all other disorders.
velopment of clinical guidelines. In the closing sections of The discussion closes with the appropriate statement
Chapter 6, Chapman-Smith introduces readers to about the lack of definitive clinical trial evidence, but also
the important and controversial development of com- proposes a reasonable algorithm for how to empirically
plementary and alternative medicine (CAM), and its deal with these conditions in the course of chiropractic
implications for chiropractic acceptance and future care. There is an obvious need to marshal resources
growth. for additional research on the effect of manipulation and
The international flavor of Chapter 6 sets the stage chiropractic on nonsomatic disorders.
for a discussion on the integration of chiropractic into One of the great opportunities for chiropractic is
the health delivery system. “Integration” is currently a to become more formally involved in the public health
major buzzword on the lips of many discussing the large arena. Chapter 10, authored by Mike Perillo, provides
interest in CAM. “Integrative medicine” is the rallying cry an excellent overview of a vast and complex topic.
of those who would transform conventional medicine Dr. Perillo has been active with the American Public
to a more humane style of care. What does all this Health Association for many years and has a wealth of
mean for chiropractic? How is it to be viewed? William knowledge to impart. The perspective of public health
Meeker and Robert Mootz have had excellent vantage is somewhat different from that of the individual health
points from which to observe and interpret this impor- practitioner in that the health of an entire population is
tant social movement. Beginning with definitions of the considered as opposed to one patient at a time. Despite
several roles that chiropractors fill in the health system, the distinction, there is little doubt that practitioners and
INTRODUCTION TO CHIROPRACTIC PRINCIPLES 3
public health workers must collaborate for the greater profession at large, but also by each individual practi-
good. As so many chapters in this section do, this one tioner on a daily basis.
also provides a broader context for understanding the In summary, Section 1 sets the stage for under-
role and potential of chiropractic in the overall health standing the role of chiropractic in the delivery of health
care system. Although focused on many details related care. It is the broad overview, providing the overarching
to the situation in the United States, the concepts of perspective of chiropractic from a historical, social, ev-
public health apply worldwide. identiary, and professional point of view. Chiropractic is
Robert Mootz, Ian Coulter, and Gary Schultz com- clearly entering a new stage of its development and the
plete Section 1 with a very important chapter on profes- details as well as the broad sweep of what is described
sionalism and ethics in chiropractic. In an increasingly here will change, sometimes dramatically, even as this
complicated world with a plurality of social norms, cus- book is being published. If anything, this section should
toms, and rules that always seem to change, knowl- give readers a point of departure and a clear warning
edge about the basic concepts that underlie health care that in order to progress, members, critics, and stu-
ethics is extremely important. As chiropractic matures, dents of the chiropractic profession should keep their
a great deal of attention will be paid to areas of ethi- eyes on the horizon.
cal controversy that must be sorted out not only by the William C. Meeker
C H A P T E R
1
HISTORY OF SPINAL MANIPULATION
Glenda Wiese and Alana Callender
O U T L I N E
INTRODUCTION THE TWENTIETH CENTURY AND BEYOND
PRIMITIVE HEALING Osteopathy
EASTERN HEALING Naprapathy
HEALING IN THE WESTERN WORLD Manual Medicine
Greece to the Renaissance (100 bc to 1600 ad) Physical Therapy
The Age of Enlightenment (1600 ad to 1800 ad) SUMMARY
The Age of Medical Dissent (1800 ad to 1900 ad) QUESTIONS
Bonesetting ANSWERS
Spinal Irritation KEY REFERENCES
Magnetic Healing REFERENCES
meanings over different historical periods that ex-

OBJECTIVES treme care is needed to avoid error.1 The Palmers (the
1. To place spinal manipulation in its proper histori- founders of the profession of chiropractic) used the
cal context. word “adjustment” for their spinal manipulative tech-
2. To understand the development of early theories nique, and gave it a precise meaning. On the other
underlying the use of manipulation. hand, “manipulation” is a generic term with a broader
3. To describe how several health professions other meaning than the chiropractic adjustment, and is not
than chiropractic have adopted and adapted spinal limited to the spine. Variation on the purposes of ma-
manipulation. nipulation also exists, and can include reduction of
a fracture or dislocation, mobilization to increase the
range of motion of a limb or joint, promotion of circula-
“Beyond all doubt the use of the human hand, as a method of re- tion, or the stimulation or inhibition of nerve function.
ducing human suffering, is the oldest remedy known to man; his- The prechiropractic literature on spinal manipu-
torically no date can be given for its adoption.” lation can be categorized in several ways. The first
John Mennell includes the manipulative practices of primitive peo-
ples; the second, manipulation by ancient Eastern civ-
ilizations; and the third, manipulative healing in the
Western world. We will also review the history of
the manipulative healing movements whose devel-
INTRODUCTION
opment is concurrent with chiropractic. These include
Alfred North Whitehead, in his book The Organiza- osteopathy, naprapathy, manual medicine, and phys-
tion of Thought, said: “Everything of importance has ical therapy. With the exception of naprapathy, which
been said before by somebody who did not discover has declined in recent decades, there is now a resur-
it.” The same can be said of spinal manipulation. One gence of traditional interest in spinal manipulation in
reason may be that words have had so many different these other health care professions.
5
folk healer who used massage, stretching, and

PRIMITIVE HEALING
manipulation of the spine and extremities with con-
In many respects the healing practices of primitive siderable success for his clients (Fig. 1–1).7
peoples are often accompanied by religious ritual or Many of the early natives of North, Central, and
magic, especially when the cause of disability is not South America performed spinal manipulation as
apparent or easily treatable. Gaucher observes how well. Gaucher cites a Jesuit missionary in north-
throughout history bones and joints have been in- ern Canada in 1724, J. F. Lafitau, who observed the
vested with a symbolic and mystical significance.2 Abnaki Indians perform surprising cures: “The
Captain Cook relates how the women of Tahiti pum- Savages are equally successful with ruptures and
meled and squeezed him to relieve him of the ef- prolapses, dislocations, luxations and fractures.”2 The
fects of his rheumatism. 3 Many early inhabitants of gauchos of South America practiced a technique
North, South, and Central America practiced some called “abrazo del ranchero” on one another, which
form of spinal manipulation, and the custom of hav- was comprised of one individual lifting another from
ing children walk on troubled backs has been reported behind after he had folded his arms across his chest.8
from both America and from Polynesia, as well as be- Thus, it appears that even in preliterate cultures,
ing a peasant healing practice in Bohemia.4,5 Robert joint manipulation, including spinal manipulation,
Anderson, an anthropologist with training in both has been a part of traditional healing methods for
chiropractic and medicine, observed a contemporary many, many years.
practitioner of traditional lomilomi who also prac-
ticed massage and employed backwalking in Hawaii.6
EASTERN HEALING
Anderson also reported a contemporary Mexican
A form of manipulation was practiced in China as
early as 2700 bc, according to the Kung Fou docu-
ment, and there is evidence of similar practices in
India.9 About 2000 years ago, the Han dynasty clas-
sic The Yellow Emperor’s Classic of Internal Medicine de-
scribed massage and exercises, which may well have
included mobilization and manipulation.2,9 Joint ma-
nipulations were known to be widely used in China
(Fig. 1–2). They were extensively developed during
the Mongol dynasty and were recorded by We Yilin in
the Shiyi dexiao fang. In one section he wrote on vari-
ous luxations and fractures, and gave specific advice
on manipulation.10 Several centuries later, evidence
suggests that spinal manipulation was still being prac-
ticed. One illustration in the Golden Mirror of Medicine
(I Tzung Chin Chien) shows a form of gravity traction
used to treat the lumbar spine (Fig. 1–3).11 The patient
is standing on a pile of tiles, with the tiles being pulled
from under him as a practitioner appears to be apply-
ing force to the lumbar region of the patient’s spine.
Robert Anderson maintains that traditional
Chinese medicine and chiropractic are remarkably
alike in their underlying theories. “Through deep
massage at the occiput, for example, (contemporary)
Chinese practitioners find that they can bring down
high blood pressure, a practice analogous to that of
chiropractors.”12
In India, joint manipulation was practiced by
bath attendants, not as a medically advised prescrip-
tion but as an act of hygiene. Anqutil-Duperron, a
French orientalist who translated the Zend Avesta in
the eighteenth century, relates how in Bombay he was
FIGURE 1–1. Manipulation of the thoracic spine by a contem- given no peace until his bath attendant had made
porary folk practitioner in Mexico. (Courtesy of Robert Anderson.) his spine crack. “He kneels on the small of your
HISTORY OF SPINAL MANIPULATION 7
back, grasps your shoulders, and makes your spine

crack by moving all the vertebrae.”10 Additionally,
Gaucher describes the ancient Arabic culture of heal-
ing, whose theories had to undergo the rigor of sci-
entific analysis, and the results were impressive: Over
1000 medical treatises were produced or translated
into Arabic during this period. One of these texts,
written by as-Zahrawi, better known as “Albucasis,”
describes spinal manipulative techniques that were
considered part of surgery. Other sources cited include
Oribasius, Paul of Aegina, Appolonius of Kitium, and
Sushruta.10
HEALING IN THE WESTERN WORLD

Greece to the Renaissance (100 BC
to 1600 AD)
According to Anderson,9 the first physician to clearly
describe techniques of spinal manipulation in the
Western literary tradition was Hippocrates (460–
377 bc), in his book On Joints, who identified two con-
trasting techniques of spinal manipulation. The first,
known as succussion, consisted mainly of gravity trac-
tion carried out in a forceful manner while the second
used a special table to adjust the spine. This table was
equipped with poles at each end, to which straps were
attached for the leverage for applying traction; wheels
and axles could be used if more force was necessary.
FIGURE 1–2. A patient receiving manipulation of the shoulder. While the patient was under traction, the physician or
Joint manipulation has always been an important feature of assistant administered a spinal thrust (Fig. 1–4).
Chinese medical treatment. (By permission The Wellcome Institute, It is noteworthy that Hippocrates referred to the
London.) above technique (rachiotherapy) as one of the cor-
nerstones of healing, on a par with drug therapy and
surgery. Hippocrates wrote three books on bones and
is often cited by chiropractors for his aphorism, “Look
well to the spine for the cause of disease.”13 Accord-
ing to Waerland,14 and Ligeros,15 Hippocrates repeat-
edly pointed out the importance of knowing about
the spinal column, since so many disorders were ap-
parently related to it, “He [Hippocrates] evidently
studied very closely the mechanism of the spinal col-
umn and understood thoroughly its importance and
significance. He appears to have known well its re-
lation and application to and effects upon the ner-
vous system, and also its influence upon the whole
organism.”15
Ligeros and Homola agree that Hippocrates recog-
nized different degrees of displacement in the spinal
joints and attempted correction accordingly.13,15 Hip-
pocrates is quoted as saying that manipulation of
the spinal column was an ancient art and that
FIGURE 1–3. A gravity traction technique used to manipulate he thought highly of those who first discovered
the lumbar spine in China. (Courtesy of Dr. Huang Min-der and the its importance.16 One feature in Hippocrates’ writ-
Free China Review, vol. 37, no. 2, p. 21.) ings that is especially compatible with chiropractic
affected part.17,18 Wardwell cites Gaucher when dis-

cussing the changing perceptions of the desirable hu-
man form: “In the Middle Ages the only require-
ment for the spine was that it should be straight . . . a
straight back was an attribute of nobility and a
sign of valour. . . . The cultural image of the Renais-
sance encouraged manipulation of the spine . . . but
only in order to impose upon it the desired
form!”1
Ambroise Paré (b. 1517–d. 1590), often called the
“Father of Surgery,” refers to dislocations or luxa-
tions in the Workes of Ambrose Parey and describes the
following manipulative technique: “The dorsal verte-
brae outwardly dislocated, when as they stand bunch-
ing forth. . . . Then must you lye with your hands upon
the extruberancyes, and force in the prominent ver-
tebrae. . . . You may know that the vertebrae are re-
stored by the equal smoothness of the whole Spine”
(Fig. 1–6).18
The Age of Enlightenment (1600 AD

to 1800 AD)
Gaucher finds that during the seventeenth century the
classical theory of bodily humors brought a greater in-
terest in the musculature of the body rather than its
frame. As a result, “massages and frictions became
the recommended treatment, and articular reductions
FIGURE 1–4. The Hippocratic method of manipulating the were condemned.”1 However, a physician might still
spine relied on traction combined with a thrust or sus- encounter a brief reference to manipulation of the ex-
tained pressure. (Courtesy Biblioteca Universitaria, Aarchiginnasio tremities in Mouton’s The Compleat Bone-Setter or in
de Bologna, Bologna, Italy.) The Surgeons Store-House, by Johannis Schultetus (Fig.
1–7).12
In spite of the venerable age of Hippocrates’
theories is “that man must be treated as a whole, method of spinal manipulation, adjusting soon went
that the ultimate curative forces are within, that we into a decline, and by the nineteenth century sur-
should study the entire patient and his environment” geons had largely abandoned it for the treatment of
(Fig. 1–5).9 subluxations.9 Even though a French surgeon wrote
Hippocrates’ influence on medicine was immense, in 1837 of an “almost immediate cure” of cases of lum-
and his method of adjusting vertebral subluxations bago when treated with spinal manipulation, such ref-
using an adjusting table persisted for more than erences were unusual.19
2000 years.9 In the East this method became part of The medical literature then began to be openly crit-
Islamic medical practice, and Avicenna of Baghdad ical of spinal manipulation. In 1833, a London physi-
included the technique in his voluminous medical en- cian described the Hippocratic adjusting table and
cyclopedia, the Qanun. At the end of the Middle Ages recommended that it be used with great caution.20 As
a translation of Avicenna’s work was published in late as 1841, a British physician observed that manip-
Europe, which contributed to Western medicine’s re- ulation was objected to on the grounds that it could
naissance. During the sixteenth century references to be potentially harmful.21 Although it is not clear why
Hippocrates’ manipulative techniques also appeared nearly all physicians and surgeons abandoned spinal
in works by influential Western European medical au- manipulation, Anderson speculates that it was proba-
thorities, such as Ambrose Pare and Guido Guidi.9 bly given up because they perceived it as dangerous.9
Another influential Greek physician, Galen (c. 130– Nineteenth century physicians worried about apply-
c. 200 ad), referenced spinal manipulation for a pa- ing manipulative pressure to tubercular vertebrae that
tient following trauma to the neck. In his Fourth Book might disintegrate, a condition of endemic propor-
of di loci affectis, Galen cites the importance of know- tions at the time.22 They also worried about being ex-
ing the points of emergence of spinal nerves to an posed to syphilis as a result of direct contact with the
FIGURE 1–5. Minor spinal displacements may be the modern counterparts of Aesculapian manipulations. (Courtesy Logan College of
Chiropractic, Chesterfield, MO.)
patient, a disease that frequently resulted in disfigure- little light.”1 Early in the century, the practice of blood-
ment, sickness, and death.12 letting was still being used. Bloodletting, blistering,
cupping (leeching), sweating, and purging, as well as
The Age of Medical Dissent (1800 AD heavy dosing with calomel and other toxic chemicals
to 1900 AD) often produced more harm than good. Not surpris-
According to Wardwell “most disputes over therapy ingly, patients often preferred the less painful and less
in the nineteenth century involved much heat and harmful remedies of unorthodox healers. Herbalists
FIGURE 1–6. This sixteenth century woodcut describes a method being used by Ambroise Pare (1517–1590) to “restore a thoracic
vertebra in its proper place.” (From Beale LJ: A treatise on the distortions and deformities of the human body. Exhibiting a concise view of the nature
and treatment of the principal malformations and distortions of the chest, spine, and limbs. London: John Churchill, 1833.)
FIGURE 1–7. A notable evolution resulted from the introduction of a spring-loaded apparatus fixed to a bed that allowed for
traction and thrust to be performed by a single person. (From Schultetus J. The surgeons store-house, 1674. Courtesy of Yale Medical
Library.)
and other folk practitioners were often consulted and even when treating cases relevant to their specialty.
enjoyed considerable local reputations. Many kinds of Nevertheless, bonesetting continued as a folk heal-
health care practices began and flourished in this plu- ing art well into the nineteenth century, when it
ralistic environment of medical opinion and dissent. again attracted the attention of medical doctors.
Samuel Thomson (b. 1769–d. 1843) developed the Dr. Edward Harrison reported that bonesetters out-
most popular system of herbal treatment. After numbered medical doctors nine to one in Lincolnshire,
patenting his remedies in 1813, he marketed them England.25 In England, doctors Harrison, Little, Hood,
widely, wrote a compendium in 1822, and organized Paget, and Dods all incorporated some variant of
his adherents into “societies” that lobbied legislatures spinal manipulative therapy into their practices, even
against medical licensing laws. They were so success- though spinal manipulation was still regarded as risky
ful that by the 1840s, most of the statutes dealing with by orthodox practitioners.1 Perhaps the best-known
regular physicians had been repealed.23 Two branches English bonesetter was Sir Herbert Barker, who was
of botanical medicine developed from the Thomso- knighted for his efforts, and who, by 1906, was calling
nians: the physiomedicalists and the eclectics. Each himself an osteopath.12
branch had its own active adherents, schools, asso- The literature on bonesetting is extensive. In
ciations, and journals, but after 1900 their impact on Germany bonesetting was called “Knochenein-
health care became minimal.24 richter” or “Wundarzt.” In France the term was “re-
boutage” or “bailleul,” in Czechoslovakia, “napravit,”
Bonesetting in Spain, “algebrista.”26 Whatever it was called, the
Although regular physicians might have retreated practice of bonesetting became widespread during
from manipulation during the nineteenth century, pa- the eighteenth and nineteenth centuries. Dintenfass
tients did not. People suffering from sciatica, lumbago, writes, “The art of manipulation, often called ‘boneset-
and rheumatism sought practitioners who could pro- ting,’ was handed down from father to son, or mother
vide relief, and ultimately found their way to lay bone- to daughter, and was practiced by at least one suppos-
setters. Bonesetting has had a long traditional history, edly ‘gifted’ person in most communities in Europe
but the earliest known text by the name was pub- and Asia . . . The results obtained by these individuals
lished by the friar Moulto in 1656. Anderson reports, were so unusual that the people believed that they in-
“Bonesetting became identified with the humble, oral herited a divine gift to heal the sick!” (Figs. 1–7 and
tradition of uneducated peasant and working people. 1–8).27
That identification became a stigma. . . . ”12 As a result, Anderson speculates that the “Little Tradition”
bonesetters were soon refused access to hospitals, of unlettered villagers—bonesetting—coexisted for
FIGURE 1–8. This photograph shows a bonesetter manipulating the low back. It was taken near Vannes in Brittany, France, circa
1880. (Courtesy Musée des Arts et Traditions Populaires, Paris.)
centuries with the “Great Tradition” of the literate ur- While the descendants of the Sweet family went
ban elitists—medicine and surgery. He hypothesizes on to become orthopedists, descendants of a popu-
that each practiced a form of spinal manipulation “in lar bonesetting family in South Dakota, the Tieszens,
a complex and fluctuating give-and-take of imitation went on to become chiropractors, as did the descen-
and differentiation.”9 By the end of the nineteenth cen- dants of the South Dakota Orton family, who were so
tury physicians harbored ambivalence toward bone- successful that they built a four-story, 72-room hotel
setters. Anderson asserts that it was a well-established with an attached clinic to accommodate their many
part of the medical culture to express disdain for patients.23 Joy attributes the decline of the boneset-
bonesetters, but physicians also acknowledged bone- ters to the fact that orthopedic knowledge was becom-
setters’ popularity with their patients.9 One of the ing more and more a part of the general physician’s
most famous surgeons of the day, James Paget, rec- skills.26
ommended in The British Medical Journal that physi- In the 25-year period between Paget’s and Hood’s
cians should learn what is good from bonesetting publications on bonesetting and D. D. Palmer’s per-
and avoid what is bad.28 Another physician, Wharton forming the first chiropractic adjustment, very little
Hood, defied the medical ethics of the time and ap- was written about spinal manipulation.19,29 An oc-
prenticed himself to a bonesetter. Publishing in The casional endorsement would appear, including one
Lancet, he offered the medical professions a basic 15 years after Palmer’s discovery that stated: “It is very
primer in extremity adjusting, but failed to describe remarkable that the medical profession should so long
spinal manipulation.9 have neglected such a wide field of therapeutics.”19
In the United States well-known bonesetters were Interestingly enough, only 11 years before the
Bonesetter Reese, of Pennsylvania and Ohio, and first chiropractic adjustment was to be administered,
the Sweet family, who practiced in Rhode Island, E. Dailly writes of manipulating the bony framework
Massachusetts, Connecticut, and New York. The of the body, “grasping the spinous processes with the
Sweets attracted patients from all over the East Coast, fingers.”2 Dailly goes on to say, “The treatment should
and even received many referrals from medical doc- therefore be directed either at the articulations or the
tors. Joy attributes the open-minded attitude on the nervous system.”2 According to Gaucher, “It would
part of the medical profession to the Sweet’s skill and seem that those who objected to the concept of ver-
to the fact that they did not exploit their patients. The tebral subluxation as proposed by Palmer ten years
last of the Sweets practiced in Rhode Island until 1917 later had not assimilated all the data that the classic
(Fig. 1–9).26 scientific medical discourse placed at their disposal.”2
FIGURE 1–9. A nineteenth century

migrant from Bohemia (Czechoslo-
vakia) administering a spinal adjust-
ment. (From Smith, et al., 1906, p. 11.
Courtesy of David D. Palmer Health Sci-
ences Library, Palmer College of Chiro-
practic.)
FIGURE 1–10. This early medical drawing illustrates

the awareness of the relationship between spinal
nerve roots and distant parts of the body. (From Monell
CG. Rheumatism, Acute and Chronic. 1845, p. 20.)
Spinal Irritation
The link between a problem with a spinal vertebral
segment and pain or a diseased organ at some dis-
tance away was unfamiliar to most doctors by the
nineteenth century (Fig. 1–10). Monell wrote in 1845,
“This symptom has been carefully noticed by a few,
superficially by several, but totally neglected by the
great majority of Practitioners.”6 Other authors in the
early part of the nineteenth century noted the rela-
tionship between the spine and organic disorders.
Stanley observed, “The internal organs, specifically of
the abdomen and pelvis, variously participate in the
nervous derangements ensuing from disease in the
spine.”30
The theory of spinal irritation was promulgated
early in the nineteenth century. It originated with
Dr. Thomas Brown in Glasgow in 1828, and was
mentioned 4 years later by Dr. Isaac Parrish of
Philadelphia.22,31 In 1843, J. Evans Riodore, a Fellow
of the Royal College of Surgeons, wrote A Treatise on
Irritation of the Spinal Nerves. Gaucher quotes Riodore,
claiming that he had to read the quotation twice
to ascertain that it had really been written in 1842,
“The cause is never suspected to be in the spine, and
the latter is never examined; the subluxated verte- FIGURE 1–11. This shows position of hands in treating heart
bra is never replaced in its original lineal direction.”10 or lungs. Right hand over upper dorsal plexus, left hand over
heart or lungs. (From Weltmer SA. Revised Illustrated Mail Course of
Riodore goes on to declare that, because spinal nerves
Instruction in Magnetic Healing, 1901.)
reach out to every organ and muscle in the body,
“We cannot be otherwise than prepared to hear of a
lengthened catalogue of maladies that are either en-
gendered, continued or the consequence of spinal
irritation.”19
Magnetic Healing
Influential in the development of both osteopathy
and chiropractic was the practice of magnetic healing.
D. D. Palmer practiced magnetic healing for nine
years before formulating his theory of chiropractic.
“Andrew Taylor Still, Magnetic Healer” was how
Still, the founder of osteopathy, was billing himself in
1875.32 But what was most significant was the fact that
practitioners of magnetic healing, faith healing, and
mental healing often made bodily contact with their
hands when treating patients (Figs. 1–11 and 1–12).
According to Homola, the Mormon leader, Joseph
Smith, Jr. practiced faith healing, using bonesetting
techniques. One of his elders advertised that while set-
ting bones, “they came together, making a noise like
the crushing of an old basket.”10 Since only the joints
of the spine give such a sound, Homola concludes
that the laying on of hands was conducted with some
force, not unlike that of chiropractic adjustments.
Others were using magnetic healing techniques.
Andrew Jackson Davis (b. 1826–d. 1910), a leading ex-
ponent of spiritualism, placed emphasis on healing, FIGURE 1–12. A. T. Still, the founder of osteopathy. (Courtesy
with his hands, which consisted of vigorous rubbing Still National Museum of Osteopathy, Kirksville, Missouri.)
the rotated spinous and transverse processes into a

more favorable position.”1 Another mention of using
the spinous process as a lever is presented by Gaucher,
citing Warner’s treatment for scoliosis: “Where the de-
viation is not very advanced a degree of correction can
be obtained by grasping the spinous processes with
the fingers.”1 Gaucher concludes that Palmer was not
familiar with Dechambre’s Dictionary, or he would not
have claimed to be the first to use the spinous process
to effect a correction. Wardwell concludes that there
was more conceptual continuity between Palmer and
his predecessors than previously believed, and that
“chiropractic was not such a radical break with the
past, but rather the product of a long evolutionary
development.”1
THE TWENTIETH CENTURY AND BEYOND

Osteopathy
Gevitz concludes that manipulation and massage did
not make the transition from their early roots to the
armamentarium of the medical practitioners of Still’s
time because “most American and English MDs felt it
was beneath them to administer treatment with their
hands.”32 Mennell stated that massage and manipula-
tive therapy were passed over because it was “impos-
sible for conscientious practitioners” to employ them
when they lacked faith in the philosophy espoused by
FIGURE 1–13. A. P. Davis, MD, DO, DC (1835–1915), per-
those who did.34
forming an osteopathic manipulation. (From Davis AP. Osteopathy
Illustrated, a Drugless System of Healing, 1899.)
The neglect of orthodox medicine allowed ma-
nipulation’s efficacy to be “discovered” by Andrew
Taylor Still, by Daniel David Palmer, and by others,
along the spine (Fig. 1–13).32 Warren Felt Evans because no one disputes the healing power of touch
(b. 1817–d. 1889) wrote that “By the friction of the hand whether the mechanism by which it works is under-
along the spinal column an invigorating life-giving in- stood, accepted, or even important to those who seek
fluence is imparted to all the organs within the cavity its relief. Andrew Taylor Still was a frontier doctor
of the trunk.”1 A. T. Still, the founder of osteopathy, in Kansas. His experiences as a Union field doctor
was able to synthesize some of the major components in the Civil War followed by the loss of three chil-
of bonesetting and magnetic healing into one unified dren to typhoid after the war left him disenchanted
theory.32 D. D. Palmer did so, too, although his chi- with the state of orthodox medicine. He was fasci-
ropractic theory was based on different concepts than nated by human anatomy, and most particularly the
osteopathy. Palmer was adamant about the influence bony structure. Still was influenced by the spiritualist
magnetic healing had on chiropractic, declaring he fervor sweeping the country and practiced as a mag-
never would have been able to conceive his chiroprac- netic healer for a time. He added bonesetting to his list
tic theory without his experience as a magnetic healer. of talents and by the 1880s was advertising himself as
Palmer wrote, “I saw fit to date the beginning of chi- the “lightning bonesetter,”32 a designation that seems
ropractic with the first adjustment, although quite a to denote great speed.
portion of that which now constitutes Chiropractic I In 1874, Still announced a new medical theory, os-
had collected during the previous nine years.”33 teopathy, which was greeted with such derision that
Although Palmer never claimed to have been the he was “read out” of the Methodist church,35 barred
first to replace subluxated vertebrae, he did claim to from presenting his concepts at Baker University, a
be the first to use the spinous and transverse pro- school his family had helped found,32,35 and run out of
cesses as levers. Wardwell suggests otherwise.1 He town. He relocated to Kirksville, Missouri, where the
refers to the British surgeon W. J. Little, who men- populace welcomed him. On October 3, 1892, he and
tions Harrison’s technique of “endeavoring to press William Smith, a European-trained medical doctor,
welcomed the first students to the American School “branch” of medicine. In those states where osteopa-
of Osteopathy. thy did not have its own separate legislation, os-
Founded on spinal manipulation in place of materia teopaths could be charged with practicing medicine
medica, osteopathy was supposed to reform medicine, without a license.
not replace it.36 The conceptual basis of osteopathy In a 1900 case (Nelson v. State Board of Health)
was that the body was a machine and the physician where an osteopath was charged with practicing
an engineer.37 Still postulated the rule of the artery medicine without a license, the court found for the
in 1870 while many early osteopaths subscribed to osteopath, reasoning that the law did not apply to the
the nerve pressure theory.17,38 Osteopaths have been appellant at all, as what he did could not be construed
described by Helminski as the “Protestants of ortho- as the practice of medicine; he was likened to a nurse.
dox medicine.”37 Still’s early osteopathic concepts in- This became a landmark case, cited by other courts to
cluded the supremacy of blood flow,39 surgery only in show osteopathy was not medicine.37
the case of emergencies, and a complete disavowal of The definition of “practice of medicine” became
drugs. Previous manual systems were thought to use a the primary legal point at issue. Orthodox medicine
“shotgun method” of general manipulation, while os- wanted the interpretation to be as broad as possible;
teopathy “works with the definite aim of finding the osteopathy wanted the interpretation to be the prac-
obstruction to health and removing it.”32 Although tice of administering drugs.32 The courts tended to
claiming specificity, osteopaths still worked to restore use a narrow interpretation. The courts also tended to
physiologic harmony even in the absence of palpable interpret osteopathy as it had been at its founding, giv-
anatomic displacement. Still and his followers added ing no credence to developments made in education
a focus on the spine. The early faculty was able to lay and practice. The profession had to appeal to legisla-
a scientific basis for Still’s work, integrating it with tures for relief and by 1900, several states had osteo-
medical discoveries of the time.32 Clinicians awaited pathic statutes either exempting DOs from the medical
the millennium when “regular” medicine would dis- practice acts or establishing separate licensing mech-
cover the accuracy of osteopathic teachings and adopt anisms. In the legislatures, the medical drive was that
them. Their work done, DOs would then be reunited osteopathy be specifically outlawed while osteopaths
with MDs in the “Truth.”37 were campaigning for separate licensing boards.35
Toward the end of the nineteenth century, legis- The National School of Osteopathy was estab-
latures and courts started tightening up on the un- lished in Kansas City in 1895,32 and was headed up
regulated practice of medicine. Under common law, by Drs. Elmer and Helen Barber. Elmer Barber wrote
anyone could practice medicine in the absence of the first book ever published on osteopathy and in
a statute requiring licensure or other qualifications. it, he claimed that Still was wrong on a number of
The purpose of law is to protect society, and it was important theoretical issues (Fig. 1–14).32 The text
believed that few members of the public were able was used by medical physicians as an illustration
to judge for themselves the qualifications of medical of their contention that osteopathy was a fraud. By
practitioners.37 With a national association founded in 1900, there were 13 osteopathic schools in the United
1847, the regulars or orthodox physicians were in a po- States.32 The relations between the new colleges and
sition to influence legislation. When established, state the American School were at best polite “and at worst,
boards of medical examiners were frequently dom- openly hostile.”32 Still believed that the other schools
inated by traditional physicians.37 In the 1870s and “stole” students that were rightfully his and that his
1880s, several states granted allopaths, homeopaths graduates had neither the training nor practical expe-
and eclectics separate boards. Boards were then com- rience to teach osteopathy on their own.32
bined and a representative of each sect was placed on a Although Still was to remain the revered figure-
single board.32 After this experience, legislatures were head of osteopathy throughout his lifetime, his fol-
reluctant to empower separate boards, so osteopaths lowers started broadening their scope of practice as
found it difficult to obtain separate licensing. Med- soon as the early 1900s,37 first adding obstetrics and
ical boards required that candidates be proficient in then surgery. This was the first philosophical split, but
surgery and materia medica, subjects not be taught in these two additions were eventually endorsed by Still.
osteopathic colleges. Those who remained loyal to the tenets of Still be-
The first attempt at osteopathic legislation was came known as “lesion” osteopaths, and those who
in its home state, Missouri, in 1895. Although the campaigned for routine surgery and materia medica
bill passed both houses, it was not signed by the became “broad” osteopaths.32 Adjuncts such as hy-
governor.40 In 1896, Vermont licensed osteopaths.37 drotherapy, suggestive therapeutics, and electrother-
In its 1897 medical practice act, Illinois included os- apy were the next additions sought by the broad os-
teopathy and magnetic healing under the definition teopaths, and Still and the lesionists considered these
of medicine. Other states were not as open to the new and pharmacology as heresy.32
the colleges, osteopathic physicians took on more of

the functions associated with medical physicians (e.g.,
surgery, prescription of drugs, issuance of birth and
death certificates, and the filling of offices such as
coroner and school physician).37 Denied commissions
during the wars but exempt from the draft, osteo-
pathic physicians filled the void left by the very med-
ical physicians who had campaigned against their ap-
propriateness in the military, assuming their civilian
patient loads.32 When osteopathy was able to prac-
tice under its own set of licensing boards, the MDs
began lobbying for basic science examinations that
would be taken prior to the state boards, thus cir-
cumventing profession-specific boards. In 1930, the
pass rate for the seven state basic science exams in
effect was 88.3% for MDs, 54.5% for DOs, and 21.9%
for DCs.32
Manipulative therapy as an integral part of osteo-
pathic patient management began a steady decline
after 1930.32 Gevitz attributes this to institutional
changes (i.e., alterations in the social structure of the
FIGURE 1–14. Elmer Barber founded the National School of colleges, hospitals, and office practice) and to scien-
Osteopathy in Kansas City in 1895. (From Barber E. Osteopathy tific changes (i.e., transformations in the osteopaths’
Complete. Kansas City, MO: Hudson-Kimberly Pub. Co., 1898.) knowledge base). Basic science instructors did not
necessarily have osteopathic backgrounds and as
more time was spent on pharmacology and surgery,
In the early part of the twentieth century, os- less was available for osteopathic instruction. The DOs
teopaths found themselves caught on the horns of a started to adopt more and more allopathic practices
dilemma. Their predecessors had used a “straight” and standards.41 Osteopathic surgeons began to ar-
argument to exempt themselves from medical legis- gue that manipulative therapy was only appropriate
lation. State licensing laws often excluded surgery,32 in an ambulatory setting. The shift from chronic to
but when later practitioners tried to establish osteopa- broad-based practices increased the demand for care
thy’s equality with medicine, asserting that they were and thus reduced the frequency and length of osteo-
qualified in the use of drugs and surgery, the earlier pathic treatments. The Spinalator and pharmacother-
arguments of purely manipulative practice would rise apy replaced hands-on practice. Patients not social-
up against them.37 In 1915, the restrictions against ized into the traditional osteopathic approach were
the teaching of materia medica in the schools was less likely to expect or desire manipulation.32
lifted but a reported great success during the in- By the end of the 1950s, most Journal of the American
fluenza epidemic of 1918–1919 once again gave cre- Osteopathic Association (JAOA) articles failed to men-
dence to osteopathic fundamentalism and materia tion osteopathic manipulation therapy/treatment
medica was removed from the curricula, not to reap- (OMT) and when they did, the mention was brief and
pear until 1929, when a curriculum for pharmacology the OMT was an adjunct to other treatment within
was approved.32,37 During the 10 years between 1897 the sphere of medicine. The use of manipulative ther-
and 1907, the number of osteopathic graduates rose apy was decreasing in colleges of osteopathy and
from 63 to 2765.37 Manipulative therapy remained an increasing in the orthopedic and physiatry depart-
integral part of most osteopaths’ practices, as they be- ments of medical schools.32 A 1954 survey of all DOs
lieved this modality gave them a decided edge over graduating between 1948 and 1953 found that only
their medical counterparts. In obstetrics, manipula- 44% used OMT on more than half their patients, cit-
tion was thought to “shorten hours of labor, lessen ac- ing lack of training in palpation and manipulation
companying pain, prevent mastitis and secure a more along with the growing number of internships in allo-
rapid convalescence of the patient.”35 pathic settings.41 Approximately 10% of active DOs
Between the world wars, the profession moved still confined themselves to distinctive osteopathic
from using the label “osteopath” to “osteopathic procedures, either by choice or by state law, but this
physician.” DOs progressed in legal status and the group steadily shrank each year32 and DOs officially
variety of functions they performed. With separate remained cultists in the eyes of the American Medical
boards and a general recognition of the quality of Association (AMA).
In 1962, osteopathy achieved the nadir of its pro- placebo remains elusive.42 A uniquely American
fessional history when the California Osteopathic As- product, osteopathic medicine has spread around the
sociation, after 19 years of negotiation, merged with world. The British College of Naturopathy and Os-
the California Medical Association. California was teopathy, founded in 1936, offers a Bachelor of Science
a stronghold for broad osteopaths. The contract of Degree in Osteopathic Medicine.44 The regulation of
merger stipulated that DOs would become MDs in the practice is not as formalized as in the United States.
state of California and that they should cease iden-
tifying themselves with the osteopathic profession. Naprapathy
The osteopathic college would be immediately con- Naprapathy, formulated in 1905 by Oakley Smith,4
verted into a medical college. The MDs favored the was based on the principle that “ligatites” caused
merger because they saw the DOs as an inferior group the vertebrae to draw too closely together, obstruct-
that was lowering the general quality of health care ing nerves and blood vessels, which resulted in dis-
in the state. The upside of the merger was the per- ease (Fig. 1–15). The ligaments could be stretched back
ception that if California considered DOs and MDs to normal by manual adjustments.4,36 Smith founded
were equivalent, they must be. In 1963, the Civil Ser- the Chicago College of Naprapathy in 1905. He de-
vice Commission said that for its purposes, the MD vised a system of charting areas of tension of the
and DO degrees were to be considered equivalent.32 spine and classified physical disorders by symptoms.
DOs began to be called upon to give expert testimony Both Palmer and Smith denied that naprapathy was a
in court, circumventing the longstanding “conspiracy branch of chiropractic.4
of silence” in which MDs refused to testify against Naprapaths were originally eligible for licensure
each other.37 The Michigan State University College of under the Illinois Practice Act. In 1949, another college
Osteopathic was chartered in 1964, the first osteo-
pathic school associated with a state university.37
Helminski, in his 1981 master’s thesis, stated that
the “equation of osteopathy with manipulation has
plagued the movement throughout its life . . . it has
given rise to the present myth that osteopathy began
as a cult of manipulation, and later somehow outgrew
its origins to embrace ‘scientific medicine.’”12,37 He
later uses the word “tainted” in referring to the em-
phasis on manipulation.37
In the twenty-first century, manipulation has be-
come a specialty within osteopathy, the same role it
appears to be headed for in orthodox medicine. A po-
sition statement of the American Osteopathic Associ-
ation (AOA) directs its members to refer to themselves
as osteopathic physicians and to use “osteopathic ma-
nipulative treatment” in place of “osteopathic manip-
ulative therapy,” presumably to avoid confusion with
physical therapy.42 In 1998, Guglielmo reported that
DOs are becoming too much like MDs in an effort
to achieve parity and that distinctive practices like
OMT are being lost. What does make the osteopathic
physician unique is doctor-patient connectedness.
Dr. Patricia Roy describes it more graphically as
“touchy-feely.”42 Louisiana, the last state to recognize
chiropractic, still won’t accept the osteopathic profes-
sion’s national licensing exams.
Although the osteopathic profession is repre-
sented by its professional organization, the AOA, the
practitioners of osteopathic medicine are recognized
by the AMA as physicians with full qualifications.43
The research on spinal manipulation therapy is led FIGURE 1–15. Oakley G. Smith, DC (1880–1967), an 1899
today by chiropractors, with OMT being studied graduate of D. D. Palmer, named the ligatite that became the
to a lesser degree.39 The need for research is still basis of his healing art: naprapathy. (Courtesy Palmer College of
paramount, but the manipulative equivalent of a Chiropractic Archives, Davenport, IA.)
of naprapathy was formed in Chicago and the two possibilities of traction and even of other methods of
schools merged in 1971.4 The Naprapathic Practice mechanical treatment, including manipulation. In this
Act of 1995 allows for limited doctoral licenses sim- way a somewhat paradoxical situation developed:
ilar to those granted to optometrists or dentists and While the osteopaths and chiropractors, who were re-
has been the impetus for a dramatic growth in the garded by the medical profession as “quacks,” were
profession.45 In 1986, there were an estimated 800– elaborating sophisticated manipulation techniques,
1000 naprapaths practicing in Illinois.4 The practice medical doctors also began to include spinal manipu-
of naprapathy today concentrates on connective tis- lation methods, sometimes employing anesthesia.48
sue manipulation and includes exercise, postural and A number of medical physicians in Europe and
nutritional counseling, and other therapeutics.45 the United States have promoted the idea that ma-
nipulation should be performed by qualified medi-
Manual Medicine cal doctors only, striving to keep the monopoly for
Manipulation does not have a clear identity within or- the profession.16,36,46,47 Manual medicine has been in-
thodox medicine in North America. Medicine comes cluded within the specialties of general practice, phys-
to manipulation through the back door, if not from ical medicine and rehabilitation, rheumatology, ortho-
the cellar. European medical doctors, however, did pedics, and neurology.47
not share the disdain for manual medicine evidenced The first international meeting of those practic-
by the Americans and British. In 1903, Naegeli, a ing manual medicine took place in Switzerland in
Swiss doctor, used traction manipulation on the cer- 1958. At the second meeting in 1962, it was de-
vical spine in the treatment of headache.46 In 1945, cided to form an international body and in 1965,
a group of German doctors became interested in the International Federation of Manual Medicine
manipulation,46 after a series of lectures by members (Fédération Internationale de Médicine Manuelle, or
of the European Chiropractic Union. During the same FIMM) was formed.46 Today, there are 21 national as-
era, The London College of Osteopathy offered train- sociations affiliated with FIMM, mainly from Europe
ing in manipulation to qualified allopaths. Graduates and Australia.16 Great Britain and the United States
of this program have played an important part in de- have lagged behind in developing a well-defined spe-
veloping manipulative medicine throughout Europe. cialty of manual medicine.48 In the United States, the
Robert Maigne gave courses in manipulation at the physician with manipulative skills can often be found
Medical Faculty of the University of Paris, attended working with professional and amateur athletes.49
mainly by specialists in physical medicine.16 In the 1970s and 1980s, the field of manual
A prominent pioneer of medical manipulation in medicine began to analyze its successes and fail-
the 1950s was James Mennell, an outspoken protag- ures, searching for neurophysiologic explanations.47
onist of osteopathic techniques which he also taught, In 1975, the National Institute of Neurological and
mainly to physiotherapists.36,46 He explained the re- Communicative Disease and Stroke of the National
luctance of medical physicians to employ massage or Institutes of Health appropriated funding for a work-
manipulative because it would have been “impos- shop on the status of chiropractic which evolved into
sible for conscientious practitioners to do so when the research status of spinal manipulative therapy. The
they lacked faith in the creed which has been so com- 1975 conference, held in Bethesda, Maryland, was at-
monly attached to the performance of those outside of tended by 58 scientists and clinicians from the United
the [medical] profession.”34 By 1955, training in ma- States and eight other countries, and included doctors
nipulative therapy was decreasing in colleges of os- of medicine, osteopathy, and chiropractic, along with
teopathy but was increasing in the orthopedic depart- specialists in 11 basic sciences. One of the tasks they set
ments of medical schools.32 Writing in the 1960s, John for themselves was the search for the neural biologic
M. Mennell opined, “The condition of joint dysfunc- basis for manipulative therapy.36
tion is the only pathologic condition that will respond Mainline medical journals are increasingly re-
to the treatment of manipulation. . . . Manipulating porting and analyzing the results of research into
joints is an art and, as with so many arts, not everyone manipulation,50–53 but orthodox medicine is finding
can expect to be able to learn to use it.”44 many of the same hindrances to manipulative research
In Europe, the reluctance to include manipulation that has hamstrung osteopathic and chiropractic re-
within orthodox medicine lies in the universities.47 search for so long.54
Postgraduate courses taught outside the universities
are generally recognized by insurance companies as Physical Therapy
adequate training to qualify for reimbursement.46 Massage developed as a profession around 1900,
The discovery of the mechanical role of disc pro- as did physiotherapy. Physiotherapists originally
lapse in root syndromes made doctors aware of the used massage and exercise as the primary treatment
approach.55 The first professional association for treated in outpatient settings.61 Most authors, how-
physiotherapists was founded in 1921 as the American ever, differentiate between mobilization, manipula-
Women’s Physical Therapeutic Association. Members tion, and manual therapy.
were known as “Reconstruction Aides.” Membership The Practice Affairs Committee of the Ortho-
was opened to men in the 1930s and the name was paedics Section of the APTA assumes the following
changed to the American Physiotherapy Association, position:
then changed to the American Physical Therapy Asso-
ciation (APTA) in the late 1940s. The polio epidemic of 1. Manipulation in all forms is within the scope of
the 1940s and 1950s increased the demand for physio- practice of the licensed physical therapist.
therapists (the term is interchangeable with physical 2. The force, amplitude, direction, duration, and fre-
therapists).56 quency of manipulative treatment movements is a
Historically, physiotherapists have worked under discretionary decision made by the physical ther-
the guidance of medical authority.47 They have been apist on the basis of education and clinical experi-
functioning as primary evaluators of neuromuscu- ence and on the patient’s clinical profile.
loskeletal conditions in the army since the early 1970s 3. Manipulation implies a variety of manual tech-
and are assuming greater responsibility for the ini- niques which is not exclusive to any specific
tial assessment and management of patients.29 The profession.60
diagnostic skills of physical therapists, however, have
been under attack by many medical practitioners of As part of the 2001 Balanced Budget Refinement
manipulation. In 1984, Dvorak wrote, “The physical Act, Congress lifted the Medicare $1500 cap on physi-
therapist is neither trained nor authorized to discern cal therapy services. To address the utilization of phys-
the contraindications to classic manipulation proce- ical therapy services, Congress mandated the Cen-
dures. The physician only can judge if and what fur- ters for Medicare and Medicaid Services to develop
ther work-up is in order and follow up accordingly.”47 utilization guidelines for physical therapy services.
In 1992, the journal Physical Therapy published a The PT guidelines include language that could allow
special issue devoted to manual/manipulative ther- physical therapists to perform spinal manipulation. In
apy. In the editorial for the issue, Rothstein wrote, a current draft, for Current Procedural Terminology
“This approach to the management of musculoskele- (CPT) code 97140 (manual therapy techniques), “ma-
tal disorders has become mainstream, a part of every nipulation may be medically necessary for the treat-
curriculum, and for some the raison d’être for much of ment of painful joint or soft tissue restrictions of the
our practice.” He bemoaned the lack of research ap- spine or extremities.”62
pearing in credible, peer-reviewed journals, stating,
“There has been little maturation and very little sci-
SUMMARY
entific development in this area. It has been as if pop-
ular opinion precluded the necessity of research and 1. Spinal manipulation has been practiced for over
refinement.”57 Other articles in that issue dealt with two millennia. A Chinese text written two thou-
treatment for back and joint pain by manual therapy,58 sand years ago describes massage and exercises,
and the efficacy of manual therapy.59 and centuries later, another Chinese text illus-
Farrell and Jensen assessed the role of manual trates a form of gravity traction. In the Western
therapy in the physical therapy profession. “Man- World Hippocrates describes a technique of spinal
ual techniques include massage, distraction and trac- manipulation in the fifth century, bc. During the
tion techniques, specific (specific to one vertebral Middle Ages Hippocrates’ technique was dif-
motion segment, such as L4-5) or general (specific to a fused through the influential work of Avicenna of
region of the spine, such as L1-S1), high-velocity ma- Baghdad, and reappeared in Western Europe
nipulation and joint mobilization, and what is called through the writings of Ambroise Paré. A tra-
‘adverse neural tissue mobilization.’” Hours of class- dition of folk healing or unschooled healers us-
room instruction in manipulative therapy are on the ing manipulation coexisted with the manipula-
rise.60 In the United States today, the physical ther- tion of the urban practitioners for centuries. By
apist has shown the strongest interest in mobiliza- the middle of the nineteenth century, urban practi-
tion techniques.36 Farrell and Jensen proposed that the tioners viewed spinal manipulation with ambiva-
choice of the term “mobilization” was to avoid strong lence, but it continued to be championed by a few
association with the word “manipulation” within the medical practitioners, notably James Paget and
chiropractic profession.60 Mobilization is already an Wharton Hood. Into this milieu appeared Daniel
accepted term in some physical therapy state practice Palmer, who performed the first chiropractic ad-
acts.60 Low back pain is the condition most frequently justment in 1895.
2. As early as Hippocrates, physicians were attempt- 4. Briefly discuss the role of manipulative therapy in
ing to treat man as a whole. Hippocrates is quoted the practice of osteopathy from its inception to the
as saying curative forces come from within and present.
that we should study the patient. Galen empha- 5. What has been the evolution of manipulation by
sized knowing the points of emergence of the physical therapists during the past century?
spinal nerves and how they affect the body. By
the seventeenth century, the interest in bodily hu-
mors brought an increased interest in musculature, ANSWERS
rather than the skeletal system, with a concur-
rent interest in massage and friction, rather than 1. The Kung Fou document describes a form of ma-
manipulation. Physicians began to believe that nipulation practiced in China as early as 2700 bc.
manipulation was dangerous, perhaps because of Centuries later, the Golden Mirror of Medicine shows
the widespread occurrence of tuberculosis. In the a form of gravity traction being used to treat the
first half of the nineteenth century Brown, Parrish, spine.
and Riodore promulgated the theory of spinal ir- 2. Hippocrates described two forms of early manip-
ritation and the relationship between a problem ulation, gravity traction and rachiotherapy. He re-
with a vertebral segment and a diseased organ. peatedly stressed the importance of knowing the
Magnetic healing developed the theory that the spinal column, and is often cited as the source of
friction of the hand along the spinal column im- the aphorism, “Look well to the spine for the cause
parted a life-giving influence. Osteopathy, devel- of disease.”
oped by Andrew Still in the late nineteenth cen- 3. Although bonesetting had a long tradition prior
tury, theorized that blood flow or the lack of blood to the nineteenth century, during the nineteenth
flow was decisive in causing or curing disease. century it became identified with the humble tra-
Palmer focused on the nervous system as his ra- ditions of the working class. The lay public con-
tionale for spinal adjustment, and taught a specific tinued to seek out bonesetters for conditions like
adjustment of a particular segment to correct a spe- sciatica, lumbago, and rheumatism, even though
cific subluxation. bonesetters were refused access to hospitals. A few
3. Although long a part of healers’ art, manipula- medical doctors, Harrison, Hood, and Paget, con-
tion became a distinct entity within health care tinued to study and incorporate bonesetting tech-
in the late nineteenth century with the founding niques into their practice and published the results
of osteopathy. The theory behind manipulation’s of their work.
success in treating ailments varies from profes- 4. Osteopathy was originally based on manipulation,
sion to profession, as do the purposes for which but manipulative practice began to decline as os-
it is used. The practice and the outcomes remain teopaths moved closer to their allopathic brethren,
similar, governed by the body’s structure and re- incorporating materia medica and surgery in the
action to the manipulation. Osteopathy considera between the world wars. By the end of the
ered the body as a machine and the physician as 1950s, manipulative therapy appears to be an ad-
an engineer, employing specific long lever move- junct to other traditional medical treatments. To-
ments to restore physiologic harmony. Naprapa- day, manipulation has become a specialty within
thy was based on the theory that ligatites caused osteopathy.
the vertebrae to draw together and obstruct nerves 5. Although manipulation may have been a part of
and blood vessels. Relief was considered granted the armamentarium of the physical therapist from
through connective tissue manipulation. Physical its earliest times, it was not separated out as a dis-
therapy used mobilization techniques for the treat- tinct treatment until the 1990s. In the short time
ment of painful joint or soft tissue restrictions of the since then, the physical therapy profession has
spine or extremities. shown a strong interest in mobilization, suggest-
ing that manipulation in all forms is within their
scope of practice.
QUESTIONS
1. Give two examples of manipulation in Eastern KEY REFERENCES
healing. Anderson RT. On doctors and bonesetters in the 16th and
2. Describe the contribution Hippocrates made to the 17th centuries. Chiropr Hist 1983;3(1):13–14,20–21.
tradition of manipulation. Gaucher-Peslherbe PL. Antecedents to chiropractic. In:
3. Discuss the role of bonesetting in the nineteenth Peterson DR, Wiese GC. Chiropractic: An illustrated his-
century. tory. St Louis: Mosby, 1995.
Gaucher-Peslherbe PL. Chiropractic: Early concepts in their 14. Waerland A. Die chiropraktik und ihre erfolge im lichte der
historical setting. Lombard, IL: National College of Chi- menschheitsentwicklung. Bern: Blume, 1960.
ropractic, 1993. 15. Ligeros KA. How ancient healing governs modern thera-
Gevitz N. The DO’s: Osteopathic medicine in america. Balti- peutics. New York: Putnam, 1937.
more: Johns Hopkins Press, 1982. 16. Lewit K. Manipulative therapy in rehabilitation of the loco-
Harris D. History and development of manipulation and motor system, 3rd ed. Oxford: Butterworth-Heinemann,
mobilization. In: Basmajian JV, Nyberg G. Rational man- 1999.
ual therapies. Baltimore: Williams and Wilkins, 1993. 17. Drummer TG, Mahe A. Out on the fringe: Osteopathy,
Lewit K. Manipulative therapy in rehabilitation of the locomotor chiropractic and naturopathy. London: Parrish, 1963.
system, 3rd ed. Oxford: Butterworth-Heinemann, 1999. 18. Morell E. Manipulation as a curative factor. London:
Ligeros KA. How ancient healing governs modern therapeutics. Methuen & Co., 1931.
New York: Putnam, 1937. 19. Schiotz EH, Cyriax J. Manipulation past and present,
Lomax E. Manipulative therapy: A historical perspective pp 59–60. London: William Heinemann Medical Books,
from ancient times to the modern era. In: The research 1974.
status of spinal manipulative therapy: A workshop held 20. Beale LJ. A treatise on the distortions and deformities of the
at the National Institutes of Health, February 2–4, 1975. human body. Exhibiting a concise view of the nature and
DHEW Publication No. (NIH) 76-998; Bethesda, MD: treatment of the principal malformations and distortions of
1975. the chest, spine, and limbs. London: John Churchill, 1833.
Schiotz EH, Cyrix J. Manipulation past and present. London: 21. Tuscon EW. The cause and treatment of curvature of the
William Heinemann Medical Books, 1974. spine, and diseases of the vertebral column. London: John
Wardwell WI: Before the Palmers: An overview of chiro- Churchill, 1841.
practic’s antecedents. Chiropr Hist 1987; 7(2):27–33. 22. Lomax E. Manipulative therapy: A historical perspec-
Wardwell WI. Chiropractic: History and evolution of a profes- tive from ancient times to the modern era. In The re-
sion. St. Louis: Mosby, 1992. search status of spinal manipulative therapy: A work-
shop held at the National Institutes of Health, Febru-
ary 2–4, 1975. DHEW Publication No. (NIH) 76-998;
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23. Wardwell WI. Chiropractic: History and evolution of a pro-
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2. Gaucher-Peslherbe PL. Chiropractic: Early concepts in tury: From sects to science. Baltimore: Johns Hopkins
their historical setting, p 12. Lombard, IL: National Col- University Press, 1972.
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3. Wilk CA. Chiropractic speaks out: A reply to medical pro- spinal diseases: Illustrated with cases and engravings. Also
paganda and ignorance. Park Ridge, IL: Wilk Publishing an inquiry into the origin and care of distorted limbs.
Co., 1973. London: T & G Underwood, 1827.
4. Zarbuck MV. A profession for ‘Bohemian chiropractic’: 26. Joy RT. The natural bonesetters with special reference
Oakley Smith and the evolution of naprapathy. Chiropr to the Sweet family of Rhode Island: A study of an early
Hist 1986;6(1):78. phase of orthopedics. Bull Hist Med 1954;28:416–441.
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6. Anderson RT. Hawaiian therapeutic massage. World- 28. Paget J. Cases that bone-setters cure. Br Med J 1867;
Wide Report 1982;24(5):4A. 1:1–4.
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C H A P T E R
2
A BRIEF HISTORY OF THE
CHIROPRACTIC PROFESSION
Joseph C. Keating, Jr.
O U T L I N E
INTRODUCTION SCIENCE AND PUBLICITY
BEFORE CHIROPRACTIC PUSH FOR RECOGNITION
A TRADITION OF PROTEST SUDDEN VICTORY
FROM MAGNETISM TO ADJUSTMENT MORE MOUNTAINS TO CLIMB
THE CHIROPRACTIC PROTEST THE RECENT PAST AND NEAR FUTURE
THE SPREAD OF CHIROPRACTIC CONCLUSION
PROSECUTION, PHILOSOPHY, SUMMARY
AND LEGISLATION QUESTIONS
BASIC SCIENCE: THE NEW BATTLEFIELD ANSWERS
EDUCATIONAL REFORM KEY REFERENCES
RESEARCH IN THE MIDDLE ERA: REFERENCES
OBJECTIVES INTRODUCTION
1. To understand the historical context of the found- When historian Russell W. Gibbons quoted Brian
ing of chiropractic and to describe D. D. Palmer’s Inglis (above) in the first edition of this book, histori-
original experience and thinking. cal scholarship bearing on chiropractic was still very
2. To summarize the genesis of the struggle between much in its infancy. Two decades later, the saga of
“mainstream” medicine and chiropractic, and the the profession remains largely unknown to the wider
efforts of chiropractic to obtain legal, institutional, scholarly community, and only slightly more familiar
and social legitimacy. to doctors of chiropractic (DCs) themselves. However,
3. To describe and understand the initiation of var- the intervening 20 years have seen a burgeoning of his-
ious competing strands of thought and politics torical literature, encouraged largely by the efforts of
within chiropractic. Gibbons, William Rehm, DC, and others (see sidebar
4. To identify the major individuals, events, and mile- “Founders of the Association for the History of Chi-
stones in chiropractic history. ropractic, 1980”) who organized the Association for
5. To appreciate the past and its effect on the current the History of Chiropractic (AHC), created its period-
and future history of chiropractic and its institu- ical, Chiropractic History, and established the annual
tions, educational and licensing processes, profes- Conference on Chiropractic History.2 A much richer
sional status, and science. understanding of how chiropractic began and what
the profession has come through is now possible.
A way of thinking about the origins and devel-
The rise of chiropractic . . . has been one of the most remarkable so-
opment of a profession is as a series of steps toward
cial phenomena in American history . . . yet it has gone virtually
legitimacy and cultural authority. The saga of chiro-
unexplored.1
practic can be viewed in this fashion, with the caveat
23
others. And, in the waning days of the nineteenth

Founders of the Association for the century, several of these alternative methods would
History of Chiropractic, 1980 be drawn together under one umbrella and combined
Cheri D. Alexander, DC
with European hydrotherapy by German immigrant
Eleanore Blaurock-Busch
Benedict Lust, MD (1872–1945) (Fig. 2–1).10 Lust’s
Fern L. Dzaman
“naturopathy” (now often referred to as naturopathic
Leonard E. Fay, DC, ND
medicine) would be a thorn in the side of chiroprac-
Russell W. Gibbons
tic purists and the orthodox medical profession for
Vern Gielow
decades to come.
A. Earl Homewood, DPT, DC, ND, LLB
Proprietary or “patent” medicines were unregu-
Herbert K. Lee, DC
lated in this earlier era. The best ones were inert, while
Joseph E. Maynard, DC
the more potent concoctions frequently contained lib-
Ernest G. Napolitano, DC
eral doses of alcohol or opiates. Unlike the heroic and
Arthur L. Nickson, DC
highly toxic preparations of the “regular physicians,”
Viola Nickson, DC
patent medicines might well provide symptomatic re-
James F. Ransom, DC
lief, if only by deadening the senses. Any individual
William S. Rehm, DC
was at liberty to purchase whatever medicine the per-
James M. Russell, DC
son preferred; patent medicines flourished. Various
Richard C. Schafer, DC
mechanical and electrical apparatuses, each claiming
to build health or to relieve various diseases, vied with
regular physicians for customer-patients. As well, the
populist movement in the first half of the century had
that special circumstances have applied. This pro- succeeded in repealing what licensing laws for doctors
fession’s quest for recognition has been drawn out that had previously existed, and by 1852 anyone who
and complicated by an extended struggle for secu-
rity (the right to exist). Confronted by a powerful
adversary determined to “contain and eliminate” it,3
and by strenuous disagreements within its own ranks
over the purposes and methods of chiropractic, legiti-
macy has been slow in coming and cultural authority
remains beyond the horizon. Chiropractors’ historic
isolation from the wider health services and scien-
tific communities, although now beginning to lessen,
has also delayed legitimization by retarding the inter-
disciplinary cross-fertilization that other health care
providers have enjoyed. It has been, as Inglis and
Gibbons point out, a remarkable story.
BEFORE CHIROPRACTIC
Health care in the United States in the nineteenth cen-
tury was a patchwork quilt of providers and remedies
with very little regulation by government.4 Doctors
of medicine (MDs) included heroic practitioners,
homeopaths, eclectics, and practitioners of botanical
medicine. Vying with the MDs for patients’ business
were an assortment of what today are called com-
plementary and alternative medicine practitioners.
Among these were herbalists, vegetarians, faith heal-
ers such as Mary Baker Eddy (1821–1910) and the
Christian Science movement, Ellen G. White (1827–
1915) and the “medical evangelism” of the Seventh-
Day Adventists, Bernard Macfadden (1868–1955) and
the “physical culture” movement of body builders,5
magnetic6,7 and phrenomagnetic healers, bonesetters, FIGURE 2–1. Benedict Lust, MD, ND, father of naturopathy
mechanotherapists,8,9 electrotherapists, and sundry in America. (Courtesy of Friedhelm Kirchfeld, MLS.)
A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION 25
early 1800s. He also coined the term “allopathy” to

describe the dominant heroic tradition of prescribing
drugs to combat symptoms. The label stuck, but even
today some MDs find the term offensive.
Herbal and botanic remedies were similarly justi-
fied, if only by their relative safety. Samuel Thompson,
a self-trained American healer, organized “friendly
botanical societies” throughout the former colonies,
and marketed his plant-based remedies through them.
Thompson and his followers decried medical treat-
ment and insisted that every family should provide
for its own health care. His writings offered guidance
to the common man. The option to go to a hospital (if
any were available) was very much a last resort; hos-
pitals were places where the most seriously ill went to
die.
Homeopathic physicians, who were often
European, university-trained immigrants, were usu-
ally better educated than their allopathic competitors
in America. But as medical statutes were gradually
reintroduced in the latter half of the century (Table
FIGURE 2–2. Benjamin Rush, MD. 2–1), homeopaths often found it necessary to establish
their own schools and licensing authorities, owing to
cared to might hang a shingle and practice the heal- the hegemony practiced by the politically dominant
ing art. One of the motivations for the formation of the and more numerous allopaths. Eclectic physicians,
American Medical Association (AMA), in 1848, was to whose guiding principle involved using the best
seek methods of bringing order out of chaos. available treatments regardless of theoretical source,
With little if any scientific understanding of dis- likewise suffered from the political machinations of
ease, therapeutic anarchy prevailed. The dominant the emerging medical establishment.
healing sect in America was heroic medicine, a tra- The heroic/allopathic tradition had much to be
dition championed by Benjamin Rush, MD (1746– humble about. Although MDs might rail against the
1813), a signer of the Declaration of Independence unrestrained advertising of the patent medicine ven-
in 1776 and a strong opponent of medical hegemony dors and competition from sundry “quacks” (i.e., non-
(Fig. 2–2). Adherents to heroic medical concepts rec- allopaths), the cultural and legal authority that an
ommended that the harshness of a remedy should be embryonic biomedical science would one day confer
in proportion to the severity of the patient’s condi- still eluded them.12 The pioneering research of Lister,
tion. Strong emetics and cathartic preparations were Koch, and Pasteur was only just under way in the lat-
used to “purify” the digestive tract, and preparations ter half of the century, and the germ theory was a pop-
of mercury and other toxic substances were liberally ular target of humor. The surgical innovations (such as
administered.11 Bloodletting, from which the British appendectomies) that the Mayo brothers would fos-
journal Lancet drew its name, was employed to purge ter were still considered quackery.13 Not until 1906,
the blood of the impurities thought responsible for when President Theodore Roosevelt signed the first
disease. George Washington would die from the best Pure Food and Drug Act, would the first regulations
care his physicians could provide—a gross depletion be imposed on patent medications. Not until 1910,
of his blood in an effort to cure an infection. when Abraham Flexner, PhD, issued his devastating
The German tradition of homeopathy, established report to the Carnegie Foundation14 on the sorry state
by Samuel Hahnemann, MD (1755–1843), offered a of medical education in the United States and Canada,
gentler alternative. Based on Hahnemann’s theory of did the first sustained and well-financed efforts to re-
“similars,” homeopathic doctors prescribed weak di- form how doctors were trained begin.
lutions of substances that produced symptoms like Medical education in the nineteenth century was
those of the disease to be treated. If remedies based on meager at best. Many MDs had little more than an ap-
the notion that “like cures like” did not improve the prenticeship before hanging their shingles. Most med-
patient’s condition, neither did they distress the in- ical schools were proprietary, and laboratory train-
valid nor impair the individual’s endogenous healing ing in the basic sciences was often not available. A
ability. Hahnemann’s followers brought homeopathy few university-based medical schools along the east-
to America, where it found an eager following in the ern seaboard began to teach the newer concepts of
TABLE 2–1. Reintroduction of Medical Statues in America, 1873–1899
Year State/Territory
1873 Arizona Territorial Act

1874 Missouri
1875 Nevada
1875–1876 California
1876 Vermont
1878 Cherokee and Choctow Nations in Indian Territory
1879 Kansas,Texas
1881 Colorado
1886 Iowa
1889 Idaho, North Carolina, Tennessee
1890 Florida, Washington
1891 Alabama, Nebraska, North Dakota
1892 Maryland, Mississippi
1893 Connecticut, Kentucky, New York, Pennsylvania, South Dakota
1894 Georgia, Louisiana, Massachusetts, Maryland amended, New Jersey, South
Carolina, Utah, Virginia
1895 Arkansas, Delaware, Indiana, Maine, Minnesota, Montana, Oregon, Rhode
Island, New York amended
1896 District of Columbia, Ohio
1897 New Hampshire, Wisconsin
1899 Illinois, Michigan, Wyoming (no date listed, but defined; also not listed are
Alaska and Hawaii)
From Wilder A. History of medicine. New Sharon, ME: New England Eclectic, 1901:775–835 (Synopsis
of Medical Statutes). Courtesy of Robert B.Jackson, DC, ND, June 20, 1996.
sanitation, hygiene, and gentler medical treatment, involved an understanding of the individual’s psy-
but the influence of their graduates would take che by palpation of cranial bumps, and the animal
decades to spread across the continent. When licens- magnetism of Anton Mesmer, MD. Like homeopathy
ing laws first reappeared in the 1870s, educational cre- and herbalism, magnetic healing was not likely to hurt
dentials were often not required. Anyone who paid the patient, regardless of its efficacy or lack thereof
the licensing fee and registered with the county clerk (Fig. 2–3). Phrenology opened up the possibility of
could receive a certificate as a “physician and sur- understanding individual human behavior; phreno-
geon.” Populist sentiments still prevailed, and the magnetism suggested that a more precise and scien-
right of the individual to employ the doctor or method tific control of behavior was also possible. Americans
of his or her choice discouraged enforcement of medi- were teased by the possibilities science might bring.
cal statutes. Public health measures were often viewed In this climate of public probing emerged the
as government intrusion upon individual liberty. The mechanical healing metaphors of Andrew Taylor
right of the sick to get well became a rallying cry of Still.15–17 The son of a circuit preacher and frontier doc-
alternative medicine practitioners and their patients tor, Still (1828–1917) and his family were passionate
for decades to come. Methodist abolitionists who served with their state
The Civil War devastated the nation, and few fam- militia in the Civil War. The young man worked as
ilies escaped the human scars of war. Spiritualism, a a hospital orderly and perhaps also as a battlefield
method of communicating with the deceased, brought surgeon, eventually rising to the rank of major. In
solace to some and intellectual curiosity to many. the decade following the war he lost several chil-
Darwin’s novel biology made its debut in the 1860s, dren to spinal meningitis, despite the ministrations
and added a new type of causality to the push–pull of his medical peers. Determined to find effective al-
thinking of the machine age. Theosophical societies, ternatives to the heroic medical practices of his era,
which asserted that the laws of God and the laws of Still practiced as a magnetic healer before unfurling
the physical world were but reflections of one an- his “banner of osteopathy” in 1874.18 As a “lightning
other, gained enthusiasts. Into this popular intellec- bonesetter,” he likened the body to a machine and
tual soup was added a pinch of phrenology, which developed manipulative procedures to keep its parts
the osteopathic curriculum would eventually loosen

the ideological grip that he initially imposed. In the
United States, today’s doctor of osteopathy (DO) is a
“physician and surgeon” in the broadest legal sense
of the term.
A TRADITION OF PROTEST
The early roots of chiropractic were planted in the
rich soil of late nineteenth century enlightenment and
liberty. The hazards of the heroic medical tradition
were widely appreciated, as were the possibilities for
a more scientific healing art. The populist sentiments
of early nineteenth century, including an aversion to
medical orthodoxy and the rallying cry of “medical
freedom,” were still in evidence. When Daniel David
Palmer opened his first clinical office in Burlington,
Iowa, in 1886,19 the future founder of chiropractic
could reasonably expect to practice without interfer-
ence from the local medical community (Fig. 2–4). If
he had begun practice 5 years earlier, he might even
have secured a license as a physician, had he chosen
to.19 In the 1860s and 1870s, Burlington had been home
to famed magnetic healer Paul Caster, and in the late
1880s, Caster’s son continued the family tradition.20
Palmer reestablished his magnetic practice in Daven-
port, Iowa, in 1887,20 perhaps in search of a less com-
petitive venue.
The father of chiropractic was born a few miles east
of Toronto at Brown’s Corner, then an agricultural re-
gion in the town of Pickering, and was raised there and
FIGURE 2–3. Nineteenth century caricature of the magnetic

practitioner.
in working order. Anticipating the later discovery of

endorphins, enkephalins, and neurotransmitters, Still
believed that the brain manufactured the body’s own
healing substances. Health, he proposed, could be
maintained and restored by keeping the various chan-
nels (circulation and nerves) from the brain to the end
organs free of obstructions. It was a mechanical theory
of health and illness, yet harkened back to medieval
humoral theories.
Conceived as a reformation of medical methods,
Still and his osteopathy were rebuffed by the “reg-
ular” (allopathic) medical community.15 Undeterred,
he practiced as an itinerant healer in several midwest-
ern states before settling in Kirksville, Missouri, where
he built his clinic and opened the American School
of Osteopathy in 1892. The medical members of his
faculty sought to broaden the scope of instruction to FIGURE 2–4. Seated left to right: D. D. Palmer and his father,
include pharmaceuticals, but the “old doctor” would Thomas; standing left to right: brothers Thomas J. and Bartlett
have none of it. However, his inclusion of surgery in D. Palmer, circa 1890.
further east in Port Perry, Ontario.21 D. D. Palmer did

their use, even to self-destruction. These misguided un-
not attend school beyond the sixth grade, but devel-
fortunates, half-living witnesses of medical incompetency,
oped a hunger to learn, which he attempted to satisfy
can be seen everywhere. Wasting diseases and prema-
as an avid reader. He was the eldest of six children,
ture deaths grow more frequent, in open defiance of med-
and matured in a culture that valued industriousness,
ical skill. (?) The simplest forms of fevers invade the family
independence, respect for elders, and a free market.
circle and leave death and desolation, as they did two thou-
The family was of Scotch, Irish, English, and German
sand years ago, when the science (?) of medicine was in
stock,22 and worshipped as fundamentalist Christians
its infancy.
(known as Millerites or Adventists). When jobs in
It is no wonder that the sick leave the regular medical
Ontario grew scarce owing to the influx of draft
fraternity and go to the “quacks” for relief.
evaders during the Civil War, D. D.’s father, unsuc-
Every man and every woman who can cure is divinely
cessful in business, relocated the clan to rural, mid-
ordained to heal, and their duty to God and humanity de-
west America along the Mississippi River circa 1865.21
mands that they do it. The license of all such is a natural
During the 1870s and early 1880s, D. D. made his living
license, which no legislature nor bigoted board of medical
as a farmer, beekeeper, and school teacher, and kept
monopolists may revoke.
meticulous records of his crops, business dealings, and
lesson plans. His was an ordered but inquisitive mind. Legislation (?) Wanted
Palmer could have practiced his magnetic tech- Yes, by all means let us have more stringent medical laws.
niques quietly in Davenport, but that was not his We all admit that class legislation leads to tyranny, but
style. As was the custom of the day, he assumed the that is what we need in this land of personal liberty. The
title “Doctor,” thereby implicitly challenging the sta- people are cursed with too much freedom, especially in
tus and credentials of the allopathic community. Dr. their choice of medical advisers and constant resort to the
Palmer widely advertised to “Cure Disease Without counter-prescriber. Surely all sensible physicians will ad-
Medicine,” and distributed newspaper-size fliers, suc- mit, without argument, that all medicines not prescribed
cessively known as The Educator and The Magnetic by regular graduates is damaging (to the profession) and
Cure, to reach prospective patients (and later, stu- should be prohibited by law. Surely, now that class legis-
dents). Palmer’s fliers were full of testimonials and lation is running to seed, we doctors ought to lobby for a
taunts directed at his allopathic competition (see side- law to protect the profession and prevent such a shameful
bar “Examples of Dr. Palmer Taunting the Competi- robbery of the physician.
tion in The Magnetic Cure, 1896”). Among the condi- Can’t we have the druggists fined for selling medi-
tions he claimed success with were “Diseases of the cines to such patients? Or, perhaps, it would be better
Head, Throat, Heart, Lungs, Stomach, Liver, Spleen, to have such foolish people arrested and placed under
Kidneys, Nerves, and Muscles, ten times quicker than the care of the doctor who owns the largest number of
any one can with medicines”.23 Palmer competed di- diplomas. This would give a great impetus to the diploma
rectly with the medical establishment, and rubbed business, and enable some of the “mills” to add another
their noses in it. course of lectures to their tyrannous exactions.
There are but two horns to the dilemma. We must
Examples of Dr. Palmer Taunting the either have the medical profession so hedged about by le-
Competition in The Magnetic Cure, 1896 gal enactments that it will be harder to get into than a
burglar-proof safe, or we must take more medical jour-
A QUACK doctor is one who cures by irregular means nals, buy more books, and study harder than we ever did
what a regular doctor cannot cure. before. Let us have the law; the more tyrannical the bet-
MY MOTTO ter. It is much easier to get laws enacted than to sit up
I give such balms as have no strife nights reading medical literature. . . .
With nature or the laws of life; The Constitution of the United States says: “No state
With blood my hands I never stain, shall pass any law abridging the privileges or immunities
Nor poison men to ease their pain. of any citizen of the United States; nor deprive any person
MEDICINE A SCIENCE (?) of life, liberty or property without due process of law.”
For many years there has been growing in the public
mind a suspicion that medicine is not a science, but that Can Drugs Cure Disease?
it is most experimental guesswork. All action must come from an active source, and an active
This ancient system of poisoning the sick has a lawful source must be a source of life. In the case of “drug ac-
right to fill our poorhouses, Keeley institutes, and asylums tion,” is the life in the drug or in the patient? Drugs have no
with their poisoned victims. They are dosed with stimu- effect on a dead body. Being in the live patient, the action
lants, sedatives, and narcotics until they must continue is necessarily from it and upon the drug. Medicines, when
disease and was always deleterious. He would “cool

taken into the stomach, are treated by it as an enemy,
off” the hot, inflamed tissue by pouring his personal,
a poison which is to be gotten rid of, either by vomiting
excess, vital magnetic force into the identified lesion.
or purging. The medical fraternity express it clearly when
D. D. considered his method superior to that of other
they say, “our most powerful remedies are our most viru-
magnetic healers because he did not waste his vital
lent poisons.” Why the most powerful? Because they call
energy by distributing it diffusely over the entire body
forth the greatest amount of vital action from the patient
of the patient.
to throw off the poison. All chemical compounds, called
During his years of magnetic practice, the inquis-
medicines, are dead, lifeless, and are powerless to sus-
itive Palmer arrived at the theory that inflamma-
tain life.
tions were caused by displaced anatomic parts: ar-
Compulsory Vaccination is Criminal
teries, veins, nerves, muscles, bones, ligaments, and
joints. Such displacements, he reasoned, created fric-
If there is virtue in vaccine virus, the vaccinated are amply
tion, heat, and inflammation. The first of his three the-
protected against the unvaccinated. If there is no virtue in
ories of chiropractic (Table 2–2) was an extension of
vaccination, coercion is vile and villainous.
his magnetic rationale.24–26 Although the self-styled
Who will contend that the old systems of healing are
“magnetic manipulator”27 was initially quite secre-
the best, and should have exclusive Legal rights. New dis-
tive about his clinical procedures, in July 1896 he in-
coveries are the order of the day in mechanics, science,
corporated his Palmer School of Magnetic Cure28 to
and arts, why not in healing the sick? Is there not a de-
teach and spread his clinical insights. The following
mand for more light in this direction?
January he offered to teach “the chiropractic” to any
“intelligent person.”27 Early training involved little
more than an apprenticeship at Palmer’s 40-bed infir-
mary and clinic in downtown Davenport.
Likening his role in the profession to that of Mary
FROM MAGNETISM TO ADJUSTMENT
Baker Eddy, the founder of Christian Science, “Old
Palmer prided himself on a unique form of magnetic Dad Chiro” similarly claimed that the principles of
treatment that involved the same anatomic specificity chiropractic theory had been revealed to him by
that would subsequently characterize his chiropractic spiritual sources.29 However, the origins of D. D.’s
methods. He used his sensitive magnetic fingers to unique, segment-specific thrusting manipulations are
palpate the patient for the site of inflammation; Palmer not known. He acknowledged that he had studied
believed that inflammation was the essential feature of osteopathy and a variety of other alternative healing
TABLE 2–2. D. D. Palmer’s Theories of Disease, 1896–1914
Concept 1896* 1897–1902† 1904–1906‡ 1908–1910¶ 1914§
Therapeusis Yes Yes No No No

Method of intervention Magnetic Manipulation Adjustment Adjustment Adjustment
Foraminal occlusion ? ? Yes No No
Circulatory obstruction ? Yes No No No
Nerve pinching ? Yes Yes No No
Nerve vibration ? ? ? Yes Yes
Nerve stretching ? Yes Yes Yes Yes
Machine metaphor ? Yes Yes Yes/no Yes/no
Tone (Vital) (Vital) Absent Yes Yes
Innate/educated Absent Absent Nerves; Intelligence Intelligence
Intelligence
Religious plank Yes Absent Absent Optional Obligatory
* From The Magnetic Cure, a newspaper-sized advertiser published by D. D. Palmer.

†
From The Chiropractic, which was a continuation of D. D. Palmer’s magnetic advertiser during the early years of his chiropractic practice.
‡
From The Chiropractor, which was a journal published by D. D. Palmer and his son, B. J. Palmer, beginning in December 1904 at the Palmer School
in Davenport.
¶ From The Chiropractor Adjuster, which was D. D. Palmer’s journal published in Portland by the D. D. Palmer College of Chiropractic, and The
Chiropractor’s Adjuster, which was the title of his 1910 book.
§ From The Chiropractor, a collection of D. D. Palmer’s essays posthumously published by his wife.
TABLE 2–3. Comparison of D. D. Palmer’s 1897 and 1904 Theories of Cancer
Theory, 1897* Theory, 1904†
. . . The cause is an obstruction to the blood circulation and Cancers are but the symptoms of impinged nerves. We no
an injury to certain nerves. Show us a case of cancer—no longer wonder that there are so many kinds when we
matter in what portion of the body that cancer may consider that no two of us sense alike. All cancers, no
be—and we will at once show you two injuries that matter in what part of the body, have one and the same
obstruct the blood circulation and injure certain nerves. It cause; they are all produced by injured nerves, but the
is this combination of injured nerves and obstructions that effect of these irritated nerves show their dissimilarity in
cause cancers. the great diversity of cancers.
* Palmer DD. Cancers: Their cause and cure. Chiropractic 1897;17:2.

†
Palmer DD. Cancers: Their cause and cure. Chiropractor 1904;1(1):15.
systems,30 but adamantly denied that he had ever vis- “borrowing” of manual methods among professions
ited or been treated at Andrew Still’s Kirksville insti- (e.g., chiropractic, manual medicine, naturopathy, os-
tution. The traditional anecdote of Palmer’s first chi- teopathy), although this cross-fertilization tends to be
ropractic adjustment has several variants; the earliest ignored for political reasons.
known account was authored by the patient, Harvey D. D. Palmer’s chiropractic continued to evolve, as
Lillard, a janitor in the building where D. D. practiced. can be discerned by comparing two distinct explana-
Palmer published Lillard’s testimonial in the January tions for cancer, the first offered in 1897 and the sec-
1897 issue of his renamed advertiser, The Chiropractic: ond in 1904 (Table 2–3). In 1903, he reduced his clinical
concern to the relief of nerve compression secondary
Deaf Seventeen Years: I was deaf 17 years and to subluxation of joints.26 It was this second of his
I expected to always remain so, for I had doc- theories that would prevail throughout much of the
tored a great deal without any benefit. I had chirocentury. However, by this time Palmer had devel-
long ago made up my mind to not take any oped methods of adjusting all the joints of the body,
more ear treatments, for it did me no good. including those of the feet, where neural compres-
sion was not possible. The founder’s 1910 volume22
Last January Dr. Palmer told me that my deaf- revealed still further metamorphosis in his thinking:
ness came from an injury in my spine. This nerve stretching and slackening as the critical factor in
was new to me; but it is a fact that my back disease production. Old Dad Chiro now denied that
was injured at the time I went deaf. Dr. Palmer nerves were “pinched” in the intervertebral foram-
treated me on the spine; in two treatments I ina, insisting instead that any subluxated joint could
could hear quite well. That was eight months alter the tension in nerves, and thereby modify their
ago. My hearing remains good.31 effective message to end organs. From this tension-
regulation point of view,35 , it mattered not whether a
nerve passed between bones; a classic quotation cap-
With the assistance of a patient, Reverend Samuel
tures some of this theoretical rethink:
Weed, Palmer named his new method from Greek
stem words, meaning “done by hand.” As disciples
increased in the early years of the twentieth cen- “I have never felt it beneath my dignity to do
tury, chiropractors’ hand maneuvers multiplied even anything to relieve human suffering. The re-
more rapidly (including adjusting by instruments).32 lief given bunions and corns by adjusting is
By 1911 the founder’s son, Bartlett Joshua Palmer, in- proof positive that subluxated joints do cause
cluded “An Exposition of Old Moves” in texts dis- disease.”22
tributed by the Palmer School of Correspondence; in
this he enumerated more than 170 adjustive proce-
dures that had blossomed in the profession’s first 15
THE CHIROPRACTIC PROTEST
years.33,34 Yet this early technique proliferation only
foreshadowed the continuing creation of new chiro- Palmer’s feisty style and direct verbal assault on his
practic procedures throughout the coming decades. medical competitors prompted retaliation. A war of
Hundreds of “brand name” chiropractic techniques words erupted in the Davenport newspapers and in
have been offered over the course of the profes- Palmer’s advertiser. The Chiropractic in 1899 devoted
sion’s first century. There has also been considerable much of its space to refuting the charges of Heinrich
Matthey, MD, a local allopath who disputed the pro- or time in jail. Outraged, Palmer refused to pay the
fession of osteopaths as the “basest of swindlers.”36 fine and was incarcerated (see sidebar “How to be
Matthey’s antipathy toward Palmer may have also Happy in County Jail”). It was the first of many volun-
operated behind the scenes in a dispute that erupted tary “martyrdoms” for chiropractic in the next seven
in 1900 between Palmer and one of his students, decades.
H. H. Reiring, who had voiced dissatisfaction with
the curriculum of the Palmer School and demanded
a return of his $500 tuition. Palmer had the police re- “How to be Happy in County Jail”
move the young man from the campus but failed to
Be sure you are in the right.
press charges, prompting Reiring to file suit for false
Keep busy; always have something to do.
arrest.37 This episode may have been part of the impe-
Keep your person and room clean and neat.
tus for Palmer’s departure for California in the spring
Don’t worry. Let the fellow who committed the injustice do
of 1902.
that.
Palmer’s stay in Pasadena was brief, and marked
If you are in the right, you can afford to hold your temper;
by his indictment for practicing medicine without a
if in the wrong, you can’t afford to lose it.
license following the death of a patient under his care.
Be thankful for small favors, hoping to receive larger ones.
The charges were dropped owing to a legal technical-
Have no regrets. Take your medicine with a smile.
ity, and D. D. moved on to Santa Barbara, where he
Jails have contained some of the best, as well as the
continued to teach and practice. However, by Decem-
worst, men.
ber 1904 he was back in Davenport (Fig. 2–5), were
Treat the sheriff, turnkey, and guards with due respect;
he and son B. J., who had revived and managed the
they have their duties to perform.
Palmer School in D. D.’s absence, commenced publi-
Have a clear conscience and a good appetite.
cation of The Chiropractor. It was this periodical, and
Feel that your cause is just, that you are imprisoned for
the claims for chiropractic made therein, that served as
righteousness. Thus does time pass quickly and pleas-
the basis for the founder’s trial for unlicensed practice
antly.
in 1906.19
Others have suffered for conscience sake and the uplifting
The father of chiropractic offered a meager legal
of their fellow men.
defense, calling no witnesses on his behalf and claim-
Persecution or prosecution creates sympathy, sympathy
ing only that the practice of chiropractic did not con-
generates investigators, investigation produces followers,
stitute the practice of medicine. The jury promptly
who become more zealous and persistent in spreading
convicted, and the judge imposed the choice of a fine
their peculiar doctrines.
Thousands will be benefited by my incarceration. It has al-
ready been copied in hundreds of newspapers, and stim-
ulates the growth of our business.
Radical changes cannot be made “on feathery beds of
cane;” new thoughts of great importance cannot be born
without labor.
“Truth crushed to earth will rise again.” DR. D. D.
PALMER, Discoverer and Developer of Chiropractic.
From Palmer DD. Davenport Democrat & Leader, 6 April 1906:6.
D. D. Palmer and his son parted company follow-

ing the father’s release from jail. The elder headed
to Oklahoma and later Oregon, where he established
several chiropractic schools. Meanwhile, young Dr. B.
J. Palmer (1882–1961) took complete charge of the
Palmer School of Chiropractic (PSC). Recognizing the
legal jeopardy faced by his growing alumni body, in
1906 he organized the Universal Chiropractors’ As-
sociation (UCA), a protective society that provided
attorneys’ services to member DCs charged with un-
licensed medical practice. The UCA’s first test came
in 1907, when PSC graduate Shegatoro Morikubo, a
FIGURE 2–5. D. D. Palmer, circa 1906. naturalized American citizen practicing in LaCrosse,
jury that the practice of chiropractic was not the prac-

tice of osteopathy.38
To accomplish this, Morris relied on expert wit-
nesses who held degrees in both manual healing dis-
ciplines. These osteopath-chiropractors testified to the
dissimilarity in theory and technique between the pro-
fessions. Chiropractors, it was argued, were only inter-
ested in the nervous system, whereas the osteopathic
“rule of the artery” focused DOs solely on the circula-
tion. This contention was not true, but was consistent
with the revised and reduced theory of chiropractic
that the founder had introduced in 1903.26 The experts’
testimony was buttressed by the introduction into ev-
idence of the first textbook of chiropractic, Modernized
Chiropractic, authored by several Palmer alumni and
competitors in the school business: Oakley Smith, Mi-
nora Paxson, and Solon M. Langworthy.39 Modernized
Chiropractic declared that chiropractors had a “sepa-
rate and distinct” philosophy and practice.
The jury took less than an hour to return a ver-
dict of “not guilty.” Morris was hired as chief legal
counsel for the UCA, a post he would hold until his
death in 1928.40 Young Dr. Palmer, delighted by the
way that “philosophy” had saved the day, had his
faculty at the PSC award him the first ever “PhC”
(Philosopher of Chiropractic) degree in 1908. Armed
with chiropractic’s separate and distinct philosophy,
chiropractors argued their case in thousands of trials,
and usually prevailed when cases were heard by ju-
ries. As well, the “separate and distinct” contention
FIGURE 2–6. Tom Morris, LLB. (Courtesy of Cleveland Chiropractic formed the centerpiece of DCs’ petitions to state legis-
College of Kansas City, Library Archives.) latures for chiropractic licensing laws. Thanks to Mor-
ris, who subsequently served as lieutenant governor
Wisconsin, was arrested for practicing medicine, of Wisconsin, the chiropractic protest had a fighting
surgery, and osteopathy without a license. The indict- chance.
ment was brought at the request of the osteopathic
member of the state medical board, and there were
THE SPREAD OF CHIROPRACTIC
strong racial overtones as well. The Japanese navy had
defeated a Russian fleet in 1902, and the “yellow scare” The earliest diplomas in chiropractic issued by D. D.
was widespread in the United States. Palmer authorized his graduates to “teach and prac-
As secretary of the UCA, B. J. Palmer hired state tice” the new healing art. The father of chiropractic
senator and former district attorney Tom Morris to must have been chagrined when several of his first
represent Morikubo (Fig. 2–6). It was a fortunate graduates took this mandate literally and competed
choice, for the Canadian-born Morris brought a num- with him for students. One such example was that of
ber of skills to the task. He had studied medicine Solon Massey Langworthy, DC, a 1901 Palmer gradu-
briefly before turning to the law, and delighted in ate who organized the American School of Chiroprac-
championing the underdog. As well, the prosecutor, tic & Nature Cure in Cedar Rapids, Iowa, and drew
Otto Bosshard, was a personal friend and protégé. Palmer alumni Oakley Smith and Minora Paxson to
Morris approached the district attorney to suggest his institution as dean and chair of obstetrics and gy-
that charges of the unlawful practice of medicine and necology, respectively.39 But it was just the beginning
surgery be dropped, because Dr. Morikubo had used of a fairly rapid proliferation of chiropractic schools,
only his hand (no drugs, no surgery) to heal. When including at least three established by the founder
Bosshard acquiesced and agreed to try the Japanese (Table 2–4). The schools would collectively produce
American chiropractor solely for the unlicensed some 12,000 practicing chiropractors by 1930.
practice of osteopathy, a weak legal precedent was cre- Early chiropractic schools were strictly for-profit
ated. Now the challenge for Morris was to convince a ventures, with great variations in the breadth and
TABLE 2–4. Several of the Earliest Schools of Chiropractic
Founding
Date Institutional Name Location Founder
1896 Palmer School of Magnetic Cure Davenport, IA D. D. Palmer

1903 American School of Chiropractic Cedar Rapids, IA Solon Massey Langworthy, DC
& Nature Cure
1904 Marsh School of Chiropractic Portland, OR John E. Marsh, DC
1904 Pacific School of Chiro-Practic Oakland, CA Harry D. Reynard, DC
1905 American School of Chiropractic New York Benedict Lust, MD, ND, DC
1905 Parker School of Chiropractic Ottumwa, IA Charles Ray Parker, DC
1906 Carver-Denny School of Chiropractic Oklahoma City, OK Willard Carver, LLB, DC, and
Lee L. Denny, DC
1906 National School of Chiropractic Davenport, IA (relocated John F. A. Howard, DC
to Chicago in 1908)
1907 Palmer-Gregory College of Chiropractic Oklahoma City, OK D. D. Palmer and Alva Gregory,
MD, DC
1908 D. D. Palmer College of Chiropractic Portland, OR D. D. Palmer and L. M.
Gordon, DC
1908 Texas Chiropractic College San Antonio J. N. Stone, MD, DC
1908 Michigan Clollege of Chiropractic Grand Rapids, MI N. C. Ross, DC
1908 Ratledge System of Chiropractic Guthrie, OK T. F. Ratledge, DC
Schools
1909 Wichita College of Kiropractic Wichita, KS J. G. Wilson, DC
1909 Robbins Chiropractic Institute Sault Ste. Marie, Ontario W. J. Robbins, MD
1909 Pacific College of Chiropractic Portland, OR William O. Powell, DC
1910 New Jersey College of Chiropractic & Newark, NJ Frederick W. Collins, DO, DC
Naturopathy
1910 San Diego School of Chiropractic San Diego F. B. C. Eilersficken, DC
1911 Ratledge System of Chiropractic Los Angeles T. F. Ratledge, DC
Schools
1911 Los Angeles College of Chiropractic Los Angeles Charles A. Cale, DC
1911 Oregon Peerless College of Portland, OR John E. LaValley, DC
Chiropractic & Neuropathy
1911 Bullis & Davis School of Neuropathy, Los Angeles Benson Bullis, DC, and Andrew
Ophthalmology & Chiropractic P. Davis, MD, DO, DC
1913 California Chiropractic College Los Angeles Albert W. Richardson, DC
1914 Canadian Chiropractic College Hamilton, Ontario Ernst DuVal, DC
depth of biological and clinical subjects taught. The dabbled in correspondence training for at least part of
original Palmer curriculum was only 3 months in the curriculum (Fig. 2–7).
duration. Twenty years later, consensus had formed The growth in the chiropractic ranks is attributable
around a course of 18 months, and the Palmer to additional factors. Like several other “irregular”
School would maintain this length of training into healing sects, chiropractors offered a gentle alterna-
the 1950s. However, even this minimum curricular tive to the harsh remedies of allopathic medicine.
standard seemed substantial in comparison to the Many early chiropractors marketed themselves as
“correspondence schools” that sprang up in the first “drugless doctors,” although this was frowned upon
few decades of the chirocentury. These mail-order for ideological reasons by the “purists” such as B.
diploma mills, most prominently the American Uni- J. Palmer and T. F. Ratledge.42 The extensive mar-
versity of Chicago,41 would stain the integrity of chi- keting examples set by the Palmers, although con-
ropractic education for decades to come. But in those sidered unethical by orthodox medicine, broadcast
early years, even some of the better schools, includ- the “gospel of chiropractic” far and wide. In ad-
ing the National in Chicago and the Palmer School, dition to advertising in the popular media and in
least for a few years. Not until the 1974 recognition of

the Council on Chiropractic Education (CCE) by the
US Office of Education, which brought with it eligi-
bility for federally guaranteed student loans, would a
steady stream of students become available.
A final and paradoxical factor in the expansion of
the chiropractic ranks involves the persecution of the
profession. Organized medicine’s persistent attempts
to “contain and eliminate” chiropractic created a sol-
idarity among the besieged. Beset by criminal pros-
ecutions, chiropractors rallied to defend their heal-
ing art and their livelihoods. The passions created by
repeated arrests, prosecutions, and jailings created a
bond among doctors and a determination to resist.
How chiropractors adapted and overcame this on-
slaught is part of the larger story of their quest for
legitimacy, but in the short term, DCs’ campaigns to
win their own licensing laws and regulatory boards
also aided in the growth of the profession by keeping
the fires of missionary fervor well stoked and fueled.
FIGURE 2–7. Early advertisement for correspondence training

from the Palmer School.
PROSECUTION, PHILOSOPHY,
AND LEGISLATION
alternative healing journals (e.g., Benedict Lust’s The glue that bound the profession together during its
Naturopath & Herald of Health), chiropractors were en- early struggles was the “philosophy of chiropractic”
thusiastic publishers of their own magazines, pam-
phlets, and brochures. Early periodicals included
The Chiropractor and the Fountain Head News (pub-
lished by the Palmer School), the Backbone (published
by the American School in Cedar Rapids), and the
American Drugless Healer (published by the American
Chiropractic Association of Oklahoma City). These
magazines carried clinical anecdotes and theoretical
discourses, news of chiropractic events, reports of
prosecutions, and, in later years, reviews of legisla-
tive and lobbying activities related to chiropractors’
quest for licensure. Their contents supplemented the
evangelical zeal taught at the schools, extending it
into doctors’ offices and on to patients and prospec-
tive students. It also seems likely that the intuitively
appealing theory of spinal nerve pinching and man-
ual correction that these periodicals spread was itself
a stimulus to growth in the chiropractic ranks.
Perhaps the biggest boon to chiropractic educa-
tion and the growth of the profession in the first eight
decades of chiropractic was the two world wars. Vo-
cational training benefits offered by the Veterans Bu-
reau (after World War I) provided federal funds for the
students’ tuition. The Palmer School reported more
than 3000 students in 1922, and by 1925 as many as 82
schools may have been in operation.43 The economic
depression of the 1930s saw a drastic decline in num-
ber of schools and sizes of student bodies. However,
the GI Bill (following World War II) once again flooded FIGURE 2–8. Dr. John F. A. Howard, founder of the National
the chiropractic institutions with new enrollments, at School of Chiropractic. (Courtesy of National College of Chiropractic.)
that won the first acquittal in 1907. Its “separate and nerves to the end organs. Any care beyond this was
distinct” character sprouted wings as B. J. Palmer elab- branded “medical,” and, as B. J. would say, “whether
orated upon his father’s notions of Universal Intel- you like it or not.”
ligence (God), Innate Intelligence (an individualized B. J. Palmer wrapped himself in the new chiro-
portion of Universal residing within the patient and practic philosophy, and as secretary of the UCA and in
controlling her/his physiology), and Educated Intelli- concert with the protective society’s chief legal coun-
gence (the repository of knowledge acquired by indi- sel, Tom Morris, organized the defense of thousands
viduals through experience and learning). Cosmic in of chiropractors arrested for unlicensed practice. Al-
its implications, pragmatic in its courtroom and clin- though several other protective societies competed
ical applications, B. J. Palmer’s philosophy became with the UCA for members and dues, not until the
both defense and explanation of all things chiro- 1922 establishment of the Chicago-based American
practic. Terms such as diagnosis and treatment were Chiropractic Association (ACA) was there any seri-
banned as “medical” from B. J.’s “straight” lexicon, re- ous and enduring rival to the UCA’s preeminence.
placed by “spinal analysis” and “adjustment.” Broad- From the time of his father’s death in 1913, and
scope or “mixer” dissenters from Palmerian chiro- notwithstanding unfounded charges of patricide,45
practic, such as John Howard, DC (Fig. 2–8), later B. J. Palmer was truly a “majority leader” in the pro-
acknowledged that this new jargon amounted to fession (Fig. 2–9).
“garments to protect the child until legal clothing Trials of chiropractors frequently took on carnival-
could be secured,”44 but many chiropractors accepted like features. The UCA could call upon an extensive
the new terminology as requisite truths. The chiro- team of specialized attorneys and experienced, ex-
practor’s sole concern, argued the purists, was the de- pert witnesses to make their legal points, and if the
tection and manual correction of subluxation, so as to courtroom proceedings were within a convenient dis-
free obstructed nerves and allow Innate Intelligence tance by train from Davenport, the PSC would pack
to direct healing messages from the brain through the the courtroom with students. Even when held at a
FIGURE 2–9. Students and faculty of the Palmer School, circa March 1910, who traveled to Montezuma, Iowa, to attend the trial
of State of Iowa vs. Corwin, a chiropractor. The two men standing center, front are the local sheriff and the defendant; C. Sterling
Cooley, DC, is fourth and B. J. Palmer is fifth from left in rear row. Note the “PSC” armbands. (Courtesy of Texas Chiropractic College.)
distance, the chiropractors could often depend upon TABLE 2–5. Early Chiropractic Practice Acts
throngs of loyal patients, who strenuously demon- in the United States
strated on behalf of their local doctor. Although politi-
cal medicine succeeded in bringing about the prosecu- Date of
tions of an estimated 15,000 chiropractors by 1930,46 Enactment Jurisdiction
the DCs prevailed in nearly 80% of these cases. The
likelihood of acquittal was greatly increased if the 1913 Kansas, Michigan
case was tried by a jury (rather than by a judge), be- 1915 Arkansas, North Dakota, Ohio, Oregon,
cause public sentiment rejected the legal monopoly Wisconsin*
that allopathy held. If the state would not license chi- 1916 Colorado
ropractors, juries would not convict them for practic- 1917 Connecticut, Illinois, North Carolina
ing medicine. 1918 Montana
Palmer and Morris were initially opposed to li- 1919 Florida, Idaho, Minnesota, Nebraska,
censing statutes for chiropractors (see, e.g., references Vermont, Washington
47–49). They argued that separate and distinct li- 1920 Kentucky, Maryland
censing laws and boards of examiners, hard won by 1921 Arizona, Georgia, Iowa,
the strenuous efforts of straight chiropractors, would New Hampshire, New Mexico,
eventually be compromised when “mixers” were ap- Oklahoma
pointed to such boards. Palmer also contended that 1922 California, Nevada, South Dakota
licensing of all healers, MDs, DCs, DOs, or otherwise, 1923 Tennessee, Utah
was inappropriate on the grounds that it usually failed 1924 Maine
to provide protection to the public, the justification for 1925 West Virginia
passage of such laws. Health care, he insisted, was a 1927 Indiana, Missouri
commodity like any other—the marketplace, he be-
lieved, would weed out the incompetent. * The Wisconsin law did not license chiropractors per se, but permit-
ted them to practice if the DC hung a sign indicating the absence of
Palmer and the UCA leadership were out of step licensure.50,51
with the profession-at-large on this point. Kansas Data from American College of Chiropractors. Medical education ver-
passed the first chiropractic statute in 1913, and North sus chiropractic education. National publicity series no. 3 (pamphlet).
Dakota issued the first chiropractic license, to Guy G. New York: The College, 1927.
Woods, DC, in 1915. (The governor of Kansas had re-

fused to appoint a chiropractic examining board on each” training into the 1950s. These early disagree-
the grounds that the available DCs in the state had ments over scope of practice and curricular standards
practiced illegally, and were therefore ineligible to foreshadowed decades of intense and sometimes bit-
serve.) In less than a decade more than half of the then ter feuding within the profession.
48 American states followed suit (Table 2–5). Bow- But the chief antagonist was organized medicine,
ing to the inevitable, Palmer and Morris redirected which prevailed upon the state attorneys general and
their efforts, and sought to organize the emerging state district attorneys to prosecute DCs in those jurisdic-
boards of chiropractic examiners. One of the earliest tions that did not yet license chiropractors. Charles
meetings of these licensing authorities took place at Lemly, DC, of Waco, Texas (Fig. 2–11) supposedly was
the Palmer School in 1919 (Fig. 2–10), and subsequent arrested 66 times, although he never spent more than
meetings were held in conjunction with the annual a few nights in jail. Herbert Reaver, Sr., DC, of Ohio
lyceum (homecoming) of the PSC and convention of may hold the record for greatest number of incar-
the UCA. In 1921, Palmer proposed a National Board cerations; after his tenth stint behind county bars he
of Chiropractic Examiners (the first of three so-named was warned that the next time he would be consid-
agencies), whose purpose was to examine and issue ered a felon, whereupon he relocated to Florida.52 In
certificates to license applicants, and with the hope California, prior to the 1922 law passed by the vot-
that the examination results would be accepted by the ers, the state medical society reportedly adopted a
various state boards of examiners. By this time also, policy of keeping at least one chiropractor behind
the UCA had introduced its “Model Bill” for imple- bars in each county, so as to set a vivid example.
mentation in those states that had not yet passed chiro- Chiropractors in the Golden State reacted by adopt-
practic statutes. The Model Bill called for an 18-month ing the Palmer-advocated policy of “Go to Jail for
curriculum in a chiropractic school and a “straight” Chiropractic.”53 When convicted, the DC refused to
scope of practice. Many chiropractic educators con- pay any fine (which money would have furthered the
sidered 18 months of training a minimum standard,37 medical board’s harassment of chiropractors), electing
but Palmer insisted it was a maximum, and contin- instead to serve time. When offered a pardon in 1916
ued to offer doctorates for “three years of six months if he would accept a license as a drugless practitioner
FIGURE 2–10. Gathering of representatives of state boards of examiners and UCA officers at Palmer School of Chiropractic,
11–12 January 1919. (Courtesy of James Edwards, DC.)
from the state medical board, T. F. Ratledge, DC, hands of the medicos during a conversation with
founder of what is today the Cleveland Chiroprac- the owner of a mortuary, the mortician summoned
tic College of Los Angeles, replied to the governor Parker (who was obligated for undisclosed reasons to
that such a license would be fraudulent, because the undertaker), and the legislator promptly reversed
the medical board knew nothing about chiropractic. his previous opposition to chiropractic licensure. Not
Ratledge served out his 90-day sentence for unli- only did Parker marshal a majority of both houses
censed practice in Los Angeles County Jail and contin- of the Missouri legislature in favor of the chiroprac-
ued his vigorous campaign for a chiropractic law. The tic bill, but he became a popular speaker at state and
“Go to Jail” strategy had the effect of creating “mar- national chiropractic conventions.
tyrs” for the profession and generated more widely Continuing criminal prosecutions in the unli-
favorable sentiment within the press and the public. censed jurisdictions produced a number of strong
In other states, different strategies won the day state chiropractic societies committed to defending
for chiropractors. Iowa’s 1921 statute is attributed to their members and to establishing “separate and dis-
the efforts of Frank W. Elliott, DC, business manager tinct” chiropractic licensing laws. The state societies
and registrar of the PSC, who was first elected to the were frequently at odds with Palmer (Fig. 2–13) and
Iowa legislature in 1919 (Fig. 2–12).54,55 In Missouri, his UCA and its “straight” policies. The UCA’s “clean
credit for passage of the first chiropractic statute (in house” edict, which demanded that state associa-
1927) goes to attorney-physician Jones Parker, speaker tions purge mixers from their ranks, further antag-
of the state assembly and former member of the AMA onized the rank and file. Those state societies that
board of trustees.56 When the mother of a chiropractor failed to comply with the UCA mandate were con-
lamented the harsh treatment DCs received at the fronted by UCA-initiated rival associations, thereby
FIGURE 2–11. Charles Lemly, DC, stands second from right in this 1943 photo taken as Texas Secretary of State Latham
(seated) signs the recently passed chiropractic statute. Others in the photo are (from left) Dr. Hugh Warren, President of the Texas
Chiropractic Association; Dr. Roy LeMond, President of the Texas Research Society and cochair of the Legislative Committee; and
standing far right is Dr. Ernest Chaney. (National Chiropractic Association photo collection.)
weakening the profession’s voice with state legisla- new instrument. The NCM could not be purchased,
tors. Dissatisfaction with Palmer and the UCA grew but was available exclusively through a 10-year lease
so great that a rival national society, the American from the PSC at a cost of more than $2000 (a fabulous
Chiropractic Association (ACA), was organized in sum in 1924). Palmer used his weekly periodical, the
Chicago in 1922 and quickly attracted state soci- Fountain Head News, to repeatedly warn that he would
ety affiliates in Colorado, Montana, New York, and sue NCM patent infringers, both those who manufac-
Oregon. By 1930, the list of ACA-affiliated state tured and distributed rival devices and those DCs who
societies also included Alabama, California, Idaho, purchased them. The NCM, Palmer insisted, would
Michigan, Minnesota, North Dakota, Ohio, Tennessee, save chiropractors from themselves by enforcing a re-
Washington, and Wyoming. vival of “straight” chiropractic theory and practice.
Palmer’s former majority support in the profes- Patient histories and symptoms would no longer be
sion was further eroded in 1924 when he intro- of much, if any, importance, for the NCM would find
duced his two-prong, spinal heat-sensing device, the “THE CAUSE OF ALL DISEASES OF THE HUMAN
neurocalometer (NCM).37,57 Henceforth, declared the RACE.”58
self-proclaimed “Developer of Chiropractic,” practice Dissatisfaction with the Davenport leader was
without an NCM would be considered unethical, be- swift and sustained. A massive exodus of members
cause no palpating chiropractor, not even “B. J. him- from the UCA was accompanied by drastic declines
self,” could detect a subluxation as accurately as the in students referred to the PSC. Enrollments at the
Ernest Thompson), discouraged by what they con-

sidered the NCM’s infringement upon their aca-
demic freedom, departed the Davenport mecca and
organized the Lincoln Chiropractic College (LCC) in
Indianapolis in 1926. They took with them the good
will of many Palmer alumni and a continuing com-
mitment to straight chiropractic (i.e., no instruction in
physiotherapy and other modalities). However, the
LCC also offered a strong curriculum in the basic
sciences and in diagnosis, and soon lengthened the
course of instruction beyond the 18-month standard
at the PSC. Lincoln’s position was a middle ground
in the ongoing war of “philosophies” in chiropractic.
The school exerted influence in the profession until its
merger (for financial reasons) with the National Col-
lege in 1971.59
With hostility mounting, in 1925 Palmer resigned
the post he had held as secretary of the UCA since
1906, and, following an unsuccessful reelection bid
FIGURE 2–12. Frank W. Elliott, DC, circa 1925.
the following year, organized the Chiropractic Health
Bureau (CHB), forerunner of today’s International
mother school, which had once numbered 3000, dwin- Chiropractors’ Association (ICA). Now there were
dled to 400–500 by the end of the decade. (The de- three national protective societies (ACA, CHB, UCA)
cline was also attributable to the expiration of vo- for chiropractors to choose from, and three voices
cational benefits for World War I veterans and the clamoring for authority in professional affairs. This
onset of the Great Depression). During 1925–1926, intolerable situation was lessened somewhat when
several disaffected faculty members (Harry Vedder, the ACA and UCA merged in 1930 to form the Na-
Stephen Burich, James Firth, Arthur Hinrichs, and tional Chiropractic Association (NCA). And if the new
FIGURE 2–13. B. J. Palmer, DC,

PhC, during a visit to the Ra-
tledge College homecoming in Long
Beach, California, in 1931. (Cour-
tesy of Paul Smallie, DC.)
society could not claim majority support (then as now,

most DCs are not members of a national association),
it nonetheless spoke for the largest membership in the
profession.
BASIC SCIENCE: THE NEW BATTLEFIELD

While the chiropractors feuded among themselves
over the appropriateness of diagnosis, physiother-
apy modalities, and curriculum standards, organized
medicine devised new strategies to frustrate them. By
the mid-1920s it was clear that the tide of licensing
legislation had eroded medicine’s former legal
monopoly in health care; indeed, by 1927, 39 of
48 American states had authorized the practice of
chiropractic.60 To be sure, chiropractors were not al-
ways satisfied with their practice acts, which often
called for “mixed” state boards of examiners, as in
Rhode Island, where the licensing authority was com-
prised of two allopathic physicians and one chiro-
practor. As well, in those states that authorized chiro-
practic practice, political medicine sought to limit the
DCs’ scope of practice as much as possible. Nonethe-
less, even these less than satisfactory statutes were a
foot in the door and provided some relief from the
arrests, prosecutions, and jailings that continued in
so-called “open” states (i.e., those lacking chiroprac-
tic licensure).
However, 1925 saw a new challenge introduced FIGURE 2–14. Dr. John Nugent. (From the cover of the National
when Wisconsin and Connecticut passed the first ef- Chiropractic Journal, November 1941.)
fective basic science laws.61,62 Basic science legislation
required that anyone wishing to sit for examination Ironically, the Connecticut basic science law was
in chiropractic, medicine, naturopathy, or osteopathy crafted and brokered by John J. Nugent, DC (Fig.
must first pass a basic science examination adminis- 2–14),68 an Irish-born chiropractor with a university
tered by a separate, and ostensibly impartial, board of education, who had clashed with B. J. Palmer while a
basic science examiners. Tests were administered in student at the PSC in 1922.69 Palmer would later
subjects such as anatomy, chemistry, pathology, phys- refer to Nugent as the “anti-Christ of chiropractic”
iology, and, occasionally, hygiene and public health. for his efforts to upgrade chiropractic schools as NCA
Chiropractors complained bitterly that inappropriate director of education (1941–1959). But in 1925, faced
“medical” subjects were included, such as bacteriol- with a nationwide scandal over medical diploma mills
ogy and, in at least two states, diagnosis.63,64 They and the lenient licensing practices of the state’s eclec-
objected also to the composition of the basic science tic medical board,51 the pressure for a basic science
boards (see, e.g., reference 65), whose members were act was simply too strong to resist. A quarter century
usually drawn from nonclinical faculty at state univer- later, Nugent indicated that he wished he might have
sities affiliated with medical schools, but sometimes written all the basic science acts in those jurisdictions
also included licensed practitioners.64 The DCs ob- where they could not be avoided.70
jected also to the pretense that examiners did not know Basic science legislation frequently accomplished
whether the applicant was a graduate in medicine, chi- its intended purpose. Chiropractors were often un-
ropractic, or other healing art. The obvious and stated able to create a compelling argument against the
(see, e.g., reference 66) purpose of basic science exam- seeming reasonableness of the basic science laws (i.e.,
inations, they argued (with justification; see, e.g., ref- that all doctors of whatever persuasion should have
erence 67), was to “contain and perhaps eliminate”51 the same basic competence in fundamental subjects)
the ranks of nonallopathic doctors. Chiropractors and (Fig. 2–15). The profession suffered a slow but cumu-
MDs alike were often distressed about the limitations lative battering. For instance, the basic science bar-
that basic science legislation exerted upon reciprocal rier erected in Nebraska in 1927–1928 meant that the
licensing across states. state’s Board of Chiropractic Examiners (BCE) issued
FIGURE 2–15. Chiropractors’ view

of basic science legislation. (From
the NCA’s Chiropractic Journal, April
1936.)
no new licenses during 1929–195071,72 because no DCs BCE, they were dismayed to find that B. J. Palmer had
sat for the basic science test. In other jurisdictions, chi- sided with the medicos to defeat the new legislation.74
ropractors were exceptionally unsuccessful in passing However, political medicine was not always victo-
the exams.70 Gevitz51 notes that new chiropractic li- rious in its basic science campaigns. In Arizona the ba-
censes in Minnesota dropped from an annual average sic science act was temporarily voided when the state
of 39 during 1922–1926 to 1.4 during 1927–1937 fol- supreme court ruled that the legislation should have
lowing passage of the basic science act; in Washington been submitted to voters for approval.75 In Arkansas,
State only 42 DCs passed the basic science exam dur- the BCE ignored the basic science law by licensing
ing 1927–1953, for an average of only 1.6 per year. And DCs without the prerequisite basic science certificate;
as the number of states requiring basic science test- when the state supreme court challenged these li-
ing expanded (Table 2–6), the ranks of licensed chiro- censes, the legislature grandfathered those who had
practors dwindled. Palmer blamed the spread of basic been licensed inappropriately.51 In Tennessee, the ba-
science legislation on the mixers, claiming that it was sic science law was finally repealed through the effort
broad-scope DCs’ encroachment on the medical scope of state representative Elbert T. Gill, DC, who pointed
of practice that had encouraged the proliferation of the out the inequitable administration of the basic sci-
scourge. Homer Beatty, DC, ND, president of the Uni- ence process by professional licensing authorities.76
versity of Natural Healing Arts (UNHA) in Denver, In Florida, the basic science statute was repealed in
laid the blame squarely on the “low educational stan- 1967 at the request of the state medical society, but
dards” of the chiropractic colleges.73 When the chiro- only with the political support of chiropractors and
practors of Oregon, led by W. A. Budden, DC, ND, osteopaths.51
of Western States College, attempted to amend their Perhaps the most dramatic challenge to political
practice act to return testing in the basic sciences to the medicine’s basic science campaign came in California,
TABLE 2–6.Enactment and Revocation of Basic president of the AMA, was singled out for vilification.
Science Legislation in the United States* When the basic science initiative went down to de-
feat (972,641 opposed vs. 507,421 in favor), chiroprac-
Dates of Enactment tors’ political clout at the state capitol in Sacramento
and Revocation State was greatly increased (Fig. 2–16). As well, DCs facing
the basic science threat in other states could point to
1925/1975 Wisconsin California as an example of the only time the issue had
1925/1975 Connecticut been placed before the voters, and with a resounding
1927/1974 Minnesota result.51
1927/1975 Nebraska However, by 1940, a number of chiropractic
1927/1979 Washington leaders had begun to change their views on ba-
1929/1977 Arkansas sic science examinations. George E. Hariman, DC, a
1929/1978 District of Columbia National College alumnus who operated a small hos-
1933/1973 Oregon pital in Grand Forks, North Dakota, and would soon
1935/1973 Iowa join the NCA’s board of directors, opined, “We may
1936/1968 Arizona not like it that Basic Science is apparently here to stay
1937/1973 Oklahoma but the sooner we accept it perhaps the better. . . . ”77
1937/1976 Colorado Hariman’s alma mater, the National College, had long
1937/1972 Michigan since advocated and provided better than average in-
1939/1967 Florida struction in the basic sciences as a means of defeating
1939/1975 South Dakota political medicine’s licensing barrier.78 School leader
1940/1971 Rhode Island Beatty of UNHA opined, “Basic Science Laws can be a
1941/1968 New Mexico boon to the improvement and progress of Chiroprac-
1943/1976 Tennessee tic,” provided such laws were coupled to state funding
1946/1970 Alaska for all healing arts colleges preparing students for the
1949/1979 Texas basic science tests.79 C. O. Watkins, DC, 1935 founder
1951/1975 Nevada and first chairman of the NCA’s Committee on Edu-
1957/1969 Kansas cation (forerunner of today’s Council on Chiropractic
1959/1979 Utah Education [CCE]) and subsequently chairman of the
1959/1975 Alabama NCA board of directors (Fig. 2–17), who had earlier
referred to the “damnatory [sic] Basic Science laws,”80
* States listed in chronological order of enactment. later softened his stance as he realized the impetus
Data from Gevitz N. “A coarse sieve”; Basic science boards and medical these statutes provided to educational improvements
licensure in the United States. J Hist Med Allied Sci 1988;43:36–63;
and Sauer BA.: Basic science—Its purpose, operation, effect. Unpub-
within the profession.
lished letter to the officers of the NCA and state chiropractic asso-
ciations, 10 June 1932. Archives, Cleveland Chiropractic College of
Kansas City.
EDUCATIONAL REFORM
where, in 1942, the chiropractors won a nearly 2:1 The standards and curricula of the chiropractic col-
victory against the proposed new law.51 The Golden leges had been an official agenda item at least since
State’s BCE and licensing law had been established by 1912, when the short-lived National Federation of Chi-
the voters through the initiative process in 1922, which ropractic Associations was organized in Kansas City.81
meant the legislature could not pass a basic science bill The issues were taken up again in 1926 by the newly
that would interfere with the chiropractic initiative formed International Congress of Chiropractic Exam-
law. Medical forces in the state were therefore obliged ining Boards (ICCEB), just a year after the first basic
to mount a costly public campaign to place basic sci- science laws were introduced. A forerunner of today’s
ence testing directly before the electorate. Straights Federation of Chiropractic Licensing Boards, the IC-
and mixers who had feuded incessantly for decades CEB sought to inspect chiropractic schools and require
came together at this point to meet the common foe. a greater number of hours of instruction as a qual-
In what has been described as a “tough and at times ification for licensure. The ICCEB and its 1934 suc-
dirty campaign,”51 chiropractors raised twice the cam- cessor, the Council of State Chiropractic Examining
paign money that the California Medical Society was Boards (COSCEB), soon found that its member boards
able to, and spent it on direct mail, newspaper adver- were reluctant to relinquish their authority as agents
tisements, and radio announcements. The traditional of sovereign states.69 Standardization and higher stan-
cry of “medical freedom” was once again sounded, dards would have to be sought through other mecha-
and the chancellor of Stanford University, a former nisms.
FIGURE 2–16. Cover of the Chi-

rogram for November 1942 sported
a “V” for victory in California’s initiative
vote against basic science.
The COSCEB’s president, Dr. John Nugent, was rein the proprietary colleges, leaders of a number of
cruited in 1939 to inspect all chiropractic schools and schools banded together as the Allied Chiropractic Ed-
to prepare formal criteria82 for evaluating these insti- ucational Institutions (ACEI) to challenge the NCA’s
tutions. Appointed NCA’s first director of education educational reforms.70 Nugent was repeatedly vilified
in 1941, for the next 20 years Nugent led the profes- in print and by word of mouth.
sion’s efforts to raise the quality of instruction at the It was not only the straight colleges that gagged
colleges and thereby to help establish greater legiti- on Nugent’s and the NCA’s innovations. Although
macy for chiropractors. It was a rocky road. Alarmed the broad-scope schools were committed in concept to
by what they perceived as threats to straight chiro- lengthening their curricula, improving basic science
practic principles and to the financial stakes they held laboratories and instructional facilities, upgrading
Chiropractic Institute of New York. Three years later

Nugent repeated this feat on the West Coast, with the
merger of the nonprofit Southern California College
of Chiropractic and the for-profit Los Angeles Col-
lege of Chiropractic (LACC) to create today’s non-
profit LACC.83 And by this time, the newly created
National Chiropractic Insurance Company (NCIC;
precursor of today’s National Chiropractic Mutual
Insurance Company), a spin-off of the NCA’s legal
protective services,40 had made the first small dona-
tions to the NCA-affiliated schools.84 Also in 1947,
the NCA education director and leaders from the
COSCEB organized the NCA-allied schools into the
Council on Education (forerunner of today’s CCE).
The Council’s formation marked the birth of the mod-
ern accreditation movement.
The war’s end aided Nugent in his consolidation
efforts. For the next few years the colleges enjoyed a
flood of students, veterans of the World War II (Fig.
2–18)and subsequently the Korean War, whose tuition
was paid by the federal government under the GI
Bill. Uncle Sam provided further, indirect support to
the schools in 1951, when chiropractic students were
exempted from the draft.85 Chiropractor-veterans,
known as “chirons,” were encouraged to return to the
schools for “refresher” courses. Meanwhile, Nugent
repeatedly cautioned prospective freshmen to spend
their tuition dollars in NCA-accredited colleges which
he contended, was the only way to ensure their even-
tual license eligibility.86
FIGURE 2–17. Dr. C. O. Watkins appeared on the March
The straight colleges and practitioners, mean-
1940 cover of NCA’s journal.
while, organized as the ICA-friendly North American
the pool of faculty, and raising admissions crite-

ria, these were expensive reforms. Most chiropractic
schools, straight and mixer, were still proprietary and
all were heavily tuition-dependent. As well, World
War II and the military draft was diminishing the
available pool of prospective students. (The Univer-
sal Chiropractic College of Pittsburgh, founded in
Davenport in 1910, was forced to close its doors in 1944
as a consequence of enrollment shortfalls.) Even those
schools allied with Nugent and the NCA complained
bitterly about the demands for costly improvements
and the absence of any significant financial support
from the national association. “It cannot be done on
tuition alone,” was the repeated lament from the NCA
Council of Educational Institutions.
Nugent, however, had a plan. He would seek the
amalgamation of the many small, for-profit schools
into a smaller set of larger, financially sounder, non-
profit colleges in selected cities around the nation.
His first major achievement in this respect came in FIGURE 2–18. Returning chiropractor-veterans were wel-
1944, when the Eastern Chiropractic Institute merged comed back to the National Chiropractic Association at war’s
with the Standard Institute of Chiropractic and the end in this 1946 cartoon. (From the National Chiropractic
New York School of Chiropractic to form the nonprofit Journal.)
Association of Chiropractic Schools and Colleges

RESEARCH IN THE MIDDLE ERA:
(NAACSC) in 1952, and later as the ICA’s Chiropractic
SCIENCE AND PUBLICITY
Education Commission, vehemently opposed NCA-
fostered instruction in physiotherapy, diagnosis, and Chiropractors since D. D. Palmer22 have claimed that
other “medical” subjects. Particularly vexing was the theirs is a scientific discipline, and some have con-
quest for a broader scope of practice sought by chiro- sidered it the “only truly scientific healing art.”88
practors in California, as suggested in the ICA’s Inter- Since identification as a science has been a progres-
national Review of Chiropractic.87 sively more important component of legitimacy and
Many chiropractors’ fears about the consequences professional identity throughout the past century,
of “mixing” were further enhanced during 1960–1962, medicine’s long-held contention that chiropractic is
when the California Medical Association absorbed quackery has not only stigmatized the profession, but
both the California Osteopathic Association and the cut to the heart of chiropractors’ sense of identity.
state’s only osteopathic school (now the College of At the start of the twentieth century, university-
Medicine at the University of California at Irvine). based medicine was just emerging from the descrip-
Straight practitioners and leaders saw this as an omi- tive and intuitive epistemology of Darwin into the lab-
nous sign of what might happen to chiropractic if ef- oratory experimentation of Koch and Pasteur. But this
forts to maintain a “separate and distinct” identity transformation would take decades to fully develop;
were not reinvigorated. nearly 40 years would pass before the widespread in-
In the late 1950s, with veterans’ benefits expired, troduction of antibiotics. The average medical prac-
the chiropractic colleges began to contract once again. titioner muddled on with the remedies of old. Chi-
The increased admissions standards that the NCA ropractors, meanwhile, found much to criticize, both
Council on Education had pushed (involving 2 years with medicine and the emerging field of public
of prechiropractic study in liberal arts colleges) were health. Inoculation against various infectious condi-
withdrawn by those few schools that had dared to im- tions seemed a vile and dangerous form of poisoning
plement them when competition from schools with- with no more apparent logic than the proverbial “hair
out such requirements necessitated it. The local mo- of the dog that bit you” (Fig. 2–19). Laws that required
nopolies that the NCA-affiliated schools anticipated citizens to submit to these shots were viewed as a clear
had not materialized. The NCA-accredited Chiroprac- violation of “medical freedom.”
tic Institute of New York continued to compete with Old Dad Chiro (D. D. Palmer) had railed against
the Columbia Institute of Chiropractic for students, vivisection, immunization, and the trial-and-error
while in California the LACC lost students to both empiricism of orthodox medical practice. Chiroprac-
the Cleveland Chiropractic College (descendant of the tic, he insisted, was scientific and superior because
Ratledge Chiropractic College) and the Hollywood it was theory-driven. What’s more, Palmer claimed,
College of Chiropractic.83 Meanwhile the PSC, al- chiropractic theory united the “material” and the “im-
though diminished in enrollments like the rest, con- material” (his theory of Universal and Innate Intelli-
tinued as the largest chiropractic institution and as a gence), in contrast to the sterile atheism of the new
thorn in Nugent’s side. When B. J. Palmer, president scientific medicine. In time, asserted the founder, the
of the PSC and president of the ICA, died in 1961, there science of chiropractic would “lift the veil which ob-
was hope that the incessant war of words between the structs the view of the life beyond.”22 While such
straights and mixers might abate. Although the Devel- rhetoric sounds decidedly and disturbingly unscien-
oper’s passing probably encouraged the reorganiza- tific today, it could strike a plausible and sympathetic
tion of the NCA into today’s ACA during 1963–1964, chord in the public of that earlier time.
there was still no reconciliation among the schools. Although allopathy had much to be humble about,
Nugent’s services to the NCA were terminated in the neophyte science of chiropractic was a home-
1961 when he fell into disfavor with the board of di- grown ideology harkening back to the populism of
rectors over his harsh and frank comments. Stepping the early nineteenth century. Chiropractors were fear-
in to fill the vacuum in leadership in educational re- less in the face of pathology, keen to test their meth-
form was George H. Haynes, MS, DC, since 1953 the ods in all manner of disease, and often administered
administrative dean and CEO of the LACC. Haynes hope where a still generally impotent medicine could
assumed the post of president of the NCA (later ACA) offer only despair. The “deductive science” offered
Council on Education, and oversaw its conversion to by the chairman of the philosophy department at the
the independently chartered CCE in 1971. He served PSC seemed to obviate empirical data collection89 ; chi-
one term as the CCE’s first president, and then headed ropractic was “scientific” by fiat, because its meth-
the committee that negotiated with the US Office of ods were consistent with and/or derivable true “first
Education (USOE) for recognition of the Council as principles.” And following the tradition established
the accrediting authority for chiropractic schools.83 by D. D. and his son, they were bold in the public
FIGURE 2–19. The Statue of Liberty

flees her pedestal in this newspaper car-
toon from 1904, which depicts a legisla-
tor restraining an unwilling citizen while
a medical practitioner injects a vaccine.
claims made for their new method. Chiropractic was promotional literature. Perhaps the earliest sustained
unabashedly offered as a panacea. B. J. Palmer ex- effort at clinical data collection was undertaken by
celled in his marketing campaign in chiropractic, and the ACA’s Bureau of Research.92 Established by Leo
proudly declared that he had built the chiropractic sci- J. Steinbach, DC, dean of the Universal Chiropractic
ence “with printer’s ink.” Early on political medicine College in Pittsburgh, the directorship of the Bureau
found that DCs themselves provided ample ammuni- passed through several hands during 1924–1929, in-
tion to use against the new healing sect. cluding A. B. Chatfield, LLB, DC, John Monroe, AM,
Isolated from universities and centers of scholarly DC, and, finally, Clarence W. Weiant, DC. The Bureau
and scientific activity, and badgered as quacks by the published a monthly report that featured quantitative
MDs, chiropractors developed their own conceptions outcomes from thousands of cases. Unfortunately, no
of the meaning of science. Their “data” lay in the many details on the definitions of diagnoses, methods of
satisfied patients and the testimonials these grateful data collection, or the criteria for reporting “improve-
clients offered; chiropractic was scientific because “it ment” were given, and no comparisons to untreated
works.” As the new century progressed, however, the patients or to patients treated by other methods were
role of systematic, experimental research gradually re- made. In short, these investigations could not be repli-
placed the museum displays of old as markers of sci- cated, and the absence of controls rendered inter-
entific prowess. When Palmer introduced his NCM in pretation of outcomes dubious at best. Nonetheless,
1924, he claimed (but apparently did not publish) ex- chiropractors, generally unfamiliar with the scientific
perimental studies involving hundreds of patients.90 method, believed the reports lent great credence to
He poured hundreds of thousands of dollars (millions their clinical work.
in today’s economy) into clinical data collection in The Bureau of Research did not continue when
the B. J. Palmer Clinic at the PSC; unfortunately, the the ACA merged with UCA to form the NCA in
mountain of data collected is largely uninterpretable, 1930. However, the leadership of the new society
owing to Palmer’s lack of familiarity with the rules recognized the need to develop some sort of re-
of evidence in clinical science. The title of the De- search infrastructure. Rebuffed in its grant seeking
veloper’s 1951 tome, Chiropractic Controlled Clinical by the Rockefeller Foundation, which pointed out the
Trials,91 seemed to suggest a marginal awareness of the lack of a nonprofit foundation to receive any phi-
advances in clinical research methodology, but was lanthropy, the NCA organized the nonprofit Chiro-
devoid of any experimental findings. practic Research Foundation (CRF) in 1944 (forerun-
By the early 1920s, however, chiropractors had be- ner of today’s Foundation for Chiropractic Education
gun to show interest in accumulating clinical outcome and Research).92 With small sums derived from the
data beyond the testimonials that so often graced their NCA’s newly formed malpractice insurer, the CRF
• The problem of recording objective clinical results

and or correlating these with the data obtained in
the pursuit of problems one through four.93
This was an ambitious set of research goals, by any

standard. During the next several years Weiant’s small
group at CINY, with the assistance of several others,
turned out a remarkable seven dozen scholarly pa-
pers and data reports.92 Although clinical outcomes
were still almost totally uncontrolled, the seeds of
programmatic investigation were clearly in evidence.
Unfortunately, funding from CRF did not continue,
largely due to the Foundation’s loss of several hun-
dred thousand dollars in an ill-conceived fundraising
appeal to the general public. By 1950, research had
become something of a dirty word within NCA/CRF
circles, and continuing discussion of the need for clin-
ical outcomes data was relegated to the NCA’s Com-
mittee on Research. Although some dollars continued
to be directed to the NCA’s college reform pro-
gram, especially after the CRF’s reorganization as
the Foundation for Accredited Chiropractic Educa-
tion (FACE) in 1958,94 a serious commitment to scien-
tific investigation would be deferred for several more
decades.
Chiropractors continued to promote their research
discoveries and inventions throughout the 1950s.
However, these efforts were generally far below the
standards set by Weiant and his cohort at CINY, and
often involved local and unsophisticated “research
FIGURE 2–20. Cover of the August 1943 issue of the National groups” of doctors, or technique entrepreneurs in-
Chiropractic Journal featured Dr. Clarence Weiant. tent on marketing their clinical innovations to fel-
low practitioners. Relatedly, instrument manufactur-
ers had proliferated since the introduction of the NCM
appointed the ACA’s former research bureau chief,
25 years before. By mid-century the variety of devices
Clarence Weiant (Fig. 2–20), to be its first director of
(Fig. 2–21) and the marketing claims made for them
research and gave him free reign to use these research
brought increasing scrutiny from the US Food and
dollars as he saw fit. Weiant, who by this time had
Drug Administration, whose 1938 expanded author-
earned a PhD in anthropology from Columbia Uni-
ity included therapeutic devices; a few of these appa-
versity, organized a small team of scholars at the Chi-
ratuses were confiscated.
ropractic Institute of New York (CINY). His list of
In the 1950s chiropractic contributions to the treat-
important research issues included:
ment of polio were widely disseminated, along with
disparagement for the Salk vaccine. However plau-
• The problem of defining and recognizing the forms sible their work with this neuromusculoskeletal con-
of anatomical relationship to which the skeleton is dition (like that of Sister Kenny), no hard evidence
subject. to support their contentions was proffered. And the
• The problem of determining to what extent these DCs sometimes let politics supersede legitimate at-
forms are fixed, or to what extent they vary with tempts at scientific research, such as in 1965, when Carl
alterations of posture and other physiological ac- S. Cleveland, Jr., DC, dean of the Cleveland Chiro-
tivity. practic College in Kansas City, was refused permis-
• The problem of recording the anatomical changes sion to present his animal model of subluxation at the
produced by the application of the various chiro- California Chiropractic Association’s annual conven-
practic techniques. tion. Carl Jr.’s father had taken over the Ratledge Col-
• The problem of determining the physiological ef- lege in Los Angeles more than a dozen years before,
fects resulting from the application of chiropractic and had infuriated broad-scope doctors by competing
techniques. with the LACC and by maintaining only the minimum
FIGURE 2–21. The photoelectric visual nerve tracer, an alternative to the NCM derived from Clarence Weiant’s “Analyte,”95 was
marketed by George Adelman, DC, of Brockton, MA.
standards necessary to meet California’s educational However, several school leaders within the ACA
and licensing requirements. This was reason enough, Council on Education resisted making some of the
unfortunately, to ignore the research that the son had tough but necessary choices. Janse of the National Col-
conducted. lege, for instance, was reluctant to replace DCs who
had taught the basic sciences for years with more ap-
propriately credentialed instructors (i.e., those with
masters’ and doctoral degrees in biology). Others were
PUSH FOR RECOGNITION
alarmed by Anderson’s intention to focus ACA and
As George Haynes took the reins of the NCA Coun- FACE funding on one institution, so as to “push one
cil on Education in the early 1960s, voices within college ahead of all the rest as a sort of spearhead”
the Council and the NCA governance structure were in the accreditation effort.99 By this time, all of the
growing in their insistence on federal recognition for ACA-affiliated schools offered 4-year curricula and
chiropractic schools. The absence of this imprimatur had converted to nonprofit status, but still relied al-
had grown increasingly troublesome for the profes- most exclusively on tuition revenues to support oper-
sion and its quest for legitimacy; political medicine ations. Circumstances would shortly persuade them
had made chiropractic education a primary target of of the necessity of meeting even greater demands.
its criticisms.70,96,97 Indeed, Dewey Anderson, PhD, Chiropractors in Louisiana had endured an espe-
who succeeded John Nugent as director of educa- cially odious status for years. Court decisions in this
tion, warned the profession that the AMA had “a unlicensed jurisdiction had construed the practice of
definite program to destroy chiropractic, root and chiropractic to be the practice of medicine (Fig. 2–22).
branch, by 1970,”98 and the schools could expect much This meant that DCs were not allowed to advertise,
of the onslaught. With the 1963–1964 reorganization and were subject to arrest, prosecution, and jailing at
of the NCA to form today’s ACA, determination to any moment. Led by Palmer graduate Jerry England
meet the higher training standards grew stronger; the and with the financial assistance of the NCA and ICA,
ACA committed 40% of membership dues to college practitioners in Louisiana challenged the constitution-
upgrading.93 ality of the medical practice act and sued the state
vow. Janse bit the proverbial bullet, made the hard

decisions, and created the higher standard. Despite a
vigorous, national antichiropractic campaign involv-
ing public disparagement (see sidebar “Antichiro-
practic Articles Appearing in Popular Magazines Dur-
ing 1963–1970”) and back room politics, organized
medicine was unable to prevent the NCC’s accredi-
tation by the New York State (NYS) Education De-
partment in 1971.
Antichiropractic Articles Appearing in

Popular Magazines During 1963–1970105
Foot in the door. Newsweek, April 8, 1963
Smith M. If your back is out, you’re in. Life, April 9, 1965
Smith RL. Chiropractic: Science or swindle? Today’s
FIGURE 2–22. Mr. J. Minos Simon (left), chief legal counsel for Health, May 1965
the Louisiana chiropractors in the England case, and Dr. Paul Fineberg H. Chiropractic education [letter]. Science,
J. Adams, member of the Legal Action Committee, are shown June 3, 1966
standing in front of the Federal Court Building in New Orleans. Sabatier JA. Chiropractic education [letter]. Science,
(Journal of the NCA, December 1959, p. 9.) June 3, 1966
The medical dispute about treatment by chiropractors.
medical society and the Board of Medical Examiners Good Housekeeping, May 1967
in federal and state courts. One of the issues to be ar- Smith RL. Golden touch for chiropractors. Today’s Health,
gued was the integrity of chiropractic education. The June 1968
case underwent a tortuous process over 8 years, but Smith RL. Visit to a bizarre world—Chiropractic alma
came to a head in 1965, when school administrators maters. Today’s Health, July 1968
Joseph Janse, DC, ND, of the National College of Chi- HEW rejects chiropractic. Today’s Health, April 1969
ropractic (NCC), and William Harper, MA, DC, of the Smith RL, Sabatier JA. Chiropractic: Issues and answers.
Texas Chiropractic College, took the stand in federal Today’s Health, January 1970
district court in New Orleans. Chiropractic journals of
the day painted a rosy picture of their testimony,100,101
While most if not all chiropractic colleges enjoyed
but the reality was something different:
recognition from their state education agencies, the
Illinois-based National College’s achievement in New
At the trial, Dr. J. J. was raked over the coals so York held special significance. The education depart-
badly by the medical attorneys over the issue ment in New York had established regional accred-
that no DC college had any accreditation status iting status with the USOE in order to facilitate su-
with USOE or any regional accreditation agen- pervision of its multicampus university system. New
cies, that our education was therefore in fact York DCs, after 50 years of lobbying, had won their
inferior to medical schools and that we were all first licensing statute in 1963, but there was a catch. Al-
a bunch of uneducated so-and-so’s. J. J. was so though chiropractors already in the state were “grand-
stimulated by his handling, he became the driv- fathered” into legal practice, new license-applicants
ing force, along with Geo. Haynes of LACC, to were required to graduate from a chiropractic college
get an accreditation agency for the profession, recognized by the federal government. When the NCC
and we know what happened. J. J. then went achieved accredited status in New York, despite stren-
for regional accreditation and I believe was first uous protest from the NYS medical society,106 its grad-
to receive this type of status. . . . 102 uates (and its graduates only) became license-eligible
in that jurisdiction. Students at the NCC were also
The case was lost, and Dr. England was again sub- among the first to become eligible to receive federally
jected to harassment and arrest.103 Meanwhile, Janse guaranteed student loans for their chiropractic train-
had departed Louisiana bruised and humiliated by ing. As well, because the NCC was also accredited
the experience, but determined to establish federal by the ACA Council on Education, its status with the
recognition of chiropractic education “or leave the NYS regional accreditor lent greater credibility to the
profession” (Janse, quoted in reference 104 at p. 111). Council’s efforts to gain USOE standing as a profes-
And during the next 6 years, he made good on this sional accreditor. A few years later, the NCC gained
TABLE 2–7.Numbers of Students Enrolled in US Chiropractic Colleges circa 1974, According to the
Association of Chiropractic Colleges108
Number of Number of
Schools Accredited by ACC Students Schools Accredited by CCE Students
Cleveland Chiropractic College/Los Angeles* 485 Los Angeles College of Chiropractic 337
Cleveland Chiropractic College/Kansas City 340 National College of Chiropractic 600
Columbia Institute of Chiropractic 260 Northwestern College of Chiropractic 130
Logan College of Chiropractic 410 Texas Chiropractic College 145
Palmer College of Chiropractic 1965 Western States Chiropractic College 140
Total students in ACC schools 3460 Total students in CCE schools 1352
Percent of total US chiropractic 71.9% Percent of total US chiropractic 28.1%
students students
* Candidate for accreditation by the Association of Chiropractic Colleges.

Data from: ACC accredited colleges represent more than 71% of chiropractic students. Association of Chiropractic Colleges, news release, 18 July
1974.
regional accreditation with the North Central Associ- independently chartered in 1971 to meet the stipula-
ation of Schools and Colleges.107 tions of USOE. Now each agency contended that it
The larger goal would not come easily. As had so was the appropriate choice for recognition by USOE.
often been the case in campaigns to establish licensing Although the ACC was not a viable candidate for
laws, chiropractors jousted not only with organized this designation (because at least one of its accredited
medicine, but also with themselves. The USOE, which straight schools was still for-profit), the ACC could
insisted on recognizing only one accrediting agency justly claim to represent a majority of all students
per profession, was confronted by two claimants enrolled in chiropractic colleges (Table 2–7). During
for federal recognition: the ICA-friendly Association 1971–1974 the Council of State Chiropractic Licens-
of Chiropractic Colleges (ACC; no relationship to ing Boards made repeated attempts to merge the two
today’s organization by the same name) and the agencies or arbitrate an agreement for a unified peti-
CCE. The CCE, formerly a division of the ACA, was tion to USOE. All of these efforts failed, but the issue
was rendered moot in August 1974, when CCE was
recognized by the USOE (Fig. 2–23).
SUDDEN VICTORY
The 1970s were a remarkable period for chiropractic,
marked by the lowering of many barriers to broader
acceptance, an abrupt shift in intraprofessional poli-
tics, the birth of several new schools, and the emer-
gence of a research community within the profession
(see sidebar “Several Milestones in Chiropractic His-
tory, 1971–1978”). Accreditation brought some quick
changes in the colleges’ fortunes. Students at all
schools recognized by the CCE were now eligible
for federally guaranteed student loans, and the col-
leges were eligible, in principle, for federal grants
for research and education.109 Enrollment increased,
ACC-accredited schools applied for standing with the
FIGURE 2–23. Dr. George Haynes, president of LACC, is
CCE, and the ICA was invited to take a seat on the
congratulated in 1975 by Leonard Fay, DC, ND, president of CCE’s governing board. State boards of examiners,
CCE and vice president of the National College of Chiropractic, encouraged by the Federation of Chiropractic Licens-
for his successful efforts in winning USOE recognition of CCE. ing Boards (FCLB; successor to the COSCEB), revised
(Reproduced from CCE awards announced. ACA J Chiropr 1975; eligibility for chiropractic licensure by requiring grad-
12(5):19.) uation either from a CCE-accredited school or from
a chiropractic college accredited by an agency rec- and Welfare (DHEW), which had advised against
ognized by USOE. Organized in 1963 by the FCLB, chiropractic inclusion in the health plan.56,110 This
the tests administered by the National Board of Chi- turnaround at the federal level constituted a moral vic-
ropractic Examiners (NBCE) gradually replaced the tory for chiropractors, who suspected the long arm of
basic science examinations that had strangled the the AMA had been at work behind the scenes. (Subse-
profession for decades. In 1979, the last three states quent revelations proved them correct.3 ) Wardwell56
(Texas, Utah, and Washington) eliminated basic sci- notes that working together for perhaps the first time,
ence boards altogether (see Table 2–6). the ACA and ICA prepared a rebuttal to the DHEW’s
report, and solicited 12 million letters to Congress in
support of their petition for Medicare reimbursement.
Several Milestones in Chiropractic History, The following year saw passage of a chiropractic
1971–1978 law in the last holdout state, Louisiana. As though to
1971: Council on Chiropractic Education (CCE) is indepen- reenact the struggle for chiropractic licensure, two fi-
dently chartered nal chiropractic “martyrs” were jailed for defying a
1971: National College of Chiropractic gains regional court order against practice (as had been the custom
accreditation from the New York State Department of throughout the chiropractic century). Arrested for un-
Education licensed practice before the new law was passed, Drs.
1973: Sherman College of Chiropractic is chartered in Brutus D. Mooring and Ellis J. Nosser of Caddo Parish
South Carolina were fined and incarcerated 6 months after the statute
1973: International College of Chiropractic Neuroverte- took effect for defying Judge Jack Fant’s injunction.111
brology (subsequently renamed Pasadena College of Chi- Like so many DCs before them, they spent their time
ropractic) is chartered in California treating fellow inmates and their jailers. The magis-
1973: US Congress authorizes payment for chiropractic trate was forced to reconsider their lockup when the
services under Medicare sheriff’s switchboard was flooded by citizens calling
1974: CCE is recognized by the US Office of Education as in to see about the welfare of their doctors. The judge
the accrediting agency for chiropractic education threw in the towel when the local press picked up the
1974: Life Chiropractic College is chartered in Georgia story; Mooring and Nosser were released after serving
1974: Final American state (Louisiana) passes a chiro- only 3 days behind bars.
practic law And in 1975, after several years of lobbying the
1975: Conference on the research status of spinal ma- US Congress, a small grant ($2 million) for chiroprac-
nipulation is convened at the National Institutes of Health tic investigations culminated in a novel research con-
1975: College of Chiropractic Sciences (Canada) seeks ference on spinal manipulation.70,112,113 Held at the
certification from the Canadian Memorial Chiropractic National Institutes of Health in Bethesda, Maryland,
College this historic 3-day meeting brought together clini-
1976: Pacific States Chiropractic College (later renamed cians, scientists, and political activists from several
Life Chiropractic College West) is chartered in California disciplines, including chiropractic, osteopathy, and al-
1977: ADIO Institute of Straight Chiropractic (later re- lopathic medicine (see sidebar “Participants in the
named Pennsylvania College of Straight Chiropractic) is National Institutes of Health’s Workshop”). The
chartered in Pennsylvania monograph that resulted, entitled The Research Status
1978: First issue of the Journal of Manipulative and Phys- of Spinal Manipulative Therapy,114 reviewed what quan-
iological Therapeutics is published titative data bearing on spinal manipulative therapy
1978: Parker College of Chiropractic is chartered in Texas (SMT) then existed, and concluded that the scientific
1978: Northern California College of Chiropractic (later validity of manual therapies had yet to be established
renamed Palmer College of Chiropractic West) is char- (Fig. 2–24). The gathering marked the first time that
tered in California practitioners of manual therapy from diverse pro-
fessions had met face-to-face to share their knowl-
edge and skills. Although chiropractors would con-
The US Congress authorized payment to chiro- tinue to experience discrimination in their scientific
practors for services rendered to Medicare patients endeavors (e.g., their research papers were rejected
in 1973. The legislation was not satisfactory in several ad hominem),115 the assembly was a turning point for
respects; for example, although radiological demon- the science of chiropractic.116 And though a few in
stration of “subluxation” was required to justify treat- the profession had repeatedly bemoaned the dearth
ment, chiropractors were not permitted to bill for the of empirical evidence in chiropractic,117,118 the impor-
x-rays. Nonetheless, the new law supplanted the con- tance of controlled clinical trials of manual therapies
clusions delivered to Congress in a 1968 report by was now officially brought to the wider profession’s
the secretary of the Department of Health, Education, consciousness.119
Scott Haldeman, DC, PhD

Joseph W. Howe, DC, DACBR
Joseph Janse, DC, ND.
Martin Jenness, DC, PhD
William L. Johnston, DO
Christopher B. Kent, DC
Igor Klatzo, MD
Andries M. Kleynhans, DC
Irvin M. Korr, Ph.D
Elizabeth Lomax, MD, PhD
Horace W. Magoun, PhD
Robert Maigne, MD
Peter A. Martin, ND, DO, DC
Joseph P. Mazzarelli, DC
Fletcher H. McDowell, MD
James H. McElhaney, PhD
John McM. Mennell, MD
William D. Miller, DO
Alf Nachemson, MD, PhD
George W. Northup, DO, FAAO
Sidney Ochs, PhD
Harry D. Patton, MD, PhD
Edward R. Perl, MD
David E. Pleasure, MD
Santo F. Pullella, PhD
Richard Remington, PhD
Akio Sato, MD, PhD
FIGURE 2–24. Scott Haldeman, DC, PhD, MD, FCCS Herbert H. Schaumburg, MD
(Canada), FRCP (Canada), participant at the 1975 conference Robert Shapiro, MD
on the research status of spinal manipulation. Seth Sharpless, PhD
Chung Ha Suh, PhD
Sir Sydney Sunderland, MD
Participants in the National Institutes of Peter Tilley, DO
Health’s Workshop on Spinal Manipulative Donald B. Tower, MD, PhD
Therapy, Bethesda, Maryland, Walter I. Wardwell, PhD
2–4 February 1975114 Edmund B. Weis, Jr., MD
Henry G. West, Jr., DC
Thomas H. Ballantine, Jr., MD Augustus A. White, III, MD
William Bromley, DC Andrew B. Wymore, DC
Robert E. Burke, MD
Thomas N. Chase, MD
Carl S. Cleveland, Jr., DC
Jerome Cornfield
Chiropractors’ preparation for the research con-
James Cyriax, MD, MRCP
ference was facilitated by faculty members of the
William S. Day, DC
Canadian Memorial Chiropractic College (CMCC),
John S. Denslow, DO
who compiled the first extensive bibliography of
Giovanni DiChiro, MD
books and scientific papers on SMT. The compendium
David Drum, DC
was later expanded and published by Williams &
Gustave Dubbs, DC
Wilkins (a medical publisher) as the Chiropractic Re-
Karl Frank, PhD
search Abstracts Collection (discontinued in 1985). Sev-
Lyle A. French, MD, PhD
eral of CMCC’s academics also took the initiative to
Ronald Gitelman, DC, FCCS(C)
establish a scholarly society, the College of Chiro-
Murray Goldstein, DO, MPH
practic Sciences, for the explicit purpose of prepar-
Philip Greenman, DO
ing future chiropractors for careers in research and
E.S. Gurdjian, MD, PhD
education.120 In collaboration with the CMCC, the
Lloyd Guth, MD
new organization established a hospital-based resi-
dency program in orthopedics at the University of
Saskatchewan, and many of its graduates subse- Dissatisfaction with the standards and purposes of
quently became productive in chiropractic research. the CCE prompted the formation of a second accred-
Among the early participants in this training were Drs. iting agency for chiropractic schools, this one focused
J. David Cassidy, Don Henderson, Silvano Mior, and on straight chiropractic education. The Straight Chi-
Howard Vernon. ropractic Academic Standards Association (SCASA)
was organized in 1978 by the Federation of Straight
Chiropractic Organizations (FSCO) and two member
MORE MOUNTAINS TO CLIMB schools: Sherman College of Straight Chiropractic in
South Carolina and the ADIO Institute of Straight Chi-
The 1970s saw the profession cross a number of sig-
ropractic in Pennsylvania. Founded by 1957 Palmer
nificant thresholds. The subsequent decade, not sur-
graduate Thomas Gelardi, DC, in 1973, Sherman Col-
prisingly, was a period of consolidation and new
lege was refused accreditation by CCE in 1975, osten-
challenges, some of which derived from chiroprac-
sibly on the grounds that it did not provide instruc-
tors’ newly won status. With federal recognition of
tion in human dissection (Fig. 2–26). However, the
the CCE, for example, came increasing demands for
contentious issues between the school and the CCE
scholarship and scientific investigation, a responsibil-
ran deeper: Sherman rejected as “medical” the notion
ity that the profession had never truly accepted before.
that chiropractors diagnose and treat human illness.
It was a challenge made all the more formidable by the
A number of lawsuits were filed by SCASA and the
still largely tuition-driven financial base of the chiro-
straight colleges against various agencies and associ-
practic schools. Meanwhile, unheralded and largely
ations in the profession to protect the institution’s vi-
unappreciated at its 1978 inception, the National Col-
sion of a nondiagnostic and nontherapeutic chiroprac-
lege’s Journal of Manipulative and Physiological Thera-
tic. Drawn into the dispute were the ACA, CCE and
peutics (JMPT), a peer-reviewed periodical, became
its accredited schools, FCLB, ICA, NBCE, the South
the center stage in the emerging research enterprise.120
Although the magazine never achieved a subscription
base of more than 10% of the nation’s chiropractors,
its 1981 acceptance for inclusion in the National Li-
brary of Medicine’s Index Medicus provided enhanced
legitimacy for the profession and international and in-
terdisciplinary visibility for the data it published. The
JMPT and its founding editor, Roy W. Hildebrandt,
DC, created a high standard and a model for others to
emulate (Fig. 2–25). The JMPT continues today as the
preeminent scholarly journal in the profession.
FIGURE 2–25. Dr. Roy W. Hildebrandt, circa 1966. FIGURE 2–26. Dr. Thom Gelardi, circa 1980.
Carolina Chiropractic Association, and the US Com-

missioner of Education.70,121,122
Accreditation was critical to the new schools, be-
cause it determined the eligibility of their students
for federally guaranteed loans, and the eligibility of
their graduates for licensure in most states. Sherman
College achieved regional accreditation from the
Southern Association of Colleges and Schools in 1984,
which gained its alumni license eligibility in a few
states. When SCASA, which accredited both Sher-
man and ADIO, was recognized by US Secretary
of Education William Bennett in 1988, the cause of
the new straight schools was strengthened. However,
SCASA’s federal status was not renewed in 1993, and
Sherman College lost its regional accreditation. The
South Carolina school eventually reached an accom-
modation with CCE, and was accredited in 1995. The
ADIO Institute, later renamed the Pennsylvania Col-
lege of Straight Chiropractic, closed its doors that
same year.
While the new straight schools struggled with
much of the profession, the two major national mem-
bership societies (ACA and ICA) attempted to merge.
The formation of the ACA in 1963 had itself been an
attempt at organizational unity, and although it drew
members from the NCA and the ICA, it fell short of
the larger goal. (The resources of the NCA were trans-
ferred to the new society.123 ) Unsuccessful attempts at FIGURE 2–27. Dr. Sid Williams. (Courtesy of Dr. Williams.)
merger in the 1970s were followed by a more promis-
ing initiative that commenced in 1982. By 1984, the two
organizations had established a joint committee to ex- derive from a consensus of opinion and a single voice
plore the issues involved in combining the resources speaking for the profession remains elusive.
and activities of ACA and ICA; a debate between lead- The ACA and ICA also threw their combined
ers of the groups was held on July 3, 1987. Whereas support behind a lawsuit against the medical estab-
the spokespersons for ACA and the ICA’s president, lishment brought by chiropractors Chester A. Wilk,
Michael D. Pedigo, DC, were in favor of combining Patricia Arthur, James Bryden, Steven Lumsden, and
the two societies, ICA board chair Sid E. Williams, Michael D. Pedigo. Filed in federal district court in
DC, who was also founder and president of the largest Chicago in 1976, the DCs charged the AMA and 14
chiropractic school, voiced his concern that ICA’s mis- codefendants (see sidebar “Defendants in the Wilk
sion to preserve chiropractic’s unique identity would Antitrust Lawsuit”) with a conspiracy to restrain
be lost in any such amalgamation (Fig. 2–27). Like trade, a violation of the Sherman Anti-Trust Act.124,125
B. J. Palmer before him, Dr. Williams was commit- Although the AMA’s efforts to “contain and elimi-
ted to preserving the “purity” of traditional straight nate” the chiropractic profession were many decades
chiropractic thought. old, the suit was based on the more recent activities
The ICA’s Board of Control (executive body) chose of AMA’s Committee on Quackery, which was or-
to put the issue before the membership, and did so on ganized in 1963 and patterned after similar efforts
two occasions, in 1988 and 1989. Each time a majority of the Iowa Medical Society and its legal counsel,
of ICA members were in favor of amalgamation, but Robert B. Throckmorton.126 The “Iowa Plan,” as it
because the ICA’s articles of incorporation required was known, involved antichiropractic publicity dis-
a two-thirds majority to effect the merger, the issue tributed by AMA members and various public agen-
was defeated.123 The two organizations have since cies, so-called “ethical” prohibitions against profes-
worked cooperatively in several arenas, most impor- sional association between MDs and chiropractors,
tantly involving national legislative issues (e.g., chiro- and exercise of behind-the-scenes influence within lo-
practic care for veterans and active duty servicemen, cal, state, and federal agencies that regulated health
Medicare reform), but continue to duplicate services care (e.g., health departments, state education offi-
in many areas. And the greater legitimacy that could cials, DHEW).
judge Susan Getzendanner, who found in favor of the

Defendants in the Wilk Antitrust Lawsuit127 DCs, awarded damages to plaintiffs, and issued an in-
junction against further abuse by political medicine.
American Academy of Orthopedic Surgeons
As well, she ordered that her ruling be distributed to
American Academy of Physical Medicine and Rehabilita-
all AMA members and be published in the AMA’s
tion
Journal.128 Several subsequent appeals by the AMA to
American College of Radiology
higher courts were unsuccessful, and the ruling held.
American College of Surgeons
While the case was in the courts, the AMA decided
American Hospital Association
(in 1980) to rescind its prohibition against interpro-
American Medical Association
fessional cooperation between chiropractors and al-
American Osteopathic Association
lopathic physicians. No longer was it considered un-
Chicago Medical Society
ethical for the two provider groups to refer patients
Illinois Medical Society
to one another, and for the first time AMA members
Joint Commission on Accreditation of Hospitals
were at liberty to collaborate with chiropractors and
Medical Society of Cook County
their institutions (e.g., as faculty members at chiro-
H. Thomas Ballantine, MD, chairman, AMA Committee on
practic schools and as coinvestigators in research).
Quackery
And though the Joint Commission on Accreditation
Joseph A. Sabatier, MD, chairman, AMA Committee on
of Hospitals, which had previously subscribed to the
Quackery
AMA’s ethical guidelines, was found not liable by
James H. Sammons, MD, AMA executive vice president
Judge Getzendanner, its previous refusal to allow hos-
H. Doyl Taylor, chairman, AMA Department of Investiga-
pital privileges for DCs fell by the wayside.
tion
The Wilk case changed the interaction between
DCs and MDs at both the national political and lo-
The lawsuit lingered in the courts for 14 years, led cal/individual levels. The AMA has grown reluctant
by antitrust attorney George McAndrews, brother of to publicly criticize chiropractors, although the fed-
Palmer College’s president, Jerome D. McAndrews, eral court order does not prohibit such expressions
DC (Fig. 2–28). Several defendants settled with the of opinion. (Several independent groups, most espe-
chiropractors out of court, but the AMA persevered. cially the National Council for Reliable Health Infor-
An initial jury verdict against the plaintiffs was over- mation, have taken up where the AMA left off.) The
turned, and the matter was finally settled by federal evolving economics of the health care marketplace
have encouraged greater cooperation between chiro-
practic and medical physicians, including the forma-
tion of interdisciplinary practices and greater cross-
referrals between practitioners than had been the case.
THE RECENT PAST AND NEAR FUTURE

The past quarter century has seen a number of pro-
gressive steps in the chiropractic profession’s long
pursuit of legitimacy. Chiropractic statutes have been
enacted in a number of foreign nations,129 and chi-
ropractic colleges are now more numerous beyond
American borders than within. This international
spread of chiropractic education has been fostered
by the creation of state-university-based training pro-
grams in Australia, Brazil, Canada, Denmark, Great
Britain, and South Africa, and educational accred-
iting agencies have been established in Canada,
Europe, and Australasia.129 These government-
funded schools, which lessen the otherwise heavy tu-
ition dependence of chiropractic education, also sig-
nificantly enhance the interdisciplinary dialogue and
collaboration between chiropractors and other health
service providers. The trend promises to lessen the
FIGURE 2–28. George McAndrews, 1989. traditional stigmatization of chiropractors.
The era has also witnessed considerable growth in identification of “subluxations”) is acceptable prac-
the quantity and quality of chiropractic scholarship.130 tice. While state laws provide some boundaries within
The emergence of a rigorous literature of controlled which the chiropractor must perform, the variabil-
clinical trials of spinal manipulation, many of them ity across chiropractic statutes in terms of what they
conducted by chiropractors, has strongly suggested permit and mandate142 is, itself, a source of confu-
the clinical usefulness of the manual arts in patients sion. Beyond the profession’s borders the question
with low back, head, and neck pain.131–133 Studies of of whether chiropractic should be considered “main-
the costs of chiropractic care have similarly suggested stream” or “alternative care” is complicated by a
somewhat of an advantage,134 and most studies of pa- multiplicity of opinions from the profession itself.
tients’ perception of chiropractic care speak to the sat- (Some accept that chiropractic methods have become
isfaction that these doctors generate.129,135 This body mainstream with respect to musculoskeletal problems
of evidence has elevated the esteem of the chiropractic of the head, neck, and back, but remain alternative
art in the eyes of legislators, government policymak- for all other disorders.) Although some consensus
ers, and segments of the health science community.136 on methodology is implicit in the creation of clini-
At least one book,137 authored by chiropractic radiolo- cal practice guidelines,140,141 “straight” chiropractors
gists Terry Yochum, DC, DACBR, and Lindsay Rowe, have disagreed with these guidelines and ventured to
DC, MD, DACBR, has been very well received in the create their own alternatives.143 There is unfortunate
allopathic community. veracity in the observation by the late Stanley Martin,
An important example of this change in perspec- DC, that “for every chiropractor there is an equal and
tive is the evidence-based clinical practice guidelines opposite chiropractor.”
for the treatment of low back pain issued by the fed- The diversity of views about the nature of the chi-
eral Agency for Health Care Policy and Research.138 ropractic art continues to sustain a number of national
Another is the emergence of chiropractic services for societies, none of which can claim a majority of the na-
active duty members of the armed forces, albeit within tion’s chiropractors as members. Among these are the
the context of a demonstration project.139 And in just ACA (largest of all, with about 20,000 full, associate,
the last decade, members of the profession have been, and student members), the ICA (about a third the size
for the first time, recipients of sizable federal grants of the ACA), and two much smaller groups: the Na-
for clinical investigations, and federal funds have tional Association of Chiropractic Medicine (which
been used to establish a Consortial Center for Chi- advocates chiropractors’ subordination to allopathic
ropractic Research (located at Palmer College of Chi- diagnosticians) and the World Chiropractic Alliance
ropractic). Chiropractors have also gained respect for (propounder of exclusively subluxation-based chiro-
their initiative in creating their own clinical practice practic practice). These divergences of opinion are
guidelines.140,141 also reflected in several jurisdictions, where multiple
Despite these achievements and the gain in respect state associations vie for legislators’ attention and the
and esteem for chiropractic methods, a great many public’s ear. The self-defeating character of speaking
century-old problems persist, and prevent the profes- with multiple voices is a recurrent problem through-
sion from achieving the cultural authority for which out chiropractic history that, even if understood, has
it thirsts. Among these impediments are (a) lack of not been overcome. The recent, broad endorsement of
consensus about the nature of chiropractic; (b) lack of the “paradigm” offered by the Association of Chiro-
organizational unity; (c) lingering stigmatization and practic Colleges144 constitutes a step toward greater
ostracism, as well as self-imposed isolation from the agreement, but as has been suggested elsewhere,145
wider health science and academic communities; and may create more problems than it solves.
(d) lack of epistemological consensus and vestiges of A strong belief in vitalism and the so far scientifi-
dogma in theory and practice. Several of these fac- cally unsubstantiated “subluxation complex” and its
tors limiting chiropractic legitimacy interact with one clinical implications has aided the profession’s oppo-
another, but it is useful to consider each. nents in maintaining the stigma against chiropractic.
Chiropractors do not all agree on their own iden- Political medicine’s traditional charge that chiroprac-
tity: what methods they use, what clinical goals are tors are quacks (i.e., pretenders to medical knowledge)
appropriate, and to which sort of patients and prob- seems particularly hypocritical in light of the gross
lems their healing art is appropriately applied (Ta- deficiency of medical training in the area of muscu-
ble 2–8). Verbal battles continue to erupt over whether loskeletal disorders. Although the voice of the AMA
DCs should be considered “physicians,” whether clin- has been generally silent with respect to chiroprac-
ical targets other than the traditional “chiropractic tic since its defeat in the Wilk antitrust case, others
lesion” should be attended to, whether intervention have found that DCs and their organizations continue
methods in addition to adjustive procedures should to provide examples of scientifically unsubstantiated
be employed, and whether diagnosis (other than the claims for the chiropractic art (see, e.g., reference 146).
TABLE 2–8. Suggested Roles and Scopes of Clinical Practice Among Chiropractors
Assessment Assessment Intervention Intervention

DC’s Role Target(s) Methods Target(s) Methods Advocates*
Primary care family Whole-person X-ray and noninvasive Whole-person Manipulative and ACA, CCE, ACA-
physician, internist orientation: methods, diagnosis orientation: physiological CDID
unlimited unlimited therapeutics
Musculoskeletal Primary contact X-ray and noninvasive Musculoskeletal Manipulative and ACCO, ACA,
specialist provider: unlimited methods, diagnosis problems physiological CCE
only therapeutics
Chiromedical Primary contact X-ray and noninvasive Musculoskeletal Analgesics and NACM
specialist provider: unlimited methods, diagonsis problems topical
only medicines,
manipulative
and
physiological
therapeutics
Radiologist or other Unlimited X-ray and noninvasive N/A N/A ACCR, ACA,
diagnostic specialist methods, diagonsis CCE
Adjustor (1) Primary contact X-ray and noninvasive Whole person, Adjusting only ACA, ICA, CCE
provider: unlimited methods, diagnosis all “diseases”
Adjustor (2) Primary contact X-ray and noninvasive Whole person, Spinal adjusting ACA, ICA, CCE
provider: unlimited methods, diagnosis all “diseases” only
Adjustor (3) Subluxations only X-ray and noninvasive Whole person, Adjusting only FSCO, SCASA
subluxation all “diseases”
detection only; no
diagnosis
Adjustor (4) Spinal subluxations Spinal x-rays and Whole person, Spinal adjusting FSCO, SCASA
only noninvasive all “diseases” only
subluxation
detection only; no
diagnosis
* Abbreviations: ACA: American Chiropractic Association; ACCO: American Council on Chiropractic Orthopedics; ACCR: American College of Chiro-
practic Radiologists; ACA-CDID: ACA Council on Diagnosis and Internal Disorders; CCE: Council on Chiropractic Education; FSCO: Federation of Straight
Chiropractic Organizations; ICA: International Chiropractor’s Association; NACM: National Association of Chiropractic Medicine; SCASA: Straight Chi-
ropractic Academic Standards Association.
The recent defeat of the CMCC’s bid for university af- At the root of many of the “philosophical” and
filiation seems to be a consequence of this sustained professional dilemmas confronting chiropractors is
antichiropractic sentiment. the lack of agreement on epistemology, that branch
However, the isolation of the profession from the of classical philosophy that deals with the nature
wider scholarly community is also, to a considerable of knowledge. Chiropractors have traditionally ad-
extent, self-imposed. Like the fear that the prospect vocated a wide range of methods of determin-
of clinical research once generated in some corners ing the usefulness of their healing art (see side-
of the profession,92 university affiliation and state- bar “Historic and Contemporary Epistemologies in
university-based chiropractic education have also Chiropractic”).147,148 Although visionary chiropractic
generated anxieties. Apprehensions that chiropractic philosopher C. O. Watkins, DC (Fig. 2–29), long ago
might lose its “separate and distinct” identity and au- suggested that the profession’s means of choosing
tonomy recently resurfaced, as seen in the efforts of patient care methods was the most important deter-
Palmer University to prevent the formation of a chiro- miner of chiropractic’s future, the message has not
practic college at Florida State University. Chiroprac- been widely heard nor taken to heart. Whereas most
tors remain unsure just how “mainstream” they wish other health disciplines agree on the scientific method
to be, and so perhaps miss out on the benefits that sci- as the most appropriate means of determining clin-
entific and professional cross-fertilization might offer. ical validity, chiropractic epistemologies are all over
Uncritical Empiricism
Cause and effect relationships in clinical practice are
considered “validated” by private (unpublished), un-
systematic (casual observation), and/or uncontrolled
(nonexperimental) data. The classical fallacy of reasoning
known as “post hoc ergo propter hoc” is exemplary (e.g.,
we know that the Logan Basic technique was effective
because the patient’s pain was decreased).
Other Fallacious Reasoning
Various classical fallacies of reasoning have been offered
in support of clinical theories and practice. Among these
are appeal to authority (e.g., we know upper cervical
adjusting works because B. J. Palmer said so), appeal to
ignorance (e.g., we know chiropractic works because it
has never been disproved), and the non sequitur (e.g.,
we know subluxations are real because otherwise there
would be no need for chiropractors).
Spiritual Inspiration
This method of knowing is a special case of an appeal
to authority; in this method, the authority figure is some
supernatural being such as Innate Intelligence. For
example, D. D. Palmer claimed that the principles of
chiropractic were revealed to him by Dr. Jim Atkinson,
who was apparently a deceased physician.
A deleterious consequence of the profession’s lack

of consensus about epistemology is demonstrated
in public communications by individual DCs and
FIGURE 2–29. C. O. Watkins, DC, circa 1955. (Courtesy of their representative state and national organizations.
Robert Watkins.)
Scientifically unsubstantiated (i.e., untested by ran-
dom clinical trials) claims for the chiropractic art are
the map.149 The profession’s recent commitment to frequently offered in marketing materials,150 profes-
developing evidence-based practice guidelines is a sional and educational web sites,146 trade journals,
hopeful sign of some convergence around scientific and other public forums. Many chiropractors have not
standards. distinguished between the use of unproved methods
of healing (which is authorized by state licensure) and
Historic and Contemporary Epistemologies the making of assertions for the value of these proce-
in Chiropractic dures (which is protected by the First Amendment,
but considered unprofessional beyond chiropractic’s
Clinical Science Method borders). Chiropractors’ harshest critics continue to
Sometimes also called the “hypothetico-deductive” draw upon the chiropractic literature for ammunition
method, this epistemology makes use of inferential and to be used against the profession.
deductive reasoning. Hypotheses (i.e., testable propo-
sitions about cause and effect) are derived from many
possible sources (e.g., basic science knowledge, clinical CONCLUSION
experience, previous research) and tested repeatedly in
Doctors of chiropractic have traveled far in their first
controlled experiments.
100 years, from their humble frontier roots in animal
Uncritical Rationalism
magnetism and alternative healing in the nineteenth
The validity of theories and effectiveness of clinical
century to their regulated status as one of the largest
interventions are thought to be established by their con-
health care provider groups in the United States, and
sistency with or derivability from some prior knowledge
by far the most frequent providers of manual thera-
(premise) such as basic science information or a meta-
pies. Chiropractors have carried the torch of populism
physical assumption. Stephenson’s (1927) “deductive
and medical liberty, and built a loyal clientele who rec-
science” is exemplary of this method.
ognize a benefit not usually obtainable from orthodox
physicians. With no assistance from government they influenced barrier to licensure. Louisiana was the
have built an educational system that, if not ideal, has last state to license chiropractors (1974), and not
nonetheless achieved federal recognition and serves until 1979 was the last of the basic science statutes
its primary purpose: basic training for future genera- repealed.
tions of DCs. And they have accomplished these goals 3. Schisms within the profession were in evidence
while enduring an abusive and hypocritical medical as early as 1903 when the first significant com-
establishment. The underdog’s survival has been its petitor to the Palmer School of Chiropractic was
victory. Along the way, DCs have acquired most if not established. Competition bred ideological dis-
all of the symbols of legitimacy available to a health putes, while courtroom struggles with the
care profession. allopathic establishment encouraged novel termi-
Beyond legitimacy, however, lies the issue of cul- nology for describing the chiropractic art. Chiro-
tural authority. Despite the recent growth in pop- practors’ inability to reach consensus over their
ularity of alternative medicine, chiropractors’ tradi- role, epistemology, and scope of practice ham-
tional “philosophy” (e.g., vitalism) and theory (e.g., pered their effectiveness in legislative campaigns
subluxation complex) have not been accepted by a and delayed the creation of a substantive research
majority of the public and the wider health science enterprise. These “philosophical” differences also
community. The profession’s core mode of interven- interfered with efforts to upgrade and establish
tion, manipulation, has fared well in scientific trials of federally recognized accreditation for chiropractic
its application for certain musculoskeletal problems. colleges.
However, the broader utility chiropractors have tra- 4. The profession was built by strong-willed, often
ditionally claimed and currently claim for spinal ad- charismatic individuals who pursued their dreams
justing (i.e., effectiveness for visceral or internal dis- tenaciously. The founder’s son, B. J. Palmer, took
orders and for disease prevention) is at least as likely over his father’s institution in 1906, and with
to produce scorn as acceptance. Continued expansion the assistance of veterans’ benefits following two
of chiropractic research can go far toward demonstrat- world wars, turned out tens of thousands of prac-
ing the usefulness (or lack thereof) of chiropractic care titioners. Chiropractors’ courtroom victories were
for nonmusculoskeletal conditions, but greater skep- guided by the Canadian-born lieutenant governor
ticism about things chiropractic and greater caution of Wisconsin, Tom Morris, whose law firm part-
in claims for the healing art will be necessary for the ners and successors defended DCs in thousands of
profession to earn the broader respect it craves. criminal cases and sired the National Chiropractic
Mutual Insurance Company, a malpractice insur-
ance provider. The tradition of “rational chiroprac-
SUMMARY
tic” is credited to John F. A. Howard, founder in
1. Chiropractic emerged in the late nineteenth cen- 1906 of the National School of Chiropractic, and to
tury as one of several alternatives to the heroic his successor, William C. Schulze, MD, DC. Credit
medical practices in the emerging “machine age.” for the 40-year struggle to improve and accredit
Despite D. D. Palmer’s mystical roots in spiritual- chiropractic education belongs largely to two men:
ism and magnetic healing, chiropractic was con- 1922 Palmer alumnus John J. Nugent and 1936
ceived as a drugless, mechanical means of reliev- Ratledge College graduate George H. Haynes. Chi-
ing inflamed tissue. Subsequent versions of the ropractors’ successful antitrust law suit against
founder’s chiropractic focused more narrowly on the American Medical Association and a dozen
mechanical effects on the nervous system and rein- other coconspirators, brought to federal court in
troduced the vitalism of his magnetic practices. 1976 by Chester Wilk, DC, and four coplaintiffs, is
2. Palmer’s feud with the local allopathic commu- largely attributable to the untiring labors of their
nity in Davenport, Iowa, foreshadowed a century legal counsel, George McAndrews. During the last
of conflict between chiropractors and organized quarter of the chiropractic century the emergence
medicine. Thousands of DCs were arrested and of meaningful research in the profession has been
tried for “practicing medicine without a license.” strongly influenced by scholars and clinicians such
When tried by juries, most chiropractors were ac- as Bernard A. Coyle, PhD, Scott Haldeman, DC,
quitted, but one in four was convicted and fined PhD, MD, and John J. Triano, DC, PhD. The Na-
or imprisoned. This persecution motivated vigor- tional College of Chiropractic provided a major
ous legislative campaigns, and by 1935 some 40 forum for chiropractic science in 1978, when it es-
American jurisdictions had passed licensing laws tablished the Journal of Manipulative and Physiolog-
for DCs. However, these early victories were un- ical Therapeutics.
dermined in half the states by the spread of ba- 5. The chiropractic profession in America has ac-
sic science legislation, which erected a medically quired most if not all of the formal characteristics
of legitimacy (e.g., licensure, accredited schools, 4. Among the purported consequences of the diver-
third-party and government reimbursement for sity of epistemologies in the chiropractic profes-
services). Cultural authority, on the other hand, sion are:
continues to elude chiropractors in this country for A. Acquittal of 75% of chiropractors arrested for
several reasons, including lack of internal consen- unlicensed practice and tried by juries.
sus about the role and scope of practice of DCs, and B. Rejection of homeopathic remedies as accept-
extraordinary diversity in epistemologies. Aver- able practice by chiropractors.
sion to the epistemology of science adopted in C. Tardiness in developing a substantive program
most other healing arts is a significant barrier to of clinical research.
internal consensus and research development. As D. Repeal of basic science laws.
well, continuing commitment to dogma perpetu- E. Appointment of Tom Morris as chief legal
ates conflict with many other stakeholders in the counsel for the Universal Chiropractors’ Asso-
health care marketplace (e.g., allopathic medicine, ciation.
insurance companies and health maintenance or- 5. Which of the following most significantly influ-
ganizations [HMOs], government). Chiropractors’ enced the growth in numbers of the chiropractic
willingness to “lower their guard,” for example, by profession?
establishing state-university-based colleges of chi- A. Passage of the Sherman Anti-Trust Act
ropractic, could go a long way toward developing B. Passage of California’s chiropractic statute in
a broader financial and scientific infrastructure for 1922 by vote of the citizens
training and research. C. Repeal of basic science statutes
D. Federal educational benefits for veterans fol-
lowing two world wars
E. Formation in 1926 of the earliest ancestor of
ACKNOWLEDGMENTS today’s Federation of Chiropractic Licensing
My thanks to Arlan W. Fuhr, DC, Bart N. Green, DC, MSEd, Boards (the International Congress of Chiro-
Robert B. Jackson, DC, ND, Jerome McAndrews, DC, and Glenda practic Examining Boards)
Wiese, PhD, for their assistance in retrieving materials, and to
the National Institute of Chiropractic Research for its financial
support of work related to the completion of this chapter. ANSWERS
1. E
2. A
3. False
QUESTIONS 4. C
5. D
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140. Haldeman S, Chapman-Smith D, Petersen DM, eds. 149. Keating JC. A survey of philosophical barriers to tech-
Guidelines for chiropractic quality assurance and prac- nique research in chiropractic. J Can Chiropr Assoc
tice parameters. Gaithersburg, MD: Aspen Publishers, 1989;33(4):184–186.
1993. 150. Keating JC, Hansen DT. Quackery vs. accountability
141. Henderson D, Chapman-Smith D, Mior S, Vernon in the marketing of chiropractic. J Manipulative Physiol
H, eds. Clinical guidelines for chiropractic practice in Ther 1992;15(7):459–470.
C H A P T E R
3
THE EVOLUTION OF VITALISM
AND MATERIALISM AND ITS IMPACT
ON PHILOSOPHY IN CHIROPRACTIC
Reed B. Phillips
O U T L I N E
INTRODUCTION VITALISM IN CHIROPRACTIC AND THE
CLASSICAL GREEK PHILOSOPHICAL THOUGHT TWENTIETH CENTURY
RENAISSANCE AND SEVENTEENTH CENTURY CONCLUSION
THOUGHT SUMMARY
EIGHTEENTH CENTURY THOUGHT DEFINITIONS
NINETEENTH CENTURY THOUGHT KEY REFERENCES
REFERENCES
influenced by subsequent followers, not the least of

OBJECTIVES whom was B. J. Palmer, his son. This philosophy was
1. To explain the historical roots and evolution of the greatly influenced by the prevailing thoughts at the
philosophy of chiropractic. end of the nineteenth century, when belief in vital
2. To understand the meanings and the implications forces governing life and action were increasingly
of the concepts of vitalism and materialism. challenged by the advancing knowledge of scientific
3. To describe how ideas about vitalism have evolved investigation. Allopathic medicine was a strong sup-
over time and who contributed to this discussion. porter of the reductionistic approach to scientific in-
quiry, aiming to explain health and medicine in terms
of purely physical, measurable phenomena. This clash
INTRODUCTION
in philosophy between chiropractic and allopathic
The chiropractic profession is more than 100 years old. medicine was an early source of friction between the
From its early beginnings to the present, an internal professions, and was only heightened when legal ma-
struggle over the philosophical underpinnings of the neuvering made chiropractors cling to this difference.
profession has resulted in a spectrum of beliefs and re- Chiropractors’ conflict with allopathic medicine en-
lated behaviors. Many chiropractors have long held to couraged reliance upon vitalistic explanations for ad-
beliefs in forces necessary for life, forces that are non- vancing the profession. The “life–matter relationship”
physical and therefore unmeasurable, such as Univer- debate happening in philosophy at that time also dis-
sal Intelligence and Innate Intelligence, the vital forces posed chiropractors to emphasize deductive reason-
that direct and govern life. Treatment with chiroprac- ing as a means of justifying and explaining chiroprac-
tic adjustments in the past has been described as ex- tic theory and practice.
erting a positive influence on the flow of Innate Intel- To better understand the roots of philosophical ex-
ligence, thereby leading to better health. planations in chiropractic, we must first travel the
The philosophical roots of chiropractic originated dusty roads of its predecessors. Appreciation of the
with its founder, D. D. Palmer, and were heavily philosophical debates over the centuries builds a
65
context for understanding our current struggles. Our depletion and repletion. In his review of Plato’s work,
focus is on this “life–matter relationship,” also known Hall suggests that
as vitalism.
If that proper equilibrium of assimilated ele-
ments which is so necessary to life be disturbed,
CLASSICAL GREEK PHILOSOPHICAL THOUGHT
the results can be catastrophic. A disproportion
The objective of this discussion is to gain an under- of elements—and especially of the triangles
standing of how ideas about life forces have evolved in marrow—can bring on diseases and death.
from the ancient Greeks to the present day. With this Such disproportion is caused specifically by
understanding one can appreciate more fully the rea- irregularities in the rate of flow of substance
sons for the diversity of thought that exists today. In [blood] into or out of the affected part of the
the space allotted, one can only trace the major strains body.1
of philosophical thought and lightly touch on some
of the more notable contributors. The focus is on the This description is very similar to the chiroprac-
development of thought as it relates to the origin, pur- tic concept of subluxation, whose presence has been
pose, and meaning of life. described as disturbing the equilibrium necessary to
The first point in need of clarification is that maintain health.
thoughts may change. The very definition of mat- Aristotle (384–322 bc) taught that natural bodies
ter was a point of discussion for the early Greeks, consisted of a primordial entity composed of two ele-
to whom biology was built upon a dual concept of ments: the matter and the form. Form was the element
life—life as action in a physiological sense, and life as capable of giving a specific determination to the mat-
soul, inducing or permitting active life. Believing that ter and of transforming it into specific things. Aristotle
life was simpler than the diversity presented to the believed that every living thing had a purpose toward
senses, the Greeks sought a simplistic (reductionistic) which it spontaneously tended. The soul was part of
explanation of life. Water was the first substance con- the living body, and could not be separated from living
sidered to have a “real existence”; other substances matter.2 In fact, Aristotle spoke of three types of soul:
were added later, such as air, fire, and earth. Every- (a) the vegetative, required for nutrition and repro-
thing in the natural world was simply a combination duction, also found in plants and other living things;
of these elements. Thus life, as a soul, was part of what (b) the sensitive, found in all animals which appear to
was defined as matter.1 Five fundamental theories de- possess tactile sensation; and (c) the rational, possessed
veloped to explain the relationship between life and by man alone.3
matter: Galen (129–189 ad) was heavily influenced by
Aristotle’s concepts. He taught that the primary cause
1. Life is identical to some element. That is to say air of any object is its final purpose, that is, the function or
and life are identical or fire and life are identical. role for which it has come into existence.1 For Galen,
2. Life is immanent (contained within). Life is imma- life depended on breathing, which was the action of
nently present in the basic substances such as air taking in spirit from the general world soul. The liver
or fire. was the center for the veins, the heart for the arteries,
3. Life is imposed. Life is a distinct but nonmaterial and the brain for the nerves. From each of these organs
entity bonded to certain objects and inducing in the appropriate “spirits” were sent to the body not
them a characteristic ensemble of behaviors (life by circulation, but by an ebb and flow up and down
as action). Plato was a strong proponent of this a single series of channels. Blood from the liver and
view. pneuma from the lungs mingled in the left ventricle and
4. Life is organization. Life is a special arrangement became vital spirits. The vital spirits that reached the
of matter that permits it to behave in a “lively” brain were turned into animal spirits, which then trav-
fashion, such as to eat or move. eled to all parts of the body through hollow nerves.
5. Life is an emergent consequence of organization. From 200–1628 all followers of medicine and biology
This differs from the previous theory in that life were Galenists and hence vitalists.3
is a result of the organization, and not the orga-
nization itself. Systems have characteristics that
RENAISSANCE AND SEVENTEENTH CENTURY
are absent from their isolated components, char-
THOUGHT
acteristics that only appear when the parts are
assembled.1 Galen’s concept of vitalism remained mostly un-
changed until the seventeenth century, when the Re-
Plato (427–347 bc), in his writing of Timaeus, taught naissance ushered in new ways of thinking. These new
that life occurred in a system subject to simultaneous thoughts clashed with the dominant doctrine of the
THE EVOLUTION OF VITALISM AND MATERIALISM AND ITS IMPACT ON PHILOSOPHY IN CHIROPRACTIC 67
church, and acceptance of change was not without These were his ideas about phlogiston, a substance sup-
challenge. posedly set free by burning objects, and his notion of
William Harvey (1578–1657) disregarded current a biomedical soul. Phlogiston influenced the history of
notions about spirits. He proposed that the heart gave biology by deflecting it temporarily from a forward-
motion to the blood and that there was only one sys- directed understanding of biological oxidation.1
tem of circulation in the body. The comingling of blood Stahl’s vitalism saw the soul as an external prin-
from the liver and the lungs to create vital spirits could ciple penetrating the inert body and vivifying it in a
not be demonstrated, which left this part of Galen’s way that generated movement and hence life:
work in question. However, Harvey’s work did not
address the possibility of animal spirits associated The principle of life is the soul, not a special
with the function of the brain and nervous system. soul, but the rational soul, that which alone
Thus, the belief in some sort of nervous spirits lin- constitutes man, and is manifestly united to his
gered and merged into the modern belief in nonma- body. . . . The soul is not the life of the body; it
terial impulses that pass along the nerves.3 cannot even be said to be alive, but only to give
Galileo Galilei (1564–1642), condemned by the life; and it accomplishes this task of vivifica-
church authorities in Rome, has been called the father tion, not by simple union with the body, but
of modern science. He was instrumental in the formu- by real action. . . . This life-giving act, the soul
lation of a new scientific methodology. Galileo asked performs with complete intelligence in all de-
not why objects move, but how they move. He was tails; it performs it by acting on all the organs,
content to describe how phenomena progress, and he directing all their functions, using every appro-
completely ignored questions about the purposes they priate means to arrive at its goal. . . . The organs,
serve, which he saw as irrelevant to the problems in thus, are not, as the name organ might suggest,
which he was interested. The questions Galileo asked merely simple instruments; it is the soul that
of nature were fundamentally different from those makes the lungs breathe, the heart beat, the
considered in the Middle Ages. Interest was directed blood circulate, the stomach digest, the liver
not to final causes operating toward the future, nor to secrete; it is the soul that, while preserving the
formal causes in the essence of the object, but to effi- body, also makes it live and that, in order to
cient causes. In all these ways, Galileo’s work embod- preserve it, maintains corruptible matter in its
ied the approach typical of modern science, and it led [condition of] essential corruptibility yet keeps
to a new ideal of what it means to explain something.4 it from the act of corruption; and it is the soul,
With the work of Galileo, the process of replacing God finally, that, to protect the body against actual
as First Cause began. God became merely the original corruption and to restore its losses, nourishes
creator of the interacting atoms in which resided all it and assimilates foreign substances to it, and
subsequent causality. Nature was considered to be in- makes repose follow movement and sleep fol-
dependent and self-sufficient; God’s role was gradu- low waking.1
ally relegated to that of First Cause only.4
René Descartes (1596–1650) attempted to show The above definition is quite similar to the defi-
that man consisted of an earthly machine inhabited nition of Innate Intelligence given by Stephenson in
and governed by a rational soul not unlike that of 1927 (see “Definitions” below). And yet, as science
Aristotle. In fact, the existence of God was essential progressed, Stahl’s views were eventually considered
for the creation and maintenance of nature and of false and misleading by most thinkers.
the spirits of men. This duality of body and mind (or Rounding out the seventeenth century was Isaac
soul) ultimately depended upon God’s intervention Newton (1642–1727). As a mathematician, he fur-
to bring harmony to the two different entities. It be- thered the work of Galileo in that he insisted that
came only too easy to omit the spiritual side of this the scientist’s job was to describe phenomena and not
duality and turn to a system of monism of a mecha- to make unfounded speculations about why certain
nistic nature.4 Descartes as a mechanist is considered phenomena existed. Scientific research, he believed,
the father of modern reductionism. His influence on should seek to explain how gravity worked, not why
biology and medicine led to efforts by others to exit existed.
plain all biological and chemical phenomena via the Newton’s laws of motion and gravity seemed ap-
laws of mechanics. His concept of spirits, especially plicable to all objects, from the smallest particle to the
in man, amounted to nothing more than bodies with farthest planet. His theory painted an image of the
no properties, extremely small and moving at a very world as an intricate machine following immutable
high speed like the parts of a flame.2 laws. Here was the basis for the philosophies of de-
Georg Ernst Stahl (1660–1734) is probably best re- terminism and materialism. Newton believed that the
membered for what are considered scientific errors. world machine was designed by an intelligent Creator
and expressed God’s purposes. The properties that to be separate from the body because the body could
could be treated mathematically, such as mass and be killed with poisons without any physical disorga-
motion, were alone considered to be characteristic of nization of the body. He concluded that if the vital
the real world. Efficient causes replaced final causes, principle is separate from the body, then at death the
and all causality was assumed to be reducible to forces vital principle may return to the universal principle
between particles and all changes reducible to the re- that was created by God to animate the cosmos.5
arrangement of particles.4 In the latter half of the eighteenth century, vital-
ism retained its influence in scientific thought. This
may have been related to the revival of the influence
EIGHTEENTH CENTURY THOUGHT
of religion in England and France, where an increased
While the science of mathematics and astronomy pros- reverence for the Bible occurred. The general antirev-
pered during the seventeenth century, the develop- olutionary movement after the excesses of the French
ment of the field of chemistry lagged. During the Revolution may have also served to support vitalis-
eighteenth century, science greatly expanded its ex- tic concepts.3 The second half of this century saw new
plorations into new lands around the world. Scien- models put forward and a general popular acceptance
tific effort focused more upon collecting and classify- of the term “vitalism.” These models had in common
ing new forms of plants and animals than observing the agencies or powers they evoked as preconditions
such things in their native habitat. While chemists and of life at a point where they could not be explained
physicists made remarkable laboratory experiments, or reduced any further. These principles, then, were
the distinction between living and nonliving entities primitive elements that acted as the cause of life, but
remained unchanged. Life remained the unexplain- of themselves were not interpretable in terms of orga-
able mystery regardless of the many varied forms that nization or any other identifiable cause.5
were discovered and classified. In spite of the grow-
ing momentum of mechanistic explanations of phe-
NINETEENTH CENTURY THOUGHT
nomena, vitalistic beliefs held sway because of the
failure of mechanistic explanations to answer some The nineteenth century saw a proliferation of revi-
fundamental biological questions. Partly because of sions in every branch of biology. The most radical were
the alleged shortcomings of mechanism and chemism, (a) the rise of organic chemistry and biochemistry,
new solutions—new causae vitae—were called for. (b) the growth of cell doctrine, and (c) the establish-
They carried appellations, varying with their au- ment and acceptance of the theory of evolution.5 For
thors, which were not new: “faculties,” “properties,” a number of chemists during this century, it was ap-
“principles,” “forces,” and “powers,” all characteris- parent how far short their chemistry fell in explaining
tically preceded by the qualifying adjective “vital.”5 the phenomena of life. They recognized causal forces
With the development of the microscope in the sev- in living systems but could not explain them. Today,
enteenth century, a new field for the vitalist argument many of those forces have been explained as enzymes
appeared. Embryology under the microscope opened and peptides. Although the complexity of the molec-
the way for the great “evolution–epigenesis” contro- ular world was yet to be elucidated, this new knowl-
versy. Evolution was defined as the unfolding or de- edge began to weaken philosophic reliance upon un-
velopment in the embryo of structures already present explainable vital forces.5
in the generative element or cells. To avoid confusion T. Schwann (1800–1840) conceptualized the cell,
with Darwinian concepts, this definition of evolution albeit imperfectly. He described the cell as a vesicle
is more correctly referred to as preformation. In con- with a cavity inside. The nucleus inside the cell was
trast, epigenesis taught that new structures developed also thought to be a vesicle. As imperfect as his de-
from undifferentiated structures that were not present scription might have been, he demonstrated that the
in the original ovum or spermatozoon.3 ultimate living units of animals and plants contained
Paul Joseph Barthez (1734–1806), a practicing the basic structural and developmental sameness.5
physician, posited a causal “principle of life.” With Nineteenth century vitalism left many unan-
this he sought to differentiate within the living sys- swered questions. For example, was this “vital force”
tem that which permits the organism to feel from that a specific nonmaterial, nonmechanical entity? What
which allows it to move. It was this vital principle made it take action? What effects was it to produce?
that led to the general use of the term “vitalism” af- Was it matter or a force? Was it natural or supernatu-
ter 1773. Barthez was unsure if his vital principle was ral? Does it have sentient or psychic properties? Was it
(a) a definite substance, (b) a mode of the body, or (c) a the cause or the consequence of physical organization?
mode of a special substance another of whose modes The term “vitalist” represented a wide variety of ideas
is the thinking soul. He considered the vital principle and was also applied to ideas from earlier eras. Hall
organized the theories of vitalism in the nineteenth and maintains the organic milieu and makes it
century into the following four areas:5 no longer susceptible to nature’s laws, but to
laws in opposition to these. . . . 2
1. Life appeared as an ensemble of activities occur-
ring when ordinary chemical elements were ar- This view is very similar to that of many early chi-
ranged in an extraordinary way. Thinkers in this ropractic practitioners, who believed that the body
group were called vitalists because of their insis- will heal itself if properly supported. Vitalistic con-
tence on life’s emergent uniqueness. cepts were opposed by the physicists and chemists
2. Vital properties consisted of certain unexplained of the day. They claimed “vital force” was a useless
and presumably inexplicable capacities or predis- concept that added nothing new to a growing body
positions of living bodies to exhibit life as action. of knowledge derived from observation and experi-
This group considered the vital cause not only un- mentation. In fact, they argued, many vital phenom-
known but unknowable. ena could now be explained by physical and chemical
3. The uniqueness of life seemed to demand the pres- knowledge.
ence in living things of some extraordinary com- Claude Bernard (1813–1878) sought to bring the
ponent, some special plastic principle, or entropy- opposing positions of the vitalists and mechanists to-
opposing force, or unique substance. gether. He reaffirmed the existence of a finality in the
4. Matter itself is immanently alive and is the out- internal units of the living being, but held that bio-
ward expression of the immanent animation of logic dualism was only possible when the organism
the organism’s substance. This theory was not well was considered as a whole:
accepted.
. . . [I]n physiology the knowledge of the
In summary, the term vitalism requires a clarifi- properties of isolated elementary units can-
cation. Does it refer to an imposed causal agent or an not give anything more than an incomplete
inscrutable property of some sort, or is it the presumed synthesis . . . in a word, when physiologic el-
immanent animateness of the organism’s substance or ements are combined new properties, which
the emergent uniqueness of extraordinary organized could not be appreciated in each single ele-
matter? And, finally, why posit vitalism at all when ment, appear. . . . This shows that the elements,
progress in scientific discovery was bringing to light although different and independent, do not
so much new knowledge? In the nineteenth century, simply associate with one another, but their
vitalism retained its role for two reasons. The first unification expresses something more than the
was the apparent “irreducibility” of vital phenomena; simple addition of their separate properties . . .
the second was the apparent orderliness of the world, the vital force directs phenomena which it does
an organization that otherwise defied explanation.5 It not produce and physical agents produce phe-
was not common for the thinkers of the day to consider nomena which they do not direct.
that the irreducibility of biological phenomena was a Among naturalists, and even more among
result of their own ignorance and not the existence of physicians, there are some who in the name
an inexplicable causal vital entity or agent. of vitalism formulate the most erroneous judg-
Giacomo Andrea Giacomini (1796–1849) was a vig- ments. . . . They consider life a mysterious and
orous supporter of vitalism in the nineteenth century. supernatural force which acts arbitrarily and
He taught that vital strength was a primary force of releases itself from any determinism, and con-
the living being, which stood as a power in opposition sider as materialists all those who try to lead
to the physicochemical laws and influences that could all vital phenomena to causes determined or-
bring harm or even death to the organism: ganically or physicochemically. . . . The vital-
istic ideas, in the sense we have discussed,
It is nature that cures disease. And by the term are nothing more than faith in the supernatu-
“nature” we mean an activity, a force within the ral. . . . I would agree with vitalists only if they
living organism, called by different people me- limited themselves to admitting that living be-
diating force, organic resistance. . . . To deny an ings present manifestations absent in the inan-
activity of the organism which counteracts dis- imate world and, for this reason, constitute a
ease and keeps the body healthy against thou- peculiar character of it.2
sands of hazards is intellectual blindness. The
mediating force of nature is the same force that Rudolph Virchow (1821–1902) viewed the cell as
renders this organism alive, develops it, and the ultimate unit of life and life as the sum of activi-
maintains it; it is the force which establishes ties that active cells have in common. He considered
himself a new vitalist because of his refusal to ac- unit and those who believed something smaller than
knowledge life at a level lower than the cell, even the cell contained “life”:
though he recognized a life force. He taught that:
If life is a complex ensemble of nutritive, re-
. . . the molecular properties of the cell are nec- productive, and behavioral responses, then the
essary for life but not in themselves suffi- least part of an organism that can be properly
cient. What was needed in addition was a vi- acknowledged as living will be the cell as a
tal force—a composite summation of all forces whole. But if life is more narrowly defined as,
through which the motion that is life is commu- for example, replication through division, or
nicated and maintained . . . that individual cells molecular assimilation, or even a fairly com-
are the loci of disease and, in fact, of normal plex combination of these, then it is arguable
life processes too. The cell is the place where that something less than a cell—a molecule, or
disease occurs, and it is also the place where multimolecular particle or mixture—could be
life occurs. It is the unit of life and the pre- regarded as “living.”5
condition of life’s uniqueness . . . life-force is
nonpsychic, nonteleological, and nontranscen- Herbert Spencer (1820–1903) defined life as
dental. . . . Life is only a special kind of the Me- follows:
chanical, the most complex form thereof in
which the usual mechanical laws occur under Life consists . . . in correlated, heterogeneous,
the most unusual and multiform conditions.5 simultaneous series of changes that adjust the
organism to changes in its environment. Since
every change is in some sense a change in re-
Charles Darwin (1809–1882) had an enormous
lations, “the broadest and most complete defi-
effect on the vitalism–mechanism controversies, al-
nition of life will be—The continuous adjustment
though he tended to remain neutral. His theory of
of internal relations to external relations.”5
natural selection embraced the concepts of random
variation, struggle for survival, and the survival of
The similarity of Spencer’s definition of life to that
the fittest. He was a classical scientist of his day, and
of chiropractic as given by Stephenson (1927) (see
recognized that
“Definitions” below) is not inconsistent with the tran-
sition of thought from one generation of thinkers to the
[n]o amount of data constitutes a scientific the- next. Stephenson defined life “. . . as the movement of
ory unless it is unified by the creative invention everything in the universe and governed by a Univer-
of an imaginative hypothesis; but no theory is sal Intelligence.”6
of use in science unless it can be tested against
individual observations and can guide the fur-
ther collection of data.4 VITALISM IN CHIROPRACTIC AND THE
TWENTIETH CENTURY
It was not until later in Darwin’s career that his the- In 1895, vitalistic thinking was waning under the
ories expanded to explain the origin of man. What had weight of scientific discovery. Mechanistic thinking
been considered sacred was brought into the sphere of paved the road to improved living conditions that be-
natural law and was analyzed in the same categories gan to reduce the rabid effects of disease and prolong
applied to other forms of life. His work emphasized life. It was in this same time period that medical educa-
that all of nature was constantly changing, that nation began to consolidate its “cultural authority”7 by
ture was a complex of interacting forces in organic drawing upon the findings of science to enhance the
interdependence, that the rule of law extended into practice of medicine. In just two decades, medical ed-
new areas of biology and nature, and that nature now ucation underwent significant changes that improved
included humans along with other species.4 This tran- its quality and raised standards required to become a
sition of thought undermined the vitalist perspective physician.
by placing man under the governing laws of nature, D. D. Palmer, the founder of chiropractic, identi-
and therefore likely devoid of a specially ordained vi- fied himself as a “magnetic healer.”8 Much of what
talistic governance. D. D. taught in the early years was consistent with the
The second half of the nineteenth century saw prevailing vitalistic thinking. Many of his ideas were
the vitalists’ traditions struggle with the definition of perpetuated at the Palmer School of Chiropractic un-
what was really alive and thus governed or at least in- der the leadership of his son B. J. These early years
fluenced by a vital force. The argument was between of chiropractic quickly saw conflict among a growing
those who believed the cell was the smallest living medical profession, a rivaling osteopathic profession,
and Palmer’s followers. In Wisconsin in 1907, Palmer inductively upon them; seeing therein the ac-
graduate Shegetaro Morikubo was charged with prac- tion of intelligence, every finding being more
ticing medicine without a license. B. J. and legal coun- proof of its Major Premise.6
sel Tom Morris rushed to his aid. In Morikubo’s de-
fense they declared that “chiropractic” was not the This dismissal of the inferential reasoning of mech-
practice of medicine. The Morikubo case spawned a anistic science denied the essential value of empirical
successful legal rhetoric which distinguished “chiro- observation that natural philosophers since Galileo
practic” from medicine and osteopathy.9 “We don’t had pioneered, and served to further alienate the
treat disease” was the cry. Chiropractors cared for profession from the wider field of science. To be
their patients by removing the cause for their dis- sure, B. J. Palmer was responsible for extensive data
ease, a state of being brought on by the presence of collection (e.g., his research clinic), but his intent was
a “subluxation.” Allopathic notions of “subluxation” to confirm preconceived ideas rather than to explore
were much more narrow than those offered by chi- the natural world. Any fact not found in support
ropractors. Given these theoretical differences, it was of the Major Premise was discounted in some fash-
argued, no real basis for criminal prosecution existed; ion. Vitalism had found a shelter in which it seemed
chiropractors did not practice medicine, but merely unassailable.
detected and corrected subluxations of the spine. This Thus, in the developing years of chiropractic,
approach kept many (but not all) chiropractors out of when much oppression from the prevailing medical
jail. establishment existed, B. J. led a segment of the chiro-
From these beginnings, and driven by survival practic profession into a then dying field of scientific
needs, B. J. and his followers developed a paradigm endeavor, namely vitalism and metaphysics, initially
rooted in vitalistic concepts. The subluxation, freed to secure a measure of protection from legal harass-
from its restricted medical meaning, was the focus of ment. This action spilled over into the developing
chiropractic practice. Subluxations impeded the flow thought patterns of the young profession and the
of vital life force (Innate Intelligence) through the desire for the security of an idealistic, isolationistic
body, and thereby caused disease. posture. However, it also unwittingly caused many
Chiropractors corrected these obstructions to life elements of the profession to evolve an antiscience,
force by applying segment-specific chiropractic ad- antiintellectual attitude that impeded scientific think-
justments. Innate Intelligence was considered a frac- ing and the development of a research basis for the
tion of the Universal Intelligence that governed practice of chiropractic.
all.10 Meanwhile, scientific discovery in the twentieth
The protective legal shield of “chiropractic philos- century surpassed all previous periods. Vision ex-
ophy” won many court battles by enabling chiroprac- panded into the heavens to distances difficult to com-
tors to successfully assert that they were not practicing prehend and into microscopic degrees never before
medicine. As well, the vitalism of chiropractic philos- imagined. Yet, the search for the essence of life, that
ophy was coupled to a restricted reasoning process. “vital force,” was not to be “scientifically” defined.
B. J. Palmer and Ralph Stephenson insisted that the Dix11 defined “life” as “the power by which a system
“deductive science”6 of chiropractic was based upon of molecules acts so as to avoid equilibrium.” He felt
derivations from a true first principle (the “Major that thought was impossible to explain by the laws of
Premise”), essentially an assertion of the existence of physics and chemistry. Even if the genetic code were
a Universal Intelligence. fully understood, he argued, particular thoughts were
not coded in the deoxyribonucleic acid (DNA) and
Chiropractic is a deductive science. The deduc- these thoughts drive the organism toward maximum
tions are based upon a major premise that life is benefit, something he felt was a survival principle.
intelligent; that there is an Intelligent Creator, This drive toward maximum benefit was termed by
Who created matter, attends to its existence and Dix as the vitalistic principle.
gives to it all that it has. . . . Scientific inquiry into the cellular world led to
Deductive reasoning is exactly suited to an increasing focus on the mechanisms by which
Chiropractic. By assuming a major premise that cells communicate with each other. Zweifach speaks
there is a Universal Intelligence which governs of “the terminal mesh of microscopic sized vessels
all matter, every inference drawn from that ma- within the tissue . . . [and] the capacity to behave as
jor premise and subjected to specific scrutiny an independent organic entity in response to local
stands the test. . . . We wish to make it clear changes in the metabolic status of tissues. . . . [T]he ba-
that at no time does Chiropractic deny labo- sic functional attribute of this all-pervasive entity can
ratory findings or discredit them as science, best be described as the maintenance of tissue home-
but Chiropractic reasons deductively instead of ostasis. . . . [H]omeostatic controls have been relegated
for the most part to the ultrastructural molecular Cartesian view, because by definition, information be-
domain.”12 longs to neither mind nor body, although it touches
Pischinger expanded the concept of the extracellu- both.”14 She also suggests the therapeutic potential of
lar matrix as part of the controlling mechanism of the this informational model, and seems to provide sup-
body and considers its vitalistic relationship:13 port for the traditional vitalism of chiropractic:
Since the extracellular matrix is connected to So, if the flow of our molecules is not directed
the endocrine gland system via the capillar- by the brain, and the brain is just another
ies, and to the central nervous system via nodal point in the network, then we must ask—
the peripheral vegetative nerve endings with Where does the intelligence, the information
their blind endings in the extracellular ma- that runs our body mind, come from? We know
trix, and both systems are connected to each that information has an infinite capability to ex-
other in the brain stem, superior regulatory pand and increase, and that it is beyond time
centers can be influenced by the extracellu- and place, matter, and energy. Therefore, it can-
lar matrix. Since capillaries, vegetative nerve not belong to the material world we apprehend
fibers, and the connective tissue cells that wan- with our senses, but must belong to its own
der through the connective tissue and regulate realm, one that we can experience as emotion,
the extracellular matrix (macrophages, leuko- the mind, the spirit—an inforealm! This is the
cytes, mast cells) are mutually “informative” term I prefer, because it has a scientific ring to
through released cell products (prostaglandins, it, but others mean the same thing when they
lymphokines, cytokines, proteases, protease in- say field of intelligence, innate intelligence, the
hibitors, etc.), the result is a vast, complex, in- wisdom of the body. Still others call it God.14
termeshed humoral system, whose historical
scientific predecessors are to be found in the
classical vital juice theory. The advantage of
CONCLUSION
such an intermeshed system is a significant in-
crease in the adjustment and performance ca- From the classical Greek philosophers to present-day
pacity, and the possibility of more and prop- molecular biologists, the relationship between life and
erties that cannot be attained through simple matter continues to elude precise scientific descrip-
addition of the single properties of the compo- tion, but likewise continues to persist as an element
nents. In this way, relationships between the of our being that is not easily dismissed. The birth
psyche and the immune system (“psychoneu- of chiropractic at the end of the nineteenth century
roimmunology”) can be understood. with its emerging philosophical foundations presents
plausible explanations for professional divisiveness.
The work of Candace Pert also addresses the life– Allopathic hegemony attempted to eliminate the
matter discussion and reintroduces modern-day vi- budding profession using legal means. Unable to
talistic concepts that have enjoyed some degree of re- withstand the frontal assault, chiropractic leadership
spect within the scientific community. Pert observes sought refuge under the shield of an alternative ver-
the interconnectedness and communication among nacular. B. J. Palmer argued that the practice of chi-
physiological systems, and locates the mind in this ropractic was different from the practice of medicine
internal dialogue: and, therefore, a chiropractor could not be punished
for practicing medicine without a license.
The mind as we experience it is immaterial, yet This protective shield apparently prompted a seg-
it has a physical substrate, which is both the ment of the profession to extend its comfort zone
body and the brain. It may also be said to have by adopting not only an antimedicine position but
a nonmaterial, nonphysical substrate that has an antiscientific stand. Chiropractors remained iso-
to do with the flow of that information. . . . With lated from the scientific and academic community.
information added to the process, we see that Science, for B. J., meant sustaining the Major Premise
there is an intelligence running things. It’s not and derivative theory and technique. The Major
a matter of energy acting on matter to create Premise (and other lesser premises) needed no ex-
behavior, but of intelligence in the form of in- planation, because they were derived from a higher
formation running all the systems and creating source and could not be questioned.
behavior.14 Although this antiintellectual position persists in
a small percentage of chiropractors in this twenty-
Information, she believes, “is the missing piece first century, the profession never developed a broad-
that allows us to transcend the body–mind split of based consensus around Stephenson’s 33 principles.
The current spectrum of thought ranges from these 3. The concept of vitalism has been discussed for
traditional concepts espoused by B. J., Stephenson, thousands of years, slowly evolving as new in-
and their adherents to an equally dogmatic and com- formation about the world was discovered. Sci-
plete denial of vitalistic concepts at the other end of entists and philosophers who participated in the
the spectrum. discussion of vitalism include Plato, Aristotle,
Fortunately, the spectrum contains a great deal Galen, Harvey, Galileo, Descartes, Stahl, Newton,
of space between the two anchoring ends, a space Barthez, Schwann, Hall, Giacomini, Bernard,
wherein may be found many types of principles, such Vichon, Darwin, Spencer, Pischinger, and Pert.
as vitalism, holism, naturalism, therapeutic conser-
vatism, critical rationalism, and thoughts from the
phenomenological and humanistic paradigms.15 A DEFINITIONS
critical review of philosophy and its impact remains
both a challenge and an opportunity for the profes- According to the dictionary, philosophy is:
sion. Diversity is generally healthy when it generates
new ways of seeing the world. However, when diver- 1. The rational investigation of the truths and princi-
sity divides the world into warring camps, genocide is ples of being, knowledge, or conduct.
often the end result. On a shrinking planet, populated 2. A system of philosophical doctrine: the philosophy
with a global community that embraces a diversity of of Spinoza.
thought, especially in the healing arena, chiropractic 3. The critical study of the basic principles and con-
is confronted with an unprecedented opportunity to cepts of a particular branch of knowledge: the phi-
obtain its own “cultural authority” through enlight- losophy of science.
ened and collegial intellectual exploration of its basic 4. A system of principles for guidance in practical
premises. affairs: a philosophy of life.
5. A calm or philosophical attitude.16
The World Book Encyclopedia lists and defines the

SUMMARY following branches of philosophy:
1. The philosophical roots of chiropractic originated
with its founder, D. D. Palmer, and were heavily 1. Metaphysics—the study of the fundamental na-
influenced by subsequent followers, not the least ture of reality and existence and of the essence of
of whom was B. J. Palmer, son of D. D. Their ideas, things.
and those of other early chiropractic writers, were 2. Epistemology—aims to determine the nature, ba-
greatly influenced by prevailing thought at the sis and extent of knowledge. It explores the vari-
end of the nineteenth century. Belief in vital forces ous ways of knowing, the nature of truth, and the
governing life and action was increasingly chal- relationship between knowledge and belief.
lenged by the advancing knowledge of scientific 3. Logic—the study of the principles and methods of
investigation. Chiropractic philosophy has evo- reasoning. It explores how we distinguish between
lved over the years as a result of several factors, in- good and bad reasoning.
cluding continued study by the founders leading 4. Ethics—concerns human conduct, character, and
to a refinement of their earlier thoughts, as well values. It studies the nature of right and wrong
as the need to protect the profession from legal and the distinction between good and evil.
persecution. 5. Aesthetics—deals with the creation and principles
2. Historically, vitalism has been defined in many of art and beauty. It also studies our thoughts,
ways based on prevailing intellectual thought and feelings, and attitudes when we see, hear, or read
scientific knowledge of the time, and the term has something beautiful.17
a dynamic existence. In general, vitalism suggests
that a “life force” concept explains the existence of Note that neither chiropractic nor medicine ap-
living organisms, while materialism implies that pears as a “branch” of philosophy. Correct use of ter-
life can be explained in strictly physical terms. In minology would dictate that there is a “philosophy
chiropractic, proponents of the vitalistic approach of chiropractic” but no “chiropractic philosophy.” A
attribute the effects of manipulation to restoring more colloquial use of the term “philosophy” may
the flow of a life force (i.e., Innate Intelligence) per- simply mean an individual’s beliefs. In this sense, one
turbed by subluxation, whereas those in the mate- may label their personal beliefs as “chiropractic phi-
rialistic camp attribute the effects of manipulation losophy” but personal beliefs, no matter how system-
to physical phenomena, such as reducing nerve atic they may be, are not recognized as a branch or
impingement or increasing joint range of motion. division of philosophy.
There are subdivisions of metaphysics relevant to matter of the universe in a constructive manner.
the discussion of vitalism, whose definitions would Organization points to centralization, or having
facilitate further discussion: a point of control. In animals, this point of con-
trol is in the brain. From this organ, Innate Intel-
1. Materialism maintains that only matter has real ex- ligence sends its controlling forces via the spinal
istence and thoughts and feelings are the result of cord through the spinal column thence through
the activities of matter. Materialists reject spiritual the nerve trunks emitting from the spinal cord
values or existence outside of matter.17 and passing through the intervertebral foramina
2. Mechanism maintains that all happenings result to nerve branches ramifying to all parts of the
from purely mechanical forces, without purpose.17 body. Perfect adaptation of universal elements for
Matter is in constant motion and may be governed this body depends upon perfect control by Innate
by natural laws, but there is no real purpose asso- Intelligence. Perfect adaptation results in health,
ciated with the motion or its resulting effects. and imperfect control results in disease. Defective
3. Teleology is just the opposite of mechanism, stating control by Innate Intelligence is never from any
that everything in the universe occurs for some imperfection of Innate Intelligence, which is al-
purpose.17 It is as if there is some final cause to all ways perfect, and assembles perfect forces in the
that is happening around us. brain, but from interference with the transmis-
4. Vitalism is the doctrine that phenomena are only sion of those Innate forces through or over the
partly controlled by mechanical forces, and are nerves. Owing to the spinal column being the only
in some measure self-determining. It is also de- segmented structure of bone through which the
fined as the doctrine that ascribes the functions of nerve trunks pass, and the possibility of the dis-
a living organism to a vital principle distinct from placement of its segments, changing the size and
chemical and physical forces. Vital principle is then shape of the intervertebral foramina, it is possi-
defined as the force that animates and perpetuates ble for subluxations to occur there and offer in-
living beings and organisms.16 terference with the transmission of Innate forces
indirectly, if not directly. All disease is thus trace-
Finally, the following are some terms proposed by able to impingements of nerve tissue in the spinal
chiropractic pioneers and the definitions commonly column.6
used in the first half of the twentieth century (with
dialogue for clarification and emphasis) and often ref-
erenced (but lacking consensus within the profession)
in philosophical discussions: KEY REFERENCES
1. Subluxation is the condition of a vertebra that has Pert C. Molecules of emotion. New York: Simon and Schuster,
lost its proper juxtaposition with the one above 1999.
Starr P. The social transformation of American medicine. New
or the one below, or both to an extent less than
York: Basic Books, 1982.
a luxation, which impinges nerves and interferes Stephenson RW. Chiropractic textbook. Davenport, IA: Au-
with the transmission of mental impulses.6 thor, 1927.
2. Mental force (impulse) is that something, transmit-
ted by nerves, which unites intelligence with mat-
ter. Mental force is called mental impulse because REFERENCES
it impels tissue cells to intelligent action. Mental
force is evidently a form of energy, or conveyed 1. Hall T. Ideas of life and matter, vol. I. Chicago: University
by a form of energy, for it can control forces that of Chicago Press, 1969.
move matter physically or balance forces that do 2. Federspil G, Sicolo N. The nature of life in the history
it. . . . Mental force is not a physical or chemical and philosophic thinking. Am J Nephrol 1994;14:338.
force; nor is it a stimulant.6 3. Wheeler L. Vitalism: Its history and validity. London: H.F.
3. Universal Intelligence created and is maintaining and G. Witherby, 1939.
4. Barbour I. Religion and science. San Francisco: Harper
everything in the universe. This is manifested by
Collins, 1997.
movement and is called Life. 5. Hall T. Ideas of life and matter, vol. II. Chicago: University
4. Innate Intelligence is a specific, definite portion of of Chicago Press, 1969.
this [Universal] intelligence, localized in a defi- 6. Stephenson RW. Chiropractic textbook. Davenport, IA:
nite portion of matter and keeping it actively or- Author, 1927.
ganized. . . . The function of an in-born, localized 7. Starr P. The social transformation of American medicine.
intelligence is to adapt some of the forces and New York: Basic Books, 1982.
8. Smith RL. At your own risk: The case against chiropractic. Heine H, ed. (Trans. N. MacLean.) Brussels: Haug In-
New York: Trident Press, 1969. ternational, 1991.
9. Keating JC. B. J. of Davenport: The early years of chiro- 14. Pert C. Molecules of emotion. New York: Simon and
practic. Davenport, IA: Association for the History of Schuster, 1999.
Chiropractic, 1997. 15. Phillips RB. A contemporary philosophy of chiroprac-
10. Gold R. The triune of life. Spartanburg, SC: Sherman Col- tic for the Los Angeles College of Chiropractic. J Chi-
lege of Straight Chiropractic, 1997. ropr Hum 1994;4:20–25; Coulter I. Chiropractic: A philos-
11. Dix D. A defense of vitalism. J Theoret Biol 1968; ophy for alternative health care. Oxford: Butterworth and
20:338–340. Heinemann, 1999.
12. Zweifach BW. Vitalism revisited—An historical per- 16. Costello R, ed. Random House Webster’s College Dictio-
spective of microcirculatory concepts. Int J Microcic. nary. New York, Random House, 1991.
1994;14:122–131. 17. Scott Fetzer Co. The World Book Encyclopedia, vol. 15.
13. Pischinger A. Matrix and matrix regulation. In: Chicago: World Book, 1987.
C H A P T E R
4
PHILOSOPHY IN CHIROPRACTIC
Joseph C. Keating, Jr.
O U T L I N E
INTRODUCTION Epistemologies in Chiropractic
THE PHILOSOPHIES OF THE PALMERS MODELS AND IMPLICATIONS OF CHIROPRACTIC
CHARACTERISTICS OF PHILOSOPHY ORIENTATIONS
AND SCIENCE CONCLUSIONS
METAPHORS, HEURISTICS, AND A PRIORI SUMMARY
ASSUMPTIONS QUESTIONS
PRINCIPLES OF CHIROPRACTIC ANSWERS
Holism and Conservatism KEY REFERENCES
Strategic Role of the Nervous System REFERENCES
Professional Autonomy
which the art of chiropractic is practiced. Others view

OBJECTIVES philosophy as a dynamic process of inquiry that might
1. To review the historical roots of the principles and give rise to scientifically testable propositions, to ex-
theories proposed by the Palmers. ploration of ethical problems, and to novel clinical
2. To distinguish between philosophy as doctrine methods, but which is inevitably fluid. Some would
(dogma) and philosophy as a mode of critical in- agree that “[d]ispossessed of its philosophy, chiro-
quiry, and to consider the relationship between practic is dispossessed of its uniqueness, and per-
philosophy and science. haps its future.”1 On the other hand, Clarence Weiant,
3. To review several prominent principles (meta- DC, PhD (Fig. 4–1), a chiropractor-anthropologist,
phors, heuristics, and a priori assumptions) in chi- suggested that “chiropractic philosophy” was “the
ropractic. misnomer that plagues the profession,” and further
4. To consider the variety of epistemological strate- opined that chiropractic theory or chiropractic princi-
gies chiropractors employ and to point out fallacies ples were better terms for what has passed for phi-
of reasoning. losophy in the profession.2,3 Still others,4 in rejecting
5. To delineate several major orientations or “schools the dogmatic characteristics of traditional chiropractic
of thought” within the chiropractic profession and thought in favor of a scientific orientation, seemed to
to note some of the implications of these variations. reject philosophy in its entirety. What is one to think?
To make sense of philosophy in chiropractic, we
will consider some of the historical roots of philosophy
in the profession; its originating and most common
INTRODUCTION metaphors; the similarities and differences between
“Philosophy” is one of the terms in chiropractic that classical/academic philosophy and the belief systems
confuses because of the multiplicity of its meanings held by chiropractors; the interactions among philos-
and the diversity of its uses. Some doctors of chiro- ophy, science, and dogma; several of the dominant
practic (DCs) view philosophy as a relatively static ideologies in the profession; and the ethical, clinical,
set of concepts from which theory is derived and upon and politico-legal implications of these perspectives.
77
FIGURE 4–2. Dr. D. D. Palmer, circa 1904.
established field of magnetic healing, and the intu-

itively sensible mechanical methods of the osteopaths.
FIGURE 4–1. Dr. Clarence W. Weiant, circa 1958. Within this context D. D. Palmer (Fig. 4–2) sought
a more rational, less esoteric explanation for the ben-
eficial results he believed his patients derived from
magnetic healing practices. He turned to the machine
THE PHILOSOPHIES OF THE PALMERS
metaphors of his day and concluded that the posi-
The views of the founder of chiropractic, D. D. Palmer, tive effects of his laying on of hands resulted from the
and his son, B. J., are the basis for much of what has cooling qualities of his personal, excess vital magnetic
been called traditional chiropractic philosophy.5 “Old energy. Palmer’s magnetic theory still involved the
Dad Chiro” (D. D.) came to the healing arts from a notion of transferring “animal magnetism” (vital en-
background in farming, grade school teaching, and ergy) from doctor to patient, but now he was in synch
spiritualism6 in the decades following the American with the machine age. His clinical targets were the
Civil War. It was an era of intellectual expansion of inflammations that he considered central to disease,
the public mind, colored by such diverse ideas as ani- and he eventually came to believe that inflammatory
mal magnetism (Mesmerism), phrenology (skull pal- processes were the consequence of anatomic disrela-
pation to determine personality traits), natural selection, that is, of body parts being out of their proper
tion (Darwinism), and the marvels of the burgeoning position.
machine age. The harsh remedies of heroic medicine As a magnetic healer Palmer used his sensitive fin-
that had dominated allopathy in the earlier part of the gers to locate the site of inflamed tissue and then,
nineteenth century were very slowly giving way to placing his fingers at these precise locations, cooled
a more conservative and scientific (laboratory-based) off inflammation much as one might decrease friction
exploration of human biology. However, the science and heat in a gear box by pouring water or other heat-
of medicine at the end of the nineteenth century was transferring lubricant into it. In his palpatory methods
crude by any standard and might well have produced can be seen the origins of “specificity” in later chiro-
more harm than good. Patients sought gentler alterna- practic diagnostic analyses. He prided himself on his
tives to the primitive surgery and still largely empir- technique of nerve tracing, which involved following
ical pharmacology of the day. Among the more pop- a dysfunctional nerve from its spinal roots to the af-
ular alternatives at this time were the infinitesimal fected end organ, or vice versa. His advertising fliers
doses of the homeopath, the “revitalizing” energies carried testimonials that lauded this seemingly more
of the emerging field of electro-medicine, the better rational approach. In later years, nerve tracing and
PHILOSOPHY IN CHIROPRACTIC 79
joint palpation continued as the founder’s primary adequately explained by analogy to the operations
chiropractic assessment methods. As well, Palmer of machines. The formation of blood cells, the chem-
pointed out to his readers, he did not waste his healing istry of digestion, the myriad functions of the inter-
energy by making magnetic passes over the patient’s nal organs, and the mental operations of the brain,
entire body, as other magnetic healers did, but focused he reasoned, required explanations that the simplic-
the outflow at the site of the biological dysfunction. ity of push–pull mechanics could not handle. And in
D. D.’s first theory of chiropractic (1896–1903) was positing Innate Intelligence as a fraction of Univer-
an extension of these concepts. Why wait for a dis- sal Intelligence (God), chiropractic theory served to
placed anatomical part to become inflamed, he rea- unite the “material and the immaterial,” in contrast to
soned, if the clinician’s hands could be used to replace what was seen as the atheism of medicine. Chiroprac-
or adjust the offending component to its proper posi- tic would be a friendlier healing discipline, not only
tion? First-stage chiropractic involved manipulation because it was gentler in its therapeutics than those of
to adjust the tissues of the body to their presumed the allopathic mainstream of medicine, but because it
normal position so as to avoid or reverse friction. The respected and appealed to the theological values and
theory suggested both the prophylactic and thera- beliefs of most patients. The vitalism of “Innate” was
peutic value of what Palmer initially termed “mag- just a short conceptual step from the souls and spirits
netic manipulation” (chiropractic). He very unam- of Christianity and the spiritualism (seances) that had
biguously declared his ability to manually reposition grown popular in the wake of the Civil War.
any anatomic part, including the circulatory system, D. D. Palmer’s final theory of chiropractic (1908–
musculoskeletal system, and the nerves. 1913) preserved the vitalism-through-the-nerves idea.
However, Old Dad Chiro had a strong political However, by this time he had abandoned his ear-
incentive to differentiate his chiropractic from the lier belief that nerves were pinched by joint misalign-
manipulative practices of his competitors, the os- ment. Instead, he proposed that skeletal misalignment
teopaths. In July 1903, while teaching and practic- caused nerves to be stretched or slackened, thereby al-
ing in Santa Barbara, California, he revised his theory tering vibrationally mediated nerve impulses sent to
to focus exclusively on the presumed effects of joint end organs. This final theory has been referred to as
misalignment upon the nervous system.7 Henceforth, the tension-regulation theory of chiropractic.10
a majority of chiropractors would insist that chiro- When B. J. Palmer took over control of his fa-
practors were only interested in neural influences ther’s institution (the Palmer School of Chiropractic)
upon health and that osteopaths were only interested in 1906,11 he adopted most of the biotheological theory
in relieving circulatory obstructions. It was a false di- and clinical methods that his father had promulgated.
chotomy, but would serve a useful purpose beginning Persecutions of chiropractors by organized medicine
in 1907, when the distinction produced the earliest were growing, and one of the son’s earliest initiatives
known acquittal (i.e., the Morikubo case in La Crosse, was the organization of the legal protective society
Wisconsin) of a chiropractor on trial for unlicensed known as the Universal Chiropractors’ Association
practice.8 (UCA; precursor of today’s American Chiropractic
Not content with his mechanical explanation of Association). The UCA’s first legal success occurred
disease, Palmer returned to the vitalistic concepts in in La Crosse, Wisconsin, in 1907, when Palmer grad-
which his magnetic healing practice had its roots.9 uate Shegataro Morikubo was acquitted by a jury of
Where once he had used such terms as “innate nerves” the charge that he had practiced osteopathy without
and “educated nerves” to differentiate the autonomic a license. The basis for this courtroom victory was de-
(involuntary) and skeletal (voluntary) divisions of the fense counsel Tom Morris’ contention that chiroprac-
nervous system, in 1904, Palmer extrapolated these tors had a “philosophy and practice” that was distinct
concepts into the “Innate Intelligence” and “Educated from the osteopaths: Chiropractors were only inter-
Intelligence” of the human organism.9 Educated In- ested in the nervous system, while osteopaths were
telligence, he reasoned, was the product of the indi- only interested in the circulation. The differences be-
vidual’s learning through interaction with the envi- tween the chiropractors’ short-lever thrusts and the
ronment. Innate Intelligence, however, was construed osteopath’s long-lever moves helped to further dis-
as a fraction of God that inhabited the body and tinguish the two manipulative professions.
was responsible for maintaining health and recuper- Only 24 years of age in 1906, the younger Palmer
ation from illness. These two “minds,” reasoned the (Fig. 4–3) was captivated by the notion that the legal
founder, were ever active within the person, but were salvation of chiropractic could be based on the unique-
unaware of one another. Each exerted its influence on ness of its philosophy. In thousands of trials in coming
the body via the nerves. decades, “chiropractic philosophy” was offered as jus-
Palmer’s idea of an Innate Intelligence led him to tification for the seeming violation of medical statutes,
reject his earlier notion that human biology could be and in the great majority of cases heard by a jury,
Ralph W. Stephenson (Fig. 4–5), a philosophy in-

structor at the Palmer School in the 1920s, provided a
codification of B. J.’s principles (Fig. 4–6) in his 1927
Chiropractic Textbook,13 a volume that went through
many printings and was required reading at the
Palmer School and several other chiropractic colleges
for decades. Stephenson declared chiropractic a “de-
ductive science” that eschewed the empirical obser-
vations and inferential reasoning of other scientific
fields in favor of deduction from a true first princi-
ple. Stephenson’s first principle posited the existence
of God as the explanation of all things, and the rest of
the 33 catechism-like tenets were said to be derivable
therefrom (Table 4–1).
Armed with this “Palmer philosophy,” B. J., the
self-styled “Developer” of chiropractic, preached the
“gospel” of chiropractic as absolute truth wherein
all of life and all of the universe were explained,
and without which chiropractic was no longer “pure,
straight, and unadulterated.”14 Those who disagreed
or who offered alternative conceptualizations were
branded “not chiropractic,” “mixers,” “mediprac-
tors,” and “medical fools.”15 Any student with the
temerity to ask a question during a B. J. lecture would
be told, “There’s a cow on the track; get that cow
off the track,” for Palmer’s philosophy train was
FIGURE 4–3. Dr. B. J. Palmer, circa 1920.
coming through.3 Heretics would abound, but none,
it seemed, could counter the grand cosmology of
the “philosophical” uniqueness of chiropractic beliefs B. J.’s and Stephenson’s “philosophy.” Palmer’s lead-
would prevail. Philosophy took on great significance ership was eventually rejected by a majority of the
within this young profession because of its practical profession,11 but that same majority of chiropractic
value in helping chiropractors stay out of jail. In 1908, college graduates had trained at the Davenport, Iowa,
B. J. had his faculty award him the first ever “Philoso- institution and had been schooled in the inflexible ide-
pher of Chiropractic” degree (PhC). Considered a spu- ology of the profession’s “Developer.”
rious degree within the mainstream of higher educa-
tion, various schools continued to award the PhC into
the 1960s.
CHARACTERISTICS OF PHILOSOPHY
The courtroom helped to shape other aspects of
AND SCIENCE
chiropractic philosophy. Because diagnosis was con-
sidered the exclusive domain of medical practitioners, As the profession has matured, and especially in
chiropractors denied that they diagnosed disease, in- the 40-plus years since B. J. Palmer’s demise, chi-
sisting, instead, that they merely analyzed the spine ropractors have grown more sophisticated in their
for “the cause” of disease, a lesion referred to as a understanding of the role that philosophical inquiry
subluxation. Following his father’s lead, B. J. taught legitimately plays in the affairs of a health care
his students and proclaimed in court that chiropractic discipline.16,17 Although a consensus around a phi-
was not “therapeutic.” Patients were not “treated” by losophy of science as an appropriate basis for the art
chiropractors; instead, the DC adjusted the spine to and science of chiropractic has not formed, chiroprac-
remove subluxations and permit the power of Innate tors have shown some increasing recognition of the
Intelligence to reach all parts of the body (Fig. 4–4). Al- need to challenge their most fundamental concepts.
though some chiropractors would later acknowledge Whereas B. J. Palmer’s philosophy involved fixed
that the new jargon was merely a semantic ploy to ideas whose truth was supposedly incontrovertible,
escape the wrath of the law until separate licensure scholars beyond the profession often construe phi-
for chiropractors could be obtained,12 B. J. and his losophy as a dynamic process of inquiry rather than
followers adopted the nondiagnostic, nontherapeu- the inputs or conclusions drawn from such question-
tic rhetoric as a key component of their chiropractic ing (Fig. 4–7).16 In this sense, philosophy is a criti-
philosophy. cal, doubting, probing endeavor wherein skepticism
FIGURE 4–4. Advertisement for the UCA appearing in popular magazines in the 1920s.
FIGURE 4–6. Suggested relationships among Innate Intel-

ligence, Educated Intelligence and the human body. (From
FIGURE 4–5. Dr. Ralph Stephenson, 1927.
Stephenson RW. Chiropractic textbook. Davenport, IA: Author, 1927.)
TABLE 4–1. “A List of Thirty-Three Principles, Numbered and Named” (Stephenson, 1927)
No. 1 The Major Premise.

A Universal Intelligence is in all matter and continually gives to it all its properties and actions, thus maintaining it in
existence.
No. 2 The Chiropractic Meaning of Life.
The expression of this intelligence through matter is the Chiropractic meaning of life.
No. 3 The Union of Intelligence of Matter.
Life is necessarily the union of intelligence and matter.
No. 4 The Triune of Life.
Life is a triunity have three necessary united factors, namely, intelligence, Force and Matter.
No. 5 The Perfection of the Triune.
In order to have 100% Life, there must be 100% intelligence, 100% Force, 100% Matter.
No. 6 The Principle of Time.
There is no process that does not require time.
No. 7 The Amount of Intelligence In Matter.
The amount of intelligence for any given amount of matter is 100%, and is always proportional to its requirements.
No. 8 The Function of Intelligence.
The function of intelligence is to create force.
No. 9 The Amount of Force Created by Intelligence.
The amount of force created by intelligence is always 100%.
No. 10 The Function of Force.
The function of force is to unite intelligence and matter.
(continued)
TABLE 4–1. (Cont.)
No. 11 The Character of Universal Forces.

The forces of Universal intelligence are manifested by physical laws; are unswerving and unadapted, and have no
solicitude for the structures in which they work.
No. 12 Interference with Transmission of Universal Forces.
There can be interference with transmission of universal forces.
No. 13 The Function of Matter.
The function of matter is to express force.
No. 14 Universal Life.
Force is manifested by motion in matter; all matter has motion, therefore there is universal life in all matter.
No. 15 No Motion without the Effort of Force.
Matter can have no motion without the application of force by intelligence.
No. 16 Intelligence in both Organic and Inorganic Matter.
Universal intelligence gives force to both organic and inorganic matter.
No. 17 Cause and Effect.
Every effect has a cause and every cause has effects.
No. 18 Evidence of Life.
The signs of life are evidence of the intellegence of life.
No. 19 Organic Matter.
The material of the body of a “living thing” is organized matter.
No. 20 Innate Intelligence.
A “living thing” has an inborn intelligence within its body, called Innate Intelligence.
No. 21 The Mission of Innate Intelligence.
The mission of Innate Intelligence is to maintain the material of the body of a “living thing” in active organization.
No. 22 The Amount of Innate Intelligence.
There is 100% of Innate Intelligence in every “living thing,” the requisite amount, proportional to its organization.
No. 23 The Function of Innate Intelligence.
The function of Innate Intelligence is to adapt universal forces and matter for use in the body, so that all parts of the
body will have co-ordinated action for mutual benefit.
No. 24 The Limits of Adaptation.
Innate Intelligence adapts forces and matter for the body as long as it can do so without breaking a universal law, or
Innate Intelligence is limited by the limitations of matter.
No. 25 The Character of Innate Forces.
The forces of Innate Intelligence never injure or destroy the structures in which they work.
No. 26 Comparison of Universal and Innate Forces.
In order to carry on the universal cycle of life, Universal forces are destructive, and Innate forces constructive, as
regards structural matter.
No. 27 The Normality of Innate Intelligence.
Innate Intelligence is always normal and its function is always normal.
No. 28 The Conductors of Innate Forces.
The forces of Innate Intelligence operate through or over the nervous system in animal bodies.
No. 29 Interference with Transmission of Innate Forces.
There can be interference with the transmission of Innate forces.
No. 30 The Causes of Dis-ease.
Interference with the transmission of Innate forces causes incoordination of dis-ease.
No. 31 Subluxations.
Interference with transmission in the body is always directly or indirectly due to subluxations in the spinal column.
No. 32 The Priciple of Coordination.
Coordination is the principle of harmonious action of all the parts os an organism, in fulfilling their offices and purposes.
Mo. 33 The Law of Demand and Supply.
The Law of Demand and Supply is existent in the body in its ideal state; wherein the “clearing house,” is the brain, innate
the virtuous “banker,” brain cells “clerks,” and nerve cells “messengers.”
First, do no harm • Is it possible to do no harm? At least try and theories (tentative principles) about causal rela-
("Primum, non • Should a risk/benefit analysis be used? to do more
nocere") • Is there a better principle to guide us? good than harm tionships among observables. The hypotheses of chi-
ropractic science are predictions about how selected
FIGURE 4–7. Relationship of philosophy to principles is illus- aspects of the real world will behave in the future,
trated by an imaginary (and simplified) philosophical analysis of and are testable by experimentation (i.e., the scien-
Hippocrates’ maxim, Primum, non nocere (First, do no harm). tific method). For example, we might predict that low-
(Reprinted by permission from the Journal of the Canadian Chiropractic back-pain patients who receive side-posture, lumbar
Association.18 ) adjustments will experience less pain than those pa-
tients who do not. To the extent that repeated experi-
is prized18 rather than repudiated. The traditional di- ments (clinical trials) tend to confirm the expectation,
visions of classical philosophy2 have involved fields our confidence in the hypothesis will grow.
such as ethics (dealing with moral issues), aesthetics Indeed, the testability of propositions provides
(concerned with the nature of beauty), logic (reason- a demarcation between science and philosophy
ing processes), ontology (dealing with metaphysics (Table 4–2). Philosophical and professional principles
and the nature of reality), and epistemology (studying may be debated endlessly with no hope of any final
the nature of knowledge and its acquisition). Like sci- resolution (e.g., Can there be any “true” scope of chiro-
ence, philosophy often advances by formulating bet- practic practice?). Scientific investigation, in contrast,
ter questions rather than by providing answers. And sometimes provides a sense of closure when repeated
though truth is the goal, philosophers recognize that hypothesis testing produces similar or identical re-
truth is an ideal to aim at rather than a plateau that sults. As well, scientific testing may lead us to abandon
can be reached; in this sense, philosophy, like science, or revise previous theory, such as when hypotheses
is always incomplete. are falsified by evidence inconsistent with the theory.
As a health care profession, chiropractic legiti- The ability of a hypothesis to be tested empirically (i.e.,
mately includes principles related to its science as well through controlled observations of the natural world),
as to its concepts, which guide its services and obli- and thereby to prove its potential falsifiability, is part
gations to patients and society. Science itself was once of what distinguishes scientific theories from philo-
known as “natural philosophy,” and may be seen as a sophical speculation. Of course, scientific “truths” are
child of philosophy; it is an activity in which observa- never truly final statements about reality; the displace-
tions of the world around us give rise to hypotheses ment of Newtonian physics by Einstein’s theory of
TABLE 4–2. Testable and Untestable Components of a Philosophy of the Profession of Chiropractic
Untestable Principles Potentially Testable (Falsifiable) Hypotheses
Professional/Moral:
Basic Science Theories:
Chiropractic is an autonomous profession
Spinal subluxations produce disease
Ethical imperatives (e.g., assessment/diagnosis)
Subluxation reduction improves immune function
Ethical prohibitions (e.g., be careful not to injure the
Subluxation produces relative leg length inequality
patient)
Subluxation severity in adolescence predicts longevity
Chiropractors should/should not function as adjustors
Motion palpation of joints produces similar findings among
only, family physicians, radiologists, industrial
multiple examiners
consultants, back specialists, minor surgeons, etc.
Palpatory tenderness covaries with fixation in joints
Patient has ultimate responsibility for his/here own health
Clinical Science Theories and Techniques:
Scientific:
Adjusting reduces or eliminates subluxations
Rules of evidence (research methods)
Adjusting improves health (and/or reduces disease)
Doctors should be cautious in drawing conclusions and
Logan Basic technique enhances immune function
making claims for theory or technique
Adjusting produces analgesia
Metaphors and Heuristic Concepts:
Soft-tissue massage facilitates the effects of spinal
The spine is a keyboard upon which the higher neural
adjusting
centers play
Gonstead adjusting produces greater subluxation reduction
Vis medicatrix naturae (the healing power of nature)
than does Hole-in-One among low-back-pain patients
Structure and function are reciprocal
Spinal manipulation relieves low back pain
Life is the expression of tone
Based on: Keating JC. Toward a philosophy of the science of chiropractic: A primer for clinicians. Stockton, CA: Stockton Foundation for Chiropractic
Research, 1992, p 21.
relativity provides an obvious example of the tenta- as Hippocrates’ admonition to first do no harm. Chi-
tive character of scientific knowledge. ropractors may adopt or reject the scientific method
Philosophy and science are also characterized by as a means of furthering knowledge of health and ill-
the reasoning process(es). Workers in both disciplines ness. The manual practitioner may accept the notion
make use of deductive reasoning. In deduction, con- that intervention in the neural activity of patients is
clusions are derived by reasoning from initial, unchal- a strategic and beneficial path to assisting patients,
lenged premises: To the extent that the premises are or may turn to alternative (e.g., mechanical) explana-
true, and assuming that one’s reasoning is logically tions for the apparent benefits of the care they provide.
sound, conclusions will also be true. A classic exam- The DC may construe her or his role narrowly, for
ple of deductive reasoning is: instance, as a spinal-subluxation-only doctor or as a
specialist in musculoskeletal problems. Alternatively,
Premise: All Greeks are mortal. the chiropractor may see herself or himself as a pri-
Premise: Socrates is a Greek. mary care physician who deals with a wide range of
Conclusion: Socrates is mortal. musculoskeletal, visceral, and behavioral disorders.
Some chiropractors limit their interventions to the root
Scientific reasoning, on the other hand, makes use meaning of “chiropractic,” that is, done by hand, while
of both deductive and inferential reasoning. Clini- others employ a variety of complementary, supple-
cians, for example, may base their manipulative tech- mentary, and alternative treatment methods, such as
nique on a knowledge of spinal architecture deduced nutritional advice, herbal remedies, exercise recom-
from the “truths” of anatomical science. When infer- mendations, electrotherapeutic devices, and adjusting
ential reasoning is employed, on the other hand, one instruments.
or more premises are admittedly tentative, inasmuch For many of these issues, there may be no inher-
as they are based on necessarily limited observations. ently right or wrong choice, while for others the pro-
Because observation may be faulty, owing to imper- cess of critical thinking and/or scientific testing may
fection in the observation process or the limitations provide at least partial answers. In many instances, so-
(unrepresentativeness) of the observations, the con- ciety and its constituents (e.g., state legislatures, other
clusions drawn may be incorrect. The hypotheses that health professions, insurance companies) may super-
comprise Newton’s theory of physics were accurate impose boundaries or offer political or financial in-
only up to a point, but could not accurately predict centives that also influence chiropractors’ choices of
natural phenomena at very high speeds (i.e., speeds principles. It is incumbent upon the DC, therefore, to
approaching that of light). A series of clinical experi- be familiar with traditional and contemporary forces
ments demonstrating pain relief for migraine patients that shape and mold the beliefs and values of the
who receive rotary cervical manipulations may not ac- profession.
curately predict the clinical outcomes of patients with Many principles of healing are expressed as
muscle contraction headache who receive similar ad- metaphors. These are statements that are not neces-
justments. And the proverbial turkey who expected sarily true, but nonetheless provide a sort of mental
to be fed each morning at 7 am based on prior expe- shorthand that conveys potentially valuable ideas. For
rience (empirical observations) may lose its head on example, physiologist Irvin Korr’s notion that “the
Thanksgiving morning. Scientific testing can produce spine is a keyboard upon which the higher centers
quite unexpected and counterintuitive results. play” is not to be taken literally. No one will mistake
the spine for a musical instrument, yet Dr. Korr’s po-
etry directs our attention to interactions within the
METAPHORS, HEURISTICS, AND A PRIORI
central nervous system (CNS), and may suggest novel
ASSUMPTIONS
or improved methods of helping patients. Similarly,
As a clinical discipline, the chiropractic profession Innate Intelligence (or vis medicatrix naturae [the heal-
quite legitimately makes use of a variety of princi- ing power of nature]) may be seen as a metaphor for
ples (see Table 4–1) to guide its service to patients, homeostasis. Whether the recuperative activities of
its quest for better understanding of the problems pa- the organism are best construed as a fraction of God is
tients present and the methods that may be helpful perhaps better left to theologians than to doctors, but if
in overcoming these problems, and to direct its in- the idea of Innate Intelligence reminds the clinician to
teractions with the rest of society. Unlike the pure or consider gentler, more conservative means of healing
basic sciences, which pursue knowledge for its own first (i.e., before more drastic remedies are applied), it
sake, chiropractors (and other types of doctors) have has served a valuable heuristic purpose.
a social mission: the betterment of their patients. As Heuristics also provide important concepts for the
members of an applied discipline, chiropractors adopt healing art. A heuristic construct or model is one
(and should critically evaluate) moral precepts, such that aids in organizing information, and therefore has
error of offering descriptive terms (e.g., homeostasis)

as causal explanations; Innate can no more explain hu-
man biological function than deities serve as scientific
explanation for the world around us. The materialism
of science is one of its defining characteristics. Science
is atheistic (which is not to say it is antitheistic).
PRINCIPLES OF CHIROPRACTIC
The healing power of nature is but one of many con-
cepts that have guided chiropractors in the profes-
FIGURE 4–8. The “safety-pin cycle.” BC = brain cell; TC = tis-
sion’s first century. Among other principles favored
sue cell. (From Stephenson RW. Chiropractic textbook. Davenport,
IA: Author, 1927.)
by chiropractors are notions such as therapeutic con-
servatism, holism, the strategic role of the nervous
system, the autonomy of chiropractic as a profession,
educational value. Like metaphors, heuristics are not and a variety of epistemologies. A closer look at these
offered as truth, or as hypotheses to be subjected to ideas is in order.
testing for validity, but as a sort of mental short-
hand. Concepts such as the “supremacy of the nerves” Holism and Conservatism
or vis medicatrix naturae have heuristic value. The Chiropractors emerged from the nineteenth cen-
“safety-pin cycle” offered by Stephenson (Fig. 4–8),13 tury as one of a few surviving alternatives to the
which conveys the notion of reciprocal communica- harsh remedies of heroic medical practice. Heroic
tion within reflex arcs, may be said to serve a heuristic medicine was characterized by such severe meth-
purpose. ods as blood-letting, purgatives and emetics, coun-
All philosophy and science are based on a priori as- terirritation, and proprietary pharmaceuticals (patent
sumptions, that is, upon ideas that are accepted as true medicines) whose constituents included heavy doses
if only for the sake of proceeding further. For example, of alcohol, opiates, mercury, and other toxins.19
scientists accept (without “proof”) that there is a real Theorists of this orientation to health care held that
world, that there are causes and effects in this physical the harshness of the remedy should be in proportion
reality, and that these causes and effects are potentially to the severity of the patient’s disease, which meant
discoverable by means of the scientific method. If sci- that the sickest individuals received the heaviest doses
entists did not posit these admittedly dogmatic (i.e., of dangerous drugs and procedures. Patients, on the
accepted without evidence) beliefs, their work would other hand, sought gentler forms of help when sick
be over before it began. The “dogma of science,” if you and turned to the less invasive, nonpoisonous meth-
will, has utility in that it allows scientific research to ods of the homeopaths, osteopaths, naturopaths, and
proceed. chiropractors. Although these alternative practition-
One of the reasons why vitalism (e.g., the vitalism ers, viewed as quacks by the politically dominant al-
of Innate Intelligence) is generally rejected in biologi- lopathic branch of the healing arts, might not cure
cal science is its lack of utility. It is difficult if not im- their patients, neither were their methods likely to ex-
possible to imagine testable propositions (hypotheses) acerbate the patients’ conditions.
that could only be spawned by belief in spirits (imma- The conservatism of chiropractors’ orientation to
terial intellect). For instance, theories of subluxations health care is fostered in part by chiropractors’ rejec-
and the clinical syndromes they supposedly produce tion of drugs and surgery as a part of the chiropractic
can be derived and tested without recourse to vital- art. (To be sure, there have always been chiroprac-
ism. Innate Intelligence fails as an essential, a priori tors who have wished to include at least some types
assumption for a science of chiropractic. of more invasive procedures, but this has been, and
Nevertheless, as noted earlier, Innate may have seemingly remains, a minority perspective.) This
clinical value as a heuristic concept. If the notion re- rejection of pharmaceuticals and surgery has been
minds practitioners of the great complexity of human written into many statutes governing the practice of
physiology and of how much we have yet to learn chiropractic; in some states it is illegal for a DC to rec-
(our innate ignorance?), then it may encourage a cau- ommend even nonprescription medications.
tious and humble approach to treating patients. If In- With medicine and surgery generally outside
nate serves as a synonym for homeostasis, that is, as their realm of legitimate practice, chiropractors have
a descriptive label for an ontological (inherent, irre- sought to maximize patient benefit through more con-
ducible) property of biological organisms, then it is ac- servative, relatively less invasive means of interven-
ceptable. Problems arise, however, when we make the tion. As well, many chiropractors have been vocal
opponents of various treatments encouraged by al- supplants the quest to understand and deal with the
lopathic medicine.20 At the turn of the century, the nuances of disease and illness, holism has gone awry
father of chiropractic railed against vaccination and and clinical conservatism may be abandoned.
vivisection (cutting into the living tissues of humans
and animals).21,22 Palmer’s conservative orientation to Strategic Role of the Nervous System
health care, as well as the views of those who have fol- Since 1903, when D. D. Palmer decided that “the body
lowed in his footsteps, is generally consistent with the is heated by nerves and not by blood,”7 a major-
beliefs associated with the construct of Innate Intelli- ity of chiropractors have contended that the bene-
gence: Chiropractors have sought by gentle methods fits derived from adjusting joints are attributable, pre-
to assist nature’s own ability to repair injury, recover dominantly or exclusively, to the effects of improved
from disease, and maintain health. joint mechanics upon the nerves exiting the spine.
This does not imply that chiropractic care is risk- Although the founder’s tension-regulating concepts10
free, of course. It seems a truism that any proce- did not gain wide acceptance, B. J. Palmer’s ideology
dure with the potential to help also carries the risk made much of neural reflexes, and emphasized af-
of harm.23 An adjustment inevitably produces at least ferent and efferent communication between neural
microtrauma in the tissue of the recipient, and more centers and end organs. “Mental impulses” were said
serious injury, although rare, should be of concern for to communicate information from Innate Intelligence
the chiropractor. The ionizing properties of x-ray also and the brain to all tissues in the body. Quoting from
have the potential to harm. Criticisms of the profes- the classic text by Gray, many chiropractors asserted
sion have often focused on acts of omission rather than that the nervous system controls all parts of the body,
commission, such as neglecting to perform an ade- and therefore the effects of manipulative interventions
quate diagnosis and/or to refer when the nature of may influence a wide range of disorders and organ
the patient’s problem lies beyond the scope of compe- systems.
tence of the DC. Conservative health care also implies The focus of clinical attention has been on sublux-
conscientious attention to the details of the patient’s ation of joints (Fig. 4–9), especially spinal joints, and
condition and circumstance. the positive effects upon neural behavior thought to
Chiropractic conservatism may also be seen as derive from the reduction or elimination of subluxa-
consistent with the principle of holism, which posits tion. For some members of the profession, the remedi-
the interconnectedness of all aspects of the individ- ation of spinal dysfunction has been linked to a belief
ual patient’s functioning. Chiropractors often express in Innate Intelligence (whose “messages” are thought
their holistic beliefs by asserting a reciprocal rela- to be disrupted or blocked by malfunctioning joints).
tionship between the structure and function of the For others, the benefits of subluxation–reduction upon
body. Another way in which holistic views are ex- neural function are considered independent of any vi-
pressed by chiropractors is the notion that the CNS talistic construct.
provides an integrative and regulatory mechanism for First appearing in the medical literature, the term
all physiological functions. Sometimes referred to as subluxation predates chiropractic by more than a
the “supremacy of the nervous system,” this idea runs century26 and classically referred to a misalignment
parallel to chiropractors’ attention to dysfunctions of of joint surfaces. Chiropractors have subsequently
the spine and to their concern to treat the patient “as a drawn a distinction between the “allopathic sublux-
whole.” As well, chiropractors have traditionally ad- ation” (joint misalignment only) and the “chiroprac-
hered to the belief that the patient, rather than disease tic subluxation,” which, by definition, involves some
per se, should be the focus of the doctor’s concern. impact upon the function of nerves passing through
Holism also involves the belief that the patient is a or otherwise influenced by associated joint structures
potent and indispensable factor in recovery from dis- (e.g., the intervertebral foramina). Contemporary us-
ease and the maintenance of health. A corollary is the age by chiropractors has greatly expanded the mean-
notion that the patient is ultimately responsible for her ing of subluxation to include joint fixation (altered
or his own health and illness. motion), changes in the tension of associated mus-
Holism has its limitations and hazards as well as its cles, and histopathological alterations; the term “sub-
benefits. One risk is that health professionals may ig- luxation complex” is often employed to refer to this
nore the details of patients’ problems in favor of what panoply of joint-centered dysfunctions.27 An addi-
Oliver Wendell Holmes referred to as the “nature- tional distinction may be drawn between subluxa-
trusting heresy.”24 When holism is coupled to vitalis- tion complex and subluxation syndrome. The latter
tic beliefs, there may be a tendency to believe that the includes the signs and symptoms of disease thought
complexities of health problems can be ignored by di- to be caused by or associated with subluxation com-
recting treatment to a supposedly centralized healing plex. The Association of Chiropractic Colleges, orga-
power.25 When belief in a patient-centered vital force nized by the presidents and senior administrators of
syndrome are deficient.31 Although some work on an-

imal models is available,32 the basic science model is
incomplete33 and clinical trials of the adjustive arts
have not concurrently monitored the putative lesions
whose eradication is thought to produce beneficial
clinical outcomes. Relatedly, clinical trials of the pur-
ported benefit of adjustive interventions are gener-
ally limited to musculoskeletal problems (e.g., low
back pain and headaches) and have ignored subluxa-
tion constructs. Clinical research on the effects of ma-
nipulation in visceral disorders is also scarce.34 Craig
Nelson has suggested that the most fundamental re-
search questions related to subluxation and its sup-
posed effects have neither been addressed nor even
properly conceptualized.35
Despite the absence of adequate scientific informa-
tion about subluxation and its hypothesized conse-
quences, the notion of the strategic role of the nervous
system is valuable and legitimate in several respects.
Part of the value of this principle is demonstrated
by the impetus it has given the profession to de-
velop the manipulative arts. As a prescientific no-
tion (i.e., offered as metaphor rather than asserted
as truth), the idea of the CNS and the spine as reg-
ulators and targets for therapeutic intervention has
given rise not only to subluxation theories, but to var-
ious non-subluxation-centered (and even non-CNS-
focused) forms of conservative care.36–38 For instance,
early college cofounder Alva Gregory proposed that
spinal segmental levels be stimulated by manipula-
tion based on spinal nerve distribution to diseased
end organs, as well as for the purpose of correcting
subluxation.39
FIGURE 4–9. “Subluxated vertebra.” (Courtesy of Cleveland Chi-
ropractic College Archives, Kansas City.)
Professional Autonomy
chiropractic schools in North America, offered the Chiropractors have struggled throughout their first
following thoughts about the quintessential chirocentury to establish themselves as an independently
practic lesion: licensed and self-regulating profession of healers; the
Chiropractic is concerned with the preservation and final American state to grant licensure, Louisiana, did
restoration of health, and focuses particular atten- so in 1974. Drawing upon nineteenth century pop-
tion on the subluxation. ulist calls for “medical freedom” and “the right of the
A subluxation is a complex of functional and/or struc- sick to get well” by means of a doctor of their own
tural and/or pathological articular changes that choosing, chiropractors successfully lobbied legisla-
compromise neural integrity and may influence tures and mounted initiative campaigns to secure le-
organ system function and general health. gal protection from the onslaught of political medicine
A subluxation is evaluated, diagnosed, and man- (which does not agree with the principle of profes-
aged through the use of chiropractic procedures sional autonomy for chiropractors). And beyond li-
based on the best available rational and empirical censure, turf battles over scope of practice, access to
evidence.28 hospitals, and inclusion in various private and gov-
ernmental health care plans have kept the profession
Many theories have been devised to account for the in a continuous state of political activism. The hurly-
supposed effects of subluxation and its elimination burly of this struggle has reinforced chiropractors’
by manual therapies.29,30 However, the critical labo- need and claim to be a “separate and distinct” profes-
ratory and clinical research that would be necessary sion. And, as we have seen, the struggle has colored
to substantiate the meaningfulness of subluxation both theory and practice.
The century-long war with medicine and other po- greater professional interaction might occur, is still
litical forces has also fostered a degree of professional rare. The autonomy implicit in state laws regulat-
xenophobia. Chiropractors have repeatedly warned ing chiropractors is complicated by differences in the
one another that organized medicine was planning scopes of practice permitted by the various jurisdic-
to “steal chiropractic.”40,41 In the wake of the assim- tions, differences that foster uncertainty about what
ilation of a majority of the state’s osteopathic pro- chiropractors can and cannot do as healers. Chiroprac-
fession by the California Medical Association in the tors continue to be the stepchildren of the health pro-
early 1960s,42 chiropractors’ fear of absorption were fessions, and must struggle for rights and privileges
ignited and would smolder for decades.43,44 Mean- that seem to come more easily to other profession-
while, the American Medical Association’s Commit- als. Even today, there are no state-university-based
tee on Quackery45 sought to “contain and eliminate” chiropractic colleges and no formal teaching-hospital
the chiropractic profession, prompting a 14-year-long residencies in the United States, although the situa-
lawsuit by several chiropractors, brought under the tion has been changing rapidly on the international
provisions of the Sherman Anti-Trust Act46,47 ; chiro- front (e.g., University of Glamorgan in Wales, Mac-
practors had good reasons for their paranoia. quarie University and the Royal Melbourne Insti-
To be sure, calmer voices have also been heard tute of Technology in Australia, Université de Quebec
within the profession. The late Joseph Mazzarelli, for- à Trois Rivières in Canada, and the University of
mer president and chairman of the board of the Inter- Southern Denmark). In the 1990s, chiropractors were
national Chiropractors’ Association (ICA) and chair finally successful in acquiring a few million dollars
of Palmer College’s board of trustees, insisted that for clinical research from the National Institutes of
the development of manipulative skills by allopathic Health, but there may be a hint of tokenism in this
physicians was not only not a threat, but something accomplishment. The granting of research funding to
to be encouraged.48 He believed that instruction in chiropractors has been increased recently with the es-
“manual medicine” for medical doctors would foster tablishment of the National Center for Complemen-
greater interdisciplinary cooperation and respect. As tary and Alternative Medicine.
recently as 1995, the Council on Chiropractic Educa-
tion (CCE), under the guidance of then CCE president Epistemologies in Chiropractic
Carl S. Cleveland III (Fig. 4–10), convened a meeting Epistemology is that branch of classical philosophy
to formally consider the relative merits of continuing that concerns itself with the nature of knowledge and
isolation versus integration with the wider health care the ways by which understanding may be increased.
community.44,49–58 Throughout most of its early history the chiropractic
Unfortunately, the profession’s ostracism from the profession differed from other health care provider
allopathic profession until the late 1980s also meant groups in that it did not widely accept the princi-
alienation from most other health care providers ples of the scientific method as a basis for advancing
and funders. Hospital-based chiropractic care, where knowledge. To the contrary, chiropractors offered a
wide range of “ways of knowing” what works and
why in its clinical art,59,60 including a great many ra-
tionales that classically trained logicians refer to as
fallacies of reasoning (Table 4–3). This is perhaps to be
expected in a profession that has, through ostracism
and in some cases by its own preference, remained
isolated from the wider health science and scholarly
communities. Among the epistemologies offered in
the profession are empiricism (knowing by doing or
observing), rationalism (based on deduction from es-
tablished knowledge), spiritual inspiration (insight
derived from ethereal sources), and the epistemology
of science. The empirical and rational approaches to
knowledge derivation may be subdivided into those
involving critical thinking and systematic method and
those lacking such qualities (e.g., critical empiricism
vs. uncritical empiricism).
The same could be said of allopathic medicine in
the nineteenth century, which was only slowly adopt-
FIGURE 4–10. Dr. Carl Cleveland III, president of the CCE, ing experimentation as a basis for the clinical art.
1995. “Trial-and-error” empiricism on the part of individual
TABLE 4–3.Several Fallacies of Reasoning Offered in Defense of the Chiropractic Profession and Its
Healing Art
Fallacy Definition Example
Appeal to authority The opinion of experts or presumed We know that subluxation is meaningful
experts is accepted as truth because Palmer (or other guru) said
so
Appeal to ignorance The absence of evidence is offered as We know chiropractic works because it
evidence has never been disproved
Argument ad hominem An argument is dismissed based not on We know Keating’s view of chiropractic
its content but upon characteristics philosophy is flawed because he is
of the individual making it not a chiropractor
Non sequitur An argument in which an irrelevancy is We know that subluxation is meaningful
offered as evidence because if it were not, there’d be no
need for chiropractors
Overgeneralization Evidence in support of some We know that subluxations are
component of a theory is meaningful because clinical trials
extrapolated beyond the limits of the have demonstrated that
study that generated it low-back-pain patients improve when
they are adjusted
Post hoc, ergo propter hoc* When two events occur close in time, We know that XYZ technique is
the first is assumed to be the cause effective because patients improved
of the second after its use
Selective evidence Refusal to consider evidence that Listing only studies that support the
refutes a favored theory value of spinal adjusting, but not
those that are equivocal or that
challenge its effectiveness
* Latin for “After this, therefore because of this.”
allopathic practitioners was widespread in that era, There have been other ways of knowing in the
and the descriptive epistemology embodied in mu- profession. Old Dad Chiro suggested that he had
seum displays gave way only grudgingly to labora- acquired his understanding of chiropractic concepts
tory studies of cause and effect in medicine. When from a physician who had practiced in Davenport,
chiropractic appeared at the turn of the century, it Iowa, some 50 years earlier65 ; it has been suggested
found its scientific justification in the older, obser- that this Jim Atkinson was deceased, and had per-
vational mode of “validating” its methods.61,62 The haps imparted his knowledge to D. D. Palmer through
proof that chiropractic “works” was considered ob- seances. Spiritual inspiration was also a theme of the
vious to anyone who would take the time to watch “Developer,” who credited many of his insights to lis-
chiropractors impart benefit to patients; remnants of tening to the Innate Intelligence within him. Dr. Fred
this casual, unsystematic, uncontrolled, and uncritical H. Barge continued this tradition when he suggested
empiricism are still found among chiropractic practi- that his literary offerings derived from “listening to
tioners and theorists today. my Innate teacher”; he characterized himself as “only
D. D. Palmer decried the trial-and-error reason- the scribe,”66 and stated the positions that “belief in
ing of his allopathic competitors, and contended that chiropractic philosophy gives one a life without fear”66
chiropractic was a superior science and art because and there are no alternatives to “true chiropractic
it was theory-based. The subsequent writings of B. J. philosophy.”67
Palmer63 and Ralph W. Stephenson13 expanded upon Such confidence, derived from a priori truths
this notion. Chiropractic as a “deductive science” and/or inspiration from beyond the physical uni-
posited 33 a priori principles (see Table 4–1) as ab- verse, may have its place, for example, in religion, but
solute truths from which all other clinical hypotheses is the antithesis of the skepticism and critical think-
and methods were derivative and subordinate. This ing that characterize philosophy and science. Nev-
uncritical rationalism finds contemporary expression ertheless, many chiropractors have found justifica-
in the teachings of some straight chiropractors.64 tion for the chiropractic art through a combination of
orientation is certainly not capable of addressing all

the issues of concern to the profession (see Table 4–2),
but is suitable for those propositions that deal with the
effectiveness of clinical methods and the mechanisms
of clinical benefit.
The delightful emergence and preliminary suc-
cess of the chiropractic scientific enterprise during the
past two decades is evidence of this commitment, and
has also served the profession well in the political
arena. As members of the profession have become
more fluent in the language and methods of clini-
cal research and science, doors have opened for DCs.
The chiropractic healing art has become more credi-
ble to government and to third-party payors of chi-
ropractic services in part because of the fruits of this
more critical epistemology. A segment of the profes-
sion increasingly shares the language and epistemol-
ogy of the wider health care community, and as com-
munication between disciplines expands, old doubts
and grudges are likely to diminish. To be sure, the
metamorphosis toward a more critical chiropractic
will be gradual, perhaps painful, but also increasingly
FIGURE 4–11. Dr. C. O. Watkins, circa 1935.
inevitable.
Nevertheless, there are many in the profession
uncritical rationalism (deduction from theory) and who have perceive this evolution toward skepti-
uncritical empiricism (casual observation). “We know cism and critical evaluation of a priori beliefs as a
chiropractic works,” it is suggested, because it is based threat to traditional chiropractic.73 A. Earl Homewood
on true principles (e.g., anatomy, physiology, or the 33 (Fig. 4–12) opined that in his nearly 50 years as a
tenets of Palmer) and proven every day in doctors’ of- chiropractor he had never seen any benefit derived
fices. from research in the profession.74 Others observe the
An orientation to a more critical empiricism and shroud of science in which allopathy has wrapped it-
critical rationalism, such as is found in science, has a self, and in rejecting the persecution by medicine, tend
briefer but increasingly prominent role within the pro- to reject the scientific method as well. Still others are
fession. One of the earliest philosophers of a science unaware of the epistemology inherent in the scientific
of chiropractic was C. O. Watkins (Fig. 4–11), a 1925 method. Some fear that the success enjoyed in con-
Palmer graduate who practiced quietly in rural Mon- trolled trials of spinal manipulative therapy for low-
tana and encouraged more critical thinking through back-pain patients will serve to limit the chiropractor
his writings and activism within the broad-scope Na-
tional Chiropractic Association.68,69 Passionate in his
commitment to conservative health care, he was also
distressed by the casual reasoning of his colleagues,
and offered numerous papers suggesting a more sci-
entific orientation for the profession. His 1944 mani-
festo, The Basic Principles of Chiropractic Government,70
called for what has since been labeled a “scientist-
practitioner model” for chiropractors.71
Watkins and those chiropractors since who
have established the burgeoning scientific enterprise
within the profession72 look to the hypothetical–
deductive model of research for their epistemology.
Deduction from almost any source is considered a
legitimate source of testable propositions (hypothe-
ses), but no theory or subset thereof (i.e., hypothe-
sis) is considered valid until it has survived repeated FIGURE 4–12. Drs. Earl Homewood (left ) and Lee Arnold in
experimental attempts at falsification. This scientific Florida, 1987.
to a musculoskeletal scope of practice. And in the still versus Republican adequately describe the political
combative intra- and interprofessional environment diversity in the United States. Nevertheless, a thumb-
in which chiropractors practice, the move toward a nail sketch of prevailing philosophical orientations
more scientific chiropractic is genuinely fraught with within the profession may serve a heuristic purpose
unknowns. Organized medicine may indeed use chi- (Table 4–4).
ropractors’ self-criticism against chiropractors, as it The notion of an evidence-based chiropractic has
has in the past.75 grown during the past decade. Widely misunderstood
to mean that only validated methods should be em-
ployed by chiropractors, evidence-based chiropractic
MODELS AND IMPLICATIONS OF
is more properly understood to be a commitment to
CHIROPRACTIC ORIENTATIONS
make use of the best available information in formu-
The diversity of thought (principles, philosophy) lating plans for patient care. Practitioners of evidence-
among chiropractors defies comprehensive evalua- based chiropractic recognize that there will never
tion. Even among the “purists” of traditional chi- be adequate clinical experimentation to make treat-
ropractic thinking, the range of beliefs is difficult ment choices solely based upon experimentally vali-
to enumerate.76 Historically, chiropractors divided dated procedures, and that each patient presents an
themselves into two camps, straights and mixers, but idiosyncratic pattern of needs, problems, and bio-
this simple dichotomy no more captures the multi- logical characteristics. Commitment to the scientific
plicity of ideas in the profession than does Democrat method of knowledge acquisition is strong; interest
TABLE 4–4. Several Characteristics of Three Orientations to (“Philosophies” of) Chiropractic
Orientations Evidence-Based Traditional Straight Purpose-Straight
Purpose “Get sick people well” and “Get sick people well” and Help patient (client?)
promote health promote health achieve maximum
potential
“Mission statement”* “Alleviation of pain and “Correction of the cause “Correction of vertebral
disease conditions”* of disease”* and health subluxations”*
and health promotion promotion
Epistemology Critical rationalism; Various† “Deductive science” (i.e.,
scientific empiricism uncritical rationalism)
Subluxation research Important, but not Important Unnecessary to prove
necessarily essential existence of subluxation;
may study detection
methods
Public health responsibilities Triage and referral; Triage and referral; Spinal analysis only
diagnosis and analysis; analysis (or spinal
prevention analysis only) and
prevention
Vitalism and holism Holism; homeostasis as Innate Intelligence as Innate Intelligence as
ontological causal explanation; causal explanation;
characteristic predictable influence; unpredictable influence;
“life is Intelligent” “life is Intelligent”
Scope of practice Broad Traditional advocate of Narrow scope; exclusively
straight chiropractic, spinal subluxation
but teaches focused
broad-scope methods
(e.g.,
physiotherapeutics)
Professional autonomy Strongly committed Strongly committed Strongly committed
Source: Based on reference 81.

* From Gelardi TA. The science of identifying professions as applied to chiropractic. J Chiropr Hum 1996;6:11–17.
†
Including critical and uncritical rationalism, critical and uncritical empiricism, spiritual inspiration, etc.
in the investigation of subluxation syndrome may or (in contradistinction to investigations of subluxation

may not be present. The evidence-based chiropractic syndrome) is considered acceptable but not impera-
doctor tends to be broad-scope in her or his meth- tive, because the primary reasoning strategy of the
ods, but this is not an essential characteristic of this purpose-straight chiropractic doctor is deduction (i.e.,
school of thought. The range of conditions to which uncritical rationalism). Stephenson’s 33 principles
the evidence-based chiropractic clinician will apply (Table 4–1) have been considered a valued basis for
her or his skills is also not a defining trait. Allevi- the art and science of chiropractic.
ation of pain and other symptoms is considered an The PSC approach to chiropractic came into con-
appropriate goal for the DC, perhaps even a moral im- flict with several constituencies. The nondiagnostic
perative. Evidence-based chiropractors commit them- orientation of this perspective stands in contrast to
selves to strenuous continuing education in order to most statutes governing the practice of chiropractic.
maintain awareness of the “state of the literature” in Some degree of compromise by the chief institutional
the science of chiropractic. As well, these doctors are proponent of PSC, Sherman College of Straight Chi-
perhaps more likely than others to support, and even ropractic (SCSC), was apparently reached with the
participate in, research activities. CCE circa 1995, when the SCSC was first recognized
Traditional straight chiropractic concerns itself pri- by the accreditation agency. The CCE’s educational
marily with the detection and correction of subluxa- standards require training in diagnosis and referral
tions, in the belief that such interventions help to re- when appropriate to other health care provides. Ac-
lieve disease and promote health. With the passage cordingly, there would seem to be some disconnect
of time and vicissitudes of chiropractic history, tradi- between this institution’s ideology and its actual in-
tional straight chiropractic practitioners have grown structional practices. It should be noted that several of
more relaxed in the range of therapeutic methods they SCSC’s presidents (e.g., Thomas Gelardi, DC, David
encompass. The Palmer College of Chiropractic, for Koch, DC) have been articulate contributors to philo-
example, today offers instruction in clinical proce- sophical dialogue within the profession (e.g., refer-
dures that its former president, B. J. Palmer, dismissed ence 64).
as medical (e.g., diagnosis, physiotherapeutics). This
orientation promotes no single epistemology, and al-
CONCLUSIONS
though the Palmer College of Chiropractic has been a
leader in developing the research infrastructure in the “Chiropractic philosophy” began its life as a series
profession, a wide variety of “ways of knowing” are of hypotheses and a priori assumptions with roots in
encountered among its faculty. Vitalism is a prominent the popular and academic culture of the nineteenth
feature of traditional straight chiropractic. century. The professional autonomy of chiropractors
Purpose-straight chiropractic (PSC), also known gained impetus from courtroom and legislative suc-
as the “objective-straight” or “super-straight” school cesses wherein the argument that chiropractors had a
of thought,42 has developed through the teach- separate and distinct “philosophy” and practice aided
ings of Reggie Gold, Thom Gelardi, and Joseph in acquittals of chiropractors charged with unlicensed
Strauss.73,77–79 Diseases are acknowledged to be mul- practice and helped to secure licensing laws. “Philos-
tifactorial in origin, and any particular patient’s dis- ophy” became a powerful rallying theme, and was
tress may or may not be caused by spinal subluxa- offered as a set of incontrovertible truths.
tion. Subluxations outside the spine and pelvis are In contrast to the inflexible beliefs of Palmerson
not considered appropriate clinical targets for the philosophy, classical philosophy is seen as a process
purpose-straight chiropractic practitioner. The signs of inquiry with no definite end-point. Much of what
and symptoms of disease are considered irrelevant for has traditionally been identified as philosophy in chi-
the purpose-straight chiropractic doctor, whose sole ropractic are principles and hypotheses that merit ei-
professional concern is the detection and correction ther the critical consideration of the philosophical pro-
of subluxation. The significance of the traditional chi- cess or the rigorous investigations of the scientific
ropractic lesion is accepted as an a priori truth, and sci- method. Shorn of their dogmatic rigidity, many of the
entific investigation of subluxation syndrome is con- ideas comprising traditional chiropractic philosophy
sidered inappropriate, because the purpose-straight are quite appropriate as metaphors, heuristics, and
chiropractic clinician has no interest in and assumes sources of testable propositions (hypotheses).
no responsibility for the patient’s state of health. Ev- As a health care profession, chiropractors quite le-
eryone, it is suggested, would be better off without the gitimately make use of professional, ethical, and sci-
“nerve interference” implicit in spinal subluxation, entific principles. A distinctiveness of the profession
but no one can predict when a subluxation may man- may be found in the unique constellations of ideas
ifest in signs and symptoms. Research to improve and methods that constitute the subject matter for phi-
methods of subluxation detection and correction losophy and science in chiropractic. Also in contrast
to most other health professions, chiropractors offer a 2. Classical philosophy is a process of probing,
variety of conflicting epistemological principles, and doubting, and skeptical inquiry. Philosophers ap-
have not reached consensus on the value of the scien- ply their critical skills to issues such as beauty
tific method. Evolving from and even today operating (aesthetics), morality (ethics), reasoning (logic), re-
within a hostile interprofessional environment, the ality (ontology), and knowledge (epistemology).
critical self-examination of principles and hypothe- Several of these fields of inquiry are quite rele-
ses that constitute classical philosophy and science is vant to the chiropractic profession and merit in-
often seen as risky. Chiropractors have been loath to depth investigation (e.g., the ethics of clinical prac-
lower their guard long enough for self-examination tice, the development of reasoned arguments, and
of the profession, for fear of further onslaught from the avoidance of logical fallacies when consid-
political medicine.80 ering chiropractic issues). The relatively recent
The diversity of ideas in the profession defies emergence of robust research by chiropractors has
comprehensive description, but several more or less encouraged commitment to the epistemology of
distinct groupings of principles may be identified. science. Like classical philosophy, science in chiro-
Among the more prominent of these are evidence- practic requires attention to logic and systematized
based chiropractic, traditional straight chiropractic, methods of gaining knowledge and understand-
and purpose-straight chiropractic. Differences among ing. Stripped of their doctrinal (dogmatic) quality,
these schools of thought often form the basis for many of the ideas offered by the Palmers and their
intraprofessional disputes, and failure to coalesce successors are useful and legitimate concepts for
around a shared set of principles has hampered for- guiding the science and practice of chiropractic.
mation of a united front for interprofessional activity. 3. Among the most prominent principles of chiro-
Greater attention to both shared and disputed princi- practic philosophy are homeostasis, holism, con-
ples (i.e., greater philosophical inquiry) might aid in servatism, the strategic role of the nervous system,
promoting unity within the profession. The rich di- and the desire for professional autonomy. These
versity of chiropractic, with its fundamental concern principles (including metaphors, heuristics, and
for patient welfare and benefit, could become a boon a priori assumptions) may give rise to testable
rather than a hindrance to the profession. propositions (hypotheses) and/or may serve as
constituents of that constellation of methods and
values that uniquely characterize the chiropractic
profession.
ACKNOWLEDGMENTS 4. Chiropractors have employed a wide range of
My thanks to Carl S. Cleveland III, DC, for his critical review, epistemologies (ways of knowing) to defend their
to Allan Gotlib, DC, and the Journal of the Canadian Chiroprac- art and professional autonomy. This diversity has
tic Association for permission to reprint, and to the National In- included critical and uncritical empiricism (e.g.,
stitute of Chiropractic Research for its financial support of work private research), critical and uncritical rational-
related to the completion of this chapter. ism (e.g., so-called deductive science), spiritual in-
spiration, and the scientific method. As well, vari-
ous chiropractic authors and speakers have offered
a number of logical fallacies in justification of the
clinical art. In order to further the profession’s
SUMMARY
research enterprise and to encourage greater in-
1. The principles of chiropractic evolved partly from tegration with the wider health science and schol-
the seminal teachings of D. D. Palmer. Their arly communities, chiropractors will need to sepa-
distinctiveness from many ideas in allopathic rate the chaff from the wheat. A stronger and more
medicine took on new significance when they pro- widespread commitment to the epistemology of
vided what was termed a “separate and distinct science may facilitate both of these goals.
philosophy” that met the legal and political needs 5. The diversity of beliefs among chiropractors de-
of the besieged new profession. B. J. Palmer defies comprehensive description. However, several
veloped the idea of philosophy as irrefutable doc- clusterings of these ideas may provide a useful
trine by which not only health care, but life itself, mental shorthand, and seem to parallel some of
seemed to be explained. B. J. rejected the infer- the major political divisions within the profession.
ential reasoning of the scientific method in favor The practical (clinical) and ethical implications of
of deduction from “true principles.” A codifica- these groupings (e.g., evidence-based chiropractic,
tion of Palmer’s principles was offered by Ralph traditional straight chiropractic, purpose-straight
W. Stephenson, and became required reading for chiropractic) deserve thoughtful study by the pro-
generations of chiropractors. fession.
QUESTIONS KEY REFERENCES

1. The major premise of the Stephenson/Palmer set
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4. Which of the following is a metaphor?
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1996;19(9):613–619. 57. Sportelli L. Isolation or integration: Is there really a
32. DeBoer KF, McKnight ME. A surgical model of a choice? J Am Chiropr Assoc 1995;32(7):46, 61–64.
chronic subluxation in rabbits. J Manipulative Physiol 58. Winterstein JF. Isolation or integration: Suggested prin-
Ther 1988;11(5):366–372. ciples of integration. J Am Chiropr Assoc 1995;32(8):52–
33. Haldeman S. Neurological effects of the adjustment. J 55.
Manipulative Physiol Ther 2000;23(2):112–114. 59. Keating JC. A survey of philosophical barriers to tech-
34. Budgell BS. Spinal manipulative therapy and visceral nique research in chiropractic. J Can Chiropr Assoc
disorders. Chiropr J Aust 1999;29(4):123–128. 1989;33(4):184–186.
60. Keating JC. Chiropractic: Science and antiscience CA: Stockton Foundation for Chiropractic Research,
and pseudoscience, side by side. Skeptical Inquirer 1992.
1997;21(4):37–43. 71. Keating JC. Toward a philosophy of the science of chiroprac-
61. Martin SC. Chiropractic and the social context of medi- tic: A primer for clinicians. Stockton, CA: Stockton Foun-
cal technology, 1895–1925. Tech Culture 1993;34(4):808– dation for Chiropractic Research, 1992, p 21.
834. 72. Keating JC, Caldwell S, Nguyen H, Saljooghi S, Smith
62. Martin SC. “The only truly scientific method of heal- B. A descriptive analysis of the Journal of Manipulative
ing”: Chiropractic and American science, 1895–1990. and Physiological Therapeutics, 1989–1996. J Manipu-
Isis 1994;85(2):207–227. lative Physiol Ther 1998;21(8):539–552.
63. Palmer BJ. Induction vs. deduction [pamphlet]. Daven- 73. Strauss JB. Refined by fire: The evolution of straight chi-
port, IA: Palmer School of Chiropractic, 1915. ropractic. Levittown, PA: Foundation for the Advance-
64. Keating JC. Purpose-straight chiropractic: Not sci- ment of Chiropractic Education, 1994.
ence, not health care. J Manipulative Physiol Ther 74. Homewood AE. What price research? Dyn Chiropr
1995;18(6):416–418. 1988;6(6):32–33.
65. Palmer DD. The chiropractor’s adjuster: The science, art 75. Gibbons RW. Chiropractic’s Abraham Flexner: The
and philosophy of chiropractic. Portland, OR: Portland lonely journey of John J. Nugent, 1935–1963. Chiropr
Printing House, 1910, pp 11–12. Hist 1985;5:44–51.
66. Barge FH. Life without fear. Eldridge, IA: Bawden Broth- 76. Keating JC. Shades of straight: Diversity among the
ers, 1987:i. purists. J Manipulative Physiol Ther 1992;15(3):203–209.
67. Barge FH. Is there a true chiropractic philosophy? 77. Gold RR. The triune of life. Spartanburg, SC: Sherman
Yes, and there are no alternatives. In: Proceedings of College of Straight Chiropractic,1998.
the 1991 International Conference on Spinal Manipulation. 78. Strauss JB. Reggie: Making the message simple. Levittown,
Arlington, VA: Foundation for Chiropractic Education PA: Foundation for the Advancement of Chiropractic
and Research, 1991. Education, 1997.
68. Keating JC. C. O. Watkins: Pioneer advocate for 79. Gelardi TA. The science of identifying professions as
clinical scientific chiropractic. Chiropr Hist 1987;7(2): applied to chiropractic. J Chiropr Hum 1996;6:11–17.
10–15. 80. Keating JC, Mootz RD. The influence of political
69. Keating JC. C. O. Watkins, DC, grandfather of the medicine on chiropractic dogma: Implications for
Council on Chiropractic Education. J Chiropr Educ scientific development. J Manipulative Physiol Ther
1988;2(3):1–9. 1989;12(5):393–8.
70. Watkins CO. The basic principles of chiropractic gov- 81. Proceedings of a conference on philosophy in chiropractic ed-
ernment. In: Keating JC. Toward a philosophy of the ucation. Fort Lauderdale, FL: World Federation of Chi-
science of chiropractic: A primer for clinicians. Stockton, ropractic, 2000, p 73.
C H A P T E R
5
COMMUNICATION IN THE
CHIROPRACTIC HEALTH ENCOUNTER:
SOCIOLOGICAL AND
ANTHROPOLOGICAL APPROACHES
Ian D. Coulter
O U T L I N E
INTRODUCTION Summary of the Preencounter Experience
QUALITATIVE RESEARCH—AN ALTERNATIVE THE HEALTH ENCOUNTER
RESEARCH MODEL FOR CHIROPRACTIC Communication
QUALITATIVE RESEARCH IN CHIROPRACTIC Explanation of the Health Problem
A MODEL FOR EXAMINING THE CHIROPRACTIC Explanation of the Treatment
HEALTH ENCOUNTER Explanation of Chiropractic
PREENCOUNTER EXPERIENCE Quality of the Communication
Route to the Chiropractor CONCLUSION
Push Factor SUMMARY
Pull Factor QUESTIONS
The Social Context ANSWERS
Social Legitimacy KEY REFERENCES
Prior Health Problems REFERENCES
limited specialty focusing on the treatment of neuro-

OBJECTIVES musculoskeletal conditions3 through spinal manipu-
1. To define what is meant by the health encounter. lative therapy.4 This has led some to argue that chiro-
2. To discuss methodological issues in studying the practic is akin to a subspecialty within medicine and
health encounter. not a broad-based alternative to traditional medicine,5
3. To discuss some of the main findings of qualitative while others have been willing to ascribe a broader,
research into the chiropractic health encounter. primary care role to chiropractic.6–8 The narrow view
4. To describe what is known from sociology and an- of chiropractic as a subspecialty stands in stark con-
thropology about communication within the chi- trast to the sociological/anthropological literature on
ropractic health encounter. chiropractic, so much so that it almost seems as if
two different professions are being described. There
are two major reasons for this: First, the focus of
the studies is quite different. For epidemiology and
INTRODUCTION
health services research, the focus is on such things
The increasing body of data on the epidemiology and as the presenting condition, the diagnosis, the distri-
utilization of chiropractic,1 as well as a growing body bution of conditions among the patients, utilization
of health services research,2 presents chiropractic as a patterns, cost of care, objectively measured outcomes,
99
satisfaction with care, and efficacy of care, which usu- for them in that particular situation. The purpose in
ally means efficacy of manipulation.2 For the sociolo- this approach therefore is to ground research in the
gist/anthropologist, the focus is more likely to be the perspective of the subjects, not the researcher. The
total health encounter and the overall effectiveness of focus is more on discovery and understanding than
the care. on explanation. The methods that have developed
The second reason is to be found in the re- to conduct this type of research have been variously
search methods used and the type of data collected. termed qualitative, interpretative, sensitizing analy-
For epidemiologists and health services researchers, ses, and grounded theory. The underlying philosoph-
the data are overwhelmingly quantitative in nature ical/theoretical paradigms include phenomenology
and derived from patient files,9 surveys,10 billing (the study of phenomena), hermeneutics (the science
records,11 clinical assessment instruments,12 validated of interpretation), and symbolic interactionism. In an-
health status instruments,13 and validated satisfac- thropology, it is the basis of ethnographic research.17
tion instruments.14 Anthropologists and sociologists, A major feature of qualitative research is a pref-
however, are much more likely to use observation erence for “grounded” concepts and theories. In
techniques and collect qualitative data.15 To under- practical terms, this implies approaching the field with
stand this, it is necessary to understand something minimum predetermined concepts and theories. Fur-
about qualitative methods. thermore, even those that are used must be amenable
to constant revision as the research proceeds. The ob-
jective is to generate concepts that do not distort or
QUALITATIVE RESEARCH—AN ALTERNATIVE
do violence to the phenomena under study and that
RESEARCH MODEL FOR CHIROPRACTIC
are sensitive to change in the study population. One
The social sciences have developed a range of qualita- of the strengths of this approach is a more dynamic
tive research techniques to overcome what are seen as picture of the social processes involved than possible
methodological weaknesses in traditional positivist, from a static view captured by quantitative methods.
empirical, quantitative studies. Although an extensive When the focus is on operationalizing quantitative
critique of these approaches is beyond the purpose measures, particularly when this is done prematurely,
of this chapter, a brief outline is necessary. A major there is the danger of either overlooking the relevant
critique is that quantitative methods are not grounded variables or oversimplifying them. A further advan-
in the perspective of the research subjects but in that of tage is that grounded theory is immediately avail-
the researcher. To this extent, they focus on objectively able to the social participant by being comprehensible
defined variables that can be correlated with behavior and self-obvious, because the results are based on the
(e.g., age, gender, income, and occupation), identify- world view of the participants.
ing those variables that have predictive explanatory The methodologies of grounded theory have been
power. extensively documented. Among the methods used
Secondly, quantitative methods tend to measure are observation, focus groups, the use of key in-
stable characteristics that can be replicated and mea- formants, unstructured questionnaires, participant
sured reliably by other researchers using valid and re- observation, ethnography, analysis of documents,
liable instruments. This approach does not give much and narrative analysis. Several methodological is-
attention to the context in which events occur and the sues present themselves in the use of qualitative
more ephemeral aspects of social interactions. The im- methodologies. There is some consensus that genuine
age of society involved in the positivist/quantitative qualitative analysis requires intimate knowledge by
research paradigm reflects a deterministic social en- the researcher of the social setting and thus is time-
vironment and structure (i.e., all events have suffi- consuming. In anthropology, this may involve long
cient causes). Under this paradigm, the social world periods of living in the field with the subjects. There
is as amenable to the methods of science as the natural are also a set of issues around the selection of infor-
world.16 mants and the choice of both what to observe and what
Within the social sciences, a contrary view of both elements to observe. There are issues of reliability and
social reality and the methods needed to investigate validity of observations by either a single informant
it has developed. Here the view is of society as a ne- or a limited number of observers, and in the selec-
gotiated order. Instead of society settling around the tion of documents. However, questions raised about
individual in some monolithic/deterministic fashion, the reliability and validity of qualitative methods have
the individual is in a constant interaction with soci- been shown not to be insurmountable. Use of multiple
ety in a process that constructs the meanings of things methods of data collection has been recommended by
and events in any given situation. If you wish to know numerous authors. Jick18 has termed this approach tri-
why individuals behave the way they do, you need to angulation. Methodologically, the best approach is to
find out what meanings the objects or events have integrate both qualitative and quantitative methods.19
COMMUNICATION IN THE CHIROPRACTIC HEALTH ENCOUNTER 101
Qualitative research is uniquely useful in areas a patient for a 6-month period to conduct a partic-
where the phenomenon under study has not been ex- ipant observation. In addition to being drawn from
tensively researched or clearly understood. Crabtree random samples, the participation rate was 80% for
and Miller17 distinguish several aims of scientific re- chiropractors and 89% for patients. The end result was
search that lead to distinct types of analysis: identifi- that the research team had available an extensive body
cation, description, explanation, generation and asso- of quantitative data from structured questionnaires
ciation, explanation testing, and prescription/control. and documents, and a wealth of qualitative observa-
In qualitative research, analysis is primarily focused tional data. The description, therefore, is grounded in
on the first three. a very comprehensive analysis. The following discus-
sion enriches the data by drawing on other qualitative
research studies that have also focused on the health
QUALITATIVE RESEARCH IN CHIROPRACTIC
encounter provided a wealth of confirmatory data.
Several authors have discussed the application of
these methods to chiropractic research.16,20–25 Among
PREENCOUNTER EXPERIENCE
these commentators there is a strongly expressed be-
lief that positivist/quantitative approaches to chiro- Strictly speaking, the health encounter begins with the
practic care have failed to capture the nature of the first visit to the chiropractor. However, encounters do
health encounter and therefore failed to understand have a history prior to this point and this history influ-
the meaning of chiropractic care for the patient, ul- ences the encounter in many ways. In analyzing how
timately failing to understand the effectiveness of a patient gets to a chiropractor, we must distinguish
this form of care. While in chiropractic these two ap- between “push” factors and “pull” factors.
proaches have tended to be used independently of
each other, they could be used as complementary Route to the Chiropractor
methods and a theoretical framework for doing this Push Factor In the Kelner et al. study, 56% of the pa-
has been developed.26 tients had used some other form of care prior to chi-
ropractic. In more recent studies1 this number had
fallen to 30%, indicating that a sizable proportion of
A MODEL FOR EXAMINING THE
the patients had tried some other form of care first. It
CHIROPRACTIC HEALTH ENCOUNTER
might also indicate that over the last 30 years a change
In a sociological sense, the health encounter embraces has occurred in that in the earlier study the majority
all those events that occur between the patient and the had not gone directly to a chiropractor (i.e., seeing
clinic staff from the moment patients enter the chiro- another health provider first), but currently the ma-
practic office until they exit. While the doctor–patient jority do. This might reflect a change in the legitimacy
interaction is generally considered to be the most im- of chiropractic as seen by the patient. In the earlier
portant part of the encounter, others may play just as period, even controlling for past experience with chi-
important a role, from the staff at the front desk to ropractic, the patients still used an indirect route to
the chiropractic assistant. Consequently, when study- the chiropractor. However, the higher the educational
ing this encounter, it is important to observe the total attainment of the patient, the more likely they were to
encounter. go directly to the chiropractor, bypassing other health
The most extensive observational study done to providers. For the most part, this prior care is medical
date on the chiropractic health encounter is by Kelner, care followed by physical therapy. The most common
Hall, and Coulter, who from 1975 until 1980 randomly reason given for seeking chiropractic care is dissatis-
sampled 1 in 5 Canadian chiropractors, for a total faction with the results from other forms of care. This
of 349 chiropractors.27 Each chiropractor was inter- therefore might be termed the push factor, that is, the
viewed in his or her practice and where possible, the reason the patient moves from one form of care to
researchers observed care being given. Additionally, considering another form of care. It, however, does
70 clinics were randomly selected for a rapid ethno- not ensure they end up in a chiropractic office.
graphic assessment where two trained qualitative re- Receiving prior care has several implications for
searchers spent 1–2 days observing all aspects of the the chiropractic encounter. First, it ensures that the
clinic.28 In addition, 658 randomly chosen patients in patient comes to the encounter with a basis for com-
these clinics completed an interview through a struc- parison by which to judge the performance of the chi-
tured questionnaire and were observed receiving care. ropractor. Second, it means the chiropractor is dealing
A smaller number of patients were interviewed in with an already dissatisfied patient. Third, it implies
depth to create vignettes of care that focused on the that a patient’s major focus is going to be on results.
total care for a given episode and not simply a single Although chiropractors often interpret the dissatisfac-
day. Last, but not least, one of the researchers became tion as a general dissatisfaction with medicine, only
5% patients listed that as a reason: 88% of the patients (as opposed to orthodox), a caste, and an outcast.31 It
had a family medical doctor and 85% were generally would be reassuring to conclude that these challenges
satisfied with the care they received from that doctor. to chiropractic legitimacy were a thing of the past, but
Thus, the dissatisfaction is highly focused for a spe- recent events, such as fierce debate over the possible
cific problem or health complaint. inclusion of a chiropractic program in a Canadian uni-
versity, has shown clearly that influential groups still
Pull Factor The overwhelming reason given for actu- question the legitimacy of this practice.32 Much of chi-
ally ending up in chiropractic is that the patient has ropractic history can be interpreted as a struggle for
heard that chiropractors are good for this particular legitimacy, culminating, perhaps, in the legal antitrust
complaint. The route to a particular chiropractor is suit successfully taken against the American Medical
most frequently via patient referrals, which accounts Association.
for 45% of the patients; for 30% this patient is a family The process of legitimacy also applies to the pa-
member. The patient therefore meets the chiropractor tient. In his seminal work on the sick role, Parsons33
with a preexisting recommendation. Given the very saw the doctor’s role as one that controlled what
high levels of patient satisfaction with chiropractic might be a form of deviance, the sick role. Under
care,14 this is likely to be a positive recommendation. this theory, for society to function it must control the
The fact that the recommendation is followed implies circumstances under which members of the society are
that the source is credible to the patient. Because the legitimately sick and can therefore be excused from so-
chiropractor has an established point of contact with cial responsibilities. “Within this framework the sick
the patient prior to meeting him or her, giving them role is supposed to be temporary, undesirable and so-
a preexisting relationship that they can build on and cially disruptive. The professional is a technical expert
into, the chiropractor may further reassure this per- who legitimizes the claim to illness and is responsi-
son by using the previous patient as an example of ble for returning the sick person to his normal role
success.29 in society.”34 Chiropractors, as primary contact health
professionals, are also in the business of legitimating
The Social Context the individual in the patient role.
Social Legitimacy The health encounter does not oc- Given this social background, we can add a further
cur in a social vacuum. It occurs in a social context important element that has implications for the health
in which certain definitions and meanings are so- encounter. For the chiropractors’ part, it has meant a
cially constructed and applied to groups, individuals, need to establish the legitimacy not only of the actual
and processes. Within the health field these meanings treatment plan but of the profession itself. This is seen
determine what illnesses are considered legitimate, in the encounter as a need to explain the nature of the
which patients are considered legitimate (as opposed chiropractic paradigm and its difference from other
to malingerers), which forms of treatment are legiti- paradigms, such as medicine. Historically, it has also
mate, and last, but not least, which therapists are legit- meant a degree of defensiveness on the part of the
imate. This process of legitimacy occurs at numerous chiropractor.35 The chiropractor faces the prospect of
levels, from legislation that controls licensure and/or a patient who may have been warned against chiro-
registration of the therapist, to what therapies are cov- practic from some powerful individuals such as his or
ered by insurance payment, to what therapies are ap- her medical physician.
proved for use, to a broader social/political process in For the patient, taking the step to consult a chi-
which the health professions compete with each other ropractor may represent an unorthodox step, a step
for legitimacy. For the most part, those groups that are into the unknown. In the past, chiropractic was virtu-
licensed by the state, that are considered to meet the ally never portrayed in the media or in popular enter-
standards of the professions (that is, are autonomous, tainment in a positive light, a fact in stark contrast to
self-disciplining, have a code of ethics, act in the pa- medicine. For the latter, most people will have been to
tient’s interest, and are therefore considered altruis- a medical doctor and a medical clinic since birth, and
tic), are bestowed legitimacy by the state and by soci- even if they have not, they will have seen it portrayed
ety. Chiropractic is one of the unique groups in that for so many times on TV and in movies, they will have a
much of its history it has achieved legislative recogni- reasonable idea of what to expect from the white coat
tion, is frequently covered by insurance plans, and has and stethoscope, the treatment room, and the wait-
all the characteristics of a profession, but has neverthe- ing room. They may even have a good idea of what
less been denied legitimacy by such powerful groups kind of magazines they will find in the waiting room.
as traditional medicine and other health professions.30 All of this means that the medical doctor–patient en-
Even within the social sciences, chiropractic was once counter occurs within a set of largely shared mean-
labeled as a marginal profession, a deviant theory of ings about what should happen. The patient is able
disease, a definition of a deviant situation, heterodox to accept within this structure a state of undress and
behavior, such as an intrusive examination, that the patients report as their presenting complaint and
would not be tolerated elsewhere. The key element which are recorded as diagnoses in the patient records
here is that much of this behavior will be expected is quite narrow.1 When asked to identify the particular
by the patient prior to the visit, and so the encounter conditions they thought chiropractic was suitable for,
can proceed with a minimal amount of justification 57% of the patients listed four or fewer complaints,
for what is to occur. with general back and spine being listed by 60% of
For the chiropractic patient on the first visit, there the patients.27
may be no prior meanings or expectations either about From one point of view this narrow range of pre-
the setting or the behavior that is to occur: Is the patient senting problems might seem to restrict chiroprac-
to disrobe? Is the patient to be given a medical exami- tic in its scope of practice and also in what it might
nation (blood pressure, temperature, weight, etc.)? In achieve. However, as we explore later, chiropractic
this sense, the first visit is much more problematic for has been able to build a broader-based “wellness”
chiropractic care because nothing prior to it may have paradigm37,38 that can focus not only on manipula-
prepared the patient for the encounter. In addition, for tion/adjustment, but also on such things as exercise,
many patients seeking care, previous care has failed, nutrition, stress management, and weight control.
which often results in a questioning of their health sta-
tus. This is exacerbated in the case of chronic nonspe- Summary of the Preencounter Experience
cific neuromusculoskeletal problems because they are This discussion of the preencounter lays out what
expected to be self-limiting, do not lend themselves to might be termed the preconditions for the health en-
a definitive diagnosis, frequently have a psychosocial counter proper. It establishes both the type of condi-
component, and do not have highly effective thera- tion presented to the chiropractor as the health prob-
pies. Sociologists have distinguished between the dis- lem and the type of patient who seeks the care. It
ease or trauma a person has (the disordered biology), also determines the social context within which both
the way the individual acts and interprets this as the the patient and the chiropractor interact. As we have
illness, and the social construction by which the indi- noted, this social context cannot always be considered
vidual acts out the illness as the sick role or sickness. benign to chiropractic, and has both debits and credits.
When the patient comes to the chiropractor, all three On the credit side, the patient comes with a con-
may be in play and impacted by the encounter. Ab- dition that appears to often respond to conservative
normal illness behavior, such as hypochondria, may care. Because patients are most likely to come because
undermine the purpose of the sick role, which is to some other patient has recommended this particular
seek care and a cure. Vernon36 has suggested that chi- chiropractor, they come with a testimonial for the chi-
ropractors may be effective because much of their care ropractor and a previous relationship the practitioner
is focused on illness behavior. Under this model, ab- can build upon. Patients also often come from therapy
normal illness behavior, such as prolonged rest, avoid- that has failed to get results for them. On the debit
ance of activity, increased stress, increased use of med- side is the fact that patients have a comparison ther-
ications, and retreat into the sick role on a permanent apy to evaluate chiropractic against. At the very least,
basis may be transformed by chiropractic care by get- the chiropractor must obtain better results than their
ting the patient focused on taking control of his or her prior care. But new patients may also come with some
life and resuming normal activities. serious concerns about chiropractic fueled in part by
questions about chiropractic legitimacy, but also fu-
Prior Health Problems eled by ignorance of what constitutes chiropractic care
The last element that must be considered as part of and further, what constitutes appropriate chiropractic
the preencounter is the actual health problem that the care.
patient brings to the chiropractor. This represents the
material the chiropractor has to work with. The con-
THE HEALTH ENCOUNTER
ditions presented are overwhelmingly neuromuscu-
loskeletal in nature. Hurwitz et al.1 found that 68% of Although the nature of chiropractic care is clearly an
the patients sought care for low back pain, nonneu- important part of the encounter, the focus here is on
romusculoskeletal conditions accounted for less than the sociological aspects of the health encounter. We
1%, and headaches for only 7%. In the earlier study by can note that 98% of chiropractors report adjustments
Kelner et al.,27 three conditions (general back/spine, as their primary mode of therapy,27 and adjustment
neck/shoulder, and lower back) accounted for 57% was recorded in 84% of the patient records for low
of the conditions being presented to the chiroprac- back pain.1
tor, while headaches accounted for 6%. Although the In one sense the chiropractic health encounter
full range of disease and illness may be experienced poses a challenge. The conditions treated by chiro-
in the chiropractic office, the number of conditions practors are not unique and are also treated by a wide
range of other health professionals. The modalities of it tends to be mechanistic in nature. “The net effect
treatment are also not unique. Spinal manipulation is a logical set of explanations which appeal to com-
is performed by osteopaths, physical therapists, and mon sense, use scientific terminology, yet promote a
medical physicians, and perhaps by many others. The natural, noninvasive, holistic approach to healing.”40
adjunctive therapies such as heat, electrical therapy, Oths,42 in analyzing communication in a chiro-
mechanotherapy, acupuncture, ultrasound, exercise, practic clinic, also stresses that chiropractic explana-
massage, soft tissue therapy, vitamins, and nutritional tions are simple and understandable and harmonize
supplements are all to be found in other practices. very well with the way individuals conceptualize
Even aspects of “chiropractic philosophy,” with its things in an industrialized society. She further notes
emphasis on vitalism, holism, naturalism, humanism, that there is a high degree of congruence between
therapeutic conservatism, and critical rationalism,39 the explanations the patients give of their illness with
are not unique to chiropractic and are shared by many those of the chiropractor. Her conclusion is that the
other complementary and alternative therapies. Yet patients internalize the chiropractic model of disease
chiropractic patients often describe their experience to a high degree. In her study of a chiropractic of-
as unique. The uniqueness therefore must be located fice, the communication was reinforced by pamphlets,
not in any single element of the encounter, but in all charts, and diagrams throughout the clinic, as well as
the elements taken together—the totality of the chi- by videos. As with Coulehan’s study, she found that
ropractic health encounter. We will attempt to give a chiropractors made extensive use of analogies and
sociological answer as to why this encounter is per- constantly translated medical jargon into lay terms
ceived as unique. the patient could understand. For her, this demysti-
fied both medicine and the patient’s health problem.
Communication Jamison23 observed that chiropractors use differ-
What sociologists/anthropologists have isolated most ent explanatory paradigms with their patients. On the
clearly is the nature of the communication that occurs one hand, much of the explanation for the problem is
within the chiropractic health encounter. Given the mechanistic, but on the other hand they invoke vari-
preencounter factors described above, communicat- ous versions of a holistic paradigm. In the mechanistic
ing with patients poses a significant challenge to chiro- model, the body is likened to a machine that will be re-
practors. Nevertheless, evidence from sociology and paired through chiropractic. In the holistic paradigm,
anthropology supports that chiropractors are very ef- the perspective is broadened to see the body as a self-
fective at communicating. In chiropractic, explana- healing entity but with interference in its ability to
tions to the patient tend to be of three different types: do so.
(a) an explanation of the health problem, (b) an ex- While the explanation will focus on the presenting
planation of the treatment, and (c) an explanation of problems, it will also be broadened to include aspects
chiropractic. of the patient’s life, such as nutrition, stress, weight,
posture, and exercises.39,40 It is in the explanation of
Explanation of the Health Problem Chiropractors report the problem that the chiropractor is presented with the
concentrating most of their explanations on the na- opportunity to expand the intervention beyond the
ture of the patient’s health problem. The patients also presenting symptoms and into lifestyle counseling, or
confirm that this is the most extensive of the expla- what some have termed wellness care.37,38
nations given. Chiropractors use a range of methods
in giving these explanations, including visual aids Explanation of the Treatment In explaining the nature
such as charts, skeletal models, and printed materi- of treatment, the chiropractor again uses a range of
als. More than 90% of the chiropractors report using techniques. Sixty-four percent of chiropractors report
such visual aids; 73% report using analogies or mod- using the theories of chiropractic to explain the treat-
els; and 63% use the theories of chiropractic in their ment, although only 12% of the patients report this is
explanation.27 The patients, for their part, report that what happened.43 This explanation will often begin
x-rays (52%), charts of the body (50%), and skeletal with the initial spinal examination41 and will usually
models (34%) are the most frequently used methods. occur concurrent with hands-on touching by the chi-
In his observation study of the chiropractic health en- ropractor; it may also be accompanied with extensive
counter, Coulehan40,41 notes that chiropractors pro- use of visual aids. The hands-on examination plays a
vide concrete, understandable explanations of the powerful role in chiropractic, both recreating the pain
health problem. The explanations tend to be physical the patient is suffering through palpation, but also
and lend themselves to the use of analogies and mod- eliciting additional stress points that may not be de-
els, such as mechanical devices (e.g., a skeletal model) tected by the patient.41 This provides powerful and
to depict the problem. While the explanation will instant confirmation that the chiropractor knows and
include elements of the philosophy of chiropractic, understands the patient’s body.39 Jamison sees this
as an important element in establishing a shared un- that only 9% of the patients gave a definition that con-
derstanding of the patient’s problem. She notes, “The tained any chiropractic philosophy.
pain, the soreness, tenderness, and tightness elicited Cowie and Roebuck29 in the first ethnographic
by palpation forms the basis of this mutual under- study of chiropractic noted that the chiropractor was
standing. In addition to responding to specific ques- well aware that the first visit posed difficulties for the
tions, the patient’s unsolicited grimaces, grunts, yelps, patient. Much of the effort of the chiropractor there-
and jocular complaints provide a useful feedback to fore was oriented towards explaining the “nature,
the practitioner.”44 It also validates the patient’s prob- purpose, philosophy, and promise of chiropractic.”29
lem as legitimate and detectable by others. They found that the chiropractor has, as a central
Oths,42 by analyzing the narratives occurring at concern, the general impression the patient forms
this point of the encounter, found that most of the about chiropractic. The chiropractor encouraged open
dialogue can be considered instrumentally oriented discussion of this with the patient so that any nega-
(information exchange) as opposed to affective (char- tive conceptions could be dealt with. This also allowed
acterized by feeling or emotion). Again she found the chiropractor to identify difficult patients. This in-
that the amount of touch in these encounters was excluded the extent to which the patient was willing to
tensive (the chiropractor maintained physical contact share the practitioner’s views, the depth of the philo-
with the patient up to 90% of the treatment time). sophical conversion, and whether they were likely to
As Coulehan notes, “Chiropractors attend to bodily accept a chiropractic model of care and comply with it.
discomfort with more handling, more touching, that Anderson,46 using narrative analysis of chiroprac-
opens up a channel of communication now neglected tic encounters, also notes that this conversion expe-
by physicians.”41 rience into the chiropractic ethos was expressed in
Explanation of the treatment goes beyond the the narratives in 64% of the patients. A conversion
immediate therapy to the discussion of a treatment was also present in all the narratives of the chiroprac-
plan which lays out the way in which the treatment tors themselves. Oths42 also notes this need to convert
will proceed but also the patient’s responsibilities.27 the patient to a chiropractic way of thinking during
A standard theme of the observation studies that which the patient comes to share the chiropractor’s
have been done on chiropractic is that the care is explanatory model. It was cemented in her study by
cooperative. Oths42 found that the chiropractor con- the “warm, caring, affable, and continuously informa-
stantly stressed negotiation and collaboration with tive manner during encounters.”42 She found that the
the patient, a model of mutual participation. Un- chiropractor went to “great lengths to educate new
der this approach, Jamison44,45 found that chiroprac- patients to a new way of thinking about their often
tors expected the patients to participate in their own long-standing problems.”42
care. Coulehan41 calls this an “engaging plan” in Coulehan41 sees this process as one in which the
which the patient and the chiropractor come together. chiropractor attempts to establish a link or fit with
Coulter39 points out that, at a fundamental level, this the patient and to determine if the patient is someone
form of cooperation is almost a prerequisite for some they can help. To do this, the chiropractor needs to
forms of treatment (such as cervical manipulation), know not only the physical problem but the patient’s
which is difficult to perform without the coopera- attitude toward the problem and toward chiropractic.
tion of the patient. He notes that manipulation should
more correctly be viewed not as something done Quality of the Communication
by the chiropractor to the patient, but as something Almost without exception, observational studies
the chiropractor and the patient’s body cooperate to point to the quality of the communication between
deliver. chiropractors and their patients. Jamison44 found that
patients ranked the explanation given to them as un-
Explanation of ChiropracticGiven the lack of knowledge derstandable, helpful, complete, believable, and sat-
that any new patient is likely to have about chiroprac- isfactory; 86% expected to understand their condi-
tic and given the questions raised about the legitimacy tion better. Coulehan40,41 notes that chiropractors have
of chiropractic, this area poses a particular challenge what he terms “faith that heals”; that is, they not
for chiropractic. In the explanation the chiropractor only believe strongly in their profession, but also
will attempt to define the profession and its practice. believe strongly that they can help a given patient.
Coulter43 found that chiropractors will use a variety of Cherkin, MacCormack, and Berg47 found in compar-
methods to do this. Fifty-one percent used the philos- ing the views of family physicians and chiropractors
ophy of chiropractic; 52% used the theories of chiro- that the former were less likely to believe they were
practic; 59% used the art of chiropractic; 53% stressed adequately trained to manage low back problems and
the science; 47% used the modalities; and 64% stressed to more often be frustrated by these kinds of patients
the scope of practice. Interestingly, Coulter43 found and to think they have no physical problem. The
chiropractors expressed more confidence and were partners in the treatment and enhancing of
more comfortable about managing back pain. Chi- their own health.27
ropractors therefore bring to their communications a
confidence and assuredness that is convincing to their Coulehan concludes:
patients. Coulehan41 also concludes that chiropractors
demonstrated both empathy for the patient (“the fact Physicians can learn from the success of the
that the patient’s symptoms are real, cause suffering, clinical art in chiropractic. This art begins with
and require serious professional attention is never at “the faith that heals,” and it involves an inter-
issue”41 ) and genuineness. The latter refers to the abil- action that may well function as a positive feed-
ity to be themselves in the relationship. This is coupled back system to promote healing. By healing, I
with a belief that all patients will do well and that mean a satisfactory outcome for the patient: re-
a promise of improvement is continuously made to lief of pain, diminished anxiety, acceptance of
the patient.46 Oths42 notes that the chiropractor was one’s lot in life, less disability, a positive mental
open and frank in his attitude to the patient, show- attitude.40
ing respect in how the patient was addressed, giving
praise and encouragement, and using sustained eye Finally, Oths draws the following conclusion:
contact. She notes, “Throughout all interactions, Dr.
A’s dialogue is characterized by acute openness, hon- Given chiropractic’s unified theory of disease
esty, and frankness.”42 etiology, which provides a rational interpreta-
Another element is that the care does not “subtract tion of a patient’s problem and an unambigu-
the patient”41 ; that is, the chiropractor does not de- ous method for treating it, the practitioner and
personalize the problem by referring to the body part. the patient can reach a common level of under-
Oths42 found that the chiropractor would always use standing. The end result is most often a patient
the possessive pronoun (“your knee”) when referring highly satisfied with the care received. From
to a patient’s body and would use the pronoun “we” the observations made in this study, one might
when talking about what was to be done, as in “all we be inclined to agree with Kleinman et al. that
can do is try to get it as strong as possible.”42 In their the chiropractor is “more interested and skilled
study, Kelner et al.27 found that the care was always in handling illness problems” than the M.D.42
highly personalized for the individual patient.
It was also highly personal in that it always in- What all the studies share is the belief that to un-
volved the chiropractor. For example, the patient does derstand chiropractic the focus must be on the total
not get referred out to fill a prescription; most vis- health encounter. It is here that we will locate all the
its will involve hands-on care by the chiropractor. As elements that structure and contribute to chiroprac-
Coulehan notes, chiropractors “do something; they tic as experienced by the patient and by the chiro-
do not just sit and talk or write prescriptions.”40 As practor. Chiropractic cannot be simply reduced to a
noted earlier, chiropractic care involves extended peri- single therapy (i.e., manipulation), to a single phi-
ods where the chiropractor is in physical contact with losophy (i.e., vitalism), or to a single condition (i.e.,
the patient. low back pain). Like all healing professions, chiro-
practic combines some science and a lot of art, the
latter expressed in the very unique relationship that
CONCLUSION
chiropractors build with their patients. At the core
What conclusions have been drawn from the qualita- of this relationship is communication, building trust,
tive observation studies of the chiropractic encounter? commitment, and, ultimately, the conversion of the
For Kelner et al. it is the following: patient into a chiropractic patient.
It offers intelligible care; the chiropractors try

to provide their patients with an understand- SUMMARY
ing of their injury or illness, using a language 1. The health encounter includes the total interac-
which patients can comprehend. They explain tion between the chiropractor, the office staff, and
the plan of treatment, the progress of the case, the patient. All health encounters are preceded
and the relation of their illness to environmen- by a preencounter history that impacts on the en-
tal conditions. Finally, they try to make patients counter, and frequently involves treatment by an-
aware of their personal role and responsibility other health care provider for the specific problem.
in the maintenance of their health. Chiroprac- In the case of chiropractic patients, this prehistory
tic is cooperative care—patients participate as will also often involve hearing negative messages
from powerful groups about the legitimacy of chi-

ANSWERS
ropractic.
2. To capture the nature and components of this 1. Quantitative methods tend to come from the per-
health encounter requires the use of qualitative spective of the researcher, while qualitative meth-
research methods, because qualitative research ods attempt to understand the perspective and
methods are grounded in the perspectives of the context of the individuals being studied.
social actors rather than the perspective of the re- 2. The health encounter encompasses all the events,
searcher. Through the use of accepted qualitative interactions, and behaviors that occur during a
observation methods we are able to capture the patient’s visit to a chiropractor’s office. This in-
total health encounter in a way not possible by cludes interaction with office staff, as well as with
the standard quantitative methods of question- doctors.
naires, interviews, or review of patient files. Al- 3. Explanation of the patient’s health problem, an ex-
though qualitative methods have been used to planation of chiropractic treatment, and an expla-
study chiropractic, the number of studies is still nation of the profession of chiropractic.
modest. 4. Most chiropractors allay a patient’s fears and un-
3. The picture of chiropractic derived from qualita- knowns regarding chiropractic by spending time
tive studies stands in stark contrast to that derived explaining to the patient the profession and its phi-
from epidemiology and health services research, losophy, theories, and methods.
which show chiropractic to consist mainly of ma- 5. Chiropractors tend to be excellent communicators,
nipulation for a limited number of health prob- providing understandable explanations to their
lems. The route to the chiropractor is influenced patients and engaging them in a cooperative ef-
by a major push factor, dissatisfaction with the re- fort to heal.
sults of other care; the route is also influenced by
one major pull factor, recommendation by another
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4. Focusing on the communication aspect of the Coulter ID. Alternative philosophical and investigatory
health encounter allows us to focus on an aspect paradigms for chiropractic. J Manipulative Physiol Ther
other than the efficacy of treatment procedures per 1993;16:419–425.
Coulter ID. Chiropractic: A philosophy for alternative health
se. The communication addresses the nature of the
care. Oxford: Butterworth-Heinemann, 1999.
patient’s health problem, the plan of treatment, Crabtree BF, Miller WL, eds. Doing qualitative research. Re-
and chiropractic itself; the end result of effective search methods for primary care. London: Sage, 1992.
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chiropractic in the future. Jamison JR. An interactive model of chiropractic prac-
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Kelner M, Hall O, Coulter I. Chiropractors, do they help?
QUESTIONS Toronto: Fitzhenry & Whiteside, 1980.
Oths K. Communication in a chiropractic clinic: How a DC
1. What is the major difference between quantitative treats his patients. Culture Med Psychiatry 1994:18(1):83–
and qualitative research methods as they apply to 113.
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2. What are some components of the chiropractic ness behavior model in the management of low back
health encounter? pain patients. J Manipulative Physiol Ther 1991;14(6):
3. Chiropractic communications to patients tend to 379–389.
be of what three different types?
4. How do questions related to social legitimacy af-
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5. What common conclusions have many sociologi- P. Use of chiropractic services from 1985 through 1991
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chiropractic health encounter? 1998;88(5):771–776.
2. Mootz RD, Coulter ID, Hansen DT. Health services re- 23. Jamison JR. Chiropractic holism: Interactively becom-
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22. Kleynhans AM. Developing philosophy in chiroprac- sophical Constructs for the Chiropractic Profession
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44. Jamison JR. Compliance or empowerment: An 46. Anderson ST. Narrative and the chiropractic encounter.
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45. Jamison JR. An interactive model of chiropractic prac- low back pain: A comparison of the beliefs and be-
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C H A P T E R
6
INTERNATIONAL STATUS, STANDARDS,
AND EDUCATION OF THE
CHIROPRACTIC PROFESSION
David A. Chapman-Smith and Carl S. Cleveland III
O U T L I N E
INTRODUCTION Research–United States
PROFESSIONAL ORGANIZATION Consortium for Chiropractic Research–Canada
International Organizations Clinical Guidelines and Task Forces
World Federation of Chiropractic (WFC) CHIROPRACTIC AND COMPLEMENTARY
Fédération Internationale de Chiropratique Sportive AND ALTERNATIVE MEDICINE
(FICS) Definitions
Council on Chiropractic Education International (CCEI) Is Chiropractic Part of CAM?
World Regional Organizations The Benefits and Disadvantages
US National Organizations of Classification as CAM
Canadian National Organizations CAM Utilization
LAWS GOVERNING THE RIGHT TO Significance for Chiropractic
PRACTICE CHIROPRACTIC ACCEPTANCE AND UTILIZATION
Right to Practice OF CHIROPRACTIC SERVICES
Professional Titles Public Acceptance
EDUCATION Utilization of Chiropractic Services
LITERATURE, RESEARCH, AND CLINICAL Satisfaction Rates and Cost Sensitivity
GUIDELINES Medical Attitudes
Textbooks FUTURE DIRECTIONS
Scientific Journals SUMMARY
Searching Chiropractic Literature QUESTIONS
Searching Biomedical Literature ANSWERS
Research—Organization and Funding KEY REFERENCES
The Consortial Center for Chiropractic REFERENCES
4. To describe the educational standards for chiro-

OBJECTIVES practors in different nations.
1. To review expansion of chiropractic around the 5. To review the importance of scientific research, the
world. peer-reviewed literature, and official guidelines in
2. To describe the goals of the major international the development and acceptance of chiropractic.
professional organizations. 6. To discuss the advantages and disadvantages of
3. To review laws governing the right to practice chi- labeling chiropractic as a complementary or alter-
ropractic in different parts of the world. native treatment approach (CAM).
111
7. To discuss the future options available to chiro- in discussions of health care policy.1 This chapter ad-
practic as a profession and the manner in which it dresses the status of the chiropractic profession today,
is likely to be identified internationally. both in the United States, where it was founded five
brief generations ago, and throughout the increasingly
small and interconnected world we now inhabit.
INTRODUCTION
The art of joint and soft-tissue manipulation, a cen-
PROFESSIONAL ORGANIZATION
tral aspect of chiropractic practice, has been practiced
and recorded since ancient Chinese, Egyptian, and International Organizations
Greek civilizations. Hippocrates, known as the father Until the 1970s relatively few countries outside North
of medicine, wrote a complete text on the subject. This America had laws formally recognizing chiropractic
art, however, fell into disuse by the medical profession practice, none had schools of chiropractic, and the fu-
in modern times. In Europe and North America in the ture status of the profession remained heavily depen-
eighteenth and nineteenth centuries, spinal manipula- dent upon the United States. That has now changed.
tive therapy was practiced mainly by bonesetters, lay Since 1999 there are more chiropractic schools outside
persons who frequently inherited the skills and tradi- the United States than within, there is chiropractic leg-
tion from their parents and were dismissed as unedu- islation in all world regions, and it is predicted that by
cated and dangerous by the medical profession. Med- 2010 there will be 150,000 chiropractors, with 50,000 of
ical education, then as now, provided no training in them practicing outside the United States. As a conse-
this approach to physical examination and treatment. quence of these developments, the last 20 years have
The history of the profession established by D. D. seen the formation and growth of world organizations
Palmer, and developed in its early years by his son to coordinate the international development of chiro-
B. J. Palmer, is described more fully in Chapter 2. practic education, practice, and growth.
Table 6–1 gives key dates relevant to the expansion
and growth of the profession to its current impressive World Federation of Chiropractic (WFC)Founded in 1988
international status. After the founding of the Palmer and having its offices in Toronto, Canada, the WFC’s
School of Chiropractic in 1897, chiropractic education voting members consist of 81 national associations
and practice spread throughout the United States and of chiropractors, which range from the largest, such
Canada. The State of Kansas (1913) and the Province as the American Chiropractic Association (ACA), the
of Alberta (1923) became the first jurisdictions in each Canadian Chiropractic Association (CCA), and the In-
of these countries to pass legislation recognizing and ternational Chiropractors’ Association (ICA), to the
regulating the practice of chiropractic. smallest, such as those associations representing the
In the early twentieth century, students came to the few pioneering chiropractors in countries such as
United States from Australia, New Zealand, Europe, Bolivia, Ghana, Iceland, Mauritius, and Saudi Ara-
Japan, and South Africa, and then returned home bia. The WFC has become the profession’s primary
to commence the development of the profession in forum for developing a consistent basis for chiroprac-
their countries. Today there are approximately 100,000 tic principles, laws, scope of practice, and education
chiropractors in more than 80 countries, many new in all world regions. This consistency is important for
schools of chiropractic, and greatly increased public patients (e.g., those who travel internationally for
awareness and acceptance of chiropractic health care, work, education, and family reasons) and the unity
and the profession is growing more quickly than ever. and future prosperity of the profession. Three exam-
In the words of a 1997 US government report, “[s]pinal ples of the important role served by the WFC are:
manipulation and the profession most closely associ-
ated with its use, chiropractic, have gained a legiti- 1. Maintains an international paradigm for chiropractic.
macy within the United States health care system that In July 1996, the Association of Chiropractic Col-
until very recently seemed unimaginable.”1 leges (ACC), representing all 17 accredited colleges
In the past several decades, chiropractic has un- in Canada and the United States, unanimously
dergone a remarkable transformation. Labeled an agreed upon a “Paradigm of Chiropractic,” a fun-
“unscientific cult” by organized medicine as little as damental position statement on the chiropractic
20 years ago, chiropractic is now recognized as the profession’s role in health care. That paradigm
principal source of spinal manipulation, one of the few was subsequently adopted for the profession in
treatments recommended by national evidence-based the United States by its two national associations,
guidelines for the treatment of low back pain. In the the ACA and the ICA. These organizations, in
areas of training, practice, and research, chiropractic turn, jointly submitted it to the WFC for adoption
has emerged from the periphery of the health care internationally. The ACC Paradigm, now also
system and is playing an increasingly important role the WFC Paradigm, was adopted at the WFC
INTERNATIONAL STATUS, STANDARDS, AND EDUCATION OF THE CHIROPRACTIC PROFESSION 113
TABLE 6–1. Chiropractic History: Key Dates
Date Historical Event
1895 D. D. Palmer commences practice as a “chiropractor.”

1897 The Palmer School of Chiropractic, the first chiropractic educational institution, opens.
1913 Kansas becomes the first US state to recognize and license the practice of chiropractic.
Louisiana became the last state in 1974.
1923 Alberta becomes the first province to license chiropractic practice in Canada. Ontario follows in
1925. Newfoundland is the last province, in 1992.
1933 The US Council of State Chiropractic Examining Boards is established with a mandate to provide
unified standards for licensure. Renamed the Federation of Chiropractic Licensing Boards
(FCLB) in 1974.
1939 The Canton of Zurich, Switzerland, becomes the first jurisdiction outside North America to license
the practice of chiropractic.
1944 The Foundation for Chiropractic Education and Research (FCER) is established and, to the
present time, is the profession’s foremost agency for funding of postgraduate scholarship
and research.
1963 The US National Board of Chiropractic Examiners (NBCE) is established to promote consistency
and reciprocity between state examining boards.
1974 The US Council on Chiropractic Education (CCE) is recognized by the federal government as
the accrediting agency for schools of chiropractic. This leads to the development of affiliated
accrediting agencies in Canada, Europe, and Australia/New Zealand.
1979 Chiropractic in New Zealand, the report of the NZ Commission of Inquiry into Chiropractic,is
published. This was the first government commission to adopt a full judicial procedure, hearing
evidence on oath and subject to cross-examination when examining patients, chiropractors,
medical doctors, and others on the role of the chiropractic profession. The Commission’s
recommendations strongly endorse chiropractic services and call for medical cooperation.
The report has a major impact internationally.
1987 Final judgment in Wilk vs. American Medical Association entered, opening the way for much
greater cooperation between medical and chiropractic doctors in education, research, and
practice in the United States and internationally.
1988 World Federation of Chiropractic (WFC) is formed. The WFC, whose members are national
associations of chiropractors in more than 78 countries, is admitted into official relations with
the World Health Organization (WHO) as a nongovernmental organization (NGO) in January
1997.
1993 The Manga Report in Canada, the first government-commissioned report by health economists
looking at the cost-effectiveness of chiropractic services, recommends a primary role for chi-
ropractors with back pain patients on grounds of safety, cost-effectiveness, and patient pref-
erence, and concludes that this will save hundreds of millions annually in direct health care
costs and work disability payments.
1994 Government-sponsored expert panels developing evidence-based guidelines for the management
of patients with back pain in the United States (Agency for Health Care Policy and Research1 )
and the United Kingdom (Clinical Standards Advisory Group) provide the first authoritative
reports that manipulation is a proven and preferred treatment approach for most acute low-
back-pain patients.
1996 US government begins official funding support for an ongoing agenda for chiropractic research.
To continue this agenda, the Consortial Center for Chiropractic Research is formed in 1997,
comprising chiropractic schools, university research departments, and federal government
agencies, and is based at Palmer College of Chiropractic.
1998 The first year in which there were more chiropractic schools outside the United States (17) than
within (16): Australia (2), Brazil, Canada (2), Denmark, France, Japan, Korea, New Zealand,
South Africa (2), Sweden, and the United Kingdom (4). In 2002, there were three schools in
Australia, two in Brazil, and one in Mexico. Several unofficial schools in Japan are upgrading
programs in partnership with accredited schools from Australia and North America.
FIGURE 6–1. The Association of Chiropractic Colleges’ Chiropractic Paradigm (July 1996), which was adopted internationally by
the World Federation of Chiropractic in May 2001. For the full text of the paradigm, visit www.chirocolleges.org.
Assembly in Paris in May 2001. Figure 6–1 sum- looked at the difficulties encountered by the os-
marizes the paradigm. teopathic profession in its development. The pro-
2. Maintains uniform policies. Working in partnership fession of osteopathy was founded in the United
with many specialized organizations in chiroprac- States in the same era as chiropractic, and had a
tic, and consulting with its member national asso- number of similarities. Because of a lack of unity
ciations, the WFC has held conferences that have and coordination it no longer has a consistent
produced important consensus, direction, and pol- international identity. In the United States, Doc-
icy on matters such as: tors of Osteopathy (DOs) have similar training
• The role of philosophy in chiropractic educa- and specialties to medical doctors, including use
tion. of prescription drugs and surgery. In the United
• Acceptable interim standards of education in Kingdom, osteopaths retain their traditional focus
countries establishing their first school of chi- on osteopathic manipulation without use of drugs
ropractic. and surgery and require a 4-year, full-time edu-
• Nonuse of prescription drugs in chiropractic cation for licensure and practice. In many other
practice. countries, other health professionals or lay persons
• An acceptable definition of chiropractic for use commence practice as an osteopath after several
internationally in general dictionaries for the weekends of technique classes. This loss of com-
public. This definition reads as follows: “Chi- mon educational standards and professional iden-
ropractic is a health profession concerned with tity has been a major impediment to the growth
the diagnosis, treatment, and prevention of dis- of a uniform identity for the osteopathic profes-
orders of the musculoskeletal system, and the sion. The international chiropractic community,
effects of these disorders on the nervous sys- through the WFC, has made the development of
tem and general health. There is an emphasis a uniform education and identity a primary goal.
on manual treatments, including spinal manip-
ulation.” The WFC enables the chiropractic profession to
3. Avoids the loss of international professional identity. play an effective and respected role in the interna-
The international chiropractic community has tional health community. The most successful agency
of the United Nations, and the one responsible for been responsible for lobbying for inclusion of chiro-
health, is the World Health Organization (WHO). The practic services in federal programs such as Medicare,
WFC was accepted into official relations with WHO Medicaid, and the Military and Veterans’ Administra-
in 1997, and is active in supporting WHO’s pub- tion Healthcare Systems, and for initiating and build-
lic health initiatives, including its antismoking cam- ing national support for major lawsuits to fight ille-
paign, or Tobacco-Free Initiative (TFI). For more in- gal discrimination against chiropractic services. They
formation on the structure and activities of the WFC are most effective when working together, and fre-
visit www.wfc.org. quently do so. The ACA is considerably larger than
the ICA, but together their members represent fewer
Fédération Internationale de Chiropratique Sportive (FICS) than 20% of American chiropractors, a much lower
FICS, which has its offices in Lausanne, Switzer- membership level than national associations in other
land, was established in 1986, and serves a simi- countries. Their work is made more difficult by small
lar role to the WFC in the specialized and increas- organizations with extreme viewpoints that claim
ingly important arena of sports chiropractic. It has democratic authority and seek a profile at the national
coordinated postgraduate education and encouraged level, groups such as the National Association of Chi-
the greatly increased participation of chiropractors ropractic Medicine (limiting chiropractic to the man-
in sports medicine teams at the summer and win- agement of musculoskeletal pain syndromes) and the
ter Olympics and at many other national and inter- World Chiropractic Alliance (limiting chiropractic to
national sporting competitions. location and correction of vertebral subluxations).
Because health care laws, rights, and funding ar-
Council on Chiropractic Education International (CCEI)
rangements are matters of state law, a chiropractor’s
Governments generally require that educational pro-
first priority in professional membership is often his or
grams for professionals meet minimum standards es-
her state association. US state associations are separate
tablished by an independent expert body approved
in structure and law from the two national associa-
by them, called an accreditation agency. In the United
tions. They are represented at the national level by the
States, the accreditation agency for chiropractic edu-
Congress of Chiropractic State Associations (COCSA)
cation, recognized by the federal government since
(www.cocsa.org).
1974, is the Council on Chiropractic Education (CCE).
The Association of Chiropractic Colleges (ACC)
CCE’s structure and standards have been followed by
(www.chirocolleges.org), as its name implies, repre-
similar CCEs in Australia, Canada, and Europe, and
sents chiropractic colleges, both in the United States
have now led to the formation of the Council on Chi-
and in other countries. The Council on Chiropractic
ropractic Education International (CCEI), which is de-
Education (CCE) (www.cceusa.com) is the organiza-
veloping standards for newer chiropractic schools in
tion that provides minimum standards, inspections,
countries and regions that do not yet have their own
and accredited/approved status for chiropractic col-
accreditation agency. CCEI presently functions from
leges.
the offices of US CCE in Scottsdale, Arizona.
The Federation of Chiropractic Licensing Boards
World Regional Organizations (FCLB) (www.fclb.org) is the national body that coor-
These exist in several regions, with the strongest and dinates and represents state licensing boards. It annu-
most developed being the European Chiropractors’ ally reviews and publishes a summary of state require-
Union (ECU). In Europe, health care policy and laws ments for a license to practice chiropractic. The FCLB
in individual countries are increasingly influenced is affiliated with the National Board of Chiropractic
by the European Union and its Parliament, based in Examiners (NBCE) (www.nbce.org), which sets and
Brussels. administers the federal licensing examinations in the
United States.
US National Organizations The Foundation for Chiropractic Education and
As the profession becomes established in each coun- Research (FCER) (www.fcer.org) was founded in 1944.
try, state/provincial and national organizations are The FCER is the premier and best-funded research
formed to represent the interests of the profession foundation established by the chiropractic profes-
and its patients in areas such as public relations, lesion. It holds a biennial International Conference
gal rights, reimbursement for care, regulation of chi- on Spinal Manipulation (ICSM) for the presentation
ropractic practice, education, and research. Contact of new research. The Consortial Center for Chiro-
addresses for national associations worldwide may practic Research (CCCR) (www.c3r.org) is a national
be found at www.wfc.org. research organization, founded in 1997, that holds
The American Chiropractic Association (ACA) an annual meeting funded by the federal govern-
(www.amerchiro.org) and the International Chiro- ment, the Research Agenda Conference (RAC), which
practors’ Association (ICA) (www.chiropractic.org) brings together researchers from chiropractic colleges,
represent the profession at the federal level. They have other university science faculties, and the National
Institutes of Health (NIH) to plan research and de- of Chiropractic Regulatory Boards (CFCRB), whereas
velop research skills. the Canadian Chiropractic Examining Board (CCEB)
Chiropractors may obtain their professional lia- (www.cceb.ca) is responsible for establishing a na-
bility/malpractice insurance from many companies. tional licensing examination.
One, originally established by the profession as a mu- The Canadian Chiropractic Research Foundation
tual society and by far the largest malpractice insurer (CCRF) (www.ccachiro.org) is an established funding
for chiropractors in the United States, is the National agency and is active in establishing training grants
Chiropractic Mutual Insurance Company (NCMIC), and small research grants for young investigators.
which also provides substantial funding for chiroprac- Professional liability insurance is provided by
tic research. the Canadian Chiropractic Protective Association
(CCPA). Similar to the United States, chiropractors
Canadian National Organizations may obtain malpractice protection from private com-
The Canadian Chiropractic Association (CCA) panies, but the great majority receive it from the
(www.ccachiro.org), with approximately 5000 mem- CCPA, an affiliate of the CCA, which uses some of its
bers, is the second biggest national association after revenue to fund chiropractic education and research.
the American Chiropractic Association. In Canada, as
in Australia, there is only one association in each LAWS GOVERNING THE RIGHT TO
province/state, and it is a division and legal part of PRACTICE CHIROPRACTIC
the national association. There is, therefore, no need
for an organization such as a council of state organi- Right to Practice
zations as exists in the United States, and information The chiropractic profession is recognized by law in
on the provincial/state associations is available from many countries, in all world regions, as summarized
the national association. in Table 6–2.
Licensing and disciplinary responsibilities for chi- Official recognition can be given by governments
ropractors are carried out by the Canadian Federation and health authorities in three different ways. The
TABLE 6–2. Countries Where Chiropractors Are Recognized by National Health Authorities
African Region Asian Region Eastern Mediterranean Region European Region
Botswana∗ China–Hong Kong∗ Cyprus∗ Libya† Belgium∗ Italy‡

Ethiopia† Japan† Egypt† Morocco† Croatia† Liechtenstein∗
Kenya† Malaysia† Greece† Qatar† Denmark∗ Netherlands†
Lesotho∗ Philippines† Iran∗ Saudi Arabia∗ England∗ Norway∗
Mauritius† Singapore† Israel† Turkey† Finland∗ Portugal∗
Namibia∗ Taiwan† Jordan† United Arab Emirates∗ France∗ Russian Federation†
Nigeria∗ Thailand‡ Lebanon† Germany† Slovakia†
South Africa∗ Hungary† Sweden∗
Swaziland∗ Iceland∗ Switzerland∗
Zimbabwe∗ Ireland†
Latin American Region North American Region Pacific Region
Argentina† Guatemala† Bahamas∗ Leeward Islands∗ Australia∗

Brazil† Honduras† Barbados∗ Puerto Rico∗ Fiji†
Chile† Mexico∗ Belize† Trinidad & Tobago† Guam∗
Colombia† Panama∗ Bermuda† United States∗ New Caledonia†
Costa Rica∗ Peru† British Virgin Islands† US Virgin Islands† New Zealand∗
Ecuador† Venezuela† Canada∗ Papua New Guinea†
Cayman Islands†
Jamaica†
Listed according to the seven world regions adopted by the World Federation of Chiropractic. In most other countries, there are no chiropractors in
practice, and national health authorities have not considered recognition or lack of recognition.
∗
Recognized pursuant to legislation.
†
Recognized pursuant to general law.
first is by legislation, and there is now legislation to Professional Titles

recognize and regulate the profession in Africa Various titles are authorized by law in different coun-
(Namibia, Nigeria, South Africa, and Zimbabwe), the tries. The title chiropractor or its equivalent (e.g.,
Asia-Pacific region (Australia, Hong Kong–Peoples chiropraktor [German], chiropraticien[ne] [French],
Republic of China, and New Zealand), the east- kiropraktor [Scandinavian languages], quiropraxia
ern Mediterranean (Cyprus, Iran, and Saudi Arabia), [Spanish]) is universal. Use of the title Doctor of
Europe (Belgium, Denmark, Finland, France, Norway, Chiropractic is common throughout North America,
Sweden, Switzerland, and the United Kingdom), reflecting the fact that North American chiropractic
Latin America (Mexico and Panama), and North colleges grant a Doctor of Chiropractic degree. In
America (Canada and the United States). In all in- North America, the title doctor is used by all pri-
stances, legislation authorizes primary practice with mary contact health professionals with the right and
the right and duty to diagnose, including the right duty to diagnose, including dentists, optometrists, os-
to provide or order diagnostic imaging. Examples of teopaths, podiatrists, and psychologists. Many states
chiropractic international legislation can be found in in the United States also authorize use of the title
Figure 6–2. chiropractic physician. These states, which include
Chiropractic practice may be recognized under California, Florida, Illinois, New York, and Ohio, rec-
general law without the existence of specific chiro- ognize three categories of physicians: (a) chiropractic,
practic legislation. Sometimes legality under general (b) medical, and (c) osteopathic.
law has been confirmed by ministerial ruling, as, for One reason for legislation to regulate a health
example, in Fiji, Mauritius, and Venezuela. On other profession is to prevent unqualified practitioners or
occasions, it has been confirmed by decisions of the lay persons from passing themselves off as members
courts, as in Brazil, Chile, and Greece. Elsewhere there of that profession, exposing the public to ineffective
may be general legislation, as in Germany, where or harmful treatments. For this reason chiropractic
chiropractors practice under umbrella legislation au- laws typically prohibit persons without a license from
thorizing many types of health providers to practice using the above protected titles or otherwise holding
natural health care methods under the general title of themselves out expressly or by implication as being
heilpraktischer. engaged in the practice of chiropractic.
The third method of recognition applies to coun-
tries where the practice of chiropractic is legally un-
recognized or technically in breach of the law, but is
EDUCATION
not obstructed by national health authorities. This is
possible because chiropractic practice is noninvasive, There is much misunderstanding of the extent and
makes no use of drugs or surgery, and is recognized to quality of chiropractic education. Focus groups held
be of public benefit. The six countries that have taken in Canada and the United States typically find that
legal action against duly qualified chiropractors in re- many members of the public think that chiroprac-
cent years are France and Iran (both of which have tic education is of approximately 2 years duration, is
now changed their positions and passed laws to rec- significantly inferior to medical education, and con-
ognize the profession), Italy, South Korea, Spain, and sists of chiropractors teaching other chiropractors in
Thailand. unregulated private schools. In fact, in North Amer-
In some European countries, including Austria, ica there is a minimum requirement of 7 years of
the Czech Republic, and Hungary, spinal manipu- university-level training, all aspects of education must
lation is expressly designated as being part of the meet official accreditation standards, and a graduate
practice of medicine. However, chiropractic services must also complete state/provincial and national li-
in Europe are in the middle of a general and rapid censing board examinations before gaining the right to
move to full legal acceptance. This is a result of practice. Independent government and medical stud-
the European Parliament’s May 1997 adoption of the ies in the United States,2 Sweden,3 and New Zealand4
Lannoye Report, which noted the high level of public have concluded that chiropractic education is the
acceptance of chiropractic and other complementary equivalent of medical education in all of the basic sci-
health care services in Europe, the unsatisfactory sit- ences. At the University of Southern Denmark, for ex-
uation for European citizens of having these services ample, chiropractic and medical students take a basic
legally recognized in some countries but not in oth- sciences program in the same department for 3 years,
ers, contrary to the principles of the European Union, with many shared subjects, lecturers, and classes, di-
and recommended that practice be approved by law viding into separate streams for clinical education.
throughout Europe. This has already led to new laws Until the 1990s, virtually all accredited chiro-
in Belgium and France, and similar legislative ap- practic education was given on the North American
proval is presently under discussion in Italy, Portugal, model and was therefore easy to summarize and de-
and Spain. scribe, that is, entrance requirements of 2–3 years in
A B
FIGURE 6–2. Chiropractic laws exist not only in all US states, but also in many other countries. Here are extracts from chiro-
practic legislation from the (A) United Kingdom and (B) Hong Kong. (Reproduced with permission from Chapman-Smith D. The chiropractic
profession. Des Moines, IA: NCMIC Group, 2000:31.)
118
qualifying subjects and then 4 years of undergraduate in their own countries, but not qualify them at the
chiropractic college education, leading to a Doctor of international level so as to allow them to sit for li-
Chiropractic degree. Now, despite a broadly consis- censing exams to practice in other countries. They
tent international standard of education, the position are going to commence upgrading local schools to
is more complex for several reasons: the international level of accredited chiropractic
education.
1. Entrance requirements vary by country, reflecting
differing educational systems. In many countries,
including Australia, Brazil, Mexico, South Africa, Table 6–3 lists the 35 chiropractic programs world-
and the United Kingdom, students enter chiro- wide in 2002 that are accredited or recognized by
practic education—as in medical and other health the government or national association in the coun-
care education—directly from secondary school try in which the school is located. A noteworthy cur-
(high school). rent development in the United States, which follows
2. In all of the above countries chiropractic educa- the newer model of chiropractic education founded
tion is within the public university system and in Australia and Europe and results from the vision
leads to different degrees. Graduates of the Tech- and work of the Florida Chiropractic Association, is
nikon Natal in Durban, South Africa, receive a the decision to open a school of chiropractic at Florida
master’s degree (M Tech Chiro), and graduates State University, with the first entering class due to
of Macquarie University in Sydney, Australia, re- commence in September 2004. This will be the first US
ceive the M Chiro master’s degree. Graduates of chiropractic program at a state university. It will likely
the University of Surrey in the United Kingdom lead to others, and represents another significant step
receive the MSc (Chiro) degree. Chiropractors are in the integration of chiropractic into the mainstream
no longer “DCs” throughout the world. American health care system.
3. The international chiropractic community,
through its adoption of the WFC’s Tokyo Charter
LITERATURE, RESEARCH, AND CLINICAL
in 1997, has recognized that when chiropractic
GUIDELINES
education is first introduced into a country, it
may initially have to be on a limited basis for an When the first edition of this text was published in
interim period. For example, in the 1990s in Japan, 1980, chiropractic literature and science were in their
the Japanese Chiropractic Association formed a infancy. There were no indexed, peer-reviewed chi-
partnership with the School of Chiropractic at ropractic journals, and there were very few specialty
RMIT University to commence a 3-year program texts in such important areas as skeletal radiology, the
for high school graduates that has now matured cervical spine, or overviews of chiropractic technique.
to a 5-year program at the international standard. At approximately the same time, the National Col-
In Brazil, the Brazilian Chiropractors’ Association, lege of Chiropractic launched the Journal of Manipula-
Palmer University, and Feevale University of tive and Physiological Therapeutics (1978), now the pro-
Novo Hamburgo, Brazil, formed a partnership fession’s flagship journal, and the ICA sponsored a
that commenced a 2-year program for health conference (1979), producing the papers on which the
professionals (e.g., medical doctors, physical first edition of this text was based.
therapists, nurses) that has now matured into a The years since have seen a dramatic growth in
5-year program for high school graduates. the number of chiropractic scientists worldwide with
4. Finally, in some countries without laws govern- doctoral degrees in the clinical and basic sciences and,
ing chiropractic education and practice, such as from them and others, the development of a mature
Germany, Honduras, Japan, and Taiwan, there are chiropractic scientific literature base. This is found
large numbers of lay persons with limited, part- both in the profession’s own periodicals and textbooks
time technique instruction only who are practicing and in other medical and health science publications.
as chiropractors. They are similar to the boneset- This literature base and the research upon which it
ters of yesteryear in Europe and North America. is founded have been vital to the continued growth
Starting with Japan, which has an estimated and status of the profession. They have become the
10,000 such practitioners, accredited colleges from basis for the profession’s future health in an era that
Australia and North America are working with the will be increasingly governed by evidence-based care.
national association (representing chiropractors Public and private reimbursement plans for employ-
from accredited chiropractic schools) and the lo- ees, injured workers, automobile accident victims, and
cal technique schools to present conversion degree seniors will generally pay for services supported by
courses that would convert these “chiropractors” sound research data on safety, effectiveness, and pa-
to a level suitable for safe and effective practice tient satisfaction, and exclude services without any
TABLE 6–3. Accredited or Recognized Chiropractic Colleges (2002)
Australia Durban, South Africa

Maquarie University Centre for Chiropractic www.ntech.ac.za
Sydney, Australia School of Chiropractic, Technikon Witwatersrand
www.chiro.mq.edu.au Johannesburg, South Africa
Faculty of Chiropractic, Murdoch University www.twr.ac.za
Perth, Australia Sweden
www.vet.murdoch.edu.au/vbs/chiro/ Scandinavian School of Chiropractic
Department of Complementary Medicine, Faculty of Stockholm, Sweden
Chiropractic, RMIT University
United Kingdom
Melbourne, Victoria, Australia
Anglo-European College of Chiropractic
www.rimit.ed.au/cocm
Bournemouth, UK
Brazil www.aecc chiropractic.ac.uk
Faculty of Chiropractic, Feevale Central University
McTimoney School of Chiropractic
Novo Hamburgo, Brazil
Oxford, Oxfordshire, UK
www.feevale.tche.br
www.mctimoney.org.uk
Faculty of Chiropractic, University Anhembi Morumbi The Welsh Institute of Chiropractic
São Paulo, Brazil School of Applied Sciences, University of Glamorgan
www.anhembi.br Pontypridd, Wales, UK
Canada www.glam.ac.uk
Canadian Memorial Chiropractic College United States
Ontario Canada Cleveland Chiropractic College
www.cmcc.ca Kansas City, MO
Université du Québec à Trois-Rivières, Sciences de la santé www.clevelandchiropractic.edu
Québec, Canada Cleveland Chiropractic College
www.uqtr.uquebec.ca Los Angeles, CA
Denmark www.Clevelandchiropractic.Edu
University of Southern Denmark, Faculty of Health Sciences Life Chiropractic College—West
Odense, Denmark Hayward, CA
www.ou.dk www.lifewest.edu
France Life University
Institut Franco-Européen de Chiropratique Marietta, GA
Paris, France www.life.edu
www.ifc.net Logan College of Chiropractic
Japan Chesterfield, MO
RMIT University Chiropractic Unit—Japan www.logan.edu
Tokyo, Japan National University of Health Sciences
Korea Lombard, IL
Hanseo University, RMIT Chiropractic Division www.nuhs.edu
Seoul, Korea New York College of Chiropractic
www.hanseo.ac.kr Seneca Falls, NY
Mexico www.nycc.edu
Faculty of Chiropractic, Universidad Estatal del Valle de Northwestern Health Sciences University
Ecatepec Bloomington, MN
Ecatepec, Mexico www.nwhealth.edu
New Zealand Palmer College of Chiropractic
New Zealand College of Chiropractic Davenport, IA
Auckland, New Zealand www.palmer.edu
www.chiropractic.ac.nz Palmer College of Chiropractic—West
South Africa San Jose, CA
School of Chiropractic, Technikon Natal www.palmer.edu
(continued)
Parker College of Chiropractic Texas Chiropractic College

Dallas, TX Pasadena, TX
www.parker.edu www.txchiro.edu
Sherman College of Straight Chiropractic University of Bridgeport College of Chiropractic
Spartanburg, NC Bridgeport, CT
www.sherman.edu www.bridgeport.edu/chiro
Southern California University of Health Sciences Western States Chiropractic College
Whittier, CA Portland, OR
www.scuhs.edu www.wschiro.edu
such data or evidence base. What follows is a brief sophisticated texts on chiropractic technique. A major
review of the literature and how it may be accessed. chiropractic text on soft-tissue examination and treat-
ment is Functional Soft-Tissue Examination and Treat-
Textbooks ment of Manual Methods,13 edited by Hammer. Texts
More major texts on chiropractic have been published such Rehabilitation of the Spine: A Practitioner’s Man-
in the last 10 years than in the previous history of ual (1996), edited by Liebenson,14 Conservative Man-
the profession, and many are of the highest quality agement of Cervical Spine Syndromes (1999), edited by
by any standards. For example, the first edition of Murphy,15 The Cranio-Cervical Syndrome: Mechanisms,
Foreman and Croft’s Whiplash Injuries: The Cervical Ac- Assessment and Treatment, edited by Howard Vernon,16
celeration/Deceleration Syndrome,5 when published in and the present text draw together contributions from
1988, was described by Ruth Jackson, MD, a lead- leading experts from many disciplines worldwide in
ing medical author in that field, as “the most remark- a way that was not possible in the past.
able compilation of scientific and factual data thus far Fundamentals of Chiropractic Diagnosis and Manage-
published concerning the many facets of the cervical ment (1991), edited by Lawrence,17 and Differential
spine.” The second edition of Essentials of Skeletal Radi- Diagnosis for the Chiropractor: Protocols and Algorithms
ology (1996),6 by chiropractic radiologists Yochum and (1997) by Souza18 are major general clinical texts
Rowe, was glowingly reviewed in the New England of 600 and 750 pages, respectively. There are texts
Journal of Medicine as a “textbook that should be of similar quality in many specialty areas such
required reading for any student of radiology.”7 An- as anatomy,19 low back pain,20 cervical spine
other major chiropractic radiology text, Clinical Imag- disorders,21 head pain,22 pediatrics,23,24 somatovis-
ing: With Skeletal Chest and Abdomen Pattern Differen- ceral aspects of chiropractic,25 and sports injuries.26,27
tials (1999),8 edited by Marchiori, has contributions Managing Low-Back Pain (1992, 3rd ed.) edited by
from many chiropractic and medical radiologists. It is Kirkaldy-Willis, a Canadian orthopedic surgeon, and
praised as “an outstanding text” from “an outstand- Burton, an American neurosurgeon, is an example of
ing group of radiologists” in the foreword by Francis a leading medical text on back pain in which the prin-
Burgener, MD, Professor of Radiology, University of cipal authors of the chapter on manipulation, Cassidy
Rochester Medical Center, Rochester, New York. and Thiel, are chiropractors.28
Professor Vert Mooney, past chair, Department
of Orthopedic Surgery, University of California at Scientific Journals
San Diego, in a foreword in Spinal Rehabilitation, The profession’s leading peer-reviewed journal, in-
edited by Stude9 of the College of Chiropractic, dexed in Index Medicus and therefore easily accessi-
Northwestern Health Sciences University, states that ble to everyone reading health sciences literature, is
the text “clearly demonstrates the ongoing integra- the Journal of Manipulative and Physiological Therapeu-
tion of chiropractic into comprehensive medical care,” tics (JMPT), which has been published in the United
is “a unique blend of the two major physical ap- States since 1978. Table 6–4 lists other peer-reviewed
proaches to spinal care—manual therapy and active chiropractic journals.
exercise,” and “is the way of the future” and “for- Most of the papers published in the chiropractic
ward thinking at its very best.” Chiropractic Technique literature, not surprisingly, come from chiropractors
(1993) by Bergmann, Petersen, and Lawrence,10 Chiro- and chiropractic research institutions. However, the
practic Manipulative Skills (1996) by Byfield,11 and Me- journals, and particularly JMPT, routinely receive and
chanically Assisted Manual Techniques: Distraction Proce- publish research from other health disciplines. Simi-
dures by Bergmann and Davis (1998)12 are examples of larly, chiropractic research is now regularly published
TABLE 6–4. Peer-Reviewed Chiropractic profession and the public at large. It indexes all chiro-
Periodicals practic peer-reviewed journals since 1985.
The Cumulative Index to Nursing and Allied
General Journals Health Literature (CINAHL) (www.cinahl.com) in-
dexes more than 1200 nursing, allied health, and
Australia Chiropractic Journal of health sciences journals, including chiropractic jour-
Australia nals, since 1982.
Canada Journal of the Canadian The Alt Health Watch (www.search.epnet.com)
Chiropractic Association database focuses on complementary and alternative
Europe European Journal of approaches to health care and wellness. It indexes
Chiropractic journals as well as various other publications, includ-
Japan Japanese Journal of ing association and consumer newsletters, since 1980.
Chiropractic Sciences AMED (www.bl.uk/services/information/amlist
United States Chiropractic Research .html), the Allied and Complementary Medicine
Journal Database compiled by the British Library Health Care
Journal of Manipulative and Information Service, is another database for students,
Physiological Therapeutics clinicians, and researchers looking for information on
complementary and alternative medicine.
Special Interest Journals
Searching Biomedical Literature
United States Chiropractic History The Cochrane Library (www.cochranelibrary.com)
Journal of Chiropractic database is compiled by the Cochrane Collaboration,
Education an international organization named after a famous
Journal of the Chiropractic British epidemiologist. This group also reviews and
Humanities summarizes all the research evidence in all fields of
Journal of Vertebral health care to formulate recommendations. The re-
Subluxation Research views currently found in the Cochrane Database of
Topics in Diagnostic Radiology Systematic Reviews, many of which are of importance
and Advanced Imaging to chiropractic practice, are indexed in MEDLINE un-
der the abbreviation Cochrane Database Syst Rev.
MEDLINE (www.pubmed.gov) is the major and
well-known database established by the US Na-
in leading medical journals such as the Annals of In-
tional Library of Medicine. MEDLINE is the electronic
ternal Medicine, British Medical Journal, Clinical Biome-
equivalent of Index Medicus, the print version, which
chanics, Journal of the American Medical Association, New
is now little used. This is the database that developed
England Journal of Medicine, Pain, and Spine.
the Medical Subject Headings (MeSH) that now form
Today, research relevant to the chiropractic pro-
the basis of searches in most databases. It covers more
fession can be published in hundreds of journals. The
than 4600 biomedical journals.
electronic database MANTIS, important for chiroprac-
Many of these databases may be accessed through
tors because it indexes research in the specialized field
EBSCO Information Services (www.epnet.com).
of manual and alternative therapies, references more
than 1000 journals. And this is only one database of rel- Research—Organization and Funding
atively narrow scope targeted at disciplines not well
Historically, as remains the case today, much chiro-
represented in the major biomedical databases such
practic research has been performed in chiropractic
as Index Medicus/MEDLINE.
colleges supported by organizations such as the Foun-
dation for the Advancement of Chiropractic Educa-
Searching Chiropractic Literature tion (FACE), the National Institute of Chiropractic Re-
MANTIS (Manual, Alternative, and Natural Therapy search (NICR), and the Consortium for Chiropractic
Index System) (www.healthindex.com) is a database Research (CCR), the latter established by 16 US chi-
that provides coverage for health care disciplines ropractic colleges in the late 1980s. However, the chi-
not significantly represented in the major biomedical ropractic profession’s principal research organization,
databases, including the chiropractic profession. established in 1944, has been the Foundation for Chi-
The Index to Chiropractic Literature (ICL) (www. ropractic Education and Research (FCER), now based
chiroindex.org) is published by the Chiropractic Li- in West Des Moines, Iowa. By 1990, the annual re-
brary Consortium (CLIBCON) for the chiropractic search budget of FCER was approximately $2 million,
drawn from within the profession from contributions medical management of patients with chronic tension-
by individual chiropractors and from chiropractic or- type headache.
ganizations and vendors. Major additional funding in
recent years has come from the National Chiropractic Clinical Guidelines and Task Forces
Mutual Insurance Company, the largest malpractice An excellent illustration of the current status and ma-
insurer for the chiropractic profession. turity of chiropractic practice and research is found
A significant new development during the past in the work of national and international clinical
decade has been the formation of chiropractic research guideline panels and other task forces since the early
networks based on a national research plan, with the 1990s. Firstly, chiropractic developed the unity, exper-
participation of multidisciplinary experts and institu- tise, and professional maturity to produce its own na-
tions and significant government funding. tional consensus guidelines for chiropractic practice
in the United States (Mercy Conference Guidelines,
The Consortial Center for Chiropractic 199129 ) and Canada (Glen Erin Conference Guide-
Research–United States lines, 199330 ). Representative panels met to forge
The Consortial Center for Chiropractic Research guidelines from the scientific literature and clinical
(CCCR) was formed as a result of an opportunity to expertise in all major areas of practice—from ex-
establish a chiropractic research center with historic amination, diagnosis, and record keeping to modes
funding from the US National Institutes of Health in of care, frequency, and duration of care and con-
1997. Headquartered at the Palmer Center for Chiro- traindications. Next, chiropractors were included on
practic Research in Davenport, Iowa, the consortium government-sponsored interdisciplinary expert pan-
has involved investigators from 13 chiropractic and els for development of national guidelines for the
other universities and colleges. The mission of the management of back pain in various countries, in-
center is to develop an infrastructure to evaluate the cluding the United Kingdom,31 the United States,32
safety and effectiveness of chiropractic care. One of Denmark,33 and New Zealand.34 All of these panels
its main functions has been to increase the experience produced national guidelines endorsing chiropractic
and sophistication of chiropractic researchers by spon- management by recommending spinal manipulation
soring training courses and conferences, and by devel- and return to activities of daily living as a first line
oping, reviewing, and funding developmental and pi- of management for most patients with low back pain.
lot studies in the clinical and basic sciences. Projects Furthermore, many recommended against many stan-
initially supported by the CCCR have been lever- dard medical treatments including bed rest, traction,
aged into larger, more definitive studies, enhancing joint injections, and various other physical therapy
the scientific basis for chiropractic. The CCCR cospon- and pharmaceutical modalities. As Redwood says,
sors, with the US Health Resources and Services Ad- “The release of the AHCPR Guidelines (the 1994 guide-
ministration (HRSA), the annual Research Agenda lines in the US from the Agency for Health Care Pol-
Conference (RAC), an interdisciplinary meeting de- icy and Research, US Department of Health and Hu-
signed to advance the scientific capabilities of the man Resources) was a truly seismic event (Fig. 6–3).
chiropractic profession. The director of the CCCR is The medical press expressed amazement that the fed-
William Meeker, DC, MPH, Vice President for Re- eral guidelines for the management of LBP (low-back
search, Palmer Chiropractic University System. The pain)—the nation’s most prevalent musculoskeletal
CCCR received the first major funding for a chiro- ailment and the most frequent cause of disability for
practic research center from the US government, indi- persons under age 45—now assign a pivotal role to
cating a major shift in attitude toward chiropractic at spinal manipulation of which 94% is provided by
this important policy and funding level. chiropractors.”35
At the same time, an interdisciplinary Task Force
Consortium for Chiropractic Research–Canada on Whiplash-Related Disorders with foremost ex-
The Consortium for Chiropractic Research (CCR) is perts from Europe and North America was meet-
similar to the US consortium but was first established ing in Quebec, Canada, to provide clinical guidelines
by the Canadian Chiropractic Association without for the management of trauma to the cervical spine.
government funding or assistance. Participating in- Again there was chiropractic representation, and in
stitutions include Canada’s two chiropractic colleges, 1995, the Quebec Task Force delivered guidelines in-
several major universities, and the Institute of Work dicating that management of soft-tissue injuries to
and Health. The CCR has now attracted several ma- the neck should be similar to management of back
jor government grants, including a recent grant of pain, that is, early return to function and activities
$1 million for a randomized controlled trial com- rather than rest or immobilization in a collar, with
paring chiropractic, medical, and joint chiropractic/ joint manipulation and mobilization recommended to
FIGURE 6–3. Clinical practice guidelines from (A) the US (Agency for Health Care Policy and Research, DHHS 1994) and (B) the
UK (Royal College of General Practitioners, 1998). (Reproduced with permission from Chapman-Smith D. The chiropractic profession. Des
Moines, IA: NCMIC Group, 2000:110.)
improve range of motion and reduce pain.36 Similar Associated Disorders. The United Nations, in con-
advice came from two other expert panels where chi- junction with the orthopedic community worldwide,
ropractic and medical scientists sat together, panels se- has proclaimed the years 2000 to 2010 the “Bone and
lected by the RAND Corporation37 and the Cochrane Joint Decade” to promote research into better under-
Collaboration.38 standing of the musculoskeletal system and its clini-
A final example of the chiropractic profession’s cal management. The Task Force is currently part way
present status as a full partner in the clinical health through a 6-year program of original research, litera-
sciences research community is the Bone and Joint ture review, and guideline development to strengthen
Decade 2000–2010 Task Force on Neck Pain and its understanding of the safety and effectiveness of the
various common methods of treating cervical spine However, the matter of definition has now ad-
disorders, a field in which all treatments lack strong vanced, and has been most thoroughly addressed so
scientific evidence of effectiveness. A number of scien- far in a British government report titled Complementary
tists with chiropractic training play a significant role and Alternative Medicine released in December 2000.39
in this Task Force along with scientists with qualifica- The Select Committee on Science and Technology of
tions in epidemiology, economics, research methodol- the UK House of Lords acknowledges in this report
ogy, and a number of medical specialties. that any exact definition of CAM, a broad and het-
erogenous field of health care, is impossible. However,
it rejects the British Medical Association’s approach
CHIROPRACTIC AND COMPLEMENTARY
of defining CAM as “forms of treatment not taught
AND ALTERNATIVE MEDICINE
in medical and paramedical schools.” Apart from
Chiropractors prefer to see themselves as a separate other considerations, this approach “is now unsatis-
and distinct profession, and traditionally they have factory” because medical schools are offering familiar-
practiced in isolation from other health professionals. ization courses in CAM, and use of various forms of
Until the 1980s, they were forced to do so because CAM by medical doctors is growing. Support is given
their central art of spinal adjustment was criticized to the philosophical position in the “more encom-
by the medical profession as potentially dangerous, passing” definition of CAM given by the Cochrane
ineffective, and inappropriate. Collaboration:
However, several major developments of the past
20 years have changed all of that. One has been new A broad domain of healing resources that
research and clinical guidelines supporting the ef- encompasses all health systems, modalities,
fectiveness and appropriateness of chiropractic care and practices and their accompanying theo-
for patients with highly prevalent conditions such ries and beliefs, other than those intrinsic to
as chronic headache, neck pain, and back pain. Of the politically dominant health system of a
equal importance is increased public dissatisfaction particular society or culture in a given histori-
with traditional medical care, its overdependence on cal period.
technology and drugs, and its failure to address the
wider aspects of health for many ailments, especially This definition, however, requires practical refine-
chronic conditions. Since the 1980s patients through- ment. The Select Committee acknowledges that it is
out the western world have gone shopping for health, inappropriate to group “well-established and gener-
and a majority have tried one or more alternatives, ally accepted CAM therapies such as osteopathy and
such as acupuncture, chiropractic, homeopathy, and chiropractic,” which have a substantial research base,
naturopathy, for various health care needs. with those that are undeveloped and have no evidence
Others in the world of health care have labeled chi- base. For this reason, the committee divides CAM into
ropractic and these professions complementary and “three broad groups”:
alternative medicine (CAM), and identified chiroprac-
tic as the leading example of a CAM discipline. This is 1. Complementary and alternative. These are the “prin-
currently proving to have at least as many advantages cipal disciplines” of acupuncture, chiropractic,
as disadvantages for the profession. Whatever an in- herbal medicine, homeopathy, and osteopathy,
dividual chiropractor’s response to this development “seen as the ‘Big 5’ by most of the CAM world.”
may be, the chiropractor should understand the CAM They are the most organized and regulated profes-
classification and its ramifications for chiropractic sions, have “an individual diagnostic approach,”
practice now and in the future. and have a research base.
2. Complementary. These are therapies that “do not
Definitions purport to embrace diagnostic skills” and “are
As yet there is no agreed upon definition for CAM, most often used to complement conventional
a term coined in 1987 by David Reilly, MD, a Scot- medicine.” Examples given are aromatherapy,
tish physician and homeopath. Until the late 1990s, Alexander Technique, bodywork therapies in-
the essence of definitions in Europe and North Amer- cluding massage, counseling, stress therapy, hyp-
ica was “forms of treatment not commonly taught notherapy, reflexology and shiatsu, meditation,
in medical schools.” This meant that CAM was a and mind/body healing.
catchall term covering everything from chiropractic to 3. Alternative. These disciplines, like those in the first
crystal therapy and folk remedies. This explains why group, have an individual diagnostic and treat-
established and legally regulated disciplines, such as ment approach but are “indifferent to the scientific
chiropractic and osteopathy, did not want to be labeled principles of conventional medicine” and propose
as CAM. “various and disparate frameworks of disease
causation.” The alternative group has two regulatory functions of the nervous system. Spinal
subgroups: adjustment or manipulation to relieve back pain and
• “Traditional systems of health care” which restore joint and muscle function is now mainstream,
have been long-established, such as Ayurvedic but the same treatment methods to empower the body
medicine (India) and traditional Chinese to regulate visceral functions such as respiration and
medicine. digestion, and to improve overall health and wellness,
• “Alternative disciplines which lack any credi- are CAM.
ble evidence base,” such as crystal therapy, iri-
dology, and radionics. The Benefits and Disadvantages
of Classification as CAM
Accordingly, under this British government clas- Overall, and against all expectations within the chiro-
sification, chiropractic is a group 1 form of CAM. By practic profession a decade ago, the classification of
definition that means that it chiropractic as CAM is proving helpful to the profes-
sion at this stage in its history. Seen as the leading force
• Is based on scientific principles compatible with in CAM, chiropractic is getting much greater govern-
western medicine (unlike group 3 disciplines). ment, legislative, media, and research attention than
• Has established a research base (unlike group 2 it could have achieved on its own. Examples of this
and group 3 disciplines). include the following:
• Has its own distinct diagnostic and treatment ap-
proach (unlike group 2 therapies). 1. In the United States, it has been the formation of
• Has well-developed professional organizations the National Center for Complementary and Al-
(more than group 2 and group 3 disciplines). ternative Medicine at the National Institutes of
• May be complementary or alternative to medical Health (NIH) that led to significant research fund-
services. ing for the profession, to federal funding for the
Consortial Center for Chiropractic Research based
For chiropractic this is a significant advance from at Palmer College in Davenport, Iowa, and to the
simply being described as CAM, and represents a first federal employment of a chiropractor at the
classification that most chiropractors will find useful NIH.
if not totally acceptable. 2. In Europe, it is the European Parliament’s 1997
adoption of the Lannoye Report on CAM that has
Is Chiropractic Part of CAM? led to legislation recognizing the chiropractic pro-
The answer to this question depends upon one’s per- fession in Belgium (1999) and France (2001), and
spective. Chiropractic opinion is divided. Most oth- that will finally bring the same legal recognition in
ers in the health care system, as evidenced by cur- Italy, Portugal, Spain, and throughout Europe.
rent policies of the US National Institutes of Health, 3. There have been recent national surveys on the use
the European Parliament in its adoption of the 1997 of CAM in Australia and New Zealand, Canada,
Lannoye Report,40 and the World Health Organiza- the United States, most European countries, and
tion in its current strategies on traditional medicine Israel. All identify high use of and satisfaction
and CAM,41 clearly see chiropractic as part of CAM. with chiropractic services—little or none of this
Arguments that chiropractic services are not CAM, data and resulting media comment on chiroprac-
but rather part of mainstream and core health care tic would have existed without CAM.
services, are that they are based upon the same 4. The rise of CAM has now brought endorse-
anatomical, physiological, and scientific principles of ment of chiropractic by the World Health Orga-
western medicine, employ treatment methods with nization, the United Nations’ influential agency
proven efficacy, and with respect to patients with governing health and health care policy in
back pain—who comprise the majority of chiroprac- all countries and world regions. Because of
tic practice—are services that represent a first line the extensive use of traditional medicine (e.g.,
of treatment recommended by evidence-based na- Chinese, Indian Ayurvedic, Arabic Unani, African
tional clinical guidelines in many countries includ- herbal/animal/spiritual medicine) in the deve-
ing the United Kingdom31 and the United States.32 loping world, and now CAM in the developed
Arguments that chiropractic is CAM flow from the world, in May 2002, WHO launched its first-ever
traditional paradigm of chiropractic care, which is global strategy for traditional medicine/CAM.41
different from medical practice in that the underly- This strategy calls for national policies in all coun-
ing focus is upon vitalism, healing from within and tries to support education and research and inte-
influencing general health through the correction of gration into health care of the major relevant disci-
subluxation/spinal dysfunction to restore the normal plines within traditional medicine/CAM. Within
this strategy, WHO is identifying chiropractic as a By 1997, 60% of US medical schools had courses
primary example of a now developed and estab- introducing students to CAM, including chiropractic,
lished CAM discipline. and the figure will now be much higher. There is a
5. Importantly, CAM provides a secure environment similar trend in Europe. For example, at the School
in which to discuss somatovisceral responses to of Medicine, University of Southampton, England,
chiropractic treatment, and to promote research all students have a 1-day clinical attachment to a
in that area. In a world where there is new ac- chiropractor or visit a chiropractic college as part of
knowledgment that traditional Chinese medicine, their CAM study module.
Ayurvedic medicine, healing touch, spiritual heal-
ing, and relaxation therapy are methods of promot- Significance for Chiropractic
ing the natural healing powers of the body and The significance for chiropractic is that the profession
influencing many disease processes, chiroprac- and its practice are no longer isolated in the health care
tors can discuss all spine-related disorders more system. Chiropractors must understand how they are
freely. viewed by others. Only then will they understand how
best to integrate their practices with those of other
However, these benefits must be weighed against providers. If the chiropractic profession is to evolve
disadvantages. At the same time as CAM brings to its full potential, generally and in the practices of
more overall awareness, recognition, and research individual chiropractors, it must respond to the now
opportunities for the chiropractic profession, it po- clear public expectation of integrated care.
sitions chiropractic as outside mainstream health
care services. This means that those responsible for
third-party funding for health services, whether in ACCEPTANCE AND UTILIZATION
government programs, managed care organizations, OF CHIROPRACTIC SERVICES
or employer health plans, tend to view chiropractic
Public Acceptance
care as an optional extra rather than a core service. Chi-
ropractic education and practice have become most Wherever the chiropractic profession has become es-
fully funded and integrated into the health care sys- tablished, general public surveys have reported high
tem where the profession has united to promote a levels of acceptance of chiropractic. A 1969 Gallup Poll
mainstream identity rather than a CAM identity, as in Denmark showed that 81% of the adult population
for example in Canada, Denmark, Norway, and the wanted chiropractors to be recognized by law and
United Kingdom. funded through the national health plan on a simi-
lar basis to medical doctors and dentists,44 which is
CAM Utilization now the case.
The use of CAM grew significantly throughout the A number of surveys in Australia, the United
Western world in the 1990s. In the United States, total States, and Canada since the 1980s report that ap-
annual visits for CAM increased by 47%, to 629 proximately 3 of 4 individuals responding to inde-
million visits, between 1990 and 1997. This exceeded pendent random telephone surveys agree that chiro-
total visits to all US primary care medical physicians practors have an important place in the total health
by 243 million.42 Chiropractic was the single most system and that chiropractic services should be cov-
used form of CAM, being used by 11–16% of the adult ered by health insurance; this support comes from a
population.42 There is similar data from Canada, substantial majority of those who have never visited a
Europe, Australia, and New Zealand. Health care chiropractor.45
experts accept that this is a permanent change in the
health care system, and not a passing fad. Extensive re- Utilization of Chiropractic Services
search in Europe and North America shows that CAM In the United States, the percentage of the adult pop-
patients are a normal cross-section of the population ulation using chiropractic services each year doubled
shopping for health. In North America, a small num- from 5% to 10% between 1970 and 1990. In addi-
ber of patients distrust and reject the conventional tion, even though access has become more difficult
medical system and therefore place their primary for many Americans because of restrictive policies
reliance on CAM including chiropractic—about 4.4% in HMOs and other managed care organizations, na-
of CAM users or 2% of the total population—but the tional surveys in 1997 by Eisenberg from Harvard42
great majority want integrated care.43 They tend to and Astin from Stanford43 report that 11–16% of adult
use the medical profession for acute infections, can- Americans now consult a chiropractor annually. The
cer, and broken bones, chiropractic and acupuncture exact rate varies by state, and significant factors in-
for back pain and headache, and homeopathy for clude the number of chiropractors in practice, as
allergies. well as levels of third-party reimbursement coverage.
Continued growth in utilization rates can be antici- copayments for chiropractic and medical care, and
pated for reasons that include the following: are then given free medical care, utilization of fee-for-
service chiropractic care falls by 80%.48
1. The growth in number of chiropractors. The same point is demonstrated by a UK study of
2. The dramatic increase in public demand for and 11 general medical practices in the Southwestern re-
use of complementary and alternative therapies. gion of Wiltshire.49 Following the 1994 UK back pain
3. The increased integration of chiropractic and med- guidelines recommending skilled manipulation as a
ical services now that medical physicians have ac- primary approach to treatment, the Wiltshire Health
cepted that chiropractors have a valuable role in Authority provided funding for “manipulation ser-
the management of back pain and other spine- vices” in a pilot project to see if general medical prac-
related disorders. titioners (GPs) would then follow the guidelines. With
this funding, there was a major shift in medical referral
In Canada, the picture is the same. In 1994– patterns. From July to October 1995, without funding,
1995, a national population health survey by Statis- GPs referred only 2% of their back pain patients for
tics Canada46 reported that 11% of Canadians aged manipulation (2% to chiropractors, 0% to osteopaths),
15 years and older consulted a chiropractor dur- while from November 1995 to March 1996, with fund-
ing the previous 12 months, varying from 17% in ing available, 53% of back pain patients were referred
the western and prairie provinces to approximately (28% to chiropractors, 25% to osteopaths). Referrals
3% in Atlantic Canada, where there are fewer chiro- for physical therapy services, funded during both pe-
practors and provincial government health plans do riods, went down from 72% to 21%. Recorded benefits
not include coverage for the cost of chiropractic ser- included fewer referrals to secondary care, less drug
vices. Studies from Australia, Canada, Europe, and the use, and fewer certified sickness days. The key to all
United States show that chiropractic patients are gen- of this was the availability of funding.
erally representative of the whole adult population
and come from all socioeconomic groups. Children Medical Attitudes
are the one group that is underrepresented. There is a In the twentieth century, there was a history of compe-
trend to overrepresent patients from higher education tition and dispute between the chiropractic and med-
and income groups. ical professions, first broken in America by the wa-
tershed judgment in the case of Wilk vs. The American
Satisfaction Rates and Cost Sensitivity Medical Association in 1987. Today, there are rapidly
All health care professions, and those who manage growing integration of chiropractic and medical ser-
or pay for health care services, are now aware that vices and mutual respect. This is illustrated in the fol-
patient satisfaction is an important measure or “out- lowing 1998 comments from Marc Micozzi, MD, PhD,
come” in health care. Satisfaction surveys have con- of the College of Physicians of Philadelphia50 :
sistently shown high satisfaction rates amongst chi-
ropractic patients. Cherkin and McCornack studied The Agency for Health Care Policy and Re-
457 back pain patients at a Washington HMO who had search (AHCPR) recently made history when it
visited either family physicians or chiropractors. They concluded that spinal manipulative therapy is
found that the percentage of chiropractic patients who the most effective and cost-effective treatment
were “very satisfied” with the care they received for for acute low-back pain. . . . One might con-
low-back pain was three times that of patients of fam- clude that for acute low-back pain not caused
ily physicians (66% vs. 22%), and that common rea- by fracture, tumor, infection, or the cauda
sons for higher satisfaction included more informa- equina syndrome, spinal manipulation is the
tion received about the back problems, the amount treatment of choice.
of time chiropractors spent listening to patients’ de- Because acute low-back pain is the most
scription of pain, the chiropractor’s acceptance that prevalent ailment and most frequent cause of
the pain was real, and confidence in both diagnosis disability for persons younger than 45 years
and effectiveness of treatment.47 of age in the United States, adherence to these
Despite this high level of satisfaction, utilization practice guidelines could substantially increase
rates for chiropractic services are very sensitive to the numbers of patients referred for spinal
cost, much more so than general medical and den- manipulation. Chiropractors provide 94% of
tal care. In the United States, Shekelle et al. have spinal manipulation.
shown that where the patient copayment is 25% of the As physicians are becoming increasingly
fee or greater, utilization of chiropractic services falls willing and able to justify referral for com-
by approximately 50%. When patients have similar plementary care . . . we must foster the
FIGURE 6–4. At the Texas Back In-

stitute in Dallas, which offers a full
range of conservative and surgical
treatments in one of the most so-
phisticated back-care facilities in the
United States, Dr. John Triano, one
of the staff chiropractors, presents
a case to staff physicians, sur-
geons, and physical therapists dur-
ing the regular interdisciplinary re-
view of interesting cases on weekend
rounds. (Reproduced with permission
from Chapman-Smith D. The chiroprac-
tic profession. Des Moines, IA: NCMIC
Group, 2000:139.)
development of training, research and clinical government and private third-party payors and man-
protocols to support integration . . . in a way aged care organizations to restrict funding for, and
that promotes favorable clinical outcomes. therefore access to, chiropractic services.
Alternative medicine can benefit from the For example, medical groups, working with mem-
kind of support from which mainstream bers and allies in the US Department of Health and
medicine has benefited over the years. When all Human Services and Blue Cross/Blue Shield, have
is said and done, what works will no longer be brought about a situation in which chiropractic ser-
called mainstream or complementary—it will vices under the federal government’s Medicare pro-
just be called good medicine. gram have primarily been delivered in recent years
by physical therapists, medical doctors, and doctors
These words, from an eminent US physician pub- of osteopathy. This situation gave rise to the pending
lished in the official journal of the American College lawsuit between the American Chiropractic Associa-
of Physicians, the Annals of Internal Medicine, illustrate tion and the Department of Health and Human Ser-
the major change that has occurred. The comments vices.
appear in an editorial regarding a study on the appro- A refreshing example of cooperation is found
priateness of chiropractic care appearing in the same in the United Kingdom where the British Medical
issue of the Annals. Association has been openly supportive of the de-
Today there are chiropractors on staff at the Asaf velopment and regulation of chiropractic services
Harofeh Hospital in Tel Aviv, Israel, the Kimberly since the 1993 publication of its study of comple-
Hospital in South Africa, the university hospitals in mentary medicine on the grounds that chiropractic
Bergen and Oslo, Norway, the Copenhagen Univer- is an established discipline and many British Medical
sity Hospital in Denmark, and in hospitals and multi- Association members wish to refer patients for chi-
disciplinary clinics throughout North America. Many ropractic care.51 There is also cooperation at the
chiropractic offices are located in health centers with international level, where principle seems to triumph
other primary care providers (Fig. 6–4). over practical politics more easily. The World Feder-
Significant barriers to the full integration of chi- ation of Neurology, the World Federation of Public
ropractic and medical services remain, but these are Health Associations, and the International Council
no longer the attitudes of individual medical doc- of Nurses all actively supported the World Federa-
tors in practice, education, and research. Instead, tion of Chiropractic during its 1997 admission into
they are barriers erected by medical associations, official relations with the World Health Organization
which, like chiropractic associations, are trade organi- and its affiliate, the Council of International Organi-
zations whose fundamental mission is to protect their sations of Medical Services (CIOMS). The World Fed-
profession and the economic interests of their eration of Neurology observed in its letter of sup-
members. These associations typically work with port that “the relationship between the medical and
chiropractic professions worldwide has become in- acknowledged that the future really depended upon
creasingly one of mutual respect and collaboration.”52 what chiropractors themselves wanted.
Almost 20 years later, in 1998, the Institute of Al-
ternative Futures (IAF) agreed. The IAF was commis-
FUTURE DIRECTIONS
sioned by the NCMIC Group, which provides profes-
The path to full integration of chiropractic services sional liability, managed care, and other services to
into mainstream health care remains a controversial the chiropractic profession, to provide expert reports
issue both within and outside the chiropractic pro- first, on the future of chiropractic, and second, on the
fession. Outside expert commentators have offered future of complementary and alternative approaches
consistent advice. In 1979, a New Zealand Commis- to health in the United States. The IAF identified three
sion of Inquiry into Chiropractic, which looked at the major priorities for the chiropractic profession:
profession more thoroughly than any independent in-
vestigation before or since, found that “chiropractic is 1. To define its role in the rapidly changing health
a branch of the healing arts specializing in the correc- care system. Are chiropractors spinal specialists,
tion by spinal manual therapy of what chiropractors primary care providers, partners with medicine
identify as biomechanical disorders of the spinal col- in mainstream health care, or holistic practition-
umn. They carry out spinal diagnosis and therapy at ers’ alternative to and separate from the medical
a sophisticated and refined level.”4 The Commission profession? The profession lacked a clear role in
concluded that “chiropractors do not provide an al- health care said the IAF, and a serious coordinated
ternative comprehensive system of health care, and effort from the grassroots up was necessary to
should not hold themselves out as doing so,” that “the correct the problem. Without a clear and agreed
responsibility for spinal manual therapy training . . . upon role, and a shared vision, the profession
should lie with the chiropractic profession,” and that would decline and suffer greatly in the near future
“in the public interest and in the interests of patients because of new competitive pressures.
there must be no impediment to full professional co- 2. To collect convincing data and practice statistics
operation between chiropractors and medical practi- from clinical practice. Currently such data only
tioners.” Chiropractic, said the Commission, should existed for the management of patients with back
be seen as an important specialized branch of main- pain, and to a lesser degree those with neck pain
stream health care services. and headache. There now needed to be a similar
In the following year, writing about the future effort in all significant areas of chiropractic
role of chiropractors in the first edition of this text, practice, including preventive care and health pro-
the eminent sociologist Walter Wardwell, PhD, saw motion.
three possible futures for the profession: (a) prac- 3. To develop the skills and capacities to work in
tice on medical referral, which he thought unlikely, many different health care environments. Major
(b) continuation of the alternative parallel status to changes lay ahead for everyone and the ability to
medicine that chiropractic had at that time, or (c) a be creative and integrate in various delivery sys-
more defined, limited primary contact status simi- tems would be key to the survival and growth of
lar to dentists, optometrists, podiatrists, and psychol- the profession.
ogists. As a long-time patient and observer of the
profession he considered the latter, based upon the The IAF described four possible scenarios for
conservative management of neuromusculoskeletal the US chiropractic profession in 2010, which are
disorders without the use of drugs or surgery, the best. summarized in Table 6–5. In scenario 1, excellent
Patients have delivered the same message. Sur- new outcomes data proves that chiropractic care is
veys consistently show that the great majority of chi- cost-effective and these services become available in
ropractic patients have neuromusculoskeletal disor- back centers, with greatly increased demand match-
ders, principally back pain, neck pain, and chronic ing an increased supply. In scenario 2, the profession
headaches. “These conditions are the kinds that the has no shared vision or good data beyond low-back
public believes that chiropractors can treat best,” says pain and has little room for growth. This results in a
Wardwell, and if the profession emphasized this iden- number of chiropractic colleges closing, and the pro-
tity, “medical opposition should cease, the public’s portion of spinal manipulation in the United States
image of chiropractors should improve, payments delivered by chiropractors dropping from 90% to
for services rendered should be more readily made, 50%.
the number of referrals to chiropractors by other In summary, the IAF’s reports are optimistic if the
types of practitioners should increase, and chiroprac- chiropractic profession can adapt to the challenges
tors should gain an even more secure place in the of the era, but sobering if it cannot. The future of
American health care system.” However, Wardwell chiropractic as a healing profession “will be shaped
TABLE 6–5. Overview of Four Scenarios for Chiropractic in 2010
Scenario 1: More and Better Health Care

Managed care, outcomes, and consumers drive health care. Chiropractic care is proven cost-effective for low-back pain,
headaches, neck pain, arthritis, scoliosis, asthma, and repetitive stress injuries, and as suplementary therapy for cancer and
other conditions where the disease or treatment involves significant pain. Wal-Mart creates ”The Back Center” in its stores and
expands access to low-cost chiropractic care. There are 103,000 chiropractors, with average visits per week holding at about
120, with back conditions representing 50% of visits and wellness another 20%. Underemployment among chiropractors holds
at about 15%,
Scenario 2: Hard Times, Frugal Health Care
Chiropractic is drastically affected by frugal universal coverage through managed care; outcomes limit manipulation to back
problems. Meanwhile, 50% of spinal manipulation is delivered by physicians, nurses, and other health professionals.
Chiropractic colleges close as only 68,000 chiropractors are needed in 2010. Many of those still practicing are forced to sell
“the $10 treatment.” Wellness visits decline and underemployment grows to 35%.
Scenario 3: Self-Care Rules
Very effective self-care, including advanced home health systems and universal catastrophic coverage, make health care a buyer’s
market. Individuals and families can do most of their care very effectively at home, lowering the need for all types of providers.
Surplus providers exceed the 450,000 number forecast in the 1990s by the Pew Commission. Health care professionals who
provide ”touch” are in high demand but competition is fierce. Chiropractors are able to increase demand significantly by
ensuring they provide care to 60% of those Americans with back problems (rather than 40% as in the 1990s). Chiropractors
also expand the indications they can treat with proven efficacy as well as provide evidence that for many people wellness visits
are appropriate. The success of chiropractors leads to 85,000 chiropractors in 2010 (about 20,000 fewer than anticipated in
1997), but they are doing well.
Scenario 4: The Transformation
Chiropractors’ clarified and expanded vision for the profession leads them to expand their contribution to health outcomes for
their patients and their communities. Wellness and self-healing through enabling the body to function effectively (the innate
healing force) becomes a much-sought-after contribution of chiropractors through manipulation—so sought-after that 50% of
manipulation in 2010 is performed by nonchiropractors. Chiropractors broaden what they do with and for their patients and
their communities. For their patients, they combine intelligent information systems with high touch and assertive coaching.
From Institute for Alternative Futures. Future of complementary and alternative approaches (CAAs) in US health care [unpublished monograph].
Alexandria, VA: Author, 1998.
by a host of forces” but the greatest of these is “the international chiropractic organizations. Founded
identity and creativity of chiropractors. . . . [T]he fu- in 1988 and having its offices in Toronto, Canada,
ture of chiropractic is in the hands of chiropractors the WFC’s voting membership consists of 78 na-
themselves.”53 tional associations of chiropractors. The WFC has
become the profession’s primary forum for de-
veloping a consistent basis for chiropractic prin-
SUMMARY
ciples, laws, scope of practice, and education in all
1. In the early twentieth century, students came to world regions. Other prominent organizations in-
the United States from Australia, New Zealand, clude the Fédération Internationale de Chiropra-
Europe, Japan, and South Africa, and then tique Sportive (FICS), the Foundation for Chiro-
returned to commence the development of the practic Education and Research (FCER), and the
profession in their countries. Today there are Council on Chiropractic Education International
approximately 100,000 chiropractors in more than (CCEI).
80 countries, and many new schools of chiroprac- 3. There is now legislation to recognize and regu-
tic. Since 1999 there have been more chiropractic late the profession in Africa (Namibia, Nigeria,
schools established outside the United States than South Africa, and Zimbabwe), the Asia-Pacific
within. Chiropractic legislation exists in all world region (Australia, Hong Kong–Peoples Republic
regions, and it is predicted that by 2010 there will of China, and New Zealand), the eastern
be 150,000 chiropractors, with 50,000 of them prac- Mediterranean (Cyprus, Iran, and Saudi Arabia),
ticing outside the United States. Europe (Belgium, Denmark, Finland, France,
2. The World Federation of Chiropractic (WFC) is Norway, Sweden, Switzerland, and the United
the largest and most widely recognized of the Kingdom), Latin America (Mexico and Panama),
and North America (Canada and the United upon and establish a much clearer identity in the
States). In all instances, legislation authorizes pri- health care system if their profession is to thrive
mary practice with the right and duty to diagnose, and realize its exciting potential.
including the right to provide or order diagnostic
imaging.
4. In North America, there is a minimum require- QUESTIONS
ment of 7 years of university-level training. All 1. What is the Association of Chiropractic Colleges’
aspects of education must meet official accredita- Paradigm of Chiropractic? Why was it adopted by
tion standards, and a graduate must also complete the World Federation of Chiropractic? What is its
state/provincial and national licensing board ex- current significance?
aminations before gaining the right to practice. In- 2. Describe and illustrate the roles of chiropractic
dependent government and medical studies in the professional associations at the state/provincial
United States,2 Sweden,3 and New Zealand4 have level, the national level, and the international
concluded that chiropractic education is the equiv- level.
alent of medical education in all of the basic sci- 3. A 1997 US government report concluded that “in
ences. the past several decades chiropractic has under-
5. The scientific literature base, and the research upon gone a remarkable transformation. . . . [I]n the ar-
which it is founded, has been vital to the continued eas of training, practice, and research, chiropractic
growth and status of the chiropractic profession. has emerged from the periphery of the healthcare
There has been a dramatic growth in the num- system and is playing an increasingly important
ber of chiropractic scientists worldwide with doc- role in discussion of healthcare policy.” Discuss.
toral degrees in the clinical and basic sciences and, 4. During the past 20 years others in the health
from them and others, the development of a ma- care system have labeled chiropractic as a ma-
ture chiropractic scientific literature base. The pri- jor discipline within complementary and alterna-
mary scientific databases relevant to chiropractic tive medicine (CAM). Discuss the advantages and
research include MANTIS (Manual, Alternative, disadvantages of this, and give your opinion on
and Natural Therapy Index System); the Index whether it has been beneficial for the profession.
to Chiropractic Literature (ICL) published by the 5. Why is a clear professional identity important for
Chiropractic Library Consortium (CLIBCON); the the future of the chiropractic profession? What
Cumulative Index to Nursing and Allied Health choices of identity are open to the profession?
Literature (CINAHL), which indexes over 1200 What do you think the profession’s identity should
nursing, allied health, and health sciences jour- be? Give reasons for your opinions.
nals, including chiropractic journals, from 1982;
Alt Health Watch; and the Allied and Complemen-
tary Medicine Database (AMED) compiled by the
ANSWERS
British Library Health Care Information Service.
6. Arguments that chiropractic services are not com- 1. The ACC Paradigm of Chiropractic is a series of
plementary or alternative, but rather part of main- statements describing the nature of chiropractic
stream and core health care services, are that they and its professional attributes. It was adopted by
are based upon the same anatomical, physiologi- the ACA, the ICA, and the World Federation of
cal, and scientific principles of Western medicine, Chiropractic, making it one of the foundation doc-
and employ treatment methods with proven ef- uments by which the professional organizations
ficacy, at least with respect to patients with back can agree to pursue common goals and objectives.
pain. Arguments that chiropractic is a CAM treat- Its significance for the WFC is that it provides a
ment flow from the traditional paradigm of chi- consistent basis upon which to develop the pro-
ropractic care, which is different from medical fession in countries that have not yet established
practice in that the underlying focus is upon vi- chiropractic.
talism, healing from within and influencing gen- 2. Each professional association deals with health in-
eral health through the correction of subluxation/ dustry issues, regulations, and legislation at its
spinal dysfunction to restore the normal regula- own level. In the United States, each state main-
tory functions of the nervous system. tains its own chiropractic law, and there are many
7. The future role of chiropractic is uncertain and its inconsistencies from state to state, necessitating a
identity internationally as yet not well defined. variety of approaches across states to support the
Chiropractic has been described as a profession profession. At the national level, the associations
that stands “at the crossroads of mainstream and take on larger roles related to national legislation,
alternative medicine.” Chiropractors must agree legal issues that have broad impact, and issues
related to public relations and image building. The to support the position, and develop the skills and
same is true with international organizations, but capacities to work in a variety of health care envi-
they tend to provide assistance and information ronments.
across international borders.
3. Until the latter part of the twentieth century, the
KEY REFERENCES
presence of chiropractic in scientific and policy
circles was relatively unseen. However, chiroprac- Bigos S, Bowyer O, Braen G, et al. Acute low back problems
tic educational institutions have significantly up- in adults. Clinical practice guideline no. 14. AHCPR Publi-
graded their programs and the profession has initi- cation No. 95–0642. Rockville, MD: Agency for Health
ated a number of scientific efforts that culminated, Care Policy and Research, Public Health Service, US De-
in the 1990s, with the advent of the first significant partment of Health and Human Services, 1994.
Chapman-Smith DA. Legislative approaches to the regula-
federal funding for research in the profession’s
tion of the chiropractic profession. J Can Chiropr Assoc
history. Today, many textbooks and scientific jour-
1996;40:108–114.
nals are being produced by the profession, and Chapman-Smith DA. The Chiropractic Profession, Chap. 9.
these have had significant impact on old medical West Des Moines, IA: NCMIC Group, 2000.
attitudes. The profession has tackled the challenge
of practice guideline development, leading to the
inclusion of chiropractic in many arenas in the REFERENCES
health industry. Collaboration and cooperation be- 1. Bigos SJ, Bowyer OR, Braen GR, Brown K, et al. Acute
tween chiropractors and other health professionals low back problems in adults. Rockville, MD: AHCPR,
have grown steadily. 1997 Feb. AHCPR Publication No. 97-N012.
4. In the 1990s, the CAM label was developed and 2. Cherkin DC, Mootz RD, eds. Chiropractic in the United
applied to a wide variety of health care practices States: Training, practice and research. AHCPR Publica-
that did not seem to fit within the standard, West- tion No. 98-N002. Rockville, MD: Agency for Health
ernized biomedical paradigm. As the largest and Care Policy and Research, Public Health Service, US
most successful of these professions, chiroprac- Department of Health and Human Services, 1997.
tic has been touted as a model of CAM profes- 3. Commission on Alternative Medicine, Social De-
partementete. Legitimization for Vissa Kiroprak-
sional development. Generally, CAM professions
torer [English summary]. Stockholm, Sweden: 1987:
and procedures have been seen as “unscientific,”
12–13–16.
even when there is solid factual evidence of util- 4. Hasselberg PD. Chiropractic in New Zealand, report of
ity for some procedures (as is the case with spinal the commission of inquiry. Wellington, New Zealand:
manipulation). The advantage of being included in Government Printer, 1979;130–131, 198.
CAM is that chiropractic has been able to capitalize 5. Jackson R. Foreword. In: Foreman SM, Croft CA.
on scientific funding opportunities and increase its Whiplash injuries: The cervical acceleration/deceleration
share of influence in CAM communities. The dis- syndrome. Baltimore, MD: Williams and Wilkins, 1988.
advantage is that the CAM label still positions chi- 6. Yochum TR, Rowe LJ. Essentials of skeletal radiology. Bal-
ropractic outside the mainstream of health care, timore, MD: Williams and Wilkins, 1996.
even though chiropractic has arguably become a 7. Book review. N Engl J Med 1996;334:1675.
8. Marchiori DM. Clinical imaging with skeletal, chest and
mainstream practice in many countries.
abdomen pattern differentials. St. Louis, MO: Mosby, 1999.
5. A clear professional identity is important to be able
9. Stude DE. Spinal rehabilitation. Stamford, CT: Appleton
to define and market chiropractic services and ben- and Lange, 1999.
efits to the public. It is also important to help focus 10. Bergmann T, Peterson D, Lawrence D. Chiropractic tech-
the resources and energies of the profession to sus- nique: Principles and procedures. New York: Churchill
tain its development in an efficient way. It is also Livingstone, 1993.
important to be able to communicate effectively 11. Byfield D. Chiropractic manipulative skills. Oxford:
and work with other health professions. There are Butterworth-Heinemann, 1996.
many identity choices, but the two major direc- 12. Bergmann TF, Davis PT. Mechanically assisted manual
tions are to integrate more fully with the rest of the techniques: Distraction procedures. St. Louis, MO: Mosby
health care industry or to remain as more indepen- Yearbook, 1998.
13. Hammer WI. Functional soft-tissue examination and treat-
dent (and perhaps more isolated) health care prac-
ment by manual methods: New perspectives, 2nd ed.
titioners. Arguments will continue about whether
Gaithersburg, MD: Aspen, 1999.
chiropractors should and can be spinal specialists, 14. Liebenson C, ed. Rehabilitation of the spine: A practi-
primary care providers focusing on the neuromus- tioner’s manual. Baltimore, MD: Williams and Wilkins,
culoskeletal system, or alternative providers. Re- 1996.
gardless of choice, the profession will need to come 15. Murphy DR. Conservative management of cervical spine
to a consensus on direction, collect convincing data syndromes. New York: McGraw-Hill, 1999.
16. Vernon H. The cranio-cervical syndrome: Mechanisms, 35. Redwood D. Chiropractic. In: McClosky MS, ed. Funda-
assessment and treatment. Oxford: Butterworth- mentals of complementary and alternative medicine, Chap.
Heinemann, 2001. 7. New York: Churchill Livingstone, 1996.
17. Lawrence DH, ed. Fundamentals of chiropractic diagnosis 36. Spitzer WO, Skovron ML, et al. Scientific mono-
and management. Baltimore, MD: Williams and Wilkins, graph of the Quebec task force on whiplash-associated
1991. disorders: Redefining whiplash and its management.
18. Souza TA. Differential diagnosis for the chiropractor: Pro- Spine 1995;20:8S.
tocols and algorithms. Gaithersburg, MD: Aspen, 1997. 37. Coulter ID, Hurwitz EL, et al. The appropriateness
19. Cramer GD, Darby SA. Basic and clinical anatomy of the of manipulation and mobilization of the cervical spine.
spine, spinal cord and CNS. St. Louis, MO: Mosby Year- Document No. MR-781-CR. Santa Monica, CA: RAND,
book, 1995. 1996.
20. Giles LGF, Singer KP, eds. Clinical anatomy and manage- 38. Aker PD, Gross AR, et al. Conservative management of
ment of low-back pain. Oxford: Butterworth-Heinemann, mechanical neck pain: Systematic overview and meta-
1997. analysis. BMJ 1996;313:1291–1296.
21. Vernon H. Upper cervical syndrome: Chiropractic diagno- 39. House of Lords Select Committee on Science and
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1998. Report. London: 2000.
22. Curl DD, ed. Chiropractic approach to head pain. 40. Lannoye Paul, Report on the status of nonconventional
Baltimore, MD: Williams and Wilkins, 1994. medicine. Committee on the Environment, Public
23. Anrig C, Plaugher G. Pediatric chiropractic. Baltimore, Health and Consumer Protection Complementary, Eu-
MD: Williams and Wilkins, 1997. ropean Parliament, 1997; #A4–0075/97.
24. Davies NJ. Chiropractic pediatrics: A clinical handbook. 41. WHO. Traditional Medicine Strategy 2002–2005,
New York: Churchill Livingstone, 2000. WHO, Geneva, Document WHO/EDM/TRM/2002.1.
25. Masarsky CS. Somatovisceral aspects of chiropractic: An 42. Eisenberg DM, David RB, et al. Trends in alter-
evidence-based approach. Philadelphia: Churchill Living- native medicine use in the United States. JAMA
stone, 2001. 1998;280:1569–1575.
26. Souza TA, ed. Sports injuries of the shoulder: Conservative 43. Astin JA. Why patients use alternative medicine: Re-
management. New York: Churchill Livingstone, 1994. sults of a national study. JAMA 98;279:1548–53.
27. Hyde TE, Gengenbach M, eds. Conservative management 44. Gautvig M, Hvird A. Chiropractic in Denmark.
of sports injuries. Baltimore, MD: Williams and Wilkins, Copenhagen: Danish Pro-Chiropractic Association,
1997. 1975.
28. Kirkaldy-Willis WH, ed. Managing low-back pain, 3rd 45. Chapman-Smith DA. The chiropractic profession, Chap.
ed. New York: Churchill Livingstone, 1992. 9. West Des Moines, IA: NCMIC Group, 2000.
29. Haldeman S, Chapman-Smith D, Petersen DM, eds. 46. Millar WJ. Use of alternative health care practitioners
Guidelines for chiropractic quality assurance and practice by Canadians. Can J Public Health 1997;155–158.
parameters: Proceedings of the Mercy Center Consensus 47. Cherkin DC, McCornack FA. Patient evaluations of
Conference. Gaithersburg, MD: Aspen Publishers, 1993. low-back pain care from family physicians and chiro-
30. Henderson DJ, Chapman-Smith DA, Mior S, Vernon practors. West J Med 1989;150:351–355.
H, eds. Clinical guidelines for chiropractic practice in 48. Shekelle PG, Rogers WH, Newhouse JP. The effect of
Canada. J Can Chiropr Assoc 1994;38(1 suppl). cost sharing on the use of chiropractic services. Med
31. Waddell G, Feder G, et al. Low-back pain evidence review. Care 1996;34:863–872.
London: Royal College of General Practitioners, 1996. 49. Scheurmier N, Breen AC. A pilot study of the pur-
32. Bigos S, Bowyer O, Braen G, et al. Acute low back prob- chase of manipulation services for acute low-back pain
lems in adults. Clinical practice guideline no. 14. AHCPR in the United Kingdom. J Manipulative Physiol Ther
Publication No. 95–0642. Rockville, MD: Agency for 1998;21:14–18.
Health Care Policy and Research, Public Health Ser- 50. Micozzi MS. Complementary care: When is it appropri-
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33. Manniche C, et al. Low-back pain: Frequency management 51. British Medical Association. Complementary medicine,
and prevention from an HDA perspective. Danish Health new approaches to good practice. Oxford: Oxford Univer-
Technology Assessment 1999;1(1). sity Press, 1993.
34. Accident Rehabilitation and Compensation Insur- 52. Letter dated 17 September 1996 from the World Feder-
ance Corporation of New Zealand and the National ation of Neurology to the CIOMS.
Health Committee. New Zealand acute low-back pain 53. Institute for Alternative Futures. Future of complemen-
guide, and guide to assessing psychosocial yellow flags in tary and alternative approaches (CAAs) in US health care
acute low-back pain. Wellington, New Zealand: Authors, [unpublished monograph]. Alexandria, VA: Author,
1997. 1998.
C H A P T E R
7
INTEGRATION OF CHIROPRACTIC
IN HEALTH CARE
William C. Meeker and Robert D. Mootz
O U T L I N E
INTRODUCTION Multidisciplinary Practice
EVOLUTION OF CHIROPRACTIC Interdisciplinary Practice
INTEGRATION: CAM AND INTEGRATIVE Chiropractic Perspective
MEDICINE Medical Perspective
MODELS FOR INTEGRATION IN THE HEALTH Public and Private Payor and Policy Level
SYSTEM Basic Payor Concepts and Integration
Chiropractic Roles The Position of Chiropractic
Patient Level CHALLENGES TO INTEGRATION
Practitioner and Clinical Level SUMMARY
A Model for Clinical Integration QUESTIONS
Parallel Practice ANSWERS
Collaborative Practice KEY REFERENCES
Consultative Practice REFERENCES
Coordinated Practice
sum of its parts. When discussing the integration of

OBJECTIVES chiropractic into the health care system, one must con-
1. To briefly discuss complementary and alternative sider what this integration means to the profession
medicine (CAM) and integrative medicine and and practice of chiropractic, why it must be discussed,
how chiropractic may relate to each model. and what the implications could be. As will be seen,
2. To describe the current position of chiropractic, the full integration of chiropractic into the health care
discuss the three main factors of integration, and system is complex and answers to these questions are
offer three potential roles for chiropractors in the not clear.
health care system. Chiropractic is constantly striving to attain higher
3. To define various types of integrated clinical be- levels of cultural authority, respect, and influence, not
havior between practitioners. just as a matter of survival, but as a matter of profes-
4. To discuss some barriers to full health system in- sional flourishing consistent with its ideals and goals.
tegration for chiropractic. At the same time, chiropractors have struggled might-
ily with fears of coaptation and loss, fearful that a
stronger alliance with other health professions and
structures would lead to the dilution and eventual
INTRODUCTION
elimination of the profession’s unique approach to
Integration is defined as the act of combining some- health. The ambiguity of this situation and the many
thing into an integral whole, with the implication that reasons for and against integration have led to bit-
the whole functions smoothly and is greater than the ter battles within the profession. An open discussion
135
of this topic will hopefully contribute to the genesis without a license, whereas today, chiropractic
of creative solutions, both short- and long-term. This education is accredited by the US Department of Edu-
chapter illustrates a scheme of integration at three lev- cation and students can receive federally guaranteed
els, each with its own attributes and interrelations. loans to attend chiropractic training institutions. A
An additional model for clinical integration is also paper on chiropractic written by chiropractors was
described. Throughout the following paragraphs, the recently published in the Annals of Internal Medicine,
position of chiropractic is defined and trends sug- one of the most influential scientific biomedical jour-
gested by data and observation are offered. Future nals in the world, making the case that chiropractic
chiropractors will be able to use the understanding is now at the crossroads between mainstream and al-
gleaned from this data to help define their own goals ternative medicine.8 The amount and quality of chiro-
and roles regarding integration, and to inform the di- practic research have also been growing steadily for
alogue that surely must continue. the past 15–20 years. From the vantage point of many
CAM professionals, these accomplishments place chi-
ropractic within the mainstream health care.
EVOLUTION OF CHIROPRACTIC
Yet, despite this apparent progress, some still
Other chapters in this book discuss the history of chi- perceive chiropractic as a controversial profession
ropractic and its struggle for survival and acceptance with controversial ideas and practices. Simply being
in a relatively hostile environment. The road to ac- identified as a CAM practice is an indication of the un-
ceptance has not been smooth, yet today chiropractic certainty that the dominant biomedical system still en-
is the largest, most regulated, and best recognized of tertains about the validity and effectiveness of chiro-
the alternative health professions. Although in exis- practic. Critics are quick to pounce on the profession’s
tence for more than a century, it is only in the past slow pace of scientific development regarding chiro-
decade or two that chiropractic has been placed by practic theory and spinal manipulation, and some ob-
many observers under the umbrella of complemen- servers question the role, value, and even safety of
tary and alternative medicine (CAM).1 The definition chiropractic care.9 Chiropractors are only rarely rep-
of CAM has been very problematic and no one defi- resented in formulating health policy and have only
nition is universally accepted. The US National Cen- recently been included in positions of scientific and
ter for Complementary and Alternative Medicine has clinical authority. For example, only one employee
defined CAM as, “health care practices outside the of the $25 billion US National Institutes of Health
realm of conventional medicine, which are yet to be is a chiropractor. From the vantage point of many
validated using scientific methods.”2 CAM is repre- within the conventional medical system, chiropractic
sented by a very diverse collection of professions with remains largely outside of the mainstream.
unique philosophies, traditions, procedures, profes- Total integration in the health care system is a
sional attributes, histories, and patients.3,4 Not all chi- multifaceted enterprise. One way to understand the
ropractors like the CAM label because of the implicit current position of chiropractic is to examine poten-
lack of research validation, which is no longer true for tial roles for its practitioners, and gauge the perspec-
conditions such as low back and neck pain. Many chi- tive of different stakeholders, such as the patient, the
ropractic leaders worry about their profession being chiropractor, the medical profession, public and pri-
lumped together with a very heterogeneous group of vate payors, and policy makers.
diverse and highly controversial practices.5 Neverthe-
less, the ongoing public debate about whether and
INTEGRATION: CAM AND INTEGRATIVE
how to integrate CAM into mainstream medicine also
MEDICINE
applies to chiropractic.
Chiropractic does appear to be in a different posi- To understand integration better, a distinction must be
tion than many CAM professions such as acupunc- made between procedures, professions, and philoso-
ture, homeopathy, massage, and naturopathy by phies. Adoption of new procedures and substances
virtue of being the most widely disseminated and (e.g., drugs) into medicine is a well-known path. Al-
licensed indigenous healing system in the United though not as logical and straightforward as assumed,
States and with growing international recognition (see the ideal process follows a given sequence. That is,
Chapter 6). In the past 30 years, the profession has en- scientific evidence is accumulated on both the mech-
joyed steadily increasing acceptance and use by the anism and clinical effect of a novel procedure or
public and third-party payors.6 Walter Wardwell, a so- substance, information is disseminated in scientific
ciologist who researched chiropractic, once described journals and discussed by experts at professional
it as “marginal” and “deviant.”7 In the not too distant meetings, and gradually (and sometimes very
past, chiropractors were jailed for practicing medicine quickly) the new procedure or substance is adopted
INTEGRATION OF CHIROPRACTIC IN HEALTH CARE 137
by practitioners. Rarely is this process called integra-

MODELS FOR INTEGRATION IN THE
tion. Instead, it is called innovation. This distinction is
HEALTH SYSTEM
puzzling because it seems to exclude CAM from the
process. For example, when a medical physician pre- To provide a context for understanding the various
scribes St. John’s wort instead of Prozac for mild de- perspectives involved in the discussion of the integra-
pression, this is referred to as integration rather than tion of chiropractic into the health care system, three
innovation. Is this because of the origin of the innova- levels of integration are offered, each demonstrating
tion, or is it something else? challenges as well as opportunities. These potential
This distinction may occur when the innovation is levels of integration in the health system are (a) the
pulled out of context from a wholly separate method patient level, (b) the practitioner or clinical level, and
of healing. For example, although a homeopathic rem- (c) the public and private payor and policy level. Each
edy may be prescribed by a medical physician, is it level is described below. The practitioner or clinical
fair to administer this remedy outside of the practice level is further explored using a model of interdis-
of homeopathy? Or more to this chapter’s point, can ciplinary behavior to describe the different ways in
spinal manipulation simply be adopted by conven- which practitioners can interact with one another.
tional medicine and declared an innovation? Perhaps,
because the use of spinal manipulation is growing Chiropractic Roles
in other professions. However, the viewpoint of this At least three distinct, but not mutually exclusive,
chapter is that the concept of integration should be roles for chiropractors have received discussion in the
reserved for the appropriate union of different health chiropractic literature7,14,15 :
practitioners and different health philosophies, and
not simply the use of CAM procedures by the medical 1. As generalist primary care providers focusing on
profession. neuromusculoskeletal conditions and prevention
The most interesting discussions regarding health 2. As musculoskeletal and spine specialists working
system integration are now going on in the context of in a multidisciplinary fashion
CAM.10,11 The term integrative medicine was coined 3. As generalist providers of an alternative to med-
by Ralph Snyderman and Andrew Weil to denote ical care focusing on subluxation, and/or using a
more than the simple use of CAM procedures by variety of CAM and conventional methods
medical practitioners.12 Integrative medicine aims to
restore the focus of medical practice on health and Chiropractors have many of the attributes of pri-
healing and to emphasize the central role of the mary care providers and often describe themselves as
patient–practitioner relationship and activating the such.16 Others point out that chiropractic has more
body’s innate healing power. Integrative medicine of the attributes of a limited medical profession, akin
promotes using both conventional medical care and to dentistry or podiatry.7 This issue is a great source
adopting some CAM concepts, such as prevention, of debate within the profession. It has implications for
which includes all aspects of lifestyle, diet, exercise, educational direction and professional policy making.
and emotional and spiritual health. It purports to re- Furthermore, the way in which each role is viewed
align medical care with the patient as the focal point outside the profession influences the extent and nature
and encourages the use of scientifically proven CAM of integration. Finally, what role chiropractors should
methods. A reason offered for the phenomenal growth or could play in the health delivery system is subject
of CAM is a perception that mainstream medicine has to several different perspectives within the system.
lost some of its caring and humanitarian roots. With
integrative medicine, it is thought that adoption and Patient Level
assimilation of CAM will heal the shortcomings of The first level to consider is the patient or health con-
modern conventional medicine by essentially giving it sumer. At this level, integration decisions are made by
a new paradigm.13 Unfortunately for the CAM profes- patients, and not by practitioners or third-party pay-
sions, it is clear that those who propose to take charge ors. Patients are clearly the most potent integrators
of integrative medicine are medical physicians.12 in the health delivery system today. Patients decide
An alternative to this scenario is to hire CAM prac- what combination of care they need regardless of the
titioners to work in conventional medical settings (and constraints, incentives, and controls placed on health
vice versa) under various forms of multidisciplinary care consumption by health plans, insurance compa-
and interdisciplinary practice, thus ensuring that panies, and government programs. While the policies
tients receive the best of both worlds and that each and procedures of the reimbursement system may en-
system of healing is preserved and practiced by those hance or constrain use of certain health services, some
with appropriate training. patients are still willing to find what they want and
pay for it themselves if deemed necessary. From this by practitioners. Integration happens when clinical
point of view, market dynamics prevail and demand decisions include more than one practitioner in the
leads to supply. best interest of the patient. This level is highly influ-
Long-time observers have noticed that modern enced by the attitudes of both chiropractors and med-
attitudes regarding health practitioners do not in- ical physicians, and when these attitudes are not in
clude the overwhelming respect and deference once alignment, integration is not likely to occur. This has
accorded them. In these times, some patients exer- been the state of affairs for much of the past century,
cise their own judgment and take personal respon- but both medical and chiropractic practitioners seem
sibility for their health. They peruse the Internet for to be willing to shift to a more cooperative mode. The
medical information and ask for second opinions. ideal integration scenario at the clinical level involves
Patients are not likely to tell their medical doctors mutual respect and understanding of the role of each
about their consultations with CAM practitioners be- profession in case management. A high premium is
cause they view their medical doctor as just one placed on strong communication and teamwork in
more member of a larger health care team, and no this model of integration.
longer the sole provider. Users of both CAM and con-
ventional medicine are equally confident with their A Model for Clinical Integration
practitioners.17 Ivey31 has presented a useful model to describe the va-
Chiropractic is very well integrated in the every- riety of collaborative relationships and behaviors that
day health care decisions of a large number of peo- can exist among health care practitioners in clinical
ple. Approximately 65,000 chiropractors in the United settings. It ranges on a continuum from individual
States see approximately 20 million patients per year.8 “parallel practice” to the formalized “interdisci-
Chiropractors are used more often than any other plinary health care team” (Fig. 7–1). Generally speak-
so-called CAM provider group, at approximately ing, as the complexity of a patient’s problem increases,
192 million patient visits per year, representing 30% of so does the need for collaboration with other health
all visits to all CAM practitioners and equal to almost practitioners. Additional knowledge, skills, and ex-
50% of all visits to primary care medical physicians perience brought by other practitioners, both conven-
in the United States.18 Utilization by the public has tional and CAM, are often necessary to provide the
tripled in the past two decades from approximately best possible care for a patient. However, as collabo-
3.6% in a 1980 survey19 to an estimated 11%, accord- ration and the need for team-like behavior increases,
ing to a national telephone survey in 1997.18 professional autonomy decreases. While developed to
Musculoskeletal pain is a common and impor- help train allied health professionals in multiprofes-
tant public health problem that has not generally sional settings, Ivey’s model can also apply to various
received much attention from traditional medical forms of chiropractic clinical integration.
practitioners,20 and chiropractors are apparently fill-
ing this void when treating these conditions. Patients Parallel practice is the traditional and
Parallel Practice
go to chiropractors overwhelmingly for muscu- most common form of health care practice, and char-
loskeletal complaints, primarily back pain (ap- acterizes most of chiropractic practice today. In this
proximately 60%) and head, neck, and extrem- model, each practitioner is an autonomous decision
ity problems.21,22 At least one-third of all patients maker, managing the majority of patients without a
seeking care for low back pain first consult with a great deal of input or communication from a profes-
chiropractor.23–25 Patients also seek chiropractic care sional colleague or organization. Each practice op-
for general health concerns and prevention.26 Multi- erates in parallel with similar practices, with little
ple studies have documented that patients are more collaboration most of the time. Each practitioner has a
satisfied with chiropractic care than medical care for
spinal conditions.16,27–29
Professional autonomy decreases
In summary, patients have direct access to licensed Shared expertise increases
chiropractors in the United States and are willing to
pay a great deal out of their own pocket to receive Parallel Consultation Multidisciplinary
chiropractic care.30 Acceptance at this grassroots level Practice Practice
is one of chiropractic’s major strengths.
Practitioner and Clinical Level Collaboration Coordination Interdisciplinary

Health Care Team
Integration at the practitioner level has complexities
of its own, and has much to do with the way in FIGURE 7–1. A model demonstrating a continuum of relation-
which delivery systems are organized and financed. ships among practitioners that helps define integration at the
At this level, integration decisions are made primarily clinical decision-making level.
clearly defined role, at least as perceived by the pub- that all practitioner-to-practitioner and practitioner-
lic, and patients choose their own providers. In this to-patient decisions and communications take place
model, practitioners rarely share their expertise with in a prescribed, timely, and documented fashion (al-
one another and in fact compete with each other for though informal discussions are common, too). This
patients in the marketplace. When parallel practice type of practice is generally expensive and compli-
prevails, patients integrate their own health care, and cated, and is generally only seen in large tertiary care
may not even tell their doctors about other profession- settings dealing with the most difficult and chronic
als they may be seeing, even when receiving care by cases.
multiple practitioners for the same condition.17
Multidisciplinary PracticeThe term multidisciplinary is
Collaborative Practice Collaborative practice is initi- often used loosely to refer to any kind of collaboration
ated when a health practitioner recognizes the need between members of two or more health professions.
to seek additional expertise. This behavior is mainly It is also often used interchangeably with interdisci-
characterized by making a patient referral to a col- plinary, but these two concepts are different. Formal
league, often a specialist. Patient referrals can be made multidisciplinary practice involves all levels of collab-
on a formal or informal basis, and may or may not re- oration, consultation, and coordination, and is usually
quire some kind of reciprocal documentation. How- managed by a leader, most often a medical physician.
ever, proper referral protocol generally requires the Members of multidisciplinary teams do not necessar-
sharing of patient information and case management ily meet together. Instead, patients are referred serially
plans.32 The decision to collaborate is generally taken from one specialist to another all of whom report to
case-by-case and leaves a great deal of professional the leader who makes most case-management deci-
autonomy intact. Additionally, practitioners may call sions and has ultimate authority for the care. In multi-
on their colleagues to give advice, but retain primary disciplinary settings, clinical integration requires that
decision-making authority. For example, a chiroprac- clinical care pathways and triage protocols be devel-
tor may refer a patient to a medical radiologist for oped. Assigned roles are affected by business reali-
magnetic resonance imaging (MRI), but the chiroprac- ties, competition, personalities, and staff availability.
tor will retain the patient’s case management. Integra- Which practitioner a patient sees is usually based on
tion at this level begins to be driven by health care scientific evidence, patient preference, provider exper-
practitioners rather than patients, although patients tise, and provider desire. As a result, there are many
often have a say in the referral decision. Although forms of multidisciplinary practices in existence to-
at times there is concern about the potential for self- day.
interest in this process, especially when there is a fi-
nancial association between practitioners, when done True interdisciplinary practice
Interdisciplinary Practice
for appropriate clinical reasons, the patient is better is rare. It involves a very high level of all forms of
served by this integrative behavior. collaboration, consultation, and coordination, and is
especially characterized by the development of a con-
Consultative Practice Consultative practice is a higher sensus about what to do, usually via group meetings.
order of collaboration in which two or more health Care pathways and treatment algorithms are explicit
professionals work together in a more extensive and and formal. A very high value is placed on mutual
ongoing fashion relative to the care of a patient. Con- goals, teamwork, and mutual respect. Shared exper-
sultation involves the giving and taking of expert ad- tise is maximized while individual professional au-
vice in a collegial and professional manner. The rela- tonomy is minimized. Activities around case manage-
tionship can also be formal or informal. In this model, ment are organized, logical, and efficient.
practitioners respect an agreed-upon division of ex-
pertise and work as a team. Practically speaking, this Chiropractic Perspective As a group, chiropractors are
kind of clinical behavior is most often found in multi- torn between wanting to be a more integral part of
professional settings where complex and chronic cases the health delivery team and being afraid of the im-
are routine. The integration of health care profession- plications of such integration. A history of unfair
als and procedures is primarily driven by practitioners medical ostracism and persecution has made chiro-
at this level and rarely by patients. practors extremely protective of their independence
and autonomy. Until 1980, the American Medical
Coordinated Practice Coordinated practice consists of Association maintained that it was unethical for a
a more formalized system of consultation and de- medical physician to associate or refer to a chiroprac-
cision making and often includes a management tor. As a result, chiropractors successfully developed
function (e.g., a case manager). The case manager loyal patient bases outside of conventional health care
(or case coordinator) is responsible for ensuring circles, and played a primary care role for some of
their patients. Referral and other forms of collabora- commission developing these guidelines and made
tion were, until recently, relatively rare. In relationship significant contributions to the discussion. When
to medical practitioners and even fellow chiroprac- chiropractors simultaneously began publishing their
tors, parallel practice prevailed. On the other hand, own practice parameters,43 this was a tremendous
largely as a result of changing medical attitudes, a boost to the credibility of chiropractic in wider health
significant number of chiropractors now enjoy prac- care circles.
tices that are increasingly based on medical referrals; Today, while it is encouraging for patients to re-
an additional number of chiropractors are working in alize that their medical and chiropractic practitioners
multidisciplinary settings.33,34 are developing better relations, some surveys37,44 in-
dicate that significant barriers still exist between the
Medical Perspective Astin,35 in a recent summary of two professions. Another recent survey of US chiro-
other surveys, indicated that chiropractic was one of practors reported that less than 5% practice in mul-
the most accepted forms of complementary and al- tidisciplinary settings.21 Perhaps of greater interest is
ternative medicine. Gordon,36 in a survey of medi- that a survey of leading CAM clinics, especially those
cal physicians in a large HMO, found that a majority in medical environments, shows that less than half in-
wanted chiropractic to be available to their patients. clude chiropractors as CAM providers.45 Other health
Patient referrals between chiropractors and medical professionals also tend to see chiropractors mostly in
physicians may be larger than many realize. A sur- the limited role of a back specialist and are uncom-
vey of family physicians and chiropractors in North fortable with suggested primary care roles.37
Carolina found that two-thirds of the physicians felt
at least moderately informed about chiropractic, and Public and Private Payor and Policy Level
that 65% had referred patients to chiropractors.37 In Regardless of how patients, chiropractors, and med-
the same survey, 98% of chiropractors had referred ical physicians view the role of chiropractic within
patients to medical physicians. Berman38 found that the health care system, the group with the greatest
49% of East Coast family practice physicians consid- leverage is comprised of public and private organi-
ered chiropractic a “legitimate medical practice.” zations and institutions that deal with the business
There is little doubt that research on spinal ma- of delivering and financing health care. The cost of
nipulation has contributed significantly to a better health care in the United States is borne by one, or a
opinion of chiropractic by medical physicians, espe- combination of, three sources: individuals, the gov-
cially among those who deal with back and neck pain. ernment (such as Medicare), and private companies
Chiropractic research has evolved significantly over (e.g., health insurance companies, employee health
the past quarter century, and has demonstrated that plans). Delivery structures that combine both financ-
collaboration with the mainstream scientific commu- ing and health care services run the gamut from HMOs
nity is effective.39 Spinal manipulation, the treatment to various forms of preferred provider organizations
procedure most identified with chiropractic, has been (PPOs), independent practice associations (IPAs), and
subjected to more than 70 randomized clinical tri- others. The delivery and financing systems are in a
als and many more additional studies with gener- constant state of flux for a variety of complex social
ally positive results.8 Many nations have created clin- and economic reasons. While the “insurer” or “health
ical guidelines for back pain, and most have included plan” is sometimes perceived as a special interest con-
spinal manipulation as an evidence-based treatment cerned only with minimizing cost of care, other issues
option.40 Multidisciplinary organizations, such as the (not to mention bureaucratic inertia) are involved.
North American Spine Society and the American Back Major integration decisions can occur at the public and
Society, have included chiropractors since the early private payor and policy level because of its political
1980s. The Chiropractic Healthcare Section is now part and economic power. This level is highly interactive
of the American Public Health Association, and chi- with both previous levels because payment and de-
ropractors have been elected to its governing council livery systems have a large influence on practitioner
for at least a decade.41 and patient behavior.
The ultimate example of the power of research cul-
minated in 1994 with the publication of clinical care Basic Payor Concepts and Integration
guidelines for acute low back pain by the US Agency Essentially, the decision to integrate a service, such as
for Health Care Policy and Research (now AHQR).42 chiropractic, into a health plan involves many ques-
While chiropractic was not specifically mentioned in tions, such as: Is the service effective? Does it have a
these guidelines, spinal manipulation received the solid evidence base? Can it be administered? Are there
highest rating for evidence (a “B”) and was en- clear thresholds for what is or is not covered under the
dorsed by the federal government as a treatment for plan? Is there consumer demand for the benefit? Will
low back pain. Chiropractors were appointed to the having it sell more policies or bring more members
into the plan? Does inclusion make business sense? Is preferences, product innovation by carriers, and
inclusion economically viable? consumer demand. Jensen49 suggested that most
Indemnity-based insurance only makes economic employer-sponsored health plans routinely include a
sense when the chance of needing a service is very low, chiropractic benefit, even in the absence of “insurance
and the cost of the service is beyond most people’s equality” mandates. However, conventional medical
means.46 For example, for an infrequent event such as and chiropractic cultures do not default to inclusion,
a car accident or a heart attack, experienced by only or even coreferral.50 As regulatory mandates have
a small number of people at any single point in time, forced conventional insurers to address various spec-
it makes sense to have large number of people con- ified benefits such as chiropractic and CAM coverage,
tribute to a pool of money to cover these costs for the the industry has responded with a variety of less-than-
few who receive them. This is the basic principle be- optimal solutions. For example, “dollar cap” benefits
hind insurance. However, it does not make economic usually allow a defined amount of coverage to be ap-
sense to cover a service that many people routinely plied to chiropractic services. Condition-based cover-
use, even if it is beneficial. For example, health insur- age tries to make allowances for specific patient di-
ance companies would go broke paying for private agnoses. Gatekeeper methods assign a primary care
chefs cooking healthy, low-fat, low-sodium meals for provider to oversee, coordinate, and allocate special-
their policyholders, even if this proposition has health ist or nonroutine care. Open access models, where
benefits. Thus, health benefit inclusion decisions are patients self-refer within their plan, are the polar op-
based on the incidence of conditions, and not on the posite of gatekeeper approaches and rely on strong
basis of health maintenance or prevention. care coordination and quality oversight in order to
For similar reasons, administrative oversight of work well.
health plans for appropriateness and quality requires In any of these approaches, a plan may contract
that clear, predictable, and accountable methods ex- with a network of providers to control quality and
ist to determine when services should be covered. costs. Many “innovations” have evolved whereby de-
Care pathways and treatment guidelines are the usual livery of benefits can be provided in parallel to the
methods used to convey appropriateness. The logis- basic or core benefits package. When providers of ser-
tics of integrating chiropractic into conventional med- vice do not have a common culture, the path of least
ical settings requires a definition of the role that chi- resistance for the plan to meet consumer demand (or
ropractic will play in specific patient scenarios. In a regulation) is to cover the service by making it self-
the current era of accountability and competition for funding. This can be done by setting aside the differ-
health care dollars, clear articulation of where and ence between the basic premium and that collected
when chiropractic fits is critical. The idea that a full from the extra fee (“a rider”) for the service. This is
cadre of providers is going to evaluate and treat every not infrequent for optometric or chiropractic benefits.
patient is unrealistic. Instead, triage and referral proto- Entirely separate plans may also be written, as is com-
cols will need to be developed.47 This may be difficult mon for dental coverage.
for some chiropractors to accept given their tradition One must understand these intricacies to under-
of autonomy and independent decision making. Fur- stand that just because a service (e.g., chiropractic)
thermore, appropriateness refers not only to what is may be paid for (covered) under the purview of a
clinically appropriate for the patient, but also with re- conventional health reimbursement plan or delivery
gard to the business contract between the health plan system, it may not be subject to any form of clinical
and the purchasers. For example, arguments for pre- integration in the actual delivery of care to a patient.
ventive care, however rational they may be, may not In other words, while the health plan may cover both
justify the use of a premium payor’s dollars under a chiropractic and conventional medicine, thus making
specific insurance contract. the plan nominally integrated, clinical integration at
Another issue that impacts integration relates to the practitioner level is completely sidestepped.
professional liability. Providers who practice together
and develop explicit patient flow protocols may share The Position of Chiropractic
each other’s legal liability for malpractice and negli- Historically, chiropractors have not been included in
gence. Hence, chiropractors seeking to work in a mul- health insurance systems because of professional iso-
tidisciplinary spine center may be subject to higher lation and other factors, which have already been de-
malpractice premiums, and medical physicians work- scribed, thus limiting their leverage when changes in
ing with CAM practitioners may worry about their the systems occur. Nevertheless, encouraging trends
shared liability.48 have emerged. It is quite clear now that CAM expen-
The issue of integration is further complicated by ditures in the United States represent a large economic
how insurance and health plan “products” evolve acc- market, estimated at $35–$50 billion per year.11 Chi-
ording to different state regulations, community ropractic probably accounts for close to $10 billion in
third-party reimbursements, plus an additional $10– means more administrative hassle, less autonomy, and
$15 billion in out-of-pocket expenses paid directly by reduced fees than with private-pay patients. Nev-
patients to chiropractors. The size of this market has ertheless, a final encouraging observation can be
not gone unnoticed by those interested in such mat- made. Attitudes, policies, and procedures regarding
ters, and it is easy to make an economic case for inte- chiropractic are no longer monolithic across health-
grating chiropractic services.51 delivery organizations. There is a plurality of diverse
A study completed in 1996 indicated that chiro- approaches, each with potential opportunities and pit-
practic care was routinely reimbursed for Medicare falls for chiropractors that must be examined on a case-
patients, as well as for injured workers, in the United by-case basis.
States. At least 75% of insurance plans and 50% of
health maintenance organizations covered chiroprac-
CHALLENGES TO INTEGRATION
tic services at least to some extent.49 The proportion
of HMOs offering chiropractic may now have reached Additional research is needed to ascertain how differ-
65%.11 Another recent survey also indicated that sig- ent forms of practice, such as collaborative and consul-
nificant gains have been made by CAM in the man- tative practices, can lend themselves to enhanced com-
aged care and insurance industries, and concluded munication between providers. Chiropractic seems
that it is largely a result of huge public demand and well-integrated from the patient perspective, and in-
the desire to be competitive with other organizations. creasingly so at the payor and delivery system levels.
Additional factors include potential cost-effectiveness However, as a consequence of the way in which these
and savings, client satisfaction, and whether or not systems are organized, chiropractic may continue to
research exists indicating clinical effectiveness of the operate only in the parallel and collaborative practice
CAM.52 models. True consultative and coordinated multidis-
The federal government is also beginning to recog- ciplinary and interdisciplinary practices may not be
nize the impact of chiropractic and CAM. Following easily obtained, and patients that could benefit from
the 1994 release of its guidelines for acute low back chiropractic care may not receive it.
pain, the Agency for Health Care Policy and Research There are significant challenges to interdisci-
(AHCPR) commissioned a monograph on the chiro- plinary practice within the current health-delivery
practic profession. Compiled and edited by a multi- system for medical practitioners and chiropractors
disciplinary team of authors, this work is a landmark, that represent special challenges inherent in differ-
representing the recognition and presence of chiro- ent philosophical discipline, “turf” battles, nonstan-
practic in the US health-delivery system.53 Recently, dard practices, administrative and other resistances to
Congress caused the White House Commission on change, history of conflict, habit, lack of experience,
Complementary and Alternative Medicine Policy to and knowledge. Although it is tempting to simply
be formed, which has now made recommendations add a few procedures from another discipline (either
regarding the coordination of CAM research, CAM chiropractic or medical) and call that integration, this
education and training, provision of information re- should be resisted. True integration will only come
garding CAM to health professionals, and appropriate when there is a sense of common goals, agreed-upon
access to and delivery of CAM for the public.54 After roles, and a common process to arrive at these goals.
years of hard negotiating and direct intervention by In addition to policy and procedural barriers, indi-
the US Congress, chiropractic care is finally being of- vidual barriers to integration exist. Integrative clinical
fered to military personnel and veterans.55 behavior requires that professionals be both willing
In summary, although most chiropractors cur- and able to work together in caring for patients. Both
rently benefit from being included in a greater range attributes are not easy to acquire, and having one does
of insurance and other types of health care reimburse- not necessarily lead to the other. All health professions
ment plans than ever before, the advent of managed tend to attract intelligent and strong-willed individu-
care has not been a boon to this phenomenon. One als whose natural proclivities for autonomy, authority,
could argue that attitudes have changed and that the and individual success are enhanced by their train-
overall market for chiropractic appears to be expanding. Interdependency and team decision making have
ing. It is also true that additional restrictions on re- not generally been stressed in their education. Chiro-
imbursable services have hampered the economic vi- practic institutions have not traditionally taught stu-
ability of many individual chiropractors. There are dents how to interact with other health professionals;
still significant barriers to what most would call a the converse is also true. Differences in terminol-
level playing field. Many chiropractors wonder how ogy, philosophy, knowledge, experience, and creden-
they will benefit by being more fully integrated in tials all serve as barriers to effective communication.
the health care system when integration generally When elements of market competition, professional
chauvinism, and fear of the unknown are considered, enterprise that involves the combining of sepa-
the challenge of integration seems forbidding indeed. rate practices and health disciplines at three levels
In fact, finding a way to overcome these personal bar- of consideration: the patient, the practitioner, and
riers to integrative care is one of the most challeng- the payor and delivery systems. Three potential
ing aspects of improving the quality of health care roles that have been described for chiropractors are
worldwide. (a) as generalist primary care providers focusing
Finally, from an overarching sociologic view of po- on neuromusculoskeletal conditions and preven-
litical and economic professional clout, chiropractic tion; (b) as musculoskeletal and spine specialists
should consider its cultural authority to improve its in a multidisciplinary mode; and (c) as generalist
integration into the health care system. As described providers of an alternative to medical care with
by Enzmann, cultural authority is the hallmark of a the focus on subluxation and/or the use of a wide
successful profession.56 Cultural authority is derived variety of CAM methods.
from competence and social legitimacy. Culturally en- 3. When diverse disciplines work together in the in-
dowed competence is composed of behaviors that terest of the patient, clinical integration is taking
are validated by peers, have a rational base (i.e., sci- place. The nature and extent of these collaborative
ence in health care professions) achieved by standard- relationships can be named and placed on a con-
ized training and practice, are measured by culturally tinuum ranging from independent parallel prac-
relevant outcomes, and are subject to group consen- tice to the extremely interactive “interdisciplinary
sus and compliance. Social legitimacy requires the health care team.” As collaboration increases, ex-
demonstration of collegial critical thinking and moral pertise is shared but autonomy decreases. At this
attributes that serve a higher social purpose (i.e., the level, integration has been increasing as a result of
public’s health). The attainment of a high level of cul- the changing attitudes of both chiropractors and
tural authority has allowed medicine to dominate the medical practitioners.
health care industry for many years. Now, with the 4. Barriers to the integration of chiropractic into the
older paternalistic practitioner-centered health care health care system include factors within the chiro-
paradigm under siege, and the new patient-centered practic profession, factors within the medical pro-
approach gaining ground, chiropractic is in an excel- fession, and factors within third-party payors. Fac-
lent position to align itself with emerging social values tors within the chiropractic profession include a
and norms. Goals and resources for attaining cultural lack of cohesiveness between practitioners and a
authority, however, have to be explicitly defined and lack of perceived social legitimacy. Factors within
addressed. the medical profession include a history of conflict
with chiropractic, competition for patients and ar-
eas of expertise, lack of understanding of chiro-
SUMMARY
practic, lack of experience in communicating with
1. Observers have placed chiropractic as a part of the chiropractors, and lack of research. Factors within
field of complementary and alternative medicine third-party payors include vastly different policies
(CAM), which generally designates those meth- regarding coverage and reimbursement levels, re-
ods of healing not commonly practiced by med- sistance to change, and fear that liberalized reim-
ical physicians. Some chiropractors may not ap- bursement policies will lead to increasing health
preciate this label because they see it as a barrier care costs.
to fully integrating chiropractic into mainstream
health care. Integrative medicine is a movement
largely led by medical physicians who seek to
QUESTIONS
transform medical care to a more humanitarian
mode, focusing more on the patient and less on 1. What does CAM stand for and why is chiropractic
disease and technology. In this sense, integrative considered a part of it?
medicine shares much of the philosophical align- 2. When integration is discussed in relation to health
ment of CAM and chiropractic. care, which items could be integrated?
2. The profession of chiropractic has evolved and 3. What are three roles that chiropractors could play
successfully reached a point where it provides in the health system?
health care for many patients. It is both mainstream 4. What are the three interacting levels of the health
in terms of its use and acceptance, and alternative system that provide the background for discussing
in terms of using a treatment approach that is very integration in this chapter?
different from that of traditional medicine. Inte- 5. What are some of the barriers to the full integration
gration in the health care sense is a multifaceted of chiropractic?
Jonas WB, Levin JS, eds. Essentials of complementary and alter-

ANSWERS
native medicine. Baltimore, MD: Lippincott Williams and
1. CAM stands for complementary and alternative Wilkins, 1999.
medicine. This term became more widely used in Kaptchuk TJ, Eisenberg DM. Varieties of healing. 1: Med-
the 1990s as a replacement for the more divisive ical pluralism in the United States. Ann Intern Med
alternative medicine moniker previously used. 2001;135:189–195.
Kaptchuk TJ, Eisenberg DM. Varieties of healing. 2: A tax-
This term also better reflects the reality that many
onomy of unconventional healing practices. Ann Intern
patients choose both traditional and nontradi- Med 2001;135:196–204.
tional care; one is not necessarily an alternative to Meeker WC, Haldeman S. Chiropractic: A profession at the
the other. Chiropractic is considered part of CAM crossroads of mainstream and alternative medicine. Ann
because it is not taught in traditional medical ed- Intern Med 2002;136:216–227.
ucation.
2. Integration could apply to specific procedures
or substances, to philosophies or approaches to REFERENCES
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3. Three potential roles that have been described
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Training, practice, and research. AHCPR Publication No. ing medicine back to its roots. Arch Intern Med
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Eisenberg DM, Kessler RC, Van Rompay MI, et al. Percep- medicine and systemic outcomes research. Issues in
tions about complementary therapies relative to conven- the emergence of a new model for primary health care.
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351. Findings of four community studies. J Manipulative
Enzmann D. Surviving in health care. St.Louis: Mosby-Year Physiol Ther 2000;23:601–609.
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systems. Gaithersburg, MD: Aspen, 2001. Mosby Year Book, 1996.
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26. Rupert R. A survey of practice patterns and the health Guidelines for chiropractic quality assurance and practice
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Smucker DR. The outcomes and costs of care for acute and alternative medicine clinics: Analysis of current
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29. Hertzman-Miller RP, Morgenstern H, Hurwitz EL, 47. Mootz RD, Bielinski LL. Issues, barriers, and solutions
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30. Jackson P. Summary of the ACA professional survey on 49. Jensen GA, Roychoudhury C, Cherkin DC. Employer-
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50. Bielinski LL, Mootz RD, eds. Issues in coverage for com- 53. Cherkin DC, Mootz RD, eds. Chiropractic in the United
plementary and alternative medicine services: Report of the States: Training, practice, and research. AHCPR Publica-
Clinician Workgroup on the Integration of Complementary tion No. 98-N002. Rockville, MD: Agency for Health
and Alternative Medicine. Olympia, WA: Washington Care Policy and Research, 1997.
State Office of the Insurance Commissioner, 2000. 54. White House Commission on Complementary and
51. Manga P. Economic case for the integration of chiro- Alternative Medicine Policy. www.whccamp.hhs.
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lative Physiol Ther 2000;23:118–122. 55. Lott CM. Integration of chiropractic in the Armed
52. Pelletier KR, Astin JA. Integration and reimbursement Forces health care system. Mil Med 1996;161:755–
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C H A P T E R
8
THE CLINICAL EFFECTIVENESS
OF SPINAL MANIPULATION FOR
MUSCULOSKELETAL CONDITIONS
Gert Bronfort, Mitchel Haas, and Roni Evans
O U T L I N E
INTRODUCTION Neck Pain
EVALUATING EVIDENCE OF TREATMENT Mid-Back Pain, Coccydynia, and Extremity Conditions
EFFECTIVENESS Cost-effectiveness of Spinal Manipulation
Evidence-Based Summaries AREAS FOR FUTURE RESEARCH
Systematic Reviews Special Populations
Clinical Guidelines Practice Optimization
Randomized Controlled Trials Manipulative Therapies
Nonrandomized Comparative Intervention Studies Regimens and Technique Systems
Uncontrolled Intervention Studies SUMMARY
Expert Opinion QUESTIONS
EFFECTIVENESS OF SPINAL MANIPULATION FOR ANSWERS
COMMON MUSCULOSKELETAL PROBLEMS KEY REFERENCES
Low Back Pain REFERENCES
Sciatica and Lumbar Radiculopathy
4. To summarize recently published clinical trials re-

OBJECTIVES
garding the effectiveness of spinal manipulation
1. To review the most appropriate study designs for extremity conditions.
for evaluating treatment effectiveness and to dis- 5. To identify gaps in existing knowledge and to sug-
cuss methods of summarizing research reporting gest areas for future research.
on treatment effectiveness, including randomized
clinical trials, systematic reviews, and evidence-
INTRODUCTION
based clinical practice guidelines.
2. To summarize, based on systematic reviews, Chiropractors, like other health care providers, have
evidence-based clinical guidelines, and recently been urged to adopt evidence-based health care as a
published clinical trials, what is known regarding basis for ensuring optimal case management by in-
the effectiveness of spinal manipulation for acute tegrating individual clinical expertise with the best
and chronic low back pain. available scientific evidence. Evidence-based health
3. To summarize, based on systematic reviews, care deemphasizes intuition, unsystematic clinical ex-
evidence-based clinical guidelines, and recently perience, and pathophysiological rationales as the
published clinical trials, what is known regarding basis for clinical decisions; instead, it emphasizes
the effectiveness of spinal manipulation for acute acquisition, understanding, and application of the
and chronic neck pain. available and accumulating scientific evidence from
147
high-quality clinical research.1 This chapter describes TABLE 8–1. Study Types
the best current scientific evidence regarding the ef-
fectiveness of spinal manipulation for several com- Evidence Hierarchy (Highest to Lowest)
monly encountered problems in chiropractic prac-
tice. Although spinal manipulation is only one of the Evidence-based summaries
procedures in the chiropractic treatment armamen- Systematic review
tarium, it is often recognized as chiropractic’s sig- Clinical guidelines
nature procedure. As such, manipulation has been Randomized controlled trials
the most studied procedure used by chiropractors. Nonrandomized comparative intervention studies
For the purpose of this chapter, manipulation refers Uncontrolled intervention studies
to segment-specific spinal manual therapy, including Expert opinion
high-velocity, low-amplitude thrust techniques, seg-
mental mobilization, and low-force and mechanical-
assisted adjustments.2 The chapter begins with a de-
scription of the key attributes of “evidence” and or rejecting the effectiveness of a treatment for a par-
the appropriate types of studies to evaluate treat- ticular condition. As always, evidence must be inter-
ment effectiveness. This is followed by a summary preted in the context of the patient population, practi-
of the best current evidence available on the clini- tioner population, clinical setting, and therapy under
cal effectiveness of spinal manipulation for low back study. Judgment must always be exercised when at-
pain, neck pain, and other musculoskeletal condi- tempting to apply evidence from a study to one’s indi-
tions. Cost-effectiveness of spinal manipulation is ad- vidual practice. For example, the results of a study on
dressed briefly. Finally, areas for future research are high-velocity, low-amplitude manipulation may not
identified and discussed. be generalized to a light or nonforce technique.
There are a number of proposed schema for clas-
sifying study designs.4 The evidence hierarchy pre-
EVALUATING EVIDENCE OF TREATMENT sented in Table 8–1 is a simplified taxonomy based on
EFFECTIVENESS two of the most important characteristics of study de-
Several attributes of scientific evidence may affect sign: randomization and control/comparison group.
its usefulness and perceived value. The most impor-
tant attributes include study type and methodolog- Evidence-Based Summaries
ical quality, as well as quantity and consistency of Systematic Reviews A systematic review is a compre-
evidence.3 Study type refers to the design of a study, hensive review of the scientific (peer-reviewed) liter-
such as a randomized controlled trial and case study, ature that includes an exhaustive literature search, a
which are often prioritized into a hierarchy reflect- specific research question, inclusion/exclusion crite-
ing the strength of evidence, the ability to minimize ria to identify the relevant studies, an evaluation of
bias, and the ability to make causal inferences regard- study quality, a summary of the literature, and a qual-
ing treatment effectiveness. It is well recognized that itative or quantitative synthesis of study findings to
greater weight must be given to a large randomized make inferences about the strength of supporting or
controlled trial than to a single case study in clinical refuting evidence.5 A meta-analysis is a quantitative
decision making. systematic review that pools the findings of multiple
Although certain study types may sit at the top of studies to give an overall numerical estimate of a treat-
the evidence hierarchy, they shouldn’t automatically ment effect.6 If studies are too dissimilar, statistical
be considered a good source of evidence. The value pooling of data may not be sensible. An alternative is
placed on research, and consequently how much faith then a type of systematic review called a best-evidence
is put in the results, is largely determined by the synthesis.7 This approach uses a predetermined set of
methodological quality of a study, or how well a study rules to evaluate the strength of evidence, weighing
has been performed. Methodological quality is deter- the magnitude of treatment benefit as well as study
mined from specific criteria according to study type. quality and quantity.
Studies with higher methodological quality within A systematic review is considered the highest form
each study type are considered to be less likely to of evidence because it combines the findings of multi-
yield spurious results, and thus their results are given ple studies to give a better perspective than any single
more importance. Also, the level of confidence in the trial.5 Of particular advantage to the clinician is that
evidence for effectiveness depends on the quantity the literature has already been summarized. A limi-
of evidence. It is preferable to have numerous high- tation of systematic reviews is that individual study
quality trials with consistent results before accepting findings may be included even when the authors of the
THE CLINICAL EFFECTIVENESS OF SPINAL MANIPULATION FOR MUSCULOSKELETAL CONDITIONS 149
original studies have made false conclusions from that do not always reflect clinical practice and con-
their own data. Additionally, as with any type of study, trolling patient selection and treatment delivery, re-
the trustworthiness of a systematic review is depen- sults often cannot be applied to everyday practice.
dent on how well it was performed. Clinicians must Furthermore, standardization of therapies in these
also be careful to assess the relevance of the review to studies does not permit individualization of treat-
their own patients and method of practice.8,9 A grow- ment, which may be an important component of care.
ing international organization, The Cochrane Collabo- All in all, the precision in information that an RCT can
ration, is likely to play an increasing role in the genera- provide comes at the expense of not always being able
tion of the systematic reviews that will carry the most to generalize research findings to practice.15
weight when it comes to informing national policy
decisions. This international, multidisciplinary group Nonrandomized Comparative
of volunteer researchers has set a goal to produce Intervention Studies
high-quality reviews with commitments to regular Nonrandomized comparative studies differ from ran-
updates.10 Cochrane reviews on the role of spinal ma- domized controlled trials in that patients are not ran-
nipulation for neck pain, low back pain, and headache domized to treatment groups. This may happen when
are underway. patients are improperly randomized (e.g., the every-
other-patient method) or in comparison studies where
Clinical GuidelinesSince the beginning of the 1990s, patients select their therapy. Quality in these studies
clinical guidelines have increasingly become a fa- varies tremendously, from poorly designed pragmatic
miliar part of clinical practice. Clinical guidelines studies to rigorously controlled treatment protocols.
have been defined as systematically developed state- These studies may be either prospective (i.e., patients
ments to assist practitioners and patients in deci- are recruited into the study when it begins) or retro-
sions about appropriate health care for specific clinical spective (i.e., patients have already received treatment
circumstances.11,12 Guidelines based on critical ap- and researchers are going through the results after the
praisal of the scientific evidence (also called evidence- fact to see how they fared).
based guidelines) are designed to provide specific in- This study type has several important advan-
formation about which interventions are of proven tages.15 First, the nonrandomized comparative study
benefit by documenting the strength of the evidence designs are amenable to large studies conducted in
of the supporting data. The limitations that exist for clinical practice to evaluate treatment effects in natural
systematic reviews also apply to clinical guidelines. settings and can be used to investigate a wide variety
of patients, therapies, and practices. Nonrandomized
Randomized Controlled Trials comparative studies can be also be used to generate
The randomized controlled trial (RCT) is considered hypotheses for RCTs, confirm findings of RCTs, and
the sine qua non of research methodology because it determine the generalizability of RCTs under less con-
provides the most reliable estimate of treatment effect trolled conditions. The downside to nonrandomized
with the least biased method of causal inference.13 The comparative studies is the absence of randomization,
inclusion of a comparison group permits the evalua- which weakens causal inference and group compar-
tion of fundamental clinical questions such as the fol- ibility. Consequently, treatment effects may be con-
lowing: Does manipulation make an important contri- founded by patient characteristics; that is, if random-
bution to patient progress? Is manipulation better than ization is not used to ensure that groups of patients are
other therapies? Is manipulation an active ingredient as similar as possible to begin with, it is possible that
in patient care? By randomly assigning patients to ex- differences in results are actually a result of some dif-
perimental and comparison treatment groups, known ference between the two groups. The generalizability
and unknown factors that could affect treatment out- to practice that a nonrandomized comparative study
come are controlled for, leaving any differences be- can provide comes at the expense of potential bias in
tween groups attributable to the specific treatments. ascertaining the cause of a treatment effect.15
Randomization also aids in concealment of allocation
to treatment or control groups, a critical factor to pre- Uncontrolled Intervention Studies
vent biased study results.14 Uncontrolled intervention studies may be thought of
Although they are considered the gold standard as nonrandomized comparative trials, as described
for determining treatment effectiveness and form above, but without comparison groups. These stud-
the underlying basis for evidence-based summaries, ies consist of case series and case studies and may be
randomized controlled trials do have limitations, prospective or retrospective. The most important such
including limited generalizability. By conducting study is the large, prospective, practice-based case se-
these studies in ideal settings with clinical protocols ries, which can give precise estimates of therapeutic
progress over time. However, these studies cannot be the addition of specific rules to determine the presence
used to make causal inferences. Without a proper con- and strength of evidence of efficacy. They, too, did not
current comparison group, we cannot rule out natural distinguish manipulation performed by chiropractors
history and external factors as the causes of the ob- from that performed by other practitioners. The re-
served patient improvement. view by Bronfort et al.21 differed from the other sys-
tematic reviews by primarily basing the evidence on
Expert Opinion studies from which the unique effect of spinal manipu-
This category refers to anecdotes and accounts of per- lation could be isolated. Also, the review did not rely
sonal experience of leaders in a health care field in the on authors’ conclusions (as others had) but formed
absence of documented evidence. Practitioners must conclusions based on evidence rules and synthesis of
often make clinical decisions regarding treatments for abstracted quantitative data from each randomized
patients where there is little or poor scientific evi- clinical trial.
dence. Consequently, clinical experience plays a crit- The number of randomized clinical trials address-
ical role in evidence-based practice.1 However, per- ing spinal manipulation for LBP increased substan-
sonal clinical experience can be misleading for many tially from 1985 to the end of the twentieth century.
reasons. For example, some patients get better in spite In the Ottenbacher et al. 1985 review,22 only 9 stud-
of care, doctors can make errors in diagnosis and prog- ies were available, compared with the most recent re-
nosis, and in the absence of careful documentation, view by van Tulder19 (1997), which identified 25 stud-
there is a greater tendency to remember successes ies evaluating spinal manipulation for LBP. Tables 8–2
than to remember failures. There are also issues of through 8–7 summarize all of the currently published
interpretation such as, “I know the patient got better randomized clinical trials assessing spinal manipula-
because he never returned to the office.” Therefore, tion for LBP.
while many such anecdotes and personal experiences All of these differences among systematic reviews
delivered by often charismatic leaders are interesting have the potential for generating varying conclusions
or even impressive, they do not represent scientific regarding the efficacy of spinal manipulation. Surpris-
evidence to prove or disprove a therapy. ingly, the conclusions regarding spinal manipulation
for acute LBP have been relatively consistent, with
the exception of the Koes et al. review.20 While the
EFFECTIVENESS OF SPINAL MANIPULATION majority of the reviews indicated that there is some
FOR COMMON MUSCULOSKELETAL evidence supporting the short-term efficacy of spinal
PROBLEMS manipulation for acute LBP, Koes et al. found the ev-
idence inconclusive. For chronic LBP, the results of
Low Back Pain the systematic reviews have been more mixed, with
Since the mid-1970s, more than 50 reviews have been the earlier reviews finding inconclusive evidence and
published assessing the effectiveness of spinal ma- later reviews finding moderate to strong evidence for
nipulation, mainly for low back pain (LBP).16 Most the benefit of spinal manipulation. Table 8–8 sum-
of these reviews have been of a qualitative nature. marizes the systematic reviews and evidence-based
However, since 1985, several systematic reviews have guidelines that have addressed spinal manipulation
emerged, as well as evidence-based clinical guidelines therapy (SMT) for low back pain, both acute and
based on these reviews. Overall, the methodological chronic.
quality of systematic reviews has continued to im- Additional randomized clinical trials of SMT for
prove over time, but there are still a number of in- LBP have been published.23–29 A study by Andersson
dividual differences in how spinal manipulation re- et al.26 compared osteopathic spinal manipulation
views have been performed. For instance, two reviews to standard medical care for patients with LBP of
by Assendelft et al.17,18 focused entirely on trials ad- 3 weeks’ to 6 months’ duration. Both groups showed
dressing the efficacy of chiropractic spinal manipula- similar clinical results, but patients who received
tion for patients with LBP, while other reviews did spinal manipulation required significantly less medi-
not distinguish practitioner type and included ma- cation. A trial by Skargren et al.24,25 compared physical
nipulation performed by medical doctors and physi- therapy and chiropractic for acute and chronic neck
cal therapists. The result of the second review (which and back pain patients and found both treatments to
was an update of the first), involving a total of eight be equally effective both short and long term for LBP
RCTs, was that no convincing evidence of the efficacy patients. A randomized trial by Cherkin et al.23 com-
of chiropractic spinal manipulation for either chronic pared chiropractic spinal manipulation, McKenzie
or acute LBP could be demonstrated.18 Van Tulder therapy, and an educational booklet that served as a
et al.19 used a protocol similar to that used by Koes minimal intervention control. No differences between
et al.20 for quality scoring and abstracting, but with spinal manipulation and McKenzie groups were
TABLE 8–2. RCTs on Acute Low Back Pain in Which It Was Possible to Isolate the Unique
Contribution of Spinal Manipulation/Mobilization to the Overall Treatment Effect
First Author, Reference

Number, and Year Study Groups (n) Results
Glover38 (1974) G1: 1 SMT-MD + 4 daily sessions of G1 more pain reduction after the first treatment in
detuned diathermy (43) subgroup with duration <1 week (SS); no important
G2: 5 daily sessions of detuned diathermy difference after 3 and 7 days
(placebo) (41)
Rasmussen39 (1979) G1: SMT-MD/PT (12) G1 many more symptom-free patients as rated by
G2: Short-wave diathermy (12) MD at 2 weeks (SS)
Farrell40 (1982) G1: Passive MOB/SMT-PT (24) A much higher percentage of patients in G1 reached
G2: Diathermy + abdominal exercise + symptom-free status in <15 days (SS); no
ergonomic instruction (24) important group difference in pain reduction at
1 and 3 weeks
Godfrey41 (1984) G1: SMT-MD/DC + low electrical G1 had more patients rating marked improvement in
stimulation (48) pain at 2 weeks (NS); no group difference in
G2: Min. massage + low electrical improvement of activities of daily living at 2 weeks
stimulation (42)
Helliwell42 (1987) G1: SMT-MD (6) G1 more improvement in symptoms at 1 week, but
G2: Sham SMT (8) not at 2 days and 1 month (NS); no group
difference in sick-leave days after 1 month
Hadler43 (1987) G1: SMT-MD (26) 50% reduction in low back disability score
G2: MOB-MD (28) (Roland-Morris) reached more rapidly in G1 than
G2 (SS) but only in subgroup with duration of
2–4 weeks
Mathews34 (1987) G1: SMT-PT (165) No important group difference in subgroup of
G2: Heat (126) patients with simple LBP who recovered at 2 weeks;
no difference in relapse rate between groups during
follow-up year
MacDonald44 (1990) G1: SMT-DO + LBP education and G1 higher reduction in low back disability scores
advice (49) (Roland-Morris) at 1 and 2 but not at 3 weeks,
G2: LBP education and advice (46) and only in subgroup of patients with duration of
2–4 weeks (NS)
Kinalski45 (1989) G1: SMT-MD (61) G1 had slightly higher percentage of patients with
G2: Heat + traction + exercise? (50) MD-rated good/very good improvement in pain
after 2–4 weeks of treatment (NS)
Gemmel46 (1995) G1: SMT-DC (16) Test of immediate effect after 1 treatment; no
G2: Activator instrument (14) important group difference in pain reduction
Seferlis27 (1998) G1: Manual spine treatment–PT (60) No important group differences at any time point in
G2: Intensive exercise (60) disability; G1 and G2 had more pain reduction at
G3: Usual care GP (60) 1 and 3 months (NS) than G3; G1 and G2 more
satisfied than G3 at all time points (SS)
Key: DC = Chiropractor; DO = osteopathic doctor; G1 = group 1; GP = general practitioner; LBP = low back pain; MD = medical doctor; MOB =
spinal mobilization; NS = statistically nonsignificant; PT = physiotherapist; SMT = spinal manipulative therapy; SS = statistically significant (p ≤ 0.05).
noted, but overall these two groups showed slightly care, but there were no significant differences in dis-
more pain reduction in the short term than the book- ability; the group receiving spinal manipulation was
let group. Seferlis et al.27 compared spinal manipula- the most satisfied. In a pilot study, Giles et al.28 found a
tion, intensive exercises, and usual care by the general trend favoring chiropractic spinal manipulation after
practitioner for acute low-back-pain patients with and 3–4 weeks of treatment, as compared to acupuncture
without sciatica. The patients receiving spinal manip- and medication for patients with LBP and neck pain.
ulation and exercise had slightly more pain reduction Hurwitz et al.29 showed in a large trial that combining
after 1 and 3 months than did the group with usual physical modalities with spinal manipulation did not
TABLE 8–3. RCTs on Acute Low Back Pain in Which It Was Not Possible to Isolate the Unique

Bergquist-Ullman47 (1977) G1: SMT-PT + exercise (68) G1 had faster recovery than G3 (SS), but was
G2: Back school 3 hours (70) equal to G2; G1 fewer days with inability to work
G3: Low-intensity heat (placebo) (79) than G3 but more than G2 (NS); equal numbers
of relapses during follow-up year in all three
groups
Waterworth48 (1985) G1: SMT-PT and/or McKenzie exercise (38) No important group difference in pain reduction at
G2: Heat + exercise (34) 4 and 12 days; no important group difference in
G3: Antiinflammatory drug (36) improvement at 12 days
Blomberg49–51 (1992) G1: SMT-MD + steroid injection + autotract G1 higher pain reduction at 1, 2, and 3 weeks (SS)
(15%) + home exercise (48) and at 3 months (SS); G1 higher reduction in
G2: Exercise + back school + electrical low back disability at 1, 2, and 3 weeks (SS), but
modalities (53) not at 3 months; G1 the lowest number of days
of work loss during the 8-month follow-up (SS)
Delitto52 (1993) G1: SMT/McKenzie extension exercise (14) G1 higher reduction in low back disability scores
G2: Flexion exercise (10) after 3 and 5 days (SS)
Erhard53 (1994) G1: SMT-MOB/extension + flexion G1 higher reduction in low back disability scores
exercise (12) after 3 and 5 days (SS)
G2: McKenzie extension exercise (12)
Key: G1 = group 1; MD = medical doctor; MOB = spinal mobilization; NS = statistically nonsignificant; PT = physiotherapist; SMT = spinal manipulative
therapy; SS = statistically significant (p ≤ 0.05 ).
result in any better outcomes when compared to using herniation patients. The study reported that the spinal
spinal manipulation alone for the treatment of LBP. manipulation group had a higher reduction in pain
Additional evidence of the effectiveness of manip- after 2 and 6 weeks, and the authors concluded that
ulation comes from nonrandomized studies, such as spinal manipulation was at least as effective as the
the prospective, practice-based, nonrandomized com- injection therapy. In their nonrandomized compara-
parative study by Nyiendo et al.30 They reported equal tive study, Nyiendo et al.30 found that chiropractic
pain and disability outcomes at 6 and 12 months for care, predominantly manipulation, had more favor-
patients with chronic, nonspecific LBP who received able pain and disability outcomes at 6 and 12 months
medical or chiropractic care. Carey et al.31 similarly than did medical care for chronic patients with leg
reported that chiropractic and medical care resulted pain radiating below the knee; the authors noted that
in similar outcomes for acute LBP. this was a promising subgroup for future random-
Since 1994, at least 10 evidence-based clinical ized trials. Chiropractic and medical care were com-
guidelines on the diagnosis and management of LBP parable for patients with leg pain above the knee.
have been published. All have issued specific recom- While the few randomized clinical trials in this area
mendations regarding the use of spinal manipulation, are promising, they lack the methodological quality
with more than 80% of the guidelines considering required to draw firmer conclusions. Recent system-
spinal manipulation beneficial, especially in the acute atic reviews19,20 have reported a lack of conclusive ev-
phase. idence to support or deny the efficacy of spinal ma-
nipulation for lumbar radiculopathy (see Table 8–8).
Sciatica and Lumbar Radiculopathy
There are only a small number of randomized stud- Neck Pain
ies that have evaluated the efficacy of spinal ma- There have been several systematic reviews as well
nipulation for sciatica and lumbar radiculopathy.33–37 as a few clinical guidelines that have assessed the effi-
The results of those trials are summarized in Ta- cacy of spinal manipulation and mobilization for neck
ble 8–7. In 2000, a small-scale randomized trial by pain.21,78,82–88
Burton et al. was published37 comparing osteopathic These, too, have used different methodological ap-
spinal manipulation with chemonucleolysis for disc proaches and have continued to improve over time.
TABLE 8–4. RCTs on Chronic Low Back Pain in Which It Was Possible to Isolate the Unique

Evans54 (1978) G1: SMT-MD (17) G1 had higher percentage of patients rating
G2: Analgesics (15) treatment as effective/highly effective at
3 weeks at cross-over (NS)
Gibson55 (1985) G1: SMT-DO (41) G3 highest reduction in pain at 2 and
G2: Diathermy active (34) 12 weeks (NS)
G3: Detuned diathermy (34)
Arkuzewski56 (1986) G1: Drugs, physiotherapy, + SMT-MD (50) G1 higher reduction in pain at 1- and 6-month
G2: Drugs, physiotherapy (50) post-treatment follow-up (NS)
Waagen57 (1986) G1: SMT-DC (11) G1 higher reduction in pain at 2 weeks (no
G2: Sham SMT-DC (18) statistical analysis reported)
Herzog58 (1991) G1: SMT-DC (19) No important group differences in pain and low
G2: Back education + exercise (18) back disability reduction at 4 weeks
Koes 59,60 (1992) G1: SMT-PT + MOB (36) G1 higher reduction in severity of main complaint
G2: Massage + exercise + patient than the 3 other groups at 6 weeks but not
modalities (36) at 12 weeks and than G2 at 12-month
G3: GP-treatment analgesic/ follow-up (SS)
antiinflammatory + advice on rest,
exercise, posture (32)
G4: Detuned modalities (40)
Pope61 (1994) G1: SMT-DC (70) G1 higher pain reduction than G3 at 3 weeks (SS)
G2: Massage (36) but not importantly different from G2 and G4
G3: TENS (28)
G4: Corset (30)
Timm62 (1994) G1: MOB-PT (50) G3 and G4 had higher reduction in low back
G2: Hot packs,TENS,ultrasound (50) disability scores than G1, G2, and G5 at
G3: Low-tech exercise (50) 8 weeks (SS)
G4: High-tech exercise (50)
G5: No treatment control (50)
Triano63 (1995) G1: SMT-DC (70) G1 had higher reduction in pain than G2 and G3
G2: Sham SMT-DC (70) at the end of 2 weeks of treatment and 2 weeks
G3: Mini back school (69) later (NS); G1 had slightly higher reduction in
disability than G2 and G3 at the end of 2 weeks
(SS) but not 2 weeks later
Bronfort64 (1996) G1: SMT-DC + strength exercise (71) No important group differences in pain and low
G2: NSAID + strength exercise (52) back disability reduction at 3, 6, and 12 months
G3: SMT-DC + stretch exercise (51)
Key : DC = Chiropractor; DO = osteopathic doctor; G1 = group 1; GP = general practitioner; MD = medical doctor; MOB = spinal mobilization;
NS = statistically nonsignificant; NSAID = nonsteroidal anti-inflammatory drug; PT = physiotherapist; SMT = spinal manipulative therapy; SS =
statistically significant (p ≤ 0.05); TENS = transcutaneous electrical nerve stimulation.
However, all of the systematic reviews have suffered In 1996, Aker et al.83 concluded that conservative treat-
from a paucity of primary studies regarding the effi- ment with spinal manipulation and spinal mobiliza-
cacy of spinal manipulation or mobilization for neck tion in combination with other therapies was effica-
pain. cious for neck pain. Hurwitz et al.84 published a re-
For example, Koes et al.82 found no convincing ev- view of three RCTs on acute neck pain89–91 and found
idence to support spinal manipulation for neck pain, short-term benefit for cervical mobilization. In addi-
but this 1991 review was based only five trials. The tion, a meta-analysis of three subacute/chronic neck
1992 review by Di Fabio78 drew the same conclusion. pain trials60,92,93 reported that spinal manipulation
TABLE 8–5. RCTs on Chronic Low Back Pain in Which It Was Not Possible to Isolate the Unique
Contribution of Spinal Manipulation/Mobilization to the Overall Treatment Effect3

Ongley65 (1987) G1: Forceful SMT-MD + 6 “proliferant” G1 higher reduction in pain and low back disability
injections (40) scores at 1,3, and 6 months (SS)
G2: Sham SMT-MD + 6 placebo
injections (41)
Sims-Williams66 (1978) G1: SMT-PT + MOB + traction (43) G1 lower percentage of patients with work loss at
G2: Placebo PT (44) (general practice 1 month (SS); no important group difference in
patients) pain reduction at 1 and 3 months
Sims-Williams67 (1979) G1: SMT-PT + MOB + traction (48) No important group difference in pain reduction
G2: Placebo PT (44) (hospital patients) and work loss 1 and 3 months
Key : G1 = group 1; MD = medical doctor; MOB = spinal mobilization; NS = statistically nonsignificant; PT = physiotherapist; SMT = spinal manipulative
therapy; SS = statistically significant (p ≤ 0.05).
TABLE 8–6.RCTs on a Mix of Acute and Chronic Low Back Pain in Which It Was Possible to Isolate
the Unique Contribution of Spinal Manipulation/Mobilization to the Overall Treatment Effect12

Doran68 (1975) G1:SMT-MD (116) G1 higher percentage of patients than the 3 other
G2: Physiotherapy (114) groups rating moderate to complete relief at
G3: Corset (109) 3 weeks (NS); no important group differences at
G4: Analgesics (113) 6 weeks and 3 months
Zylbergold69 (1981) G1: Heat + SMT-PT (8) G1 the highest reduction in pain and low back
G2: Heat + flexion exercise (10) disability scores at 1 month (NS)
G3: Ergonomic instruction (10)
Hoehler70 (1981) G1: SMT-MD (56) G1 higher reduction in pain after 1 treatment (SS)
G2: Soft-tissue massage (39) and at discharge and 3 weeks postdischarge;
no important group difference in percentage of
patients reporting treatment being effective at
discharge, but 3 weeks later G1 was
superior (SS)
Rupert71 (1985) G1: SMT-DC (?) G1 higher reduction in pain at 8 weeks (NS)
G2: Placebo touch (?)
G3: Drugs + bedrest (?)
Postacchini72 (1988) G1: SMT-DC (?) (87) For acute patients, G1 highest increase in global
G2: Drugs (81) improvement index score at 3 weeks but no
G3: Massage + diathermy (78) important group difference at 2 and 6 months;
G4: Bed rest (29) for chronic patients, G1 to G3 higher increase in
G5: Back school (50) global improvement index score than G6 at
G6: Placebo ointment (72) 3 weeks and at 6 months; no statistical analysis
Kinalski45 (1989) G1: SMT-MD (61) No important group difference in MD-rated
G2: Heat + traction + exercise (?) (50) improvement but G1 lower treatment time
in days
Bronfort73 (1989) G1: SMT-DC (11) No group difference in patient-rated improvement
G2: GP-MD (drugs + injections + physical at 1 month but G1 superior to G2 at 3 and
therapy + advice) (10) 6 months (NS); G1 lowest number of work-loss
days during the 6 month follow-up (NS)
(continued)

Wreje74 (1992) G1: SMT-MD (23) G2 higher reduction in pain (NS) and fewer days
G2: Friction massage (23) on sick leave after 3 weeks (SS)
Meade75,76 (1990,1995) G1: SMT-DC (384) G1 slightly higher reduction in low back disability
G2: PT + SMT-PT (357) (Oswestry) scores at 6 weeks (NS), and at 6
(SS), 12 (NS), 24 (SS), and 36 (SS) months
Skargren24 (1997) G1: SMT-DC (138) No important group differences in reduction of
G2: Physiotherapy (115) pain and disability after 6 and 12 months
Cherkin23 (1998) G1: SMT-DC (133) G1 and G2 had more reduction in low back
G2: McKenzie exercise–PT (122) bothersomeness than G3 at 4 weeks (G1 [SS],
G3: Educational booklet (66) G2 [NS]) and at 12 and 52 weeks (NS); trend
toward more disability reduction in G1 and G2
than G3 at all time points (NS)
Anderson26 (1999) G1: SMT-DO (83) G1 slightly more reduction in pain after 12 weeks
G2: Usual care–GP (72) (NS); no important group differences in disability
and satisfaction after 12 weeks
Giles28 (1999) G1: SMT-DC (32) G1 higher reduction in pain and disability than G2
G2: Acupuncture (18) and G3 after 3–4 weeks (NS)
G3: Medication (19)
Hurwitz29 (2002) G1: SMT-DC (169) No important group differences at 2, 6, and
G2: SMT-DC + modalities (172) 26 weeks in pain and disability; perceived
treatment effectiveness greater in G2.
Hemmilä77 (2002) G1: Manual spine treatment–BS (45) G1 had higher disability reduction than G2 and G3
G2: Exercise (35) at 6 weeks (SS), 3 months (NS), and at 6 and
G3: Physiotherapy (34) 12 months (SS)
Key : BS = bone-setter; DC = chiropractor; DO = osteopathic doctor; G1 = group 1; GP = general practitioner; MD = medical doctor; NS = statistically
nonsignificant; PT = physiotherapist; SMT = spinal manipulative therapy; SS = statistically significant (p ≤ 0.05).
and/or mobilization resulted in a clinically impor- found no important group differences in pain and dis-
tant short-term advantage over muscle relaxants and ability after 6 weeks of treatment and during 1-year
usual medical care. The review by Bronfort et al.21 followup.
found limited evidence as to the short-term efficacy The Quebec Task Force85 on whiplash-associated
of spinal manipulation and mobilization for chronic disorders concluded in 1995, despite a lack of conclu-
neck pain, and insufficient data regarding acute neck sive evidence to show its effectiveness for whiplash-
pain. Kjellman et al.87 found some evidence support- associated disorders, that spinal manipulation should
ing the effectiveness of spinal manipulation for neck still be considered a plausible treatment option. The
pain. Swedish clinical guidelines on back pain86 from
Fortunately, calls for more high-quality random- 2000 included a review of the evidence of effi-
ized clinical trials of SMT for neck pain appear to have cacy of different treatments for neck pain, and con-
been heeded and several RCTs have been published cluded that spinal manipulation was appropriate
in the last few years. A number of small, preliminary only when combined with other treatment modal-
trials have compared different spinal manipulation ities, such as analgesics for acute conditions; evi-
approaches for neck pain, but have had insufficient dence of its effectiveness for chronic neck pain was
sample sizes to reach any conclusions.28,95–97 Among lacking.
the larger, higher-quality trials, Skargren et al.24 More recently, two additional RCTs with long-term
found that physical therapy resulted in greater pain followup have been published. Bronfort et al.99 in-
reduction at the end of treatment and 12 months after dicated that combining rehabilitative exercise with
treatment than chiropractic management. Jordan spinal manipulation produced more long-term pain
et al.98 compared spinal manipulation, intensive exer- reduction than spinal manipulation alone for chronic
cise, and physical therapy for chronic neck pain. They neck pain patients. Hoving et al.100 compared manual
TABLE 8–7. Clinical Trials on Spinal Manipulation for Sciatica

Coxhead33 (1981) Factorial study of 322 patients with Main effect of SMT in subgroup of patients with
16 different combinations of: sciatica higher at 4 weeks than in those who
1: SMT did not receive SMT (SS)
2: Traction
3: Exercise
4: Corset
5: No treatment
(All the combination groups also received
back school and diathermy)
Mathews34 (1987) G1: SMT-PT (165) In subgroup of patients with sciatica, G1 had
G2: Infrared heat (126) higher recovery rate at 2 weeks (SS); no
difference in relapse rate between groups
at 1 year
Nwuga35 (1982) G1: Oscillatory SMT-MD (26) G1 higher increase in range of motion and straight
G2: Heat + low-intensity exercise (25) leg raise at 6 weeks (SS)
Siehl36 (1971) G1: Conservative care + SMT-DO (21) G3 more electromyographic and clinical
G2: Conservative care (7) improvement than the two other groups; no
G3: Disc surgery (19) statistical analysis
Burton37 (2000) G1: SMT-DO (20) G1 higher reduction in pain at 2 and 6 weeks (SS)
G2: Chemonucleolysis (20) and at 12 months (NS); G1 higher reduction in
disability at 2 weeks (SS) and at 6 weeks and
12 months (NS); no group difference in leg pain
post-treatment and at follow-ups
Key: DO = osteopathic doctor; G1 = group 1; MD = medical doctor; NS = statistically nonsignificant; PT = physiotherapist; SMT = spinal manipulative
therapy, physical therapy, and general practitioner and 8–10 summarize all of the randomized clinical tri-
care for acute and chronic neck pain, and found als published to date assessing SMT for neck pain, and
that patients receiving manual therapy had faster im- Table 8–11 provides a summary of the existing system-
provement and significantly less pain than the other atic reviews of spinal manipulation and mobilization
two groups both in the short and long term. Tables 8–9 for neck pain.
TABLE 8–8.Summary of Conclusions from Systematic Reviews

Regarding Spinal Manipulation for Low Back Pain
Systematic Reviews Low Back Pain

(First Author, Reference
Number, and Year) Acute Chronic
Ottenbacher22 (1985) + ?
Di Fabio78 (1992) + ?
Anderson79 (1992) +* ?
Shekelle80 (1992) + ?
Koes20 (1996) ?** ?
Bronfort21,81 (1997) + +
van Tulder19 (1997) + +
+ = Conclusions in favor of spinal manipulation efficacy; ? = inconclusive evidence of spinal manipulation

efficacy.
* = no differentiation made between acute and chronic conditions.
** = evidence of spinal manipulation efficacy in subgroups.
TABLE 8–9.RCTs on Neck Pain in Which It Was Possible to Isolate the Unique Contribution of Spinal
Manipulation/Mobilization to the Overall Treatment Effect

Nordemar90,90 (1981) G1: analgesic + education + rest + collar + G1 similar pain reduction to G2 but more than
MOB (10) G3 at 1 week (NS); no group difference in
G2: analgesic + education + rest + collar + pain at 6 weeks and 3 months
transcutaneous electrical nerve stimulation
(10)
G3: analgesic + education + rest + collar (10)
Sloop93 (1982) G1: Amnesic dose diazepam + SMT-MD (21) G1 substantially more pain reduction and
G2: Amnesic dose diazepam, no treatment perceived improvement than G2 at 3 weeks
(18) (NS)
Brodin101 (1982) G1: Analgesics, information + MOB-PT (23) G1 had higher percentage of patients with
G2: Analgesia, light massage, information no/slight pain at 4 weeks as compared to
(17–25) G2 and G3 (SS)
G3: Analgesics (23)
Howe92 (1983) G1: SMT-MD (26) G1 had higher percentage of patients with
G2: No treatment (26) improvement in neck pain immediately, and
after 1 and 3 weeks (NS)
Koes59,60 (1992) G1: SMT-PT + MOB (21) G1 had more reduction in severity of main
G2: Massage + exercise + heat + patient complaint than G3 and G4 at 6 weeks (NS)
modalities (13) and more than G2, G3, and G4 at 12 weeks
G3: GP treatment analgesic/anti-inflammatory (NS); at 12 months’ follow-up of G1 and G2
+ advice on rest, exercise, posture (17) only, G1 had more reduction in severity (NS)
G4: Detuned modalities (14)
Cassidy102 (1992) G1: SMT-DC (52) No important group difference in pain
G2: MOB-DC (48) immediately after one treatment
Vasseljen103 (1995) G1: PT including mobilization (12) No important group difference in pain
G2: Group exercise (12) reduction at 6 weeks and 26 weeks
Skargren24 (1997) G1: SMT-DC (41) G2 had more pain reduction than G1 after
G2: PT (29) treatment and at 12 months’ follow-up (SS)
Jordan98 (1998) G1: SMT-DC (40) No important group differences in pain and
G2: Intensive exercise (40) disability after 6 weeks of treatment and at
G3: Physical therapy including MOB (39) 4- and 12-month follow-up
Parkin-Smith95 (1998) G1: SMT-DC cervical spine only (13) No important group differences in pain and
G2: SMT-DC cervical + thoracic spine (17) disability after 6 treatments
David97 (1998) G1: MOB-PT (13) G1 had more pain reduction than G2 at
G2: Acupuncture (17) 6 weeks and 6 months (NS)
Giles28 (1999) G1: SMT-DC (23) G1 higher reduction in pain than G2 and G3 after
G2: Acupuncture (15) 3–4 weeks (NS)
G3: Medication (12)
van Schalkwyk96 (2000) G1: SMT-DC “rotation” (15) G1 had a little more reduction in self-rated pain
G2: SMT-DC “lateral break” (15) and disability than G2 at 4 weeks
posttreatment and at 4-week follow-up (NS)
Wood104 (2001) G1: SMT-DC “manual” (15) No important group differences in pain and
G2: SMT-DC “instrument” (activator) (15) disability after up to 8 treatments
Hoving100 (2001) G1: MOB-MT (40) G1 higher perceived recovery rate, more
G2: Usual care–GP (40) reduction in physical dysfunction and in
G3: Physical therapy including massage, bothersomeness of pain than G2 and G3 in
exercise, and stretching (39) the short term (during first 13 weeks) (SS)
and in the long term (during 52 weeks) (SS)
(Continued )

Bronfort99 (2001) G1: SMT-DC (64) G2 and G3 more pain reduction than G1 at
G2: SMT + low-tech exercise (64) 3 months (NS) and 12 months (SS); G2 and
G3: High-tech exercise (63) G3 more disability reduction than G1 at 3
and 12 months (NS); G2 higher satisfaction
than G1 and G3 at all time points
Sterling105 (2001) G1: Mobilization 30 patients in cross-over trial of 1 session in
G2: Placebo each phase—G1 had higher pain reduction
G3: Control than placebo and control (SS)
Key : G1 = group 1; GP = general practitioner; MD = medical doctor; MOB = spinal mobilization; NS = statistically nonsignificant; PT = physiotherapist;
SMT = spinal manipulative therapy; SS = statistically significant (p ≤ 0.05).
Mid-Back Pain, Coccydynia, and management of coccydynia, but the results from
Extremity Conditions one RCT on this subject by Maigne et al.111 sug-
Although spinal manipulation is often used for the gest that these treatments in isolation are associated
treatment of mid-back pain, very little research has with very modest success rates. Davis et al.114 found
been done in this area. One RCT, a preliminary study that combining cervical manipulation with upper ex-
by Schiller et al.,110 found that spinal manipulation tremity manipulation, ultrasound, and a night brace,
was superior to placebo ultrasound for thoracic pain. as compared to nonsteroidal antiinflammatory drugs
Different manual techniques are common for the (NSAIDs) and a night brace, has similar beneficial
TABLE 8–10.RCTs on Neck Pain in Which It Was Not Possible to Isolate the Unique Contribution of
Spinal Manipulation/Mobilization to the Overall Treatment Effect

Kogstad106 (1978) G1: SMT + heat + massage (13) G1 had higher proportion of improved patients
G2: heat + massage + traction + exercise than G2 and much higher than G3 after
(21) 5 weeks and 18 months (NS)
G3: (Control) placebo drug (16)
Mealy91 (1986) G1: Ice + MOB + exercise (31) G1 more pain reduction than G2 at 4 weeks (SS)
G2: Rest + collar (30) and at 8 weeks (NS)
McKinney89 (1989) G1: analgesic + collar + advice on exercise + G2 had more pain reduction than G1 (SS) and
posture + heat + shortwave diathermy + similar reduction to G3 at 1 month; same result
hydro + traction + MOB-PT (71?) was seen at 2 months (NS)
G2: Rest first + analgesic + advice on
exercise after 2 weeks (33?)
G3: analgesic + collar + advice on exercise +
rest (66?)
Fitz-Ritson107 (1995) G1: SMT-DC + standard exercise (15) Post-treatment reduction in NDI percentage points
G2: SMT-DC + phasic exercise (15) were higher in G2 than in G1
Giebel108 (1997) G1: Mobilization-PT + exercise (47) G1 had more pain reduction than G2 at 2 and
G2: Collar immobilization (50) 12 weeks (SS)
Provinciali109 (1996) G1: Manual treatment + psychological and G1 had higher pain reduction at 2,4, and
posture training (30) 26 weeks than G2 (SS at all time points)
G2: PT-modalities (30)
Key : G1 = group; MD = medical doctor; MOB = spinal mobilization; NDI = Neck Disability Index; NS = statistically nonsignificant; PT = physiotherapist;
SMT = spinal manipulative therapy; SS = statistically significant (p ≤ 0.05).
TABLE 8–11. Systematic Reviews of Spinal Manipulation and

Mobilization for Neck Pain
Neck Pain
Systematic Reviews First Author,
Reference Number, and Year Acute Chronic
Koes82 (1991) ? ?
DiFabio78 (1992) ? ?
Aker83 (1996) (+) (+)
Hurwitz84 (1996) + +
Bronfort21 (1997) ? +
Kjellman87 (1999) (+) +
Hoving*88 (2001) ? ?
+ = Conclusions in favor of spinal manipulation efficacy; (+) = conclusions with reservations in favor of
spinal manipulation efficacy; ? = inconclusive evidence of spinal manipulation efficacy.
* Review of systematic reviews.
effect on carpal tunnel syndrome. Finally, two small- selected health outcome, such as pain reduction, im-
scale RCTs indicate that spinal manipulation may be provement in disability, and functional status.115 In
helpful in the management of elbow epicondylitis112 the past decade, recommendations have been made by
and anterior knee pain.113 Table 8–12 summarizes the health economists for chiropractic inclusion in public
RCTs of spinal manipulation for musculoskeletal con- health care plans116–118 based to a large extent on work-
ditions other than neck pain and LBP. ers’ compensation studies and retrospective analyses
of health insurance claims data.117–119 In the system-
Cost-effectiveness of Spinal Manipulation atic review by Assendelft and Bouter,119 the method-
Cost-effectiveness is defined as the cost associated ological limitations of the workers’ compensation
with a specified clinical intervention per unit of a studies were highlighted. These included the studies’
TABLE 8–12. RCTs on Mid-Back Pain, Coccydynia, and Extremity Conditions
First Author,
Reference Number,
and Year Condition Study Groups (n) Results
Schiller110 (2001) Thoracic pain G1: SMT-DC (15) G1 had higher reduction in pain and
G2: Placebo ultrasound (15) disability than G2 at the end 6 treatments
(SS) and at 1-month follow-up (NS)
Vicenzino112 (1996) Elbow epicon- 15 patients (cross-over trial) G1 had more improvement in pain and pain
dylitis G1: MOB-PT threshold after 1 treatment than G2 and
G2: Placebo maneuver G3 (SS)
G3: Control
Davis114 (1998) Wrist carpal G1: SMT-DC + upper extremity Similar improvement after 9 weeks in both
tunnel manipulation + wrist ultrasound + groups in symptoms and function
syndrome night wrist support (45)
G2: NSAID + night wrist support (46)
Suter113 (2000) Knee pain G1: SMT-(sacroiliac joint) DC (14) G1 had greater decrease in muscle
with muscle G2: Back functional assessment—no inhibition than G2 (NS)
inhibition treatment (14)
Maigne111 (2001) Coccydynia G1: MOB of coccyx (25) Massage and stretching associated with
G2: Massage (24) better outcome than mobilization (NS)
G3: Stretching (25)
Key : DC = chiropractor; G1 = group 1; MOB = spinal mobilization; NS = statistically nonsignificant; PT = physical therapist; SMT = spinal manipulative
retrospective nature, inadequate measures of effec- manipulation for a given musculoskeletal condition?
tiveness, and uncontrolled group differences. As a What is the optimal intensity and duration of spinal
result, the authors concluded that randomized con- manipulative care? What other modalities should be
trolled trials were needed before the cost-effectiveness included in the chiropractic care regimen? What are
of chiropractic care could be reliably determined.119 the cost-effectiveness and cost utility of different types
Prospective studies evaluating the cost-effective- of chiropractic procedures as compared to other treat-
ness of chiropractic and other treatments for back pain ments for low back pain, neck pain, and other muscu-
have provided less favorable results than earlier ret- loskeletal conditions? These questions suggest further
rospective studies. The study by Shekelle et al. used research in the following areas.
predefined episodes of care for back pain as a ba-
sis for cost determination in their secondary analysis Special Populations
of the RAND Health Insurance Experiment data,120 Most research to date has looked at the effective-
and found that chiropractors had the highest cost per ness of manipulation for ambulatory patients in gen-
outpatient episode and medical general practition- eral practice. With the exception of acute and chronic
ers the lowest. A prospective observational study in pain, subgroupings of patients have usually been ad-
North Carolina31 compared care from chiropractors, dressed only in secondary or exploratory analyses.
orthopedists, and medical general practitioners for the Prospective experimental confirmation is necessary to
treatment of acute low back pain, and reported similar properly evaluate effectiveness in various age groups,
time to recovery among provider types. Total outpa- genders, and patients with different levels of pain
tient charges were highest for patients managed by and disability. Specific attention needs to be given to
orthopedists and chiropractors, but this cost data was children and the elderly, to the obese, hospitalized,
based on an extrapolation from state averages rather and disabled, and to patients with differing types
than actual payments to providers. and severity of comorbidities. Investigation of a broad
A cost-effectiveness component has been added spectrum of types of patient populations is needed to
to clinical trials in many areas of health care.121–124 establish the generalizability of the effectiveness of
The 2001 study by Korthals-de Bos et al. provides one spinal manipulation.
of the finest examples to date in the back and neck
pain literature of a cost-effectiveness analysis (CEA)
Practice Optimization
in conjunction with an RCT.125 This study compared
manual therapy, physical therapy, and general practi- Maximizing patient health outcomes and minimiz-
tioner care for neck pain. A societal perspective for the ing costs are not only important to clinical practice,
economic evaluation was taken and consequently a but can also inform future trials regarding the most
comprehensive assessment of costs relative to that per- promising treatment protocols to investigate. Some
spective was then performed.125 Effectiveness mea- of the most perplexing questions chiropractors and
sures included perceived recovery, pain intensity, and researchers face are the following: How many visits
disability. Quality of life (measured by the EuroQol are required? What should their frequency be? How
5D)126 was used as the utility measure and expressed long should care continue? What modalities, if any,
in quality-adjusted life years (QALYs). The results in- should be used in conjunction with SMT? In other
dicated that manual therapy was more effective and words, studies are required to determine the optimal
less costly than physical therapy and general practi- dosage and posology of chiropractic care. This could
tioner care.125 be accomplished with a dose–response trial, where
Although reasonable recommendations have been patients are randomly assigned to varying amounts
made by some health economists for chiropractic in- of treatment.
clusion in public health care plans,116–118 the substan-
tial limitations of the work upon which some of these Manipulative Therapies
recommendations are based warrant further evalua- Most of the studies presented in this chapter in-
tions of the cost-effectiveness of chiropractic care.125 vestigated the efficacy of manual high-velocity low-
amplitude (HVLA) thrusting manipulation. There has
been a dearth of work on other types of manipu-
AREAS FOR FUTURE RESEARCH
lation/adjusting, including low-force and segmental
The documented scientific evidence for the effective- mobilization techniques, which also need to be tested
ness of spinal manipulation is encouraging. How- for efficacy against both HVLA manipulation and
ever, optimizing chiropractic clinical practice requires placebo. One type of research that is perhaps prema-
that critical gaps in the knowledge base underpinning ture is the investigation of the equivalence of therapies
clinical decision making be filled. There are a num- that have no known efficacy. Such comparison studies
ber of important questions that remain to be an- would not be able to discern whether different types
swered, such as: What are the best forms of spinal of manipulation were equally good or equally bad.
Regimens and Technique Systems is also currently inconclusive for the long-term ef-
Manipulative therapies are often performed as part ficacy of spinal manipulation for low back pain.
of therapeutic regimens or technique systems that in- 3. For neck pain, evidence from the existing random-
volve both diagnostic and treatment procedures. Yet, ized trials suggests that spinal manipulation and
there have been few studies testing the effectiveness especially mobilization have effects that are simi-
of these technique systems for any musculoskeletal lar to commonly used treatment such as physical
condition. There are a number of very interesting re- therapy and exercise but appear superior to usual
search questions outstanding, such as the following: medical care. To date, the evidence for the effec-
Does a full regimen or complete technique system tiveness of spinal manipulation and mobilization
approach perform better than the individual manip- for the treatment of neck pain is emerging, but cur-
ulative therapies associated with them? Are the tech- rently awaits more high-quality trials and a syn-
niques themselves effective for various musculoskele- thesis of these trials in new, updated systematic
tal conditions? Are different techniques more effective reviews.
for different conditions and different patient popula- 4. The results of the few randomized trials assessing
tions? What are the most clinically active components spinal manipulation for mid-back pain, coccygeal
of these technique systems as compared to the value pain, and disorders of the knee, elbow, and wrist
of the psychosocial elements of the clinical encounter? seem promising. However, the evidence is cur-
These are extremely challenging questions for chi- rently insufficient to draw any conclusion regard-
ropractors and those researching chiropractic, and ing the efficacy of spinal manipulation for these
further research is likely to yield even more such ques- conditions.
tions. However, if the profession is committed to pro- 5. A number of important areas regarding the ef-
viding patients the best care possible, it should in- fectiveness of chiropractic spinal manipulation re-
vestigate the unknown and embrace the outcomes of main to be addressed by new research. There is
the best available evidence to lead chiropractic into a need to determine which are the best types of
a new era of health care practice in the twenty-first spinal manipulation for a given musculoskeletal
century. condition, and in which subgroups of patients.
Little is known about what the optimal dose and
frequency of the treatment are. More research is
needed on the cost-effectiveness and cost utility of
SUMMARY
different types of chiropractic procedures as com-
1. In the absence of documented scientific evidence pared to other treatments for low back pain, neck
of treatment effectiveness, chiropractors must of- pain, and other musculoskeletal conditions.
ten rely solely on their own clinical experience
or on expert opinion. Case studies or case se-
ries may provide more precise estimates of ther- QUESTIONS
apeutic progress over time, but do not allow for
strong causal inferences. Nonrandomized compar- 1. What is evidence-based health care?
ative intervention studies may be used to gener- 2. What is the best way of determining the evidence
ate hypotheses for randomized trials or confirm for the efficacy of a treatment for a given condition?
findings from such studies and can help determine 3. Is there any scientific evidence for the efficacy of
generalizability to practice. The randomized clin- spinal manipulation for the treatment of low back
ical trial provides the best research methodology pain?
for reliable estimates of treatment effects and con- 4. Is there any scientific evidence for the efficacy
trol of bias. Systematic reviews of randomized tri- of spinal manipulation for the treatment of neck
als summarize the evidence of effectiveness of a pain?
treatment by synthesizing the data or results from 5. What are some of the most important areas that
all published studies, and inform recommenda- need to be addressed regarding the effectiveness
tions made in evidence-based clinical guidelines. of chiropractic spinal manipulation?
2. As of 2002, based on the conclusions of the latest
systematic reviews and the majority of national
ANSWERS
evidence-based clinical guidelines, there is some
evidence for short-term efficacy of spinal manip- 1. A system of practice that optimizes patient care by
ulation in the treatment of both acute and chronic combining clinical expertise with the best available
low back pain. There is insufficient data available external scientific evidence.
to draw firm conclusions regarding the efficacy 2. By performing a high-quality systematic review of
of spinal manipulation for lumbar radiculopathy all available published randomized clinical trials
caused by confirmed disc herniation. The evidence on the topic.
3. There is some evidence for short-term efficacy of for back and neck pain: A blinded review. BMJ 1991;303:
spinal manipulation especially in the treatment of 1298–1303.
acute but also chronic low back pain. There is in- Koes BW, Bouter LM, van Mameren H, et al. The effec-
sufficient data available to draw firm conclusions tiveness of manual therapy, physiotherapy, and treat-
regarding the efficacy of spinal manipulation for ment by the general practitioner for nonspecific back
and neck complaints. A randomized clinical trial. Spine
lumbar radiculopathy caused by confirmed disc
1992;17:28–35.
herniation. Koes BW, van Tulder MW, Ostelo R, Burton AK, Waddell
4. Emerging evidence from the existing randomized G. Clinical guidelines for the management of low back
trials suggests that spinal manipulation and espe- pain in primary care: An international comparison. Spine
cially mobilization have effects that are similar to 2001;26:2504–2513.
commonly used treatment such as physical ther- Nachemson A, Johnson E, eds. Neck and back pain:
apy and exercise but appear superior to usual med- The scientific evidence of causes, diagnosis, and treatment.
ical care. There is a need for more high-quality tri- Philadelphia: Lippincott Williams & Wilkins, 2000.
als and synthesis of existing trials in new, updated, Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook
systematic reviews. RH. Spinal manipulation for low-back pain. Ann Intern
5. There is a need to determine the best types of spinal Med 1992;117:590–598.
van Tulder MW, Koes BW, Bouter LM. Conservative treat-
manipulation for different types of musculoskele-
ment of acute and chronic nonspecific low back pain: A
tal conditions in various types of patients, as well systematic review of randomized controlled trials of the
as the optimal dose and frequency of spinal ma- most common interventions. Spine 1997;22:2128–2156.
nipulation.
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C H A P T E R
9
THE TREATMENT OF HEADACHE,
NEUROLOGIC, AND
NONMUSCULOSKELETAL DISORDERS
BY SPINAL MANIPULATION
Howard Vernon
O U T L I N E
INTRODUCTION Gastric Disorders
LITERATURE SEARCH AND EVIDENCE Sinusitis
EVALUATION Enuresis and Pediatric Developmental Problems
Headaches DISCUSSION
Vertigo Additional Features of a Trial of Therapy
Nonmusculoskeletal Conditions CONCLUSION
Premenstrual Syndrome/Dysmenorrhea SUMMARY
Asthma QUESTIONS
Colic ANSWERS
Hypertension KEY REFERENCES
Otitis Media REFERENCES
Visual Disturbances
6. To present a generic algorithm to guide chiroprac-

OBJECTIVES
tors’ decision making in their approach to the treat-
1. To review the historical basis for chiropractors’ ment of nonmusculoskeletal conditions.
consideration of nonmusculoskeletal disorders.
2. To present and evaluate the evidence base for chi-
ropractic treatment of tension-type, migraine, and
INTRODUCTION
cervicogenic headaches.
3. To present and evaluate the evidence base for the The treatment of nonmusculoskeletal disorders by
chiropractic treatment of vertigo or dizziness. chiropractors dates to the very inception of the pro-
4. To present and evaluate the evidence base for chi- fession. The archetypal experience of D. D. Palmer
ropractic treatment of nonmusculoskeletal condi- in treating Harvey Lilliard for deafness resonates
tions with pain as a primary symptom. throughout the profession’s history. The early texts
5. To present and evaluate the evidence base for by chiropractors and osteopaths alike are filled with
chiropractic treatment of nonmusculoskeletal con- discussions of such treatments.1–4 Two major themes,
ditions not chiefly associated with pain and de- which were of great importance to both of these
scribed as “functional disorders.” professions in their late nineteenth century infancy,
167
influenced such thinking: vitalism and wholism. A Irwin Korr’s mid-century work8–11 crystallized
brief review of these themes provides a historical con- these two phenomena into the interrelated theories
text for this chapter. of sympathicotonia and the central facilitated seg-
Vitalism, by definition, is a metaphysical theory.5 ment. The former established the notion of disturbed
Traditional chiropractic theory proposed the existence autonomic outflow as an important consequence of
of a universal life force or principle governing all in- spinal dysfunction, resulting in disturbed regulation
teractions of matter which was embodied in each liv- of vaso-, sudo-, and secretory motor control, all vital
ing organism (hence, the “vitalism” of early chiro- functions for visceral health. The latter theory estab-
practic thinking). The unique chiropractic perspective lished the role of a disturbed central (spinal) regula-
on this philosophy of vitalism lay in the notion that tory mechanism linking somatic pain, spinal neuronal
the individual’s life force, termed innate intelligence, dysfunction, and disturbed motor and autonomic out-
operated or flowed through the physical medium of flows. Several other chiropractic writers, most notably
the nervous system. It was further postulated that in- Sandoz12 and Homewood,13 contributed to the devel-
terference with the flow of this life force would lead opment of these two theories into a coherent physio-
to disturbed bodily function and, ultimately, disease. logical model, which was offered as a more modern
Chiropractic theory proposed that this interference oc- explanation of the relationship between spinal dys-
curs in the spinal column as the peripheral nerves function and visceral disorders, as well as the con-
run their course through the intervertebral foram- nection between spinal manipulation and improved
ina formed by each intervertebral joint. Misalignment visceral function.
of these joints (subluxation) was thought to create a This latter connection—that is, that spinal manip-
mechanical interference (i.e., pressure) on the spinal ulation can result in improved visceral function—
nerve, the result of which would be interference with appears as a clinical observation in much of the
the flow of life force within the nerve, and, thence, to profession’s writings and may be said to part of
the portion of the body to which that nerve traveled. the profession’s clinical folklore. Systematic report-
Traditional chiropractic theory also posited that an ing of these observations remained scanty until the
individual’s health is based upon optimum function latter part of the century. Its place in the clinical folk-
of the nervous system. This was stated in the physi- lore of the profession was challenged by Nansel and
ologic models of the day, where the nervous system Szlazak14 on the basis of its anecdotal nature and
was viewed as the master regulatory system of the its susceptibility to other theoretical interpretations.
body and neural activity was seen to not only control They presented a series of alternate explanations for
the function of each body organ or tissue, but also to the origination and survival of the notion that chiro-
coordinate all functions, so that the entire organism practic care (primarily spinal manipulation) resulted
would operate within its optimum homeostatic lim- in improvements in visceral disorders.
its. This is the basis of the “wholism” of chiropractic Nansel and Szlazak14 proposed that afferent con-
theory. vergent mechanisms result in visceral signs and symp-
In summary, a central connection was drawn be- toms that are indistinguishable from somatic sources.
tween the function of the nervous system, its dis- They suggested that in many of the instances where
turbance by spinal dysfunction, and the health of chiropractic treatments appeared to provide cures of
the body’s systems. This connection was viewed in visceral disorders, these outcomes were really the re-
both wholistic and what we might call “segmental” sult of changes in the somatic system, which had been
perspectives. From the wholistic perspective, inter- mimicking visceral disease, and may have been incor-
ference of nervous system functioning was seen as rectly labeled in the diagnostic process. They warned
systemic, with wide-ranging consequences. From the that clinicians need to be more cautious when diag-
“segmental” viewpoint, neural disturbance was seen nosing an organic disorder in association with spinal
as focused by the particular nerves affected by spinal dysfunction and attributing improvement to a ther-
subluxation, resulting in specific consequences spe- apeutic intervention. Although Nansel and Szlazak
cific to the viscera innervated by those nerves. This pointed out the lack of controlled studies for the effect
is the basis of the so-called “meric” approach to ad- of spinal manipulation on organic disease, they them-
justing the spine6 ; European practitioners of manual selves provided no controlled trial to support their
medicine have termed this “neuromeric medicine.”7 theory.
These theories and philosophies evolved through the
next century. In both the chiropractic and osteopathic
LITERATURE SEARCH AND EVIDENCE
professions, interest came to be focused on the emerg-
EVALUATION
ing field of neuroscience. This resulted in two major
fields of interest: the autonomic nervous system and This chapter reviews the evidence with regards to the
the phenomenon of “spinal cord facilitation.”8–11 use of spinal manipulation for nonmusculoskeletal
THE TREATMENT OF HEADACHE, NEUROLOGIC, AND NONMUSCULOSKELETAL DISORDERS BY SPINAL MANIPULATION 169
TABLE 9–1. Nonmusculoskeletal Conditions strong clinical trial) with a class B recommendation
(promising).
Nonspinal Pain Complaints Functional Disorders In 1999, Vernon et al.18 published a system-
atic review of clinical trials of all complementary/
Cervicogenic complaints Asthma alternative therapies for tension-type and cervico-
Headache Hypertension genic headache. The evidence table in this report (with
Vertigo Visual disturbances the exception of the studies on migraine headaches)
Other pain complaints Otitis media is taken from that study. A total of 286 subjects were
Dysmenorrhea Sinusitis included in these studies. The quality scores ranged
Gastric pain complaints Enuresis from 56–80, with a mean score of 67.5. No trial in-
Infantile colic Neurologic or developmental cluded an exclusively placebo or sham-controlled
disorders group, so the efficacy of spinal manipulation (as com-
pared to the “effectiveness”) could not be determined.
In tension-type headaches, chiropractic spinal manip-
ulation (CSM) was shown to be more effective than
disorders in two broad categories: nonspinal pain no treatment (in a single treatment session20 ), as effec-
complaints and functional disorders involving non- tive as amitriptyline after a 4-week follow-up period,24
musculoskeletal symptoms or disorders (Table 9–1). and no better than sham therapy plus soft-tissue
There have been several publications on this topic, therapy when CSM was combined with soft-tissue
spanning the entire range of the evidence hierarchy, therapy (in a short course of treatment25 ). In cervico-
including single case reports, case series, clinical genic headaches, Nilsson’s trials,22,23 as well as the
trials, randomized controlled trials, and systematic Jensen et al. trial,21 showed a superior benefit for CSM
reviews.15–18 The evidence for each condition reas compared to soft-tissue therapy and ice therapy,
viewed is presented below. respectively.
In 2001, McCrory et al.33 published a systematic
Headaches review that was comparable to that of Vernon et al., but
After low back and neck pain, headaches are the con- also included trials for behavioral treatments. With
dition for which the largest number of randomized regard to spinal manipulation, they concluded that it
clinical trials of spinal manipulation have been pub- was effective in patients with cervicogenic headache.
lished, including the three main categories of primary Its effectiveness in tension-type headache was rated
headaches19 : tension-type (n = 3), migraine (n = 3), as unproven. They found no convincing evidence to
and cervicogenic headache (n = 4). Table 9–2 summa- support the use of any other physical treatments for
rizes the results of these studies. these two headache types.
In 2001, Whittingham et al.30 reported on the re- In 2001, Bronfort et al.34 published a system-
sults of a clinical trial of a specific chiropractic manip- atic review and meta-analysis of all trials for cer-
ulative technique (upper cervical recoil adjustment) in vicogenic, tension-type, and migraine headache. A
chronic cervicogenic headache. Subjects participated study by Howe et al.35 primarily involved neck
in a crossover design, alternating between active ad- pain subjects, but these investigators also reported
justments and inactive or “placebo/sham” adjust- on their results pertaining to headache symptoms,
ments. Statistically significant intergroup differences which showed improvement with spinal manip-
occurred in the first phase for headache frequency, du- ulation. The study by Bitterli et al.36 was pub-
ration, severity, and medication usage. They also re- lished in the German literature in 1977, and was
ported on significant improvements in Neck Disabil- not included in Vernon et al.’s review18 for that
ity Index31 scores, pressure algometry measurements reason.
in the head and neck region, and cervical ranges of Bronfort et al. reported effect sizes for all these tri-
motion. als, the majority of which were in the range of 0.5
In addition to the systematic reviews of Hurwitz to 1 (fair to moderately strong) in favor of spinal
et al.15 and Aker et al.,16 which were cited above, manipulation. The primary exception to this trend
four other important systematic reviews on the benefit was the trial by Bove and Nilsson,25 which sug-
of spinal manipulation for headache were published. gested a revised explanation for the negative results
Pryse-Phillips et al.32 published a systematic review from this trial, stating that “SMT [spinal manipulation
of clinical trials of nonpharmacologic management of therapy], when combined with soft-tissue therapy, is
migraine headaches. They cited Parker et al.’s two no better than soft-tissue therapy alone for episodic
studies and concluded that “chiropractic manipula- tension-type headache. This conclusion neither sup-
tions reduced migraine frequency and severity,” and ports or refutes the efficacy of SMT as a separate
rated this conclusion as level I evidence (at least one therapy.”34
TABLE 9–2. Evidence Table for Studies of Spinal Manipulation for Headaches
First Author,
Reference Number, Number of Quality
and Year Type n Treatments Groups (n) Results Side Effects Scores
Hoyt20 “Muscle 22 1 (1) MANIP = 10 Posttreatment S: Not 56

(1979) contraction” (2) MOB = 6 (1) −48%* mentioned
(3) REST = 6 (2) 0
(3) 0
Jensen21 Post- 19 2 (1) MANIP = 10 Posttreatment S: Not 60
(1981) traumatic (2) ICE = 9 (1) −30.7/100† mentioned
(2) +6.7/100
Nilsson22 Cervicogenic 39 6 (1) MANIP = 20 Posttreatment F: Not 64
(1995) (2) STT = 19 (1) −3.4 (−59%) mentioned
(2) −2.1 (−45%)
Posttreatment S:
(1) −15 (−45%)
(2) −10 (−24%)
Nilsson23 Cervicogenic 53 6 (1) MANIP = 28 Posttreatment F: Not 72
(1997) (2) STT = 25 (1) −3.2‡ (−69%) mentioned
(2) −1.6 (−37%)
Posttreatment S:
(1) −17‡ (−36%)
(2) −4.2 (−17%)
Boline24 Tension-type 126 12 (1) MANIP = 70 Posttreatment F: (1) 4.3% 75
(1995) headache (2) AMIT = 56 (1) −3.8/28 neck
(IHS) (2) −4.0/28 stiffness
Followup F: (2) 82.1%
(1) −1.0† dry mouth,
(2) +5.0 drowsy, or
Posttreatment S: weight gain
(1) −1.3/20
(2) −1.8/20†
Follow-up S:
(1) −.5†
(2) +2.0
Bove25 Tension-type 75 8 (1) MANIP + Posttreatment F: Not 80
(1998) headache STT = 38 (1) −1.5 h mentioned
(IHS) (2) SHAM + (2) −1.9 h
STT = 37 Posttreatment S:
(1) No change
(2) No change
Parker26 Migraine 85 (1) CMT = 30 Pre-Post F Not
(1978) (2) MT = 27 (1) 8.5, 5.1 mentioned
(3) MOB = 28 (2) 11.4, 9.9
(3) 8.7, 5.7
Pre-Post Dur
(hours)
(1) 30.5, 19.4
(2) 12.2, 11.2
(3) 14.9, 11.9
(continued)
First Author,
Pre-Post DIS (0–5)

(1) 2.8, 1.8
(2) 2.7, 2.6
(3) 2.8, 2.2
Pre-Post S (0–10)
(1) 4.9, 2.8‡
(2) 5.0, 4.4
(3) 5.3, 4.4
Parker27 Posttreatment−F1/up F
(1980) (20 months)
(1) 5.1, 3.8
(2) 9.9, 8.0
(3) 5.7, 4.9
Nelson28 Migraine 218 14 (1) CMT = 77 Headache 0%
(1998) (1) AMI = 70 index (0–70)
(1) CMT + AMI (1) Pre: 18.6 (9.6)
= 71 Post: 11.1 (8.6) 10%
F1/up: 10.8 (9.6)
(2) Pre: 16.5 (8.7)
Post: 8.4 (9.0)
F1/up: 12.5 (8.3)
(3) Pre: 15.1 (6.5)
Post: 8.9 (7.5)
F1/up:11.3 (7.5)
Pre-Post S
(0–10)
(1) Pre: 5.3 (1.3)
Post: 4.3 (1.5)
F1/up: 4.4 (1.7)
(2) Pre: 4.6 (1.1)
Post: 4.3 (1.6)
F1/up: 4.5 (1.3)
(3) Pre: 4.4 (1.1)
Post: 4.1 (1.4)
f1/up: 4.3 (1.4)
Tuchin29 Migraine 123 16 (1) CMT = 83 Pre-Post F Not
(2000) (2) PLA = 40 (# per mo.) mentioned
(1) 7.1 (7.0) −
4.1 (6.6)∗
(2) 7.3 (6.5) −
6.9 (6.6)
Pre-Post S
(0–10)
(1) 7.9 (1.4)
6.9 (1.8)
(2) 7.9 (1.2)
6.2 (1.7)
(continued)
First Author,
Pre-Post DUR
(hours)
(1) 22.3 (28.3)
14.8 (19.8)†
(2) 22.6 (27.4)
19.8 (17.7)
Pre-Post DIS
(hours)
(1) 19.8 (21.2)
13.0 (18.2)
(2) 18.9 (21.2)‡
15.6 (18.2)
Pre-Post Meds
(# per mo.)
(1) 21.3 (28.4)
9.8 (12.4)‡
(2) 20.1 (28.4)
16.2 (12.4)
Total or 712 7 68
average
Key: AMI = ; AMIT = amitriptyline; CMT = chiropractic manipulative therapy; ICE = ice; IHS = inclusion based on criteria of the International
Headache Society Classification (9); MANIP = chiropractic spinal manipulation; MOB = mobilization; MT = manual therapy; PLA = placebo; REST =
rest; SHAM = sham placebo treatment; STT = soft-tissue therapy.
∗ †
Statistical significance: = .001; = .01; ‡ = .05.
In summary, of the three randomized controlled patients with (n = 31) or without (n = 19) findings of
trials (RCTs) for tension-type headache, two reported upper cervical joint dysfunction. Both groups received
a positive benefit for spinal manipulation as com- physiotherapy treatments over a 3-month interval,
pared to mobilization or rest20 or as compared to and the cervical dysfunction group also received
amitriptyline,24 while one reported no benefit of SMT spinal manipulation. In this group, improvement in
when added to soft-tissue therapy.25 For the studies vertigo symptoms was reported by 77.4% of the sub-
on migraine patients, all three RCTs report a positive jects, while in the group without cervical dysfunc-
effect when compared to other manual therapies,26,27 tion, only 26.3% of subjects reported improvement.
sham SMT,29 and amitriptyline.28 The three complete Carlsson et al.48 reported on improvements in oculo-
studies on SMT for cervicogenic headache reported motor function in a sample of headache subjects who
substantial positive benefit when this therapy was had randomly been allocated to receive either phys-
compared to ice treatment,21 soft-tissue therapy,22,23 iotherapy or acupuncture.
or sham SMT.30
Nonmusculoskeletal Conditions
Vertigo Table 9–3 displays the results of the literature search
At least eight case series studies of spinal manipu- in this area. The following sections review those areas
lation specifically for vertigo or dizziness have been for which more than two RCTs exist, namely premen-
published.37–44 Improvement in vertigo symptoms strual syndrome (PMS) and dysmenorrhea, asthma,
has been reported in other case series reports on and colic.
headache patients,45–47 as well as in one of the clin-
ical trials for headaches.21 The only clinical trial to Premenstrual Syndrome/Dysmenorrhea
be retrieved that specifically addressed vertigo was a Two smaller trials51,52 have demonstrated benefit from
nonrandomized study by Mahlstedt et al.50 of vertigo SMT when compared to sham placebo maneuvers
TABLE 9–3. Results of Literature Search for for patients with asthma.” Three small case series69–71
Studies of Spinal Manipulation in and two case studies72,73 were also retrieved.
Nonmusculoskeletal Disorders
Colic
Case
The majority of case reports on the treatment of
Condition RCTs Case Series Reports
infantile colic by spinal manipulation appear in
European non–English-language journals. One of the
PMS or dysmenorrhea 3 7 3
largest involves the ongoing work of Biedermann. An
Asthma 4 3 2
English-language version of this work was published
Colic 3 3 5
in 2001.74 Wiberg reviewed the literature on this topic
Otitis media 1 1 4
and retrieved 10 case series reports.75 Two of these
Hypertension 2 3 2
are notable, as they come from the Danish chiroprac-
Visual disturbances 1 0 6
tic group, which has since published one of the three
Sinusitis 0 0 1
RCTs in this area. This group first reported on large
Gastrointestinal disorders 1 0 1
retrospective76 and then prospectively obtained77
Enuresis, developmental 1 0 3
samples amongst Danish children. Favorable results
disorders
were suggested by these reports. Since the late
1990s, three RCTs have been reported.78–80 Table 9–4
compares these studies.
in reducing pain and menstrual distress, although While the Norwegian study may have had the
Kokjohn et al.’s study involved only a 1-hour measure- least bias in the reporting of symptoms, it appears
ment interval. Hondras et al.’s53 larger trial reported to have provided the least amount of treatment. As
no difference in these symptoms between groups re- well, these treatments were nonmanipulative spinal
ceiving SMT and those receiving sham manipulation. mobilizations, as compared to the spinal manipula-
A Cochrane Review by Proctor et al.54 in 2000 con- tions used in the other two studies. This could explain
cluded that there is no current evidence supporting the smaller difference between treated and untreated
the benefit of SMT over placebo in the treatment of groups of infants in the Norwegian study than was
primary or secondary dysmenorrhea, although there obtained with the other two studies. Five case reports
is some evidence of benefit when SMT is compared to were also retrieved.81–85
no treatment at all. Seven case series54–60 and three case
reports61–63 were also retrieved that, typically, present Hypertension
favorable results. Two published RCTs for hypertension were retrieved.
In 1985, Morgan et al.86 reported on 29 subjects with
Asthma hypertension who were divided into two groups.
Three RCTs have been published since 1995 that in- One group received 6 weeks of weekly spinal ma-
volve both adult and pediatric subjects. The trials nipulation to C0-C1, T1-T5 and T11-L1, areas that
by Neilsen et al.64 and Bronfort et al.65 on adult and have been proposed to correlate with hypertension.
pediatric subjects, respectively, did not show any dif- The other group received sham soft-tissue therapy to
ferences between SMT and sham SMT when SMT was other spinal areas. After 6 weeks, the groups were
added to usual medical management. Each of these crossed over. There were no significant differences be-
studies had small sample sizes of 31 and 36 subjects, tween the groups or the treatment phases within each
respectively. Hviid’s earlier study showed some im- group.
provements in the group receiving SMT, but this study Yates et al.87 conducted an RCT of a single manip-
was also quite small in size.66 Balon et al.’s trial of 91 ulative procedure in 21 subjects with elevated blood
children with moderately severe asthma showed no pressure. These subjects were randomly allocated to
differences in physiological measures of lung func- real mechanically assisted manipulation, sham ma-
tion between groups receiving usual medical treat- nipulation, and no-treatment control. The subjects in
ment when either active or inactive SMT was added the manipulation group demonstrated a mean re-
to their management.67 The active SMT group showed duction in systolic and diastolic blood pressure of
some clinically important, but not statistically sig- 14.7 mm Hg and 13 mm Hg, respectively, as well
nificant, differences in self-ratings of quality of life. as a reduction in anxiety rating of 5.2 (of 10). These
Hondras et al.68 recently reviewed these studies in a findings were statistically significant and greater than
Cochrane-based review and found “insufficient evi- those of the other two groups, who demonstrated es-
dence to support or refute the use of manual therapy sentially no change. Several pilot studies88–90 and two
TABLE 9–4. Comparison of three RCTs of SMT for Infantile Colic
Wiberg et al.76 Mercer et al.80 Olafdottir et al.81
Ages 0–10 weeks 0–10 weeks 0–10 weeks

Sample size 50 30 100
Blinding Assessor blinded Assessor blinded Assessor and parents blinded
Treatment (1) 3–5 manipulation treatments Spinal manipulation; 6 treatments Nonmanipulative mobilizations;
over 2 weeks over 2 weeks 3 treatments over
maximum of 2 weeks
Control (2) Dimethicone for 2 weeks Placebo ultrasound Untreated control
Outcomes Interviews and 24-hour diary Parental questionnaire Interviews and 24-hour diary
Results At 1 week: (1) Complete resolution in 93% of (1) 69.5% subjects improved
(1) 2.4 hours reduced crying* cases receiving manipulation (2) 60% subjects improved
(2) 1 hour reduced crying (p <.05)
At 2 weeks:
(1) 2.7 hours†
(2) 1 hour
* = .04;
†
= .004.
case reports91,92 have also been published pertaining comparable in terms of age, gender, and pretreatment
to hypertensive patients. ulcerous defect size. Clinical parameters and weekly
endoscopy were used as outcome measures. The
Otitis Media group receiving SMT achieved ulcerous healing
Only one feasibility study for a clinical trial has been within 16.3 ± 4.7 days as compared to 25.7 ± 7.3 days
reported. Sawyer et al.93 recruited 20 children ages for the medically treated group (p <0.001). One case
6 months to 6 years old to participate in a pilot study. report on gastrointestinal disorders treated with SMT
Otoscopy and tympanoscopy were used to create a has also been published.108
middle ear infection profile. Daily diaries that tracked
symptoms and medication usage were collected. Sub- Sinusitis
jects were randomly allocated to spinal manipulation No clinical trials of SMT for sinusitis or for other adult
(n = 9) or a sham/placebo group (n = 11). All sub- ear, nose, and throat disorders were found. Only one
jects completed the 4-week treatment phase and the 4- case study has been published.109
week follow-up. While the results were not subjected
to analysis, there appears to have been little benefit to Enuresis and Pediatric Developmental
either treatment. One large case series was reported by Problems
Fallon with clinical improvement reported for many In an RCT, 46 bedwetting children were randomized
of these cases.94,95 Several other case reports have been to spinal manipulative therapy (n = 31) or sham ma-
published.96–99 nipulation (n = 15).110 At the end of 3 months, a mean
of 25.7% fewer wet nights was reported by the SMT
Visual Disturbances group (p = 0.07). A case series of chiropractic care for
Several case reports from an Australian clinical team enuresis,111 as well as two case studies of chiropractic
have noted benefit in visual function after spinal care for childhood developmental or neurologic disor-
manipulation.100–105 One quasi-clinical trial reported ders, were retrieved.112,113 Biedermann’s case series74
a form of visual improvement in normal subjects after reports on a large number of cases of pediatric neu-
one manipulation.106 rologic and developmental problems that benefited
from manual therapy.
Gastric Disorders
Pikalov and Kharin reported a comparative case se-
DISCUSSION
ries of 11 ulcer patients who received SMT.107 They
compared the results of this group with those of Chiropractic theory proposes a relationship between
a nonrandomized control group (n = 24) who re- the spine and the nervous system, an important man-
ceived standard medical treatment. The groups were ifestation of which would be the health of the various
organ systems of the body. If this theory is correct,

then there should be an etiologic connection between SYMPTOM X
spinal joint dysfunction and visceral dysfunction, as

well as a therapeutic connection between spinal ma-
nipulation of spinal joint dysfunction and the course
of the visceral dysfunction. In other words, spinal ma- Is the condition
No REFER
nipulation should be beneficial for at least some vis- benign and stable?
ceral disorders.
This chapter has not delved into the validity of
Yes
these theoretical proposals. Rather, a review of the ev-
idence from published therapeutic studies was con-
ducted. From this review, it is evident that clinical tri- Can clinically
relevant spinal
No REFER
als have been successfully conducted in the area of dysfunction be
demonstrated?
headaches, although the degree to which headache is
a nonmusculoskeletal condition is arguable. In all 10 of
Yes
the published trials, subjects with migraine, tension-
type, and cervicogenic headaches have obtained ben-
efit from spinal manipulation. No serious adverse What is the
contribution of the
Questionable REFER
effects or worsening of the headaches has been re- dysfunction to the
condition?
to none
ported in these trials. The evidence base is best for

Substantial
cervicogenic headache, where all three trials show
greater benefit from SMT than from comparison
treatments.
For a small group of nonmusculoskeletal dis-
orders, namely asthma, premenstrual disorder, and What is the risk of
applying SMT More than REFER
colic, a few clinical trials have been published. When complementarily? negligible
interpreting the results of each of these studies,

it is helpful to consider three different categories
of clinical outcome: pain, musculoskeletal function, None to
negligible
and pathophysiology. As examples, consider asthma
and dysmenorrhea. In the case of asthma, asthmatic
Does the patient
episodes are clear-cut in their symptomatic manifes- consent to a No REFER
clinical trial?
tation and can even take the form of life-threatening
Yes
emergencies. In the chronic experience of this con- COMMENCE CLINICAL
TRIAL
dition, patients may feel discomfort in the chest,
upper back, and anterior neck (pain), restrictions
of chest and neck function (musculoskeletal func- FIGURE 9–1. Episodic gastric pain in a 45-year-old male.
tion), and, of course, pulmonary dysfunction. It may
be that chiropractic treatments might affect the first
two categories of symptoms and signs, but not af- Figure 9–1 presents an algorithm for considering the
fect the third category. This appears to be the re- use of SMT in benign visceral dysfunction. The central
sult that Balon et al.67 have reported, where their principles of the algorithm are (a) accurate diagnosis
subjects experienced subjective improvements on the of a chronic, benign condition with lack of response
Pediatric Asthma Quality of Life instrument, but to standard medical treatments; (b) identification of
showed no appreciable improvement in pulmonary clinically important spinal or related axial joint and
function. myofascial dysfunction; (c) thorough discussion of
In the case of dysmenorrhea, female patients re- the treatment options and objectives with the pa-
port pelvic and lumbar pain, stiffness, and reduced tient and his or her provision of informed consent
function in the trunk, as well as disordered menstru- to treatment; and (d) the use of the single-case clin-
ation. It may be that the effects of chiropractic treat- ical trial framework with systematic assessment of
ments are, again, in the former two categories, with- clinically important outcomes, even if these are not
out significant changes in the function of the affected yet standardized in the literature. Such outcome as-
viscera. sessments can be in the form of simple diary mea-
Given the state of the evidence as reviewed in this sures for episodic complaints or the frequent use of
chapter, how is the modern chiropractor to approach basic clinical measures, such as blood pressure, when
the treatment of nonmusculoskeletal symptoms? appropriate.
The following scenarios serve to demonstrate how Parent shows signs of poor nutritional manage-
this algorithm could be employed in clinical practice. ment of infant.
3. Predictive validity of therapy is inappropriately
Scenario 1: Episodic gastric pain in a 45-year-old low. Appropriate diagnosis and therapy may be
male. delayed.
1. Tenderness, spasm, and spinal joint dysfunction Opinion: SMT is inappropriate. Refer for full medical
are elicited in the thoracic spine. workup.
2. Findings are localized to T5-T7.
3. Endoscopy is negative. Response to Tagamet is Additional Features of a Trial of Therapy
only modest, with recurrences off the drug. All In cases where a trial of SMT therapy is deemed rea-
other disorders are ruled out. X-rays of the tho- sonable based on the principles of this algorithm, it
racic spine are negative for pathology. would be ideal to communicate with the patient’s
4. Symptomatic medications will not be terminated. physician to specify the precise objectives and in-
SMT may relieve dorsal and epigastric pain. Local tended procedures of the clinical trial. Informing a
risks of appropriate SMT are virtually nil. physician that “I am treating your patient, Mr. X,
Opinion: Trial of SMT is appropriate. for his ulcer . . .” is inappropriate. An appropri-
ate explanation would be that “a clinical trial of
Scenario 2. Persistent hypogastric pain in a 50-year- SMT for Mr. X’s dorsal pain will be undertaken.
old male. Should improvement in his epigastric pain occur,
1. Thoracic spinal dysfunction is detected. he will be referred for reexamination of his current
2. Dysfunction ranges from T9-T11. Diffuse pain therapy.”
spreads to the lower lateral costal border. Once the clinical trial has commenced, the chiro-
3. Source of pain is suspected as primary visceral dis- practor must be vigilant in monitoring the response to
order. Spinal dysfunction is a result of visceroso- therapy, as well as the patient’s general health status
matic reflex mechanisms. for evidence of any emergent clinical features. Contin-
4. Delay of appropriate care. SMT is ineffective for ued treatment despite lack of symptomatic response
primary disorder. SMT may produce harm if bone within a reasonable time is indefensible. If the pa-
metastasis is present. tient’s condition fails to improve or his or her general
health status deteriorates, immediate medical referral
Opinion: SMT is inappropriate. Refer for primary should be considered.
medical care. Once appropriate therapy is com-
menced, palliative chiropractic care may be appropri-
ate with the patient’s consent. CONCLUSION
Scenario 3. Four-month-old infant with colic. Given the state of the clinical evidence to date, it
is not possible to point to a consistent body of evi-
1. Spinal dysfunction is detected at C0-C1.
dence that confirms the beneficial effects of spinal ma-
2. All previous medical interventions have been un-
nipulative therapy directly on visceral function. It is
successful. No organic cause is diagnosed. Parent
also not currently possible to identify statistically sig-
is seeking alternative solutions because stress in
nificant and clinically important differences between
the family is high. Parent(s) are informed of recent
SMT and other comparative or standard treatments
clinical trials of SMT for colic, as well as the chiro-
in these trials, with the possible exception of the two
practor’s own experience with gentle treatments of
colic trials.78,79 This conclusion is supported by other
infants (these are demonstrated). Parent consents
attempts at similar, if not even more systematic, re-
to SMT.
views of the same literature.114
3. No local risks of SMT are expected. No useful ther-
In pediatric asthma and colic, as well as adult pre-
apy is being withheld. Parent will witness treat-
menstrual dysfunction, some reliable symptomatic
ments.
benefit from SMT has been reported by some of
Opinion: Trial of gentle SMT suitable to pediatric the subjects in these trials. Consequently, SMT could
population is appropriate with parent informed con- be considered as a complementary therapy option
sent. for these conditions. The principles of the treat-
ment algorithm presented in this chapter can then
Scenario 4. Four-month-old infant with colic.
be used. In none of the clinical trials has the mech-
1. Dysfunction is detected at C0-C1. anism of this effect been clearly demonstrated, so
2. Baby has other digestive symptoms and signs. this remains unproven. Until many more robust clin-
Baby has not been assessed by a pediatrician. ical trials have been reported, this area of clinical
practice remains controversial and unresolved. The 4. How would you characterize the results of the
debate in the profession at present is whether it is three randomized trials of chiropractic care for in-
“best practice” to refrain from employing SMT for fantile colic?
any nonmusculoskeletal disorders, or whether some 5. What is the state of the evidence base for the
form of empirical practice such as outlined above is treatment by spinal manipulation of nonmuscu-
reasonable. loskeletal conditions which are not predominated
by pain?
SUMMARY
1. Chiropractors’ considerations of nonmusculoske- ANSWERS
letal disorders are a product of the profession’s
philosophic foundations, practical clinical experi- 1. Korr’s hypothesis suggested that autonomic nerve
ence, and scientific theories. function was a consequence of spinal joint dys-
2. The evidence base is strongest for the chiropractic function that could lead to disturbances in vaso-
manipulative treatment of headaches. At present, motor, sudomotor, and secretory motor control;
there is sufficient evidence to support the treat- all are important to visceral organ physiology.
ment of cervicogenic headache by spinal manipu- Nansel and Slazak proposed that afferent input
lation and to indicate that sufferers of tension-type from spinal pain syndromes resulted in signs and
and migraine headaches may receive benefit from symptoms that mimicked visceral dysfunction,
this treatment. but that was incorrectly diagnosed as visceral
3. The evidence base for the chiropractic manipula- in origin. Spinal manipulation relieved the signs
tive treatment of some forms of vertigo is sugges- and symptoms but did not truly affect visceral
tive of the potential for benefit. function.
4. The evidence base for the chiropractic manipu- 2. At the time of publication, there are three each
lative treatment of nonmusculoskeletal disorders for tension-type and migraine headache, and four
or conditions with pain as the primary symptom for cervicogenic headache. Additional random-
provides variable support for benefit in infantile ized trials need to be performed to address a num-
colic, premenstrual syndrome or dysmenorrhea, ber of remaining questions.
and gastric disorders. 3. There are four randomized trials, four case se-
5. The evidence base for the chiropractic manipula- ries, and two case reports. Two randomized trials
tive treatment of “functional” nonmusculoskeletal did not demonstrate a difference between spinal
disorders or conditions is currently insufficient to manipulation and a sham manipulation when
support its use as the primary (sole) treatment for added to usual medical management. A third trial
these conditions. demonstrated improvement, but all three were
6. An algorithm was presented as a guide to practi- small studies. The larger trial by Balon also did
tioners’ clinical decision making in the treatment not demonstrate any differences between a sham
of nonmusculoskeletal disorders or conditions. adjustment and actual adjustments, although pa-
tients did improve their quality of life.
4. Two of the trials indicated that spinal manipula-
ACKNOWLEDGMENT tion had more beneficial effects than the control
group. However, one trial was unable to demon-
The author expresses his appreciation to Claire Johnson, DC, for
strate a difference between spinal mobilization and
her assistance with this chapter.
an untreated control group.
5. The state of evidence is poor; there are very few
randomized trials, case series, or case reports.
QUESTIONS Much additional research needs to be done.
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treatment on respiratory function in patients with res- 87. Morgan JP, Dickey JL, Hunt HH, Hodgins PM. A con-
piratory distress symptoms and patients without. Bull trolled trial of spinal manipulation in the manage-
Euro Chiropr Union 1978;26:17–34. ment of hypertension. J Am Osteopath Assoc 1985;85:
68. Balon J, Aker PD, Crowther ER, et al. A comparison 308–313.
of active and simulated chiropractic manipulation as 88. Yates RG, Lamping DL, Abram NL, Wright C. Ef-
adjunct treatment for childhood asthma. N Engl J Med fects of chiropractic treatment on blood pressure and
1998;359:1013–1020. anxiety: A randomized controlled trial. J Manipulative
69. Hondras MA, Linde K, Jones AP. Manual therapy for Physiol Ther 1988;11:484–488.
asthma. Cochrane Database Syst Rev 2001:2:CD001002. 89. Knutsen GA. Significant changes in blood pressure
70. Jamison JR, Leskovec K, Lepore S, Hannan P. Asthma post vectored upper cervical adjustment vs. resting
in a chiropractic clinic: A pilot study. J Aust Chiropr control groups: A possible effect of the cervicosym-
Assoc 1986;16:137–143. pathetic and/or pressor reflex. J Manipulative Physiol
71. Beyeler W. Experiences in the management of asthma. Ther 2001;24:101–109.
Ann Swiss Chiropr Assoc 1965;3:111–117. 90. Mannino J. The application of neurologic reflexes to
72. Lines D. A wholistic approach to the treatment of the treatment of hypertension. J Am Osteopath Assoc
bronchial asthma in a chiropractic practice. Chiropr 1979;79:225–231.
J Aust 1993;23:4–8. 91. Long CR, Lotun K, Meeker WC, Menke JM, Plaugher
73. Bachman T, Lantz C. Management of pediatric asthma G, Shelsy A. A randomized controlled-comparison clin-
and enuresis with probable traumatic etiology. Proc ical trial of chiropractic adjustments and brief massage
Int Conf Spinal Manip 1991:14–22. treatment in patients with essential hypertension: A pilot
74. Killinger L. Chiropractic care in the treatment of study. Bournemouth, UK: International Conference on
asthma. Palmer J Chiropr Res 1995;2:74–77. Spinal Manipulation, 1996:71–72.
75. Biedermann H. Manual therapy in children: With 92. Backman T, Plaugher G. Chiropractic management
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Vernon HT, ed. The cranio-cervical syndrome: Mecha- 1993;16:544–549.
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Heinemann, 2001:207–230. tive therapy on autonomic activity and the cardio-
76. Wiberg JMM. Infantile colic: The scientific evidence for vascular system: A case study using the electrocar-
chiropractic management. Paris: Proceedings of the diogram and arterial tonometry. J Manipulative Physiol
World Federation of Chiropractic, 2001. Ther 2000;23:545–550.
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cases. J Manipulative Physiol Ther 1989;12:281–288. ulation versus sham spinal manipulation for chronic
78. Nilsson N. Infantile colic and chiropractic. Eur J Chi- otitis media with effusion in children. J Manipulative
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79. Wiberg JM, Nordensen J, Nilsson N. The short-term 95. Fallon JM. The role of the chiropractic adjustment in
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fantile colic: A randomized controlled clinical trial dia. J Clin Chiropr Pediatr 1997;2:167–183.
with a blinded observer. J Manipulative Physiol Ther 96. Edelman MJ, Fallon J. Chiropractic care of 301 children
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80. Mercer C, Nook BC. The efficacy of chiropractic spinal 1998;4:93.
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98. Peet JB. Chiropractic results with a child with recur- manipulative therapy: A prospective case study and
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99. Phillips N. Vertebral subluxation and otitis media: A 107. Carrick F. Changes in brain function after manipula-
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102. Gorman R, Stephens D. The association between 109. Kobrossi T, Steiman I. Thermographic investigation of
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314. agement of primary nocturnal enuresis. J Manipulative
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R. Bilateral simultaneous optic nerve dysfunction af- study: Multi-disciplinary care of a child with multiple
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Manipulative Physiol Ther 1999;22:615–621. 114. Araghi H. Juvenile myasthenia gravis: A case study
106. Wingfield BR, Gorman RF. Treatment of severe glau- in chiropractic management. Proc Int Conf Spinal
comatous visual field deficit by chiropractic spinal Manip 1993:122–131.
C H A P T E R
10
PUBLIC HEALTH RESPONSIBILITIES
FOR CHIROPRACTIC
Michael G. Perillo
O U T L I N E
INTRODUCTION Definition
Health Care in the Twenty-first Century Measures of Morbidity and Mortality
Definition and Characteristics of Public Health Epidemiological Practice
PUBLIC HEALTH INFRASTRUCTURE Surveillance
The Legal Basis of Public Health Investigation and Analysis
Civil Laws and Agencies Evaluation
Controversial Nature of Public Health Behavioral Health Sciences
Public Health Agencies Prevention
State Departments of Health Screening
Local Departments of Health National Disease Prevention and Health Promotion
Public Health Organizations Initiatives
American Public Health Association Healthy People 2010
World Health Organization US Preventive Services Task Force
World Federation of Chiropractic Put Prevention into Practice
THE SCIENCES OF PUBLIC HEALTH Environmental Health Sciences
Health Services Administration Immunization and Vaccine-Preventable Diseases
The National Health Care Expenditure Characteristics of Immunity
The Uninsured and Underinsured SUMMARY
Access and the Quality of Care QUESTIONS
From Fee-for-Service to Managed Care ANSWERS
Types of HMOs KEY REFERENCES
Epidemiology REFERENCES
5. To describe the components of epidemiology, in-

OBJECTIVES cluding surveillance, investigation, analysis, and
1. To define and describe the characteristics of public evaluation.
health. 6. To describe the fundamentals of clinical preventive
2. To describe the federal, state, and local infrastruc- services, including the natural history of disease,
ture of US public health resources and services. levels of prevention, screening, and counseling.
3. To describe the magnitude, sources, and trends of 7. To describe US National Health Promotion and
the US health care expenditure. Disease Prevention initiatives, including HP2010,
4. To describe common types of managed care orga- the US Preventive Services Task Force, and Put Pre-
nizations. vention into Practice.
183
This forecast, as well as those of others, clearly

INTRODUCTION
suggests that chiropractors will need to develop com-
Public health encompasses a diverse array of subjects petencies in such areas as the delivery and finance
and health-related activities in its core sciences of epi- of health care, epidemiology, population-based care,
demiology, biostatistics, health services administra- and preventive health services.2 Study in public health
tion, environmental health sciences, and behavioral sciences can provide this knowledge, as well as lay
health sciences. These areas each contain a wealth of the foundation for incorporation of these competen-
information relevant to health care providers, includ- cies into clinical practice and research. Public health
ing the foundations of evidence-based practice; the principles should be viewed as a tool in the chiro-
nature of causation, structure, and functions in the practor’s tool box of competencies needed to meet the
health care delivery system; screening and clinical pre- challenges of practice in the twenty-first century.
ventive services; and environmental and occupational
impacts on health. This chapter provides an overview Definition and Characteristics of Public Health
of the field of public health, emphasizing topics ap- Public health has been defined as:
plicable to the chiropractic student and practitioner.
The chapter begins with a brief consideration of char- The science and the art of preventing disease,
acteristics of public health, including a definition, and prolonging life, and promoting physical health
consideration of its core functions. It then presents se- and efficiency through organized community
lected topics from core sciences of public health and re- efforts for sanitation of the environment, the
lated areas. It emphasizes public health and the health control of community infections, the education
care delivery system in the United States, with a com- of the individual in principles of personal hy-
parison and an inclusion of international perspectives giene, the organization of medical and nursing
when possible. Limited historical information is pre- services for the diagnosis and preventive treat-
sented as needed to gain a perspective on some of the ment of disease, and the development of the
key developments and accomplishments in the field of social machinery which will ensure to every
public health. Examples use recent reports pertaining individual in the community a standard of liv-
to contemporary public health issues. A list of sources, ing adequate for the maintenance of health, so
suggested references, and important Internet sites is organizing these benefits as to enable every cit-
presented at the end of the chapter. izen to realize his birthright right of health and
longevity.3
Health Care in the Twenty-first Century
In the past, health care providers concerned them- This frequently cited definition has stood the test
selves primarily with the needs of the patient; twenty- of time. It is well regarded because it affords one an ap-
first century providers will face a variety of new chal- preciation of the character, broad scope, activities, and
lenges in health care. For one, they need to address participants that collectively describe modern pub-
the needs of the patient as a health care consumer, lic health. The Institute of Medicine (IOM)4 has sug-
the needs of the community, and the needs of the gested that the mission of public health is “the fulfill-
health care delivery system. To meet these challenges ment of society’s interest in assuring the conditions in
they will need to consider how to best add value to which people can be healthy,” and describes three core
their delivery of health services.1 The Pew Health public health functions in addressing this mission for
Professions Commission, in its report, “Recreating the community:
Health Professional Practice for a New Century,” of-
fered 21 competencies for health care providers, which 1. Assessment and monitoring of the health of com-
included: munities and populations at risk to identify health
problems and priorities.
1. Incorporate the multiple determinants of health in 2. Formulating public policies, in collaboration with
clinical care. communities and government leaders, designed
2. Rigorously practice preventive health care. to solve identified local and national health prob-
3. Integrate population based care and services into lems and priorities.
practice. 3. Assurance that all populations have access to ap-
4. Provide culturally sensitive care to a diverse pop- propriate and cost-effective care, including health
ulation. promotion and disease prevention services, and
5. Partner with communities in health care decisions. evaluation of the effectiveness of that care.
6. Work in interdisciplinary teams.
7. Advocate for public policy that promotes and pro- The IOM’s definition provides us with a de-
tects the health of the public.1 scription of what public health does. Both of these
PUBLIC HEALTH RESPONSIBILITIES FOR CHIROPRACTIC 185
definitions stress that the community is the primary The federal government can then shape the states’
focus of public health activities, and both stress the use public health activities by offering financial and struc-
of effective and cost-effective health care, and empha- tural support to enable the state to administrate a fed-
size preventive health services. These key concepts eral public health program on a state or local basis. The
also have direct implications for the administration of federal government can also influence public health
health care services to the individual patient. activities through its ability to regulate the quality of
Public health should be differentiated from indi- products that may come under interstate commerce
vidual patient care. Typically, a health care provider regulations. This includes, for instance, foods (meats,
treats a patient for a particular complaint. The partic- poultry, fish), drugs, and some bottled waters.
ipants, roles, and outcome are easily identified. Treat-
ment is based on a body of evidence, and ideally the Civil Laws and Agencies
patient is cured. In public health, the community or Public health laws are generally civil laws. They are
population is the patient. The primary focus is the pre- intended to direct or influence one’s future behaviors.
vention of disease in the population, rather than treat- Public health laws are usually the result of a legisla-
ment once disease has occurred. Public health practice tive act that frequently authorizes the creation of some
is based on a body of evidence from its core sciences, public agency, for instance, a state’s department of
and outcomes are measured on a population or group health or the Centers for Disease Control. The agency
level, not on the level of the individual. Public health created is granted the power to make its own rules
also requires an intact political and social system. Be- and regulations, and to retain or obtain expert opin-
cause many public health actions are aimed at pre- ion. It can move quickly and decisively on any matter
vention in the population, they require government within its mandate and range of functions. Decisions
involvement, usually in the form of public health laws about how an agency may act are not made by a jury
and agencies. or judge. Rather, they are made based on the opin-
ions of an agency’s internal (and/or external) experts.
Such decisions may be questioned by a court after
PUBLIC HEALTH INFRASTRUCTURE
the fact, as was the case for mandated immunization
To accomplish the mission and goals of public health for smallpox, and decisions to close bathhouses dur-
requires a variety of governmental public health ing the early years of the AIDS epidemic. State pub-
functions. These functions, if working properly, for lic health agencies generally will act on issues based
the most part remain unseen and largely unappre- on the police power of the state, when the health of
ciated; we typically become aware of the functions the public may be adversely impacted by some sit-
of public health when it appears that something has uation or behavior. Areas of public health law that
gone wrong. For instance, an outbreak of food or may become the focal point of public health activities
waterborne disease may be a result of a failure to typically include environmental health, disease and
properly treat potable water, or a lower-than-expected injury reporting (reportable diseases and registries),
health status of the population may be related to some vital statistics (birth and death certificates), disease
poorly working aspect of the health care delivery sys- control, involuntary testing, contact tracing, immu-
tem. This section presents the salient features of the nization, and mandated treatment.5
infrastructure and functions of public health in the
United States. Controversial Nature of Public Health
Personal freedom, individual moral judgments, and
The Legal Basis of Public Health economic interests frequently conflict with govern-
While the US Constitution does not explicitly men- mental actions taken in the interests of public health.
tion “health” with respect to the federal government, Each of the above-mentioned categories of public
it does indicate that the government is empowered health law and associated actions are designed to pro-
to “provide for the common defense and promote tect and/or enhance the health of the public. However,
the general welfare of the people. . . .” The Consti- actions such as establishing no-smoking zones to de-
tution also gives states the power to preserve the pub- crease the public’s exposure to environmental tobacco
lic health and states that “whatever reasonably tends smoke, or conducting mandatory contact tracing hear-
to preserve public health is a subject which the leg- ings to help control the transmission of sexually trans-
islature, within its police power, may take action.”5 mitted diseases, also impact the freedom or actions of
Thus, it is the state and not the federal government individuals. It is through the complex blending of fed-
that has the majority of the legal right to engage in eral and state powers that the mission of public health
public health actions. is accomplished. Concomitantly, a delicate balancing
In contrast, the federal government has the power act is required to ensure that actions taken under
to tax and spend, and to regulate interstate commerce. the police power of the state or through federal-level
activities do not infringe on the rights of the citizens quality of milk products, drugs, and meats. Today it
in such a way as to exceed benefits to the public wel- functions to ensure that foods are safe and nutritious,
fare, or go beyond that which is supported by the evi- as well as to evaluate all new drugs, food additives,
dence contained in current public health science. The colorings, and certain types of medical devices.
controversial nature of public health is the result of Description and functions of the remaining agen-
the real need to balance governmental agency activ- cies, such as the Health Resources and Services Ad-
ities on behalf of the public health, and the loss of ministration, the Indian Health Service, the Substance
rights/freedom for the individual citizens impacted Abuse and Mental Health Services Administration,
by these actions. and others can be accessed through the DHHS web
site listed below in the “Key References” section.
Public Health Agencies
The Marine Hospital Service (established in 1798) was State Departments of Health The administration of
transformed into the US Public Health Service (PHS) public health programs on a local level is carried
in 1944. The PHS has been reorganized on several oc- out by state, city, and county health departments. A
casions. Today it is regarded as a functional organiza- state department of health typically sets the agenda
tional unit of the Department of Health and Human for health and public activities and functions in that
Services (DHHS), which is the primary federal cabinet state. Its functions closely follow the public health ap-
department concerned with the health and welfare of proach to health problems: (a) define the health prob-
the American public. The PHS consists of eight agen- lem; (b) identify the risk factors; (c) develop and test
cies, several of which are discussed below.6 community-level interventions to control or prevent
The National Institutes of Health (NIH) is one of the cause of the problem; (d) implement interventions
the larger and best known agencies of the PHS. It was to improve the health of the population; and (e) mon-
formed from the original hygienic lab in the United itor those interventions to assess their effectiveness.
States, also part of the old Marine Hospital Service. Table 10–17 highlights some of these functions.
Its primary function is to provide funding for both in-
tramural (within and by NIH itself) and extramural Local Departments of Health The local health depart-
(by entities outside of NIH) basic health sciences re- ment’s mission is to protect, promote, and maintain
search. By 2000, NIH had 25 institutes, centers, and the health of all peoples in its jurisdiction. There are
divisions, including the National Center for Comple-
mentary and Alternative Medicine (NCCAM), the Na-
tional Library of Medicine, and the Office of AIDS Functions of State Health
TABLE 10–1.
Research. Department
Another agency within the PHS is the Centers for
Disease Control and Prevention (CDC), which func- Area Functions
tions as the major agency responsible for the protec-
tion of the American public against sickness and dis- Health information Collecting and publishing birth,
ease, both acute and chronic in nature. It was formed death, and various health
shortly after World War II, when it was realized that statistics; may maintain disease
there was a need for an agency complementary to the registries
NIH, but concerned primarily with applied, or “in the Disease and disability Screening programs, investigating
field,” health sciences research. The CDC contains di- prevention disease outbreaks, testing
visions such as the National Center for Health Statis- infectious diseases, immunization
tics, whose primary function is to collect, analyze, and programs, TB control, AIDS
disseminate health data in the United States and to prevention and counseling
administer the National Health Interview Surveys, an programs
important source of public health data. Health protection Environmental health issues: water
The Centers for Medicare and Medicaid Services, quality, inspection of dairies and
formerly known as Health Care Financing Adminis- restaurants, licensing functions
tration (HCFA), is the agency that administers Medi- Health promotion Women, Infants, and Children (WIC)
caid policies, and all aspects of Medicare. In addition, programs, prenatal care, family
it compiles and publishes detailed statistical informa- planning, dental services, school
tion about the national health care expenditure and a health education programs
variety of national and state health status indicators. Improving health care Rural health polices, certificates of
The Food and Drug Administration (FDA) is a delivery need
well-known component of the PHS. Its main function
Adapted from Dandoy S. The state department of health. In: Scutchfield
is the regulation of the food and drug industries. It was DF, Keck CW. Principles of public health practice. Albany, NY: Delmar,
formed in the early 1900s to address such issues as the 1997:57–58.
about 3000 local (e.g., city, county, district) health de- through the application of chiropractic knowledge
partments nationwide whose functions are similar to to the community by conservative care, disease pre-
those of the state department of health, but attuned vention, and health promotion. Its activities are sup-
to local population needs. These include (a) local dis- ported by some several hundred members, including
ease surveillance and epidemic control; (b) access to instructors of public health at chiropractic colleges, re-
laboratory testing (especially for sexually transmit- searchers, private practitioners, national chiropractic
ted diseases [STDs]); (c) providing a safe and healthy organizations, and many chiropractic colleges.
environment; (d) performing targeted outreach pro- Membership and participation in APHA is an im-
grams (such as Women, Infants, and Children (WIC), portant and valuable asset to the chiropractic profes-
teen pregnancy, HIV counseling, testing, and refer- sion. Today, the American Public Health Association
ral); (e) promoting healthy lifestyles; and (f) providing is the largest and most influential public health or-
health education and personal health care services. It ganization in the world. It currently represents about
has been reported that about 40 million Americans 50,000 members worldwide, from more than 50 dif-
(yearly) turn to their local health department for var- ferent public health–related occupations. With mem-
ious types of personal health care services that would bership, we accept the responsibility to contribute to
typically be rendered in a private practitioner’s office. public health developments in chiropractic science
These services range from dental care to immuniza- and policy issues, and have the opportunity to rep-
tions and well-baby care.8 resent the profession and network with other health
care professionals in education, public health practice,
and public health agencies. Furthermore, through the
Public Health Organizations Chiropractic Healthcare Section, we have the oppor-
American Public Health Association The American Pub- tunity to ensure greater recognition of the profession,
lic Health Association (APHA) was formed in 1872 by and include its views during the grassroots discus-
Steven Smith, MD, and a group of nine other health sions and formulation of policy statements, which are
and social reformers, including physicians and an ar- promoted nationally, and often worldwide.
chitect. At the time, living conditions and health and
social reform were deservedly receiving much atten- World Health Organization The World Health Organiza-
tion. The organization’s goal was the “advancement tion (WHO) was founded in 1946 as a special agency
of sanitary science and the promotion of organizations within the terms of Article 57 of the charter of the
and measures for the practical application of pub- United Nations (UN). Concerns at the time stemmed
lic hygiene.”9 It stressed nonphysician membership, from the health conditions that resulted from World
health administration, communicable disease control, War II, particularly in Europe, and the desire to cre-
WIC programs, health education, and a variety of ate a “single (international) health organization.” The
other areas that today are commonly performed by WHO’s involvement in health was to be broad-based
state and local health departments. Early members and included issues of medical practice, hospitaliza-
included physicians, public health sanitarians, pub- tion, social diseases, health education, medical train-
lic engineers, and epidemiologists. ing, and research on an international basis, and to have
The chiropractic profession’s participation with representatives from all member states of the UN.11,12
APHA was formally recognized in 1984 with the for- The objective of the WHO is “the attainment by
mation of the Chiropractic Forum, designated a spe- all peoples of the highest possible level of health,”
cial primary interest group. This was a tremendous addressed through 22 functions, including:
accomplishment. However, special primary interest
group status did not include direct representation or 1. Acting as the directing and codirecting interna-
voting on the governing council, the leadership body tional authority on health work.
of APHA. This is reserved for groups that have at- 2. Assisting governments on request to strengthen
tained the status of a section. This required a larger health services.
membership and a record of consistent participation 3. Working toward the eradication of epidemic, en-
with APHA programs and meetings. The Chiroprac- demic, and other diseases.
tic Forum engaged in scientific paper and poster pre- 4. Promoting in cooperation with other agencies the
sentations, and had successful membership drives. In prevention of accidents and improvement of nu-
1994, a group of Chiropractic Forum members offi- trition, housing, and environmental hygiene.12
cially began work on an application to attain section
status. After debate by the governing council, the ap- WHO has numerous international public health
plication was passed, and the Chiropractic Health- activities including:
care Section was formed as the twenty-fifth section
of the APHA in 1995.10 The object of the Chiroprac- 1. Polio Eradication 2005, a program for worldwide
tic Healthcare Section is to enhance public health eradication of polio by 2005.
2. Africa Malaria Day, a campaign to call attention to developed in many European and Scandinavian coun-
the dramatic need for malaria prevention methods tries, where health care is predominantly financed
in many African countries. through public sources and is available to all through
3. World Health Day, a campaign to dramatize the government- or employer-sponsored plans.
importance of access and care for mental health The total US health care expenditure can be di-
conditions. vided into two main categories. One is the personal
4. World No Tobacco Day, a campaign to highlight health expenditure, which represents the costs associ-
the health dangers of secondhand or environmen- ated with the delivery of health care to the population,
tal tobacco smoke. including health care services (hospital, ambulatory,
personal) and supplies (drugs). The second compo-
World Federation of Chiropractic The World Federation nent is money spent for research, medical facilities,
of Chiropractic (WFC), founded in 1988, is a non- and other public health services, and administrative
governmental organization member of the WHO. costs of public programs. For the past several years
Its primary function is to support international the personal health expenditure has averaged approx-
health programs of the WHO. The WFC, through imately 90% of the total expenditure. The other ser-
its “Health-for-All” committee, monitors WHO pro- vices, including funding for public health activities,
grams, projects, and priorities, and works toward co- have averaged approximately 10% combined.
ordinating the WFC’s activities in support of many of The United States spends more on health care than
the WHO programs outlined above. Current activities any other developed nation in the world. For exam-
include continuing its support of the WHO’s world- ple, in 1996, the per capita health care expenditures
wide antitobacco initiative, the Framework Conven- for Canada and Switzerland were about $2000 and
tion on Tobacco Control and its support group, the $2400, respectively14 ; for the United States, it was
Framework Convention Alliance, of which WFC is a about $3700.15 The United States finances its health
member.13 care very differently, but some strong trends have
emerged. In 1960, 75% of the health care expenditure
was financed by private sources (patients and private
THE SCIENCES OF PUBLIC HEALTH insurance) and 25% from public sources (government-
sponsored programs such as Medicare, Medicaid, Vet-
Health Services Administration
erans Administration). By 1999, this proportion had
Health services administration, or health policy and changed considerably, with private costs reduced to
management, is the area of public health concerned 55% and public costs increased to 45%.15 By contrast,
with the analysis and formulation of health policy to the private/public proportion is 29/71% in Canada
address issues related to the US health care delivery and 21/79% in Japan.14 The largest shift to public fi-
system and the health status of the American people. It nancing occurred from 1960–1980, primarily as a re-
may use information generated from various areas of sult of the 1965 addition of Medicare and Medicaid to
public health, but concentrates on the relationship be- the Social Security Act.
tween the cost, access, and quality of available health Although there are two primary sources of funds
services and the health of the public. This section con- spent to finance health care, public and private, the
siders the magnitude, composition, and trends of the principal difference between these two sources is the
US health care expenditure. route the money takes to get to its final destination.
The United States spends the most of any nation The real source is the same, the citizens of the coun-
on health care, and this amount is rapidly increas- try in question. Public sources include monies col-
ing. The system has also transitioned from mostly pri- lected by the government in the form of taxes, fees, or
vate financing to an even split public–private financ- contributions and expended through such programs
ing. Despite the expense, the health of Americans and as Medicare, Medicaid, workers’ compensation pro-
the quality of care they receive are questioned, and a grams, veterans’ and Department of Defense health
growing segment of the population remains outside coverage.16 Most nations have analogous programs
the system, either without health insurance, or with and organizations. In the United States, the bulk of
access problems in spite of their insurance. the funds are spent through Medicare and Medicaid
programs.
The National Health Care Expenditure Medicare is designed to provide health care ser-
The current US health care delivery system and the vices for those Americans older than 65 years of age.
associated health care expenditure represent a com- Medicare consists of Part A, which pays for care ren-
plicated combination of public and private financing dered in hospitals, and Part B, which covers certain
and widely varying delivery systems. It is much more costs of care in physicians’ offices and some other
costly and differs from the current systems that have medical expenses. Medicare A/B does not include
payment for prescription drugs, although recent legis- employed; many were self-employed at least part of
lation passed by Congress may change this. Medicare the time they were without insurance. Many (40% in
costs represented about 40% of the total public pay- one study) had access to employer-sponsored plans,
ment in 1998.17 but most reported high cost or the lack of such plans
Medicaid is a generic name for 50 different US state as primary reasons for not having insurance. Only 1
programs of insurance. It is jointly run and financed by in 10 reported choosing to not have coverage.24 Most
federal and state monies, and is designed to cover care were from households within 100–150% of the federal
for the aged poor, the blind, the disabled, and families poverty level and so were not eligible for Medicaid.23
with dependent children if one parent is absent, un- The problem is apparently not solely a result of un-
employed, or unable to work. It covers four different employment or a choice to do without health insur-
areas of services: (a) inpatient and outpatient hospi- ance. Rather, it is related to a combination of lack of
tal care; (b) laboratory and x-ray services; (c) physi- employer-based insurance plans and ineligibility for
cian services (if included in that state’s program); and Medicaid.
(d) nursing facility care for persons older than age 21
years. Medicaid is restricted to those with very low in- Access and the Quality of Care
comes, with eligibility determined by the states based Quality of care refers to the degree to which health
on the federal poverty level (about $16,700 in 1997).18 services for individuals and populations increase the
In 1998, federal and state funding for Medicaid totaled likelihood of desired health outcomes and are consis-
approximately 27% of the public payment.17 tent with current professional knowledge.25 Quality
There are two primary sources of private rev- of care has several measurable components, including
enues in the health care expenditure. One is direct structure, process, health outcome, and patient satis-
payment from patients receiving health care services, faction. This discussion will focus primarily on issues
the so-called out-of-pocket payment, and the other related to cost and access, with limited consideration
is payments made by private insurance for patient of quality. An in-depth consideration of the quality of
services. The out-of-pocket payment has decreased care can be found in the work of Donnabedian, and in
considerably, from approximately 55% in 1960 to ap- the text by Graham (see “Key References” below).
proximately 19% in 1998. The private insurance por- The public health relevance of the quality–access
tion has remained constant at 31–33% during the relationship is the impact this has on the health of the
same period.19 Most of the initial decrease was re- nation, as well as policy issues that arise when con-
lated to the advent of public sources (Medicare and sidering strategies to reduce the problem. A common
Medicaid). More recently, the decrease is the result public concern is that the quality of care, as demon-
of slower growth in private insurance, coupled with strated by leading health status indicators, would suf-
large growth in managed care programs. fer with efforts to contain and decrease the health care
expenditure. Some international data suggests that
The Uninsured and Underinsured this may not be so. For instance, the life expectancy
To have access to health care has been defined as the for Canadian females is 81 years at birth and 20 years
timely use of personal health services to achieve the at age 65 years, and the infant mortality rate is 6/1000.
best possible health outcomes.20 The National Health In Japan, comparable rates are 83 years at birth, and
Insurance system of the United Kingdom is one of the 21 years at age 65 years, and the infant mortality rate
oldest such systems in the world, and likely the most is 4.3. In the United States, female life expectancy is
well studied. Like many other national health insur- 79 years at birth and 19 years at age 65 years, and
ance systems, it is not without service and cost prob- the infant mortality rate is 8/1000 live births.14 Yet,
lems. However, it is financed directly through general as previously discussed, the cost of care in the United
tax revenues, is free of charge, and is accessible to all States is several times greater than these nations. Cau-
British subjects and to all legal residents. In the United tion must be exercised to not overinterpret these statis-
States, by contrast, more than 44 million Americans tics, as morbidity and mortality are subject to various
(approximately 16%) are uninsured at any given time determinants of health. However, they do cast some
(1998).21 In addition, some 50–60 million more Amer- doubt on the notion that “he who spends the most gets
icans may be uninsured at some time during a given the best.”
calendar year22 and millions more are estimated to be
underinsured, having coverage that does not finan- From Fee-for-Service to Managed Care
cially allow them access to needed care. For most of the twentieth century, payment for
Who are the uninsured? In 1998, 25% were 18– health care services in the United States, particu-
34-year-olds, 12% were children younger than age larly in the ambulatory care setting, was on a fee-
6 years; 34% were Hispanic, 21% were black, and 15% for-service basis; that is, once services were deliv-
were white.23 A large segment (70% in one study) were ered, the provider would bill either the patient directly
(private out-of-pocket cost) or the insurance carrier Types of HMOs There are several types, or models,
for the patient (private insurance coverage). The rate of HMO.28 In the staff model, physicians are direct
or value would be determined by the provider, usu- employees of the HMO, practice in HMO-owned
ally based on geographic area, termed the “usual and facilities, are paid a salary (plus bonus), and have little
customary” rate. Most insurance coverage was of the (if any) financial risk, but also have limited financial
traditional indemnity type, obtained through not-for- incentive in the selection of services delivered. Dis-
profit Blue Cross/Blue Shield plans, other for-profit advantages to staff-model HMOs include the need to
commercial carriers, or employer-sponsored insur- establish one or more centralized facilities for patient
ance plans. For a variety of reasons, some unique care, physician pay, limited marketability because of
to fee-for-service, the cost of health care rose year small provider base and few locations, and the need
by year. Despite this increase in cost, disparities in to contract out to other groups and/or hospitals for
quality, access, and health status were still rampant. services not provided in the center. This results in a
Over the past two decades, rather than continuing large financial risk to the HMO.
to respond to these problems with more money, the In the group model, the HMO contracts with
new approach in health care has been to reduce costs one multispecialty group to provide all services. The
through increased management, hence the birth of physicians are employed by the group, not the HMO,
managed care. By 1999, about 81 million Americans the facilities usually belong to the group, and the con-
were included in some of 643 different health main- tract may be on a capitated or cost basis. Variants are
tenance organizations (HMOs), with perhaps similar the captive model, where the group can treat only a
numbers in preferred provider organizations (PPOs). specific HMO’s enrollees, and the independent model,
The result is that approximately 75% of insured peo- where the group treats both HMO and non-HMO pa-
ple in the United States are in some type of managed tients. The group has control over practice patterns
care plan, with the remainder in conventional fee-for- but also disadvantages similar to the staff model.
service plans.26 Kaiser-Permanente is an example of a captive group
Managed care refers to a variety of techniques that model.
can be used by an insurer, or an employer, to gain In the network model, the HMO contracts with
some control over the utilization and cost of health several groups to provide either multispecialty or
care services by the enrollees. These techniques can primary care. The multispecialty type resembles the
be of a financial nature (capitation, deductibles, co- group model, in that the group must supply all ser-
payments) or service nature (care pathways, clinical vices. In the primary care variant, groups represent
preventive services or well-care visits).27 These tech- most types of primary care providers, the primary
niques can be used by any type of health care organi- contract is capitated, and the network must pay (out
zation. An HMO is an organized health care system of their pool) other physicians for services they cannot
responsible for both the financing and the provision of provide themselves.
a broad range of comprehensive health services to an The HMO or separate health insurer may con-
enrolled population, usually for a prearranged fee. It tract with an independent practice association (IPA)
is thus a combination of a health insurer and a health of physicians who practice in their own offices and
care provider system, and is just one type of managed treat both HMO and non-HMO patients. In theory,
care organization. At inception, these and other types the association represents the professional and finan-
of HMO plans allowed physicians to offer patients two cial interests of the providers. Services may be broad
types of arrangements: prepaid and fee-for-service. or limited. Payment is from the HMO to the IPA on a
This was a distinct advantage. Inherent in these mod- capitated basis. The IPA, in turn, can pay providers
els and varying by type is the disadvantage that the with a simple fee-for-service or with some type of
health care provider accept “some” financial risk for capitation. Also, a portion of the fee may be with-
the delivery of health care services for a fixed, prepaid held pending analysis of monthly or yearly costs.
amount. Consequently, providers may have substantial risk.
There are a number of different types of managed This continues to be the most rapidly expanding type
care organizations, typically varying by the setting of managed care organization, providing care to ap-
in which health services are rendered and how pay- proximately 40% of the 81 million HMO enrollees in
ment is made. Many include some form of capitation 1998.27
where the total pool of money for the services of the Other types of managed care organizations include
enrolled population is determined in advance. Either the PPO, the exclusive provider organization (EPO),
the provider(s), or the managed care company, or both point of service (POS), and a variety of employer-
may be at financial risk if the total pool turns out to be sponsored plans (ERISA). A detailed discussion of
less than needed to care for the population of patients these plans and other aspects of managed care can
at the end of the contract period. be found in the text by Kongstvedt.28
Epidemiology (some health-related status). A typical example would

Epidemiology is regarded as the foundation of pub- be the exposure to tobacco by smoking, a voluntary
lic health. It is a very broad field, and includes sev- behavior, and the subsequent development of lung
eral components: (a) surveillance, including sources cancer as an outcome.
of epidemiological data; (b) investigation, including Epidemiology has many uses in public health, in-
common study types; (c) analysis, including causal cluding (a) monitoring of disease frequency and pat-
relationship and biases; (d) issues related to the use terns of disease (disease surveillance); (b) clarifying
of information in the clinical setting; and (e) evalua- disease causation by identifying true disease risk fac-
tion. Biostatistics is also essential to public health. It tors; (c) providing description of the natural history
serves to display and interpretation of the findings of or the typical sequence of events of a disease or con-
epidemiological and other types of studies. By the use dition; (d) testing to determine the effectiveness of
of inferential statistics, one can apply the results of an screening in preventive health services; and (e) test-
investigation on a target or sample population to the ing new treatments or interventions on a population
greater population. Only those areas of biostatistics basis.
relevant to understanding the common study types
found in the public health literature are presented in Measures of Morbidity and Mortality A central function
this chapter. of epidemiology is the counting and categorizing of
people based on their exposures to a variety of pos-
Definition Epidemiology is defined as the study of the sible causes or risk factors for diseases, as well as the
distribution and determinants of health-related states health outcome. Health outcome is probably a more
or events in specified populations, and the application appropriate way to think about this, because it allows
of this knowledge to control health problems.29 There us to consider and apply these methods of study of
are two different components to this definition. One is many different health-related states, both acute and
concerned with the methods of epidemiological study chronic in nature. This type of counting and measure-
and determining distribution and determinants. The ment is frequently referred to as a measure of morbid-
other component, more uniquely public health in na- ity (disease status) or mortality. This type of measure-
ture, involves the use of this information to prevent ment begins with a consideration of the distribution of
and control health problems. the disease or condition by describing the basic char-
Distribution refers to the occurrence of health- acteristics of the event in terms of person, place, and
related events or conditions in a population, described time.
by person, place, and time. Determinants of health re- Another way to analyze the distribution of disease
fer to any of the various factors that an individual is by observing its rate measures, which describe how
may have or experience that may influence health. the frequency of a disease may have changed over
These are usually divided into two categories: genetic time. In measuring the frequency of disease or out-
and behavioral. Genetic or hereditary determinants come, it is necessary to do two things: (a) to have a
include characteristics such as age, gender, and race; “definition” of who or what constitutes a case, and
these are not characteristics we choose. In contrast, (b) to know that this case comes from a particular
most behavioral determinants include such factors as population, called the population at risk. These items
physical and biological exposures, personality, social are needed to calculate a rate, which is defined as the
variables such as housing, income, occupation, edu- amount of cases from a given population at risk, in
cation (socioeconomic status), and cultural and spiri- some unit of time.
tual views. Because many of these characteristics can Incidence is the rate of new cases of a condition or
be modified and hence reduced, they receive much disease in a defined population over a defined period
attention from public health in the form of preven- of time. Alternatively, this can be considered the prob-
tion initiatives, and from health professionals during ability that a healthy person in a given population will
individual patient encounters. develop the disease or condition in that period of time.
Epidemiology stresses a focus on human popula- Incidence rates are useful in identifying the cause of
tions and the concept that diseases are more the re- disease by studying those from the population at risk
sult of an individual’s genetic and behavioral deter- who develop a condition.30 For example, if 100 new
minants and not simply the result of a cosmic roll of the cases of prostatic cancer were detected in a population
dice. The epidemiological approach stresses the use of of 10,000 noncancerous men over a 1-year period, the
observational studies. Observational studies examine incidence rate would be 100/10,000 = 0.01, or 1/100
the development of diseases in people by observing per year.
populations in the environments in which they ex- Prevalence is the total number of existing cases of a
ist. These methods then seek to describe the possible condition or disease in a defined population. It can be
relationships between these exposures and outcomes measured at a point in time, called point prevalence, or
during some point in time, called period prevalence. The government sponsors a number of major
Because it provides a measure of all of the people with large-scale surveys to determine the health of the pop-
a given condition, prevalence is used to estimate the ulation. For example, the National Health and Nu-
burden that a condition or disease places on a pop- trition Examination Survey (NHANES) was created
ulation, particularly for health care and manpower through the National Study of Health and Activity,
planning.30 For instance, a survey asked a population surveys civilian noninstitutionalized persons age 1–
of women if they smoked at any time over the past 74 years, and also performs physical and laboratory
year and 100 of 1000 responded yes; the period preva- examinations. NHANES III, the most recent edition,
lence is 10% for the year. was conducted from 1988–1994. During this time,
Incidence and prevalence are related by what is teams of physicians and nurses conducted interviews
commonly referred to as the prevalence plot. Preva- and examinations of some 30,000 participants, cover-
lence (P) approximately equals incidence (I) × dura- ing such areas as hypertension, cholesterol, blood lead
tion (D) (P = I × D). Once the condition has occurred levels, obesity, and allergies. Because of the physical
(incidence), the person can either become well, suc- examination portion, NHANES is considered a de-
cumb to the disease, or remain affected (prevalence). tailed and highly accurate population-based source
The longer the person remains affected, the greater of health status data. NHANES IV began in 1999 and
the prevalence. This is common in chronic conditions, will reach about 5000 people annually.31
such as arthritis, and in some forms of heart disease. The Behavioral Risk Factor Surveillance System
(BRFSS) was begun in 1984 to monitor state-level
Epidemiological Practice prevalence of major behavioral risks in adults. The
Epidemiological methods used for public health prac- Surveillance, Epidemiology, and End Result (SEER)
tice are (a) surveillance, (b) investigation and analysis, program is a cancer surveillance system conducted
and (c) evaluation. The sequence provides a program- by the National Cancer Institute since 1971; it col-
matic approach to monitor and address problems in lects cancer data on a routine basis from designated
health status of most any population. population-based cancer registries in a number of ar-
eas throughout the United States. The National Health
Surveillance Surveillance is the ongoing systematic Interview Survey (NHIS) is a population-based gen-
collection, analysis, interpretation, and dissemination eral household survey of noninstitutionalized civil-
of data about the occurrence of diseases to those ians, with continuous weekly sampling to ensure a
who contribute to the surveillance process, as well as representative population.
the public. The purpose of surveillance is to observe Public health surveillance of reportable diseases
trends over time in the person, place, and timing of and conditions in the United States, and in many parts
incidence and/or prevalence of diseases, new or old, of the world today, is based on a system of data col-
and then use this information to help control or pre- lection about diseases or conditions considered im-
vent the disease. An example is the initial reporting of portant to humankind. Communicability and ability
Pneumocystis carinii pneumonia, an infrequently en- to successfully treat are usually important considera-
countered opportunistic infection in otherwise pre- tions. There are some 60 diseases and conditions that
viously healthy gay men in 1981. This observation are reportable today, as decided on by the CDC and
marked the beginning of the HIV/AIDS epidemic in the Council of State and Territorial Epidemiologists
the United States, and is an example of how surveil- (CSTE). This list changes frequently, although the last
lance can be used to discover previously unknown major revision was 1996.31
diseases.
A census of the US population is required by the Investigation and AnalysisLarge amounts of descriptive
US Constitution every 10 years. This enumeration is data are collected during surveillance. An investiga-
used to determine each state’s representation in the tion, in contrast, is a limited action to determine a
House of Representatives. However, this information possible relationship between an exposure and an
also serves several important public health functions. outcome, once existing information (surveillance or
It provides a detailed picture of the population with otherwise) suggests that some type of problem or as-
respect to geographic location, age, sex, and ethnicity. sociation may exist.
It also captures detailed information pertaining to the In observational studies, exposure to the study
socioeconomic status of the population, in terms of variable (physical activity, smoking, use of alcohol,
economics, housing, health insurance, and education. unprotected sex, etc.) is not controlled by the investi-
This data can form the basis for a variety of cross- gator, as in an experiment. Rather, epidemiology seeks
sectional studies and is commonly used to form the to study people in their natural environment, observ-
denominator (population at risk) for a rate in a speci- ing the patterns of exposure and development of dis-
fied geographic region.31 ease as they would occur “naturally.” This is thought
to be more reflective of the real world, for it observes included, and were followed twice the first year, then
the outcome in people who may have many different once per year. Outcome was based on self-reports and
exposures to many different variables, both sporadi- a review of medical records, death certificates, and
cally and simultaneously. At the same time, it carries autopsy reports. The findings suggest that the expo-
the caveat to not jump to conclusions based on any sure (to physical activity in this case) is protective,
one study, because there may be a number of possible that is, it lowers the risk of coronary heart disease in
explanations for the results. women.32
There are two different types of observational Epidemiology practice is concerned about cause-
studies: descriptive studies and analytic observational and-effect relationships and has developed detailed
studies. Descriptive studies use the elements of per- methods to help public health policy makers. For ex-
son, place, and time as a means of describing a disease ample, about 50 studies over the past 25 years have ex-
or condition in a population. When little is known amined the nature of the relationship between smok-
about the relationship between an exposure and an ing and low back pain. Smoking is a significant public
outcome, person, place, and time are examined to see health problem that has a number of documented ef-
if any particular patterns emerge. For example, a pat- fects on health status, all of them negative. Low back
tern may be found between a gender, age, type of em- pain is a very common cause of disability and loss of
ployment, physical activity, or use of alcohol, and the workdays, and also is a significant public health prob-
development of some particular condition. Descrip- lem. But does smoking cause low back pain? Many
tive studies are not able to confirm such a relationship. studies suggest that it does.33 When should we be con-
However, observation of such a pattern suggests that vinced that exposure truly causes a particular disease
an analytic or hypothesis testing type study is war- or condition? To establish a relationship as causal re-
ranted. quires that all the information about a possible risk
Analytic studies are able to test the hypothesis that factor is considered subject to formal criteria. Modern
a relationship exists between an exposure and some concepts of causality were advanced by Sir Austin
outcome. They are usually performed after descrip- Bradford Hill in the mid-1960s, associated with the
tive studies suggest that an exposure–disease rela- then emerging discussion on the relation of cigarette
tionship exists. In a cross-sectional study, frequently smoking and lung cancer. He originally suggested
called a prevalence study, either the exposure vari- nine categories, of which five are commonly cited
able and/or the outcome variable may be measured (Table 10–2).31
at the same time. For instance, a study may ask respon- Studies on the smoking–low-back-pain relation-
dents whether they have a particular exposure and a ship have been evaluated according to these criteria,
particular disease at the time the time the study was and particularly with strength of association, dose–
administered. These studies are not able to establish a response, temporality, and consistency. The conclu-
temporal relationship between exposure and disease, sion was that the relationship is weak at best, and that
and therefore not able to establish a cause-and-effect smoking may not be considered a cause of low back
relationship. pain at this time.33
Prospective studies, often called cohort studies,
as the name suggests, proceed forward in time from This refers to the scientific process of de-
Evaluation
some point of initiation. A cohort (a group of peo- termining the effectiveness and safety of a given
ple with something in common, e.g., race, occupation,
some exposure status) is identified as the study popu-
TABLE 10–2. Concepts of Causal Relationship
lation. For example, a recent large-scale cohort study
examined the relationship between physical activity,
Strength of Large increases in risk with
particularly walking, and coronary heart disease in
association exposure
women. The study followed a cohort of some 39,372 fe-
Consistency on Observed in different populations,
male health professionals (nurses) in the United States
repetition at different times, using
and Puerto Rico prospectively from 1992 to 1999. It
different study designs
used questionnaires to establish demographic data on
Temporal sequence The exposure occurs before the
possible risk factors for coronary heart disease, such as
outcome develops
smoking, alcohol, history of elevated cholesterol, dia-
Dose–response The more exposure, the greater
betes, and hypertension. It also collected the amount
the occurrence of the outcome
and intensity (pace or rate) of physical activities, such
Biologic plausibility Fits with current knowledge of the
as walking, running, cycling, aerobic exercises of var-
disease
ious types, stretching, yoga, racket sports, and swim-
ming. Study participants had to be free of coronary Adapted from Friis RH, Sellers TA. Epidemiology for public health prac-
heart and cerebrovascular disease and cancer to be tice, 2nd ed. Gaithersburg, MD: 1999:281–304.
intervention or program that is intended to control or designed to change personal health behaviors of pa-
prevent a health problem. In the context of evaluation, tients before clinical diseases develop represent a po-
effectiveness refers to or is determined during the ac- tentially fertile area of public health and clinical prac-
tual use of the intervention in a prescribed population. tice activities.36
Efficacy generally refers to the benefit of an interven- Sickness and disease are not usually all or none
tion as demonstrated during a randomized controlled matters. One may have varying degrees and stages of
trial, where exposures are assigned to the participants health and disease. The state of susceptibility is where
by researchers in an experiment. Efficiency refers to the no disease is manifest, but as a result of the existence
demonstration that the intervention in question is also of risk factors, possibly genetic in nature, disease is
cost-effective and time-effective. more likely. The preclinical stage is marked by the oc-
currence of pathogenesis of disease but with no symp-
Behavioral Health Sciences tomatic expression. In this case, disease is still below
Prevention of disease and disability is a basic goal the “clinical horizon,” but changes have begun to take
of public health. The very notion of prevention is place. The clinical phase of disease is the one clinicians
certainly appealing and congruent with chiropractic are most familiar with. This is the phase when most
principles. The United States has a detailed disease people go to doctors because they have symptoms and
prevention/health promotion program for the nation are looking for assistance and rapid resolution. At this
in the form of Healthy People 2010, which is based point several things may happen. The patient gets well
on a variety of concepts and functions in the areas of and returns at least to the preclinical phase or the pa-
screening, health behaviors, and a related battery of tient succumbs to the condition. More often, the pa-
clinical preventive services. tient retains some measure of dysfunction associated
The leading causes of death in the United States with the disease or condition and remains in the final
in the early 1900s were primarily related to infectious phase of the continuum, that of the stage of disability.31
diseases such as pneumonia, TB, and nonspecific en-
teritis. Cancer and heart diseases were much lower Prevention
on the list. By contrast, in 1980, the leading causes of A principal effort of public health is to advance the
death had changed dramatically, with two-thirds of detection and intervention in the disease process to
the deaths attributable to diseases of the heart, can- a point where precursors and risk factors are being
cers, stroke, and accidents. This trend remained for dealt with, as opposed to end-stage disability. This
1998 (Table 10–3).34,35 suggests that the emphasis should be on prevention,
The current leading causes of death and disability not curative procedures. Prevention is intimately tied
in the United States are generally the result of behav- to provider training and workload, patient coopera-
iors such as smoking, use of alcohol, and drug use; tion and compliance, and the ability to identify risk
injury; violence; and exposures to the environment; factors and disease during the early stages. Preven-
Accessibility to, and quality of, health care services are tion is also a matter of effective intervention; the abil-
also important determinants of health. This suggests ity to detect a problem does not automatically mean
that disease prevention/health promotion programs something can be done about it (Table 10–4). There
TABLE 10–3. Leading Causes of Death in the United States in Years 1900, 1980, and 1998
1900 1980 1998
Pneumonia 12% Heart disease 38% Heart disease 31%

Tuberculosis 11% Neoplasms 21% Neoplasms 23%
Diarrhea/enteritis 8% Cerebrovascular 9% Cerebrovascular 7%
Heart disease 6% Injuries 5% Chronic obstructive pulmonary disease 5%
Liver disease 5% Chronic obstructive pulmonary disease 3% Injuries 4%
Injuries 4% Pneumonia/influenza 3% Pneumonia/influenza 4%
Cancer 4% Diabetes mellitus 2% Diabetes mellitus 3%
Senility 3% Liver disease 2% Suicide 1%
Diphtheria 2% Atherosclerosis 1% Nephritis/nephrosis 1%
Suicide 1% Liver disease 1%
Adapted from US Department of Health and Human Services. HP2010: Understanding and improving health. Washington DC, US DHHS, 2000, and
National Center for Health Statistics population web site.
TABLE 10–4. Combined Phases of Disease and Levels of Prevention
Stages of Disease Susceptibility Preclinical Clinical Disease Disability/Recovery
Tissue changes Prepathogenesis Pathogenesis Resolution/sequelae

←− −→
Levels of prevention Primary Secondary Tertiary
←− −→
Modes of intervention Health: promotion, specific Detection: screening, early Treatment and rehabilitation
protection diagnosis, prompt Limitation of disability
treatment ←− −→
are three recognized levels of prevention, which are 2. The natural history of the disease should be un-
directly tied to the natural history of disease: derstood.
3. The disease must have a recognizable latent or
Primary: The prevention of disease, typically by presymptomatic stage.
changing susceptibility or decreasing exposure to 4. The screening test should be a suitable and accept-
known risk factors, performed in the stage of sus- able to the population.
ceptibility. 5. There should be an effective and accepted treat-
Secondary: The early detection and treatment of dis- ment.
ease, performed in the preclinical phase. 6. There should be an agreed-on policy concerning
Tertiary: Treatment of the disability of a disease, whom to treat as patients.
including attempts to restore functioning, per- 7. Cost of case finding and case treatment should be
formed in the stage of disability.36 balanced.
8. Case finding should be a continuous process.
Screening
Screening is defined as the presumptive identifica- National Disease Prevention and Health
tion of unrecognized disease or defect by the appli- Promotion Initiatives
cation of tests, examination, or other procedures that We have examined a variety of concepts in the area of
can rapidly sort out apparently well persons who prevention including stages of disease, levels of pre-
probably have disease from those who probably do vention, and fundamental of screening. Put to use in
not. Common examples include Papanicolaou (Pap) the field, this constitutes health promotion, the use
smears, mammography exams, and fecal occult blood of clinical preventive services and prevention pro-
tests. Screening is not a diagnostic test. Persons with grams to actually lessen the incidence of disease. There
“positive” screening exams must be referred for diag- are several important national health disease preven-
nosis and treatment. Screening is associated with section/health promotion initiatives that are designed to
ondary prevention and targets the population that is accomplish this.
in the preclinical (presymptomatic) stage of disease.
Screening is based on two assumptions: (a) Persons Healthy People 2010 Healthy People 2010 (HP2010) is
with a disease can be identified by means of “screen- a comprehensive, nationwide, health promotion and
ing” or testing, before the time of routine diagnosis as disease prevention agenda. It is designed to serve as
a result of symptoms; and (b) treatment at the time of a blueprint for a 10-year strategy for improving the
detection by screening, rather than at the time of rou- health of all people in the United States.34 HP2010 was
tine diagnosis, may result in decreased morbidity or formulated by the Healthy People Consortium, an al-
mortality. A proposed screening program must satisfy liance of public health and health experts from some
both of these assumptions. 350 national organizations and 250 state public health,
Considerations for screening include a combina- mental health, substance abuse, and environmental
tion of factors related to the disease or condition in agencies. The consortium functions, including three
question, the screening test, and the health care deliv- national meetings and two public comment meetings,
ery system. Screening tests should fulfill most, if not were coordinated by the Office of Disease Prevention
all, of the following criteria: and Health Promotion of the DHHS. The final ver-
sion of HP2010 was developed under direction from
1. The condition should be an important health the secretary of HHS and the office of the Surgeon
problem. General.
TABLE 10–5. Leading Health Indicators TABLE 10–6.USPSTF Patient Education/

Counseling Strategies
Physical Mental health
Overweight and obesity Injury and violence 1. Frame the teaching to match the patients’ perceptions.
Tobacco use Environmental quality 2. Fully inform patients of the purposes, expected effects of
Substance abuse Immunization interventions, and when to expect these effects.
Responsible sexual behaviors Access to health care 3. Suggest small changes rather than large ones.
4 Be specific.
Adapted from US Department of Health and Human Services. HP2010:
5. It is sometimes easier to add new behaviors than to
Understanding and improving health. Washington, DC: DHHS,
2000. eliminate established behaviors.
6. Link new behaviors to old behaviors.
7. Use the power of the profession.
HP2010 has two central goals: (a) to increase qual- 8. Get explicit commitments from the patient.
ity and years of healthy life, and (b) to eliminate health 9. Use a combination of strategies.
disparities. These two goals are addressed and mon- 10. Involve the office staff.
itored by health promotion activities in 28 focus ar- 11. Refer.
eas containing 467 specific health objectives. The focus 12. Monitor progress through follow-up contact.
areas include cancers and diseases of the heart, kid-
ney, and respiratory systems, and a number of other Adapted from USPSTF. Guide to clinical preventive services report of
chronic diseases, as well as infectious and sexually the US Preventive Services Task Force, 2nd ed. Baltimore: Williams
and Wilkins, 1996.
transmitted diseases and HIV. Also included are a
number of other exposures related to food safety and
to occupational safety and health. The USPSTF provides com-
Put Prevention into Practice
Of these focus areas, a subset of 10 leading health prehensive information and recommendations in the
indicators has been chosen. Many are evidence-based area of clinical preventive services. Put Prevention
determinants for major public health concerns of into Practice (PPIP)37 parallels the USPSTF by consid-
the nation that highlight individual health behav- ering many of the age-specific recommendations for
iors, physical and social environmental factors, and screening and counseling described in the periodic
important health system issues. They are listed in health examinations for many of the important tar-
Table 10–5. get conditions discussed by the USPSTF. Specifically,
Examples of specific health objectives include in- it provides detailed “how to” information on the ac-
creasing to 30% the proportion of adults who engage tual performance of clinical preventive services with
regularly (preferably daily) in moderate physical ac- patient populations for these target conditions and
tivity for at least 30 minutes per day, and increasing to suggests approaches based on theory and modeling
100% the proportion of persons with health insurance of health behaviors and systems designed to facilitate
and to 96% the proportion who have a specific source providers’ successful intervention in clinical preven-
of ongoing health care. tive services. Many of these approaches address the
concepts embodied in the 12 strategies for patient ed-
US Preventive Services Task Force The US Preventive ucation and counseling issued by the USPSTF, which
Services Task Force (USPSTF)36 was convened in 1984 are described in Table 10–6.
to develop specific criteria to judge the quality of ev-
idence in the literature about clinical preventive ser- Environmental Health Sciences
vices, and to make recommendations for clinicians on Environmental health sciences is that branch of public
the appropriate use of preventive interventions based health that addresses the health impact of the myriad
on systematic review of the evidence of clinical ef- of items that one may be exposed to in one’s envi-
fectiveness. The first USPSTF issued its findings in ronment. It includes consideration of how we, the in-
1989, making recommendations on some 60 topic ar- habitants of the planet, use and abuse the resources
eas for patients from infancy to old age. To continue of the planet, and how changes imparted to one part
and update these recommendations, the second USP- of the ecosystem, for example, water, air, or soil, may
STF was set to work in 1990, and published its findings impose changes on other parts of the system. It consid-
as the Guide to Clinical Preventive Services (2nd edition) ers exposures such as accidents and injuries at work
in 1996. Its objectives were to evaluate the effective- and at home, and in the physical environment of our
ness of clinical preventive services not previously con- existence, including noise levels and foods. Environ-
sidered, to reevaluate those already examined based mental health sciences examines these issues to con-
on new evidence that may be available, and to make sider the nature of the health effects that result from
recommendations accordingly. these exposures, to describe how the health effects are
produced, and to use this knowledge to design risk sewage, and improved living conditions may account
reduction and prevention programs. Several impor- for a greater degree of health and decreased mortality,
tant areas are air and water quality, human and solid no other effort of modern medicine has had as great
wastes, food and waterborne diseases, and the loom- an impact as immunization.
ing global issues of global warming resulting from In the United States, routine childhood vaccination
“greenhouse effect” and depletion of the ozone layer. is required for a number of diseases nationwide, repre-
For example, surveillance and reporting of food and senting a form of mandated treatment. Each state has
waterborne diseases in the United States has been con- an opt-out clause, which allows a person, or their chil-
ducted in some form since about 1925. Original sum- dren, to remain unvaccinated. However, outbreaks
maries were published to monitor outbreaks of gas- can frequently be traced to exempted populations.
trointestinal illness related to milk. In 1938, this was Objection to vaccination usually centers in two areas:
expanded to illness related to any food. Since 1966, freedom of choice and a lack of true efficacy from vac-
annual summaries of food or waterborne enteric dis- cination. This is a complex issue that partly dates back
ease outbreaks attributed to microbial and/or chemi- to early objections to smallpox inoculation based on
cal contamination have been published by the CDC. It the then real problem that it produced a transmissible
is estimated that although these diseases cause about form of disease.39,40
76 million illnesses and 5000 deaths each year, only a
fraction are reported. Characteristics of Immunity
Two federal agencies are primarily responsible for Immunity may be innate or natural. Such immunity
the quality and safety of foods and drugs in the United refers to resistance not acquired by contact with an
States. The US Department of Agriculture (USDA) is antigen. It is nonspecific, does not improve after ex-
responsible for meat and dairy products, conducting posure to an organism, is usually an acute rapid re-
daily inspections of meat and dairy plants, as well sponse, and does not create immune system memory.
as on-site inspection of operating meat slaughtering Immunity may also be acquired. This type of immu-
plants. Unfortunately, USDA methods of observation, nity can be active or passive. Active immunity is re-
mainly touch and smell, are not able to detect micro- sistance acquired after the host has contact with a
bial contamination of foods. The Food and Drug Ad- foreign antigen. This may be accomplished by expo-
ministration (FDA) is responsible for all other types of sure to an immunobiologic agent, as each provides
foods, including fish, and prescription and over-the- the host with contact to an immunogenic region or
counter drugs and labeling requirements. epitope. Active immunity requires that the host re-
sponds to the immunobiologic to actively produce an
Immunization and Vaccine-Preventable Diseases immune response consisting of antibodies and acti-
Modern man’s early attempts to control and prevent vated helper and cytotoxic T lymphocytes. Active im-
communicable diseases are highlighted by his efforts munity is slow to develop, but is long-term and im-
to battle smallpox. The disease was prevalent in many proves upon repeated exposure to the antigen because
areas of the world, with repeated deadly epidemics a pool of memory lymphocytes and cytotoxic T cells
marked by infant case fatality rates of 10–17%. In is produced on initial exposure. Passive immunity is
1796, Edward Jenner discovered that humans could resistance acquired by the host once it is given anti-
be protected from smallpox after the introduction of bodies produced in or by another host. There is no
sera from a cow infected with cowpox. Prior to this primary immune response or cell memory in the host.
time the only form of protection from smallpox was Passive immunity is rapid, but of short duration.41
by inoculation, which consisted of infecting a healthy Herd immunity is the resistance of a group to in-
person with the pus of a smallpox victim. If success- vasion and spread of a specific agent, based on the
ful, the healthy person could develop a mild case of immunity of a high proportion of the individual mem-
smallpox, and immunity to the disease. By the early bers of the group. It is an important factor underlying
1800s, vaccination campaigns leading to the eventual the spread of propagated epidemics and the periodic-
eradication of smallpox had begun.38 Of importance, ity of common communicable diseases. It is the prod-
smallpox produces only apparent infection, while the uct of the number of susceptible individuals and the
vaccine produced a nontransmissible form of disease, probability that those who are susceptible will come in
was highly effective, and produced lifelong immu- contact with an infected individual. Herd immunity
nity. The WHO declared smallpox eradicated in 1980, is the “in the field” result of a population’s natural
which remains one of the great achievements of med- and acquired immunity and is perhaps the most im-
ical science. The program also helped set the stage portant public health factor in considering the control
for WHO global vaccine programs to eliminate other and prevention of common communicable diseases.33
communicable diseases, such as polio by 2005. Al- A complete presentation on the subject of vaccine-
though it is acknowledged that clean water, proper preventable diseases is beyond the scope of this
chapter. Please refer to the references for additional testing studies, including cross-sectional, prospec-
information. tive, and retrospective studies. This includes
consideration of study biases. Analysis includes
the examination of study results for statistical
SUMMARY
meaning. Evaluation includes consideration of ef-
1. The mission of public health is “the fulfillment fectiveness of the study results in the field, efficacy,
of society’s interest in assuring the conditions in the examination of an intervention in a clinical trial
which people can be healthy.” This is addressed setting, and efficiency, the demonstration that the
through functions of assessment, development of intervention is cost- and time-efficient.
policy, and assurance of access to needed services. 6. Most diseases evolve through stages along a con-
In public health, the population is the patient and tinuum, from the stage of susceptibility to preclin-
the emphasis is on prevention. ical disease, clinical disease, and disability. Most
2. Public health services in the United States are pro- prevention activities are conducted in the preclini-
vided by agencies on the federal, state, and local cal phase and are designed to push back in time
levels. Legal authority rests primarily at the state the development of clinical disease, referred to
level. Public health agencies, such as the PHS, the as secondary prevention. The use of clinical pre-
CDC, the FDA, or a state or local health depart- ventive services is determined by two attributes:
ment, are formed by legislative acts. Such agencies (a) the ability of a screening test to accurately iden-
act based on internal expert opinion and their de- tify asymptomatic persons who are at risk to de-
termination of what is in the best interest of the velop a disease or condition and (b) the ability of
population as a whole. counseling to produce a change in health behav-
3. The US health care expenditure is the largest of any ior that will in fact lessen the person’s risk of that
country in the world, and it continues to increase. disease.
In spite of costs, approximately 16% of the popu- 7. The United States has several national disease pre-
lation experiences access problems related to lack vention and health promotion initiatives. HP2010
or type of health insurance. Payment for the per- is a 10-year plan of activities to increase years of
sonal health care expenditure, approximately 90% healthy life and to decrease health disparities in
of the total expenditure, is from public and private Americans. The US Preventive Services Task Force
sources, and has shifted significantly to public fi- is a source of recommendations of specific preven-
nancing, now approximately 46% of the total ex- tion services, based on efficacy and effectiveness,
penditure. By 2000, about two-thirds of those with of some 70 diseases and conditions. Put Prevention
insurance were enrolled in a plan that used some into Practice is a resource of “how to” procedures
variety of “managed care” strategy. designed to assist the practitioner to successfully
4. Managed care is represented by strategies used to incorporate clinical recommendations.
control the use, cost, and outcome of health care
services. Therefore, there are any number of com-
binations this may take. An HMO is a combination QUESTIONS
of health insurer and health care provider. These
1. What is public health?
may vary from the most controlled and restricted
2. Why is public health differentiated from individ-
models with centralized locations and group prac-
ual patient care?
tices, such as the staff and network types, to those
3. Why is public health sometimes controversial, as,
where the providers practice from their own of-
for example, in the ongoing debate over smoking
fices, as part of a provider association, called an
in public?
individual practice association. These are the most
4. Name some of the organizations with major roles
rapidly expanding type of plan.
in public health.
5. Epidemiology and biostatistics are regarded as the
5. Does the chiropractic profession have a role in the
basic sciences of public health. Epidemiology is
American Public Health Association (APHA)?
the study of the distribution and determinants of
disease and health conditions in a human popula-
tion, and the use of that information to control and
ANSWERS
prevent disease. Epidemiology is applied to pub-
lic health through its methods. Surveillance is the 1. Public health is the science and art of prevent-
observation of the population for disease trends ing disease, prolonging life, and promoting phys-
using such tools as the National Health Interview ical health and efficiency through organized com-
Surveys, vital statistics, and disease registries. In- munity efforts for sanitation of the environment,
vestigation includes description and hypothesis control of community infections, education of
individuals in personal hygiene, and organization Centers for Disease Control. www.cdc.gov.
of health care services for diagnosis and preven- Council of State and Territorial Epidemiologist. www.
tion of disease. It is also the development of the cste.org.
social machinery to ensure every individual a stan- Donabedian A. Explorations in quality assessment and moni-
dard of living adequate for the maintenance of toring, vol. 1. The definition of quality and approaches to its
assessment. Ann Arbor, MI: Health Administration Press,
health and longevity.
1980.
2. Individual patient care treats one person at a time Graham N, ed. Quality assurance in hospitals, 2nd ed. Aspen
for a specific complaint, based on a body of evi- Publications, 1990.
dence. Success is measured on a case-by-case ba- Health Resources and Services Administration. www.
sis. Public health treats the community as a whole, hrsa.gov.
with the primary focus on prevention. Success is Healthy People 2010. www.health.gov/healthypeople.
measured from the population or group level. Pub- National Center for Complementary and Alternative
lic health must concern itself with political and Medicine. http://nccam.nih.gov.
social forces in order to meet its goals. Generally National Institutes of Health. www.nih.gov.
speaking, individual patient care is less concerned US Department of Health and Human Services. www.
with laws and social forces at work. dhhs.gov.
US Public Health Service. www.usphs.gov.
3. The good of the population sometimes is at odds
Wallace R, ed. Public health and preventive medicine, 14th ed.
with the rights and concerns for an individual. For Stamford, CT: Appleton and Lange, 1998.
example, antismoking laws prevent the exposure World Federation of Chiropractic. www.wfc.org.
of nonsmoking individuals to the unhealthy effects World Health Organization. www.who.org.
of smoke; on the other hand, the right of a smoker
to engage in the habit is curtailed. The tension be-
tween individual rights and the health of the over- REFERENCES
all population is an ongoing fact in public health
debates. 1. Pew Health Commission. Recreating health professional
4. The World Health Organization is part of the practice for a new century. San Francisco: University of
United Nations and is concerned with global California, San Francisco Center for the Health Profes-
sions, 1998:1.
health concerns and coordination of efforts to im-
2. Bougie JD. Acquiring necessary skill sets for the
prove the health of all nations. The United States
competent and successful clinician. Top Clin Chiropr
Public Health Service is comprised of eight gov- 2000;7(1):17.
ernmental agencies, all working in distinct ar- 3. Winslow CEA. The evolution and significance of the mod-
eas. Some of the most prominent are the National ern public health campaign. New Haven, CT: Yale Uni-
Institutes of Health, concerned with biomedical versity Press, 1923, reprinted in J Public Health Policy
research, the Centers for Disease Control and Pre- 1984. In: Turnock B. Public health, what it is and how it
vention, concerned with the prevention, identifi- works. Gaithersburg, MD: Aspen, 2001:10.
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in the population, and the Food and Drug Ad- the Future of Public Health. The future of public health.
ministration, which concerns itself with the safety Washington, DC: National Academy Press, 1988.
5. Richards E, Rathbun K. The legal basis for pub-
and effectiveness of drugs and foods. Each state
lic health. In: Scutchfield DF, Keck CW. Principles of
and most communities have departments of health
public health practice. Albany, NY: Delmar Publishers,
with related concerns at the local or state level. 1997:43.
5. Yes. The APHA is one of the largest and oldest pub- 6. Brandt E. The federal contribution to public health. In:
lic health organizations in the world. It includes the Scutchfield DF, Keck CW. Principles of public health prac-
Chiropractic Healthcare Section as one of its sub- tice. Albany, NY: Delmar Publishers, 1997:57–58.
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tion was established in 1995 after a decade of Scutchfield DF, Keck CW. Principles of public health prac-
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Chiropractic Health Care Section represents the 8. Rawding N, Wasserman M. The local department of
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health practice. Albany, NY: Delmar Publishers, 1997:
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87–95.
9. Duffy J. The sanitarians. Champaign, IL: University of
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10. Haas M, Baird R, Colley F, Meeker W, Mootz R, Per-
Agency for Healthcare Research Quality. www.ahrq.gov. illo M. An application to establish an American Public
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11. Minutes of the Technical Preparatory Committee for ventable hospitalizations and access to health care.
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Geneva:. ed. Gaithersburg, MD: Aspen, 2001:1–16.
14. Rodwin V. An international perspective: Comparative 29. Wagner E. Types of managed care organizations. In:
analysis of health systems. Chapter 5 in Health Care Kongstvedt P, ed. Essentials of managed health care, 4th
Delivery in the United States. Kovner, A (ed). 5th edi- ed. Gaithersburg, MD: Aspen, 2001:17–30.
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15. National Health Expenditures 1960–1999, Table 1. Health Keck CW. Principles of public health practice. Albany, NY:
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26. Bindman A, Grumback K, Osmond D, et al. Pre- 1998.
C H A P T E R
11
PROFESSIONALISM AND ETHICS
IN CHIROPRACTIC
Robert D. Mootz, Ian Coulter, and Gary D. Schultz
O U T L I N E
INTRODUCTION Professionalism at the Individual Level
DEFINING PROFESSIONALISM Self-Promotion
Professional Autonomy Evidence-Informed Practice
Professional Responsibilities Inter- and Intraprofessional Interaction
Professions, Politics, and Power THE STUDY OF ETHICS: CONCEPTUALIZING THE
Characteristics of a Profession BIG PICTURE
Systematic Theory Applied Ethics
Authority Right versus Wrong
Community Sanction Right versus Right
Ethical Codes Ethics in Health Care
Culture Professional and Ethical Accountability
PROFESSIONALISM AND COMPLEMENTARY AND ETHICAL ISSUES SPECIFIC TO CHIROPRACTIC
ALTERNATIVE MEDICINE Evidence-Based Practice
Professionalism in Chiropractic Documentation
Elements of Professionalism in Chiropractic Accuracy in Communication
Teaching Good Samaritan
Scholarship and Research Professional Boundaries
Service Efficient Use of Resources
Resolution of Differences of Opinion Informed Consent
Professional Evolution and Growth CONCLUSIONS
Demeanor SUMMARY
Professional Conscience QUESTIONS
Competition ANSWERS
Quality Improvement KEY REFERENCES
Needs of Underserved Populations REFERENCES
4. To identify the three distinct societal bodies to

OBJECTIVES
which a professional is accountable for ethical be-
1. To appreciate and explain what places a profession havior.
in a unique position of public trust. 5. To explain the difference between professionalism
2. To identify many professional privileges that ac- and ethics.
crue to a health care profession and its members. 6. To distinguish between morals and ethics.
3. To identify a profession’s social obligations and re- 7. To identify major professional boundary issues in
sponsibilities as a result of receiving social sanction chiropractic and explain the difference between a
as a profession. boundary “crossing” and boundary “violation.”
201
The word “professionalism” contains within it the

INTRODUCTION
verb “profess.” Professionals are groups in society that
Against seemingly insurmountable odds, chiropractic profess to know something and possess skills the rest
has evolved into one of the largest and most promi- of society does not.15 Health professionals profess to
nent of the health professions in North America, with have certain knowledge (often esoteric) and skills rel-
an ever-increasing presence worldwide. As an out- evant to a patient’s health problems. Although not
sider to the health care mainstream for most of the unattainable by the layperson or patient, professional
twentieth century, much of the profession’s devel- knowledge and skills cannot be attained without con-
opment occurred in isolation from other disciplines. siderable time, study, and dedication of resources.
Nevertheless, codes of ethics and professional behav- The Pew Health Professions Commission identified
ior developed by chiropractic professional associa- 21 characteristics of health professions16 :
tions are similar to those of other health professions
in dealing with patient care and responsibility for the 1. Embrace a personal ethic of social responsibility
broader public health.1–3 However, other aspects re- and service
lated to professionalism have lagged behind those of 2. Exhibit ethical behavior in all professional activi-
other professions. This is seen most clearly in the rela- ties
tionships between colleagues. The collegiality of aca- 3. Provide evidenced-based, clinically competent
demic dialogue characteristic of most professions has care
not routinely been visible in professional differences 4. Incorporate the multiple determinants of health in
of opinion between chiropractors.4 Disparate opinion clinical care
within chiropractic has often caused any number of 5. Apply knowledge of the new sciences
professional organizations to be formed. This is unfor- 6. Demonstrate critical thinking, reflection, and
tunate, because in other professions, divergent views problem-solving skills
frequently serve as core strengths for resolving issues 7. Understand the role of primary care
related to diversity, professional self-appraisal, vital 8. Rigorously practice preventive health care
growth, and collaboration. 9. Integrate population-based care and services into
In the past, chiropractors have been described as practice
“marginal” professionals.5 Chiropractic was thought 10. Improve access to health care for those with unmet
to be unique in being both professional (sharing the health needs
characteristics of a profession), but also being so- 11. Practice relationship-centered care with individu-
cially stigmatized at the same time.6 Chiropractors als and families
saw themselves variously described in the social sci- 12. Provide culturally sensitive care to a diverse soci-
ence literature as deviant,7,8 heterodox,9–11 a caste,12 ety
outcastes,13 and as having no scientific validity.14 As 13. Partner with communities in health care decisions
a result, much of chiropractic’s history is rife with at- 14. Use communication and information technology
tempts to establish itself as a legitimate health profes- effectively and appropriately
sion. To understand how far the profession has come, 15. Work in interdisciplinary teams
and how far it must still travel, requires an examina- 16. Ensure care that balances individual, professional,
tion of the concept of professionalism and the concept system, and societal needs
of ethics. 17. Practice leadership
18. Take responsibility for quality care and health out-
comes at all levels
19. Contribute to continuous improvement
DEFINING PROFESSIONALISM
20. Advocate for public policy that promotes and pro-
Profession: A social group that has exclusive access tects the health of the public
to knowledge and skills, is autonomous, is self- 21. Continue to learn and help others learn
regulating, has authority, controls entry, is reg-
ulated by the state, and has exclusive powers In some instances, an individual outside a profes-
and/or rights. sion cannot learn the information or skill unless admit-
Health professional: To claim to be a health professional ted to its unique “social order,” which may have exclu-
derives from the concept “to profess” or claim to sive rights to both. For example, when people are ill,
have knowledge, technical skills, or an art form they may be less able to judge their own health prob-
that contributes to a patient’s health with the im- lems and may lack the objectivity needed to make ap-
plication that these attributes are better than those propriate care decisions. Thus, the two most relevant
that the patient might possess. elements when looking to a health care professional
PROFESSIONALISM AND ETHICS IN CHIROPRACTIC 203
are knowledge/skill and trust. An essential feature of individual members to include control of entry into
the social trust is that the patient’s interest is placed the profession by accrediting education programs,
above that of the professional.17 In commercial rela- control of licensure, and defining legal scopes of prac-
tionships, the concept of caveat emptor (let the buyer tice. Indirectly, such control also limits competition.
beware) prevails. Customers are warned to look out Other social groups engaged in commerce are rarely
for their own interests. In contrast, professional rela- given such self-policing authority. For serious of-
tionships are based on the concept of credat emptor (let fenses, a profession’s regulating bodies can (and are
the taker believe in us). When a group of individuals expected to) remove the offender’s license to prac-
with special information and skill accepts the respon- tice. Having an enforced code of ethics is clearly a key
sibility of public trust, society turns over extraordi- method by which professions exercise autonomy. Ul-
nary powers and privileges, thereby bestowing the timately, professions determine who joins and who
mantle of a “profession.” stays. For many years, in the case of medicine, this
Such privileges, however, are not “natural rights control included the prohibition of any professional
of the professions.” Rather, they are rights and privi- relationship with chiropractors. This prohibition was
leges bestowed by the state and given because they are successfully enforced by the American Medical Asso-
believed to be in the public interest. Groups bestowed ciation until challenged in a landmark antitrust suit
with social privileges and responsibilities typically or- brought on by chiropractors.18
ganize into professional bodies and adopt codes of Third, professional autonomy goes beyond mem-
ethics and behaviors to police themselves. The pro- bers of a given health profession. Professions often
cess of becoming a socially recognized health profes- strive for exclusivity and laws of trespass. The latter
sion is an evolutionary one rather than a sequential allow the profession to discipline anyone outside the
one. Obtaining and maintaining professional stature profession considered to be practicing within the pro-
is not a static process; what the state gives it can also fession’s scope. This is the mechanism by which or-
take away. ganized medicine persecuted chiropractors for prac-
Professions can also be at risk of losing respect (as ticing medicine without a license until the 1950s.
evidenced by the abundance of lawyer jokes). When Expertise was not necessarily an issue. A medical doc-
professions take unpopular actions or are perceived to tor may not have spent a single hour learning to per-
negatively affect the social good, reactions can result form spinal manipulation, but most medical scope-of-
in professional independence being taken away. For practice laws allow the practice of this skill. A related
example, spiraling health care costs of recent decades aspect of professional autonomy is the authority to
(deemed not in the public interest and, at least in part, be a gatekeeper, which may place another profession
under the purview of doctors) triggered the establish- under its control. Dental hygienists within dentistry
ment of managed care, which has substantially re- or physical therapists and nurses within medicine are
duced doctors’ independence in rendering health care examples. In many jurisdictions, organized medicine
decisions, and reduced their incomes as well. managed to restrict chiropractors by causing govern-
ment insurance coverage to be dependent on a referral
Professional Autonomy by a medical doctor.19
Autonomy is arguably the most important privilege a A fourth element of autonomy can extend beyond
profession is granted and gives a profession incredi- the actual practice of the profession. This is seen most
ble social authority. In the case of medicine, this his- clearly in the case of medicine, where it has been able
torically has meant the power to “medicalize” the to historically influence and shape the majority of
health care delivery system. Autonomy has numer- health care policy. For example, the American Medi-
ous dimensions. The first is that professionals have cal Association is federally empowered to control how
the power to make independent decisions regarding all clinical procedures are coded for billing purposes,
their own behavior based on their own knowledge. and for how physician work is calculated to determine
For example, until quite recently, a physician’s clini- reimbursement rates.20
cal decisions were not second-guessed. The mark of a
professional has traditionally been the ability to ren- Professional Responsibilities
der an objective, autonomous decision that is assumed In return for power and influence, commensurate re-
to be in the best interest of the client or patient. sponsibilities are also given to professions. The most
Second, professions are given autonomy with re- important of these responsibilities entails acting in
gard to self-regulation. They are expected to estab- the patient’s interest, as well as for the greater pub-
lish a code of ethics and regulations, and to enforce lic good. In return for controlling who may become a
them on the members of the profession. Historically, professional, a profession is expected to only choose
this autonomy extends beyond the power to discipline persons of moral, upstanding character who would
act ethically at all times, and who would abide by for power. Because medicine has the broadest scope of
the laws, regulations, and codes of ethics. This is re- practice, any competing health profession that wishes
flected by the high admissions standards required to establish its own scope of practice, particularly if an
in most health professions. The distinguishing char- exclusive scope of practice is desired, must do it at the
acteristic of a profession is to never place its self- expense of the scope of medical practice. Medicine, for
interests above those of its patients or those of society its part, will not readily surrender any of its power, a
at large. Professional oaths and codes of ethics fre- concept characterized as medical dominance.22 Con-
quently require health providers to treat persons irre- flicts between medical physicians and chiropractors,
spective of their color, class, creed, or ability to pay for ophthalmologists and optometrists, medical physi-
services. cians and physical therapists, dentists and dental hy-
Furthermore, in return for exclusive rights to a gienists, dentists and denturists, chiropractors and
body of knowledge, skills, and art, professions are physical therapists, psychiatrists and psychologists,
also required to contribute to the advancement of and so on, all represent examples of professions at-
their own knowledge, skills, and art. A professional tempting to exercise their power of exclusivity over
is expected to put service above rewards, to have vo- other groups.23 Interestingly, many sociologists have
cation or calling, and to be trustworthy and honest. credited chiropractic with demonstrating the limits
Many of these responsibilities can be found in profes- of medical dominance. Although medicine has been
sional codes of ethics and are discussed later. Codes of able to historically restrict the acceptability of chi-
ethics also delineate etiquette and conduct for interac- ropractic, it has not been able to stop its growth or
tions with colleagues as well as with patients and the legitimization.24,25
public. Increasing intellectual and social scrutiny of pro-
True collegial relationships are fairly unique to fessions and professionalism have occurred in recent
professions within Western culture. Although collo- decades. Since the 1960s, a reevaluation of profes-
quial references to someone being a “professional col- sions as organizations acting for the social good has
league” are common, explicit collegial relationships occurred.22 Sociologists have shown that professions
spell out a set of courtesies that someone is entitled to have acted in their own interests over those of the
simply by being a member of a professional group. In public.21 Concurrently, the consumer movement be-
most other human relationships, respect, love, admi- gan to apply the same critique to the professions as it
ration, and the like are earned through performance. had to manufacturers.26 Patients have come to be seen
Collegial respect, however, is due a person simply be- as consumers who have rights with regard to their
cause that person is in one’s profession. Although care. The transformation of the notion of informed
one may withdraw respect as a response to a col- consent becoming a legal mandate is one of the prod-
league’s behavior, this is usually done only in excep- ucts of this movement. Patients have a right to choose,
tional circumstances. Collegial respect is awarded au- yet they cannot choose if they do not know their op-
tomatically and without question. Aspects of collegial tions. Furthermore, they cannot know their options if
respect may be codified in ethics guidelines such that they are not adequately informed. Ergo, patients have
criticizing a colleague’s work to a patient is not al- a right to be informed, and health care professionals
lowed. Such guidelines might also condone treating a have seen their domains inch toward those of other
colleague’s family without cost to ensure that a pro- commercial ventures at the expense of autonomy.
fessional does not treat his or her own family mem-
bers. The collegial relationship is one between equals Characteristics of a Profession
and is cooperative and supportive by default. Knowl- To appreciate the nature of the chiropractic profes-
edge is expected to be shared freely with colleagues, sion, the characteristics of a profession, first described
as in the example of providing comprehensive patient in the 1950s, offer a useful approach. A profession
background information without charge when mak- should possess (a) a systematic theory, (b) authority,
ing a referral. Professional courtesies, such as return- (c) community sanction, (d) ethical codes, and (e) a
ing a patient after referral, are considered standard culture. Greenwood proposed a continuum in which
within collegial health care relationships. well-recognized professions anchor one end and sim-
ple occupations exist at the opposite end.27 The “dis-
Professions, Politics, and Power tance” a given occupation is from the well-recognized
While professions are supposed to act in the public professions can serve as a quantitative method to char-
interest, it would be naı̈ve to suggest that they do not acterize differences between professions. Different
act in their own interests.21 Increasingly, professional- professions may all share some characteristics to vary-
ism has come to be seen as a highly political process, ing degrees. For example, many occupations require a
as much about power as it is about the public interest. distinct body of skills but have no theoretical body of
The professions quite clearly struggle with each other knowledge per se (e.g., manual laborers). Others may
start out principally as skill occupations, then later infrastructure, accountability, and codes of profes-
develop theoretical bodies of knowledge, and hence sional conduct dictate that patient need and appropri-
evolve into professions. (Engineering is an example; ateness prevail when at odds with a patient’s desire.
bridges were built long before science explained why A professional possesses the perspicacity to differen-
the structures worked.) tiate a need from a want and has the courage to tell
the patient as much. In an era of business realities re-
Systematic Theory The skills that characterize a profes- garding client service and satisfaction, the distinction
sion should flow from, or be supported by, a body of between patient and customer is particularly relevant.
theory. Theory provides the basis for what a profes- Within the dynamics of a doctor–patient relationship,
sion does and helps to define the class of phenomena the patient is the vulnerable party and may not be the
that are the profession’s interest. Ideally, acquisition of best arbiter of quality or appropriateness.
skills unique to a given profession should occur con-
currently with the acquisition of knowledge regarding Community Sanction Regulation by the state through
its theory. All professions require that the neophyte licensure represents the most substantive indicator
master both. Within health care disciplines, clinical of community sanction. Positive sanction is also re-
skills and decision making central to patient care all flected by the fact that chiropractic is a covered benefit
stem from well-formed theoretical underpinnings. throughout government and private indemnity plans.
From its earliest history, chiropractic developed These achievements are often the result of hard-fought
both a theoretical rationale regarding the relation- battles with other professions, regulators, and private
ship between spinal structure and neurological func- entities by professional guilds and associations. His-
tion and skills involved with administering spinal ad- torically, litigation has proven to be as important as
justments. However, the construction of theory and consumer demand and political lobbying in defining
knowledge typically occurs in professions through community sanction of a profession.
systematic research. Chiropractic’s evolution has of-
ten been fraught with unwavering adherence to the- Ethical Codes Self-regulation begins with written eth-
ory rather than to its development. Greenwood makes ical codes of conduct developed by professional bod-
a relevant and powerful distinction between profes- ies. Nearly every professional trade guild or organiza-
sions and nonprofessions regarding how theory is de- tion adopts these, including chiropractic. Discussion
veloped and refined27 : of ethics, its nature, and the issues a health profession
and its members grapple with warrants detailed ex-
ploration (see below). The American Chiropractic As-
As an orientation, rationality is the antithesis
sociation and International Chiropractors Association
of traditionalism. The spirit of rationality in
have codes of ethics.1,2 The American Chiropractic
a profession encourages a critical, as opposed
Board of Sports Physicians3 undertook a particularly
to a reverential, attitude toward the theoretical
systematic effort that led to the adoption of a com-
system. It implies a perpetual readiness to dis-
prehensive code of ethics that has been recognized by
card any portion of that system, no matter how
the National Commission for Certifying Agencies.28
time honored it may be, with a formulation
The document includes specific codes of conduct that
demonstrated to be more valid. The spirit of
were developed using both legal and professional re-
rationality generates group self-criticism and
view and explicit appeals processes.3
theoretical controversy. Professional members
convene regularly in their associations to learn
Culture Greenwood’s identification of a professional
and evaluate innovations in theory. This pro-
culture also suggests that each profession has a sub-
duces an intellectually stimulating milieu in
culture that may be unique. Culture is shaped by val-
marked contrast to the milieu of a nonprofes-
ues, norms, and symbols (e.g., much of what chiro-
sional occupation.
practors call “principles”). Elements of culture might
include the worth of the service the profession pro-
Authority vides (in some cases the actual fee); that professionals
Social authority is bestowed with the expectation that must not jeopardize autonomy by putting themselves
the good of the consumer and society prevail over under the direction of another profession; not to teach
a professional’s self-interest. Additionally, provision the skills to those outside the profession (something
of professional services should be based on patient included even within the Hippocratic oath); a com-
needs (as opposed to wants). Although patient prefer- mitment to professional etiquette about recruiting pa-
ence has a role in clinical decision making, congruence tients; setting appointments; dress; referrals; discharg-
with patient need is essential. For example, although ing patients; and nature of allowed and frowned-upon
a patient may want an addictive narcotic, professional relationships with patients (particularly sexual ones).
TABLE 11–1. Questions Regarding Professional

PROFESSIONALISM AND COMPLEMENTARY
Attributes for CAM Professions That May Be
AND ALTERNATIVE MEDICINE
Challenging for Chiropractic
A recent report by the Center for Health Professions,
at the University of California, San Francisco, lays out Definition and description of the profession
a format for evaluating the attributes of complemen- • Is there a professional consensus document describing the
tary and alternative medicine (CAM) professions.29 profession, how the consensus was developed, and who
The report poses a set of questions that fall in five was or was not involved?
general areas: (a) definition and description of the pro- • How does the profession describe itself in terms of the type
fession; (b) safety and efficacy; (c) government and of care it provides and the types of care beyond its
private sector recognition; (d) education and training; professional scope?
and (e) proactive practice model and viability of pro- • What differences of opinion within the profession exist
fession. A set of questions is described for each area. In about the range of care appropriate for the profession to
two of the areas, government and private sector recog- provide?
nition and education and training, chiropractic can • What interventions and modalities does the profession use,
answer affirmatively to all the questions. In the other including the diagnostic range and scope of patient
areas, answers to several key questions are less clear. conditions the profession cares for?
Although all of the center’s questions are not in- • What is the philosophy behind the profession and its
cluded, Table 11–1 illustrates several key challenges knowledge base (beyond technical skills)? What ethics,
for chiropractic that are posed by these questions. concepts, and values define the profession?
Within chiropractic’s many distinct factions, some of • Is there a professional consensus on its philosophy?
these questions have been grappled with. However, How is it maintained and integrated into clinical decision
in terms of the profession as a whole, a professional making?
identity based on plurality and consensus remains
elusive. Individual chiropractors, chiropractic institu- Safety and efficacy
tions, and trade associations would be wise to con- • Does the profession measure the safety and efficacy of the
sider many of these questions and what might be services its members provide?
done to better position the profession through train- • Where and how does the profession or field recognize gaps
ing and engagement with society along many of these in its members’ knowledge and perhaps even competency?
dimensions. • What is the profession’s research agenda?
• What needs does the profession have for inclusion in
Professionalism in Chiropractic monitoring systems, research, or other activities available
The concept of professionalism has received discus- to established professions, in order to improve availability of
sion in chiropractic, but frequently from the profes- information on safety and efficacy?
sion’s vantage point more so than society’s vantage • How is the profession working internally and with other
point. Strang articulated the debate between chiro- professions to support the safe development of new and
practic’s obligations to its patients (e.g., health pro- unconventional practices?
motion, self-sufficiency) and its own perpetuation
(practice building, use of philosophy of chiropractic to Proactive practice model and viability of profession
encourage treatment dependency).30 He argued that • What efforts has the profession made to develop practice
a profession had an obligation to not lose sight of its guidelines and treatment protocols for clinical care?
“original franchise,” such as the elimination of dis- • Has the profession endorsed standards of care that
ease, in pursuit of its own perpetuation. Within chiro- members of the profession can access and use?
practic, the incentive to encourage or enable the use • Does the profession encourage the use of peer review
of a service (e.g., spinal adjustments) over a lifestyle meetings and outcomes and treatment measures as
change (e.g., exercise) exemplifies such a dilemma. feedback for individual practitioners? If so, what was the
“Medicalizing” conditions overtly or unknowingly to process for developing the mechanisms? Are procedures in
foster treatment dependency may be one of the most place to update and improve the mechanisms?
substantive professional issues of the day. • What guidelines has the profession developed and
Peer oversight is another dimension of chiroprac- encouraged for work in interprofessional teams and
tic’s professional maturation that is frequently dis- consulting and referral arrangements?
cussed but remains a source of consternation. The es- • What commitment has the profession made to ensure
teem and social recognition that may have accrued that care provided by its members is culturally
to professions in the past have diminished in large appropriate? How diverse (by sex, race, and ethnicity) is
measure because of the failure of ethical self-policing. the profession?
While extreme examples of sexual misconduct or (Continued )
TABLE 11–1. (Cont.) chiropractic. While chiropractic’s “scientific enter-

prise” was once little more than extrapolation from
• How does the profession support and encourage new published medical reports, original research and
modalities and therapies within the profession? scholarship has dramatically increased in the past sev-
• How is the profession working to secure the financial eral decades. There has been a proliferation of texts
support for innovation? How is the profession incorporating and research journals in addition to sustained forums
new technologies and communications capacity into its for publishing new knowledge gained through re-
practice? search, for example, the Journal of Manipulative and
Physiological Therapeutics. There are also journals that
focus on clinical practice (Chiropractic Technique), the
insurance fraud make the headlines, there are, how- profession’s history (Chiropractic History), and chiro-
ever, limited enforcement and litigation resources practic education (Journal of Chiropractic Education).
available to regulatory boards. Economic concerns Scholarly activities contribute to promotion and ad-
from declining trade association memberships dis- vancement of faculty in chiropractic institutions. A
courage removal of a member, and the arbitrary nature hallmark of learned professions is that the keepers
of political agendas common to all disciplines remains and teachers of the knowledge are directly involved
a concern. Unfortunately, once a chiropractor enters in its creation, maintenance, and dissemination.
practice, mechanisms for mentorship and peer over- For decades, research activity at chiropractic insti-
sight are not widely available. Although continuing tutions has been an explicit requirement of accredita-
education coursework is mandated in many states, tion. Given the limited resources within chiropractic
formalized mechanisms to assess and intervene on (both funding and expertise), consortial relationships
issues of clinical competency or ethics in individual were established between several colleges in the 1980s
situations have not been well established. that helped establish a research culture in the pro-
Professional behavior is a topic of discussion fession. Initially supported by membership contri-
within chiropractic,31 but it often remains isolated butions from the California Chiropractic Association
and voluntary. Chiropractic organizations encourage and the colleges themselves, today, the National In-
a high level of professional behavior, but rarely is it stitutes of Health and similar government bodies di-
an objectified enforceable standard such as that used rectly fund chiropractic research activities. Although
by the American Bar Association (ABA).32 The ABA only the proverbial tip of the iceberg has been illumi-
Standards for Imposing Lawyer Sanctions establishes en- nated in terms of content and productivity thus far,
forceable baseline professional behaviors and states: the chiropractic research enterprise is now becoming
“Members of the public are entitled to be able to trust substantially inculcated into the profession’s con-
lawyers to protect their property, liberty, and lives. sciousness and infrastructure.
The community expects lawyers to exhibit the high-
est standards of honesty and integrity, and lawyers Service Service, toward achieving both the ideals of
have a duty not to engage in conduct involving dis- its own interests and those of the community at large,
honesty, fraud, or interference with the administration is an element of a profession’s activity. In chiropractic,
of justice.”32 This code of conduct has been frequently this area remains in the early stages of development.
invoked to remove members from the bar. Participation in membership organizations remains
low.33 Demands for increased administrative tasks at
Elements of Professionalism in Chiropractic lower reimbursement levels impact both the motiva-
Teaching A key distinguishing aspect of the learned tion and available time a practitioner might have to
professions is that they establish and maintain their volunteer for the “good of the order.”34
own knowledge base, curricula, and educational stan- Community service is not as widespread as one
dards, organize their own educational programs, and would like to see. Although one can find examples of
often coordinate practice residencies. Chiropractic or- free college clinics and countless examples of regional
ganizes its own programs and institutions, sets edu- or individual chiropractors coming forward for a good
cational standards, oversees its own compliance and cause,35 there are only a few examples of institution-
accreditation, and confers unique degrees. After pro- alized efforts of chiropractors devoting energy to the
gram completion, multiple layers of competency as- community. Perhaps one of the best is the Kentuckiana
sessment, licensure or certification, and continuing Children’s Center in Louisville, Kentucky. As a non-
education requirements are maintained and overseen profit organization, it provides tens of thousands of
by members of the profession. dollars worth of chiropractic care annually for chil-
dren with special needs. Free or low-cost chiropractic
Scholarship and Research The profession’s knowledge clinics may also be affiliated with chiropractic clin-
is increasingly maintained and developed within ical internship programs at some colleges. Driven as
much by the need for student interns to receive clinical about what they do.31 Chiropractic has an “image
experience and meet graduation requirements, these problem,” in part because the profession is still grap-
facilities do help underserved populations. The lack pling with its own identity, but also because more than
of organized attention in this arena is reflected in the a few practitioners have promoted their self-interests
limited cultural and ethnic diversity of chiropractors in an unprofessional manner. Giving away free ser-
and their patients.36 This is an area in need of devel- vices, hard sales tactics, and tacky advertising may
opment within the profession. have currency in an era of disposable consumerism
but taint a profession striving to improve its image.
Resolution of Differences of OpinionDissent and differ- Communication and promotion that emphasize pa-
ences of opinion need not be destructive, as fre- tient and community needs over the attitudes and
quently seems to be the case in chiropractic. The vit- preferences of proponents of a profession convey the
riol with which some chiropractors have characterized essence of professionalism. Promotion based on the
colleagues of different persuasions has puzzled out- contributions of chiropractic to health and well-being
side observers.4 In everything from rival theories to alis far more congruent with learned professionalism.
ternative ideas and preferences in practice or politics,
there is nothing less useful to professional develop- Professional ConscienceAs mentioned previously, chi-
ment; growth comes from thinking “outside the box.” ropractic organizations do proffer laudable codes
The moment when diversity is harnessed to unity (as of ethics. However, professionalism as a core
opposed to disunity) is a key indicator of a mature pro- educational mission or priority remains underdevel-
fession; the goal is to find ways to agree to disagree oped in chiropractic. Much of the prevailing organized
without collateral damage. emphasis associated with chiropractic principles
centers on competing preferences for professional
Professional Evolution and Growth Increasing the num- identity and political agendas. However, several
ber of practitioners has long been an accepted strategy individual efforts have contributed to a dialogue
for enhancing chiropractic’s social influence. In fact, on professionalism.30,38 The Journal of Chiropractic
the recruitment of students with a resultant increase in Humanities, sponsored by the National University of
the quantity of practitioners has been one of the most Health Sciences (now exclusively a web-based pub-
successful organized efforts the profession has under- lication: www.nuhs.edu/whats new/publications/
taken to raise its cultural exposure. In addition, orga- humanities/joch.html) provides a formal forum for
nized effort has been made to enhance and improve professional dialogue on the subject.
basic chiropractic education by establishing and en-
forcing minimal training standards.37 Increasing pre- Competition A team sports metaphor may best char-
requisites for matriculation and lengthening of train- acterize professional behavior regarding competition.
ing programs have also gone a long way to improve Although individual competitive performance occurs
the quality, capabilities, and confidence of practition- between members of the same team, it is most ef-
ers. However, a similar amount of organized attention fective when everyone strives to better their past
remains to evolve once chiropractors graduate. performance and that of their teammates and inef-
fective when there is an attempt to undermine or
Demeanor Professional demeanor might be best char- levy public complaints about other members of the
acterized as carrying oneself with cultural authority. team. Contests between different teams also occur,
In short, if the profession’s view of itself is that of but, again, it is bettering each team’s performance
“victim” or “second-class citizen,” it is easy to fos- (as opposed to undermining one’s opponents) that
ter an image of defensiveness and blaming others for is the most effective and reflective of professional-
the profession’s shortcomings. Despite the legal pro- ism. Other health care disciplines might represent
fession’s less-than-stellar reputation, attorneys are of- different teams, but nevertheless must be respected
ten among the most amused and first to perpetuate and extended professional courtesy. As other profes-
lawyer jokes. Acknowledgment of deficiencies and ac- sions engaging in manual medicine embrace higher
ceptance of responsibility to address them is essential. standards of training, skill, accountability, and per-
Confidence to carry on, ever striving to improve one’s formance, the competition with chiropractors will
profession and one’s self, is key to conveying a profes- increase. The osteopathic and physical therapy pro-
sional demeanor. Professionals handle adversity and fessions have actively embraced and begun strate-
dissent with charm, perspective, altruism, and lead- gic development in efficient and effective delivery of
ership, not denial. manual therapy. Given their resources and existing
An additional dimension of professional de- relationships within mainstream medicine, chiroprac-
meanor in practice relates to educating the public tic can only respond by delivering a better product.
Quality Improvement Monitoring one’s own perfor- (e.g., theoretical models of spinal dysfunction, spinal
mance and striving for self-improvement, efficiency, anatomy) can be alienating to patients who just want
and effectiveness characterize quality improvement help with their problem. Additionally, patients who
activity. Although “protecting turf” can never be have not tried chiropractic have identified doctor-
removed from the equation of professional evolu- centered promotion as a barrier to use of chiropractic
tion and development, supporting the development services.41 Informative advertising based on the pa-
of more effective, less expensive, more comfortable tient’s needs may be the most useful.
health care procedures is far more important for main-
taining credibility and market share. This is an area Evidence-Informed Practice Patient-centered care is of-
ripe for development in chiropractic. For example, ten the reason why chiropractors are appreciated.
older studies on chiropractic versus medical care for Staying current and striving to offer the most effec-
work injuries have reported large advantages for chi- tive and efficient evaluation methods, management,
ropractic in terms of costs and return-to-work rates.39 and care coordination are as much a part of being
However, more recent studies suggest that those mar- an excellent chiropractor as adjusting skills. As chi-
gins have dramatically reduced, to the point of little to ropractic physicians increasingly take on attending or
no difference.40 When the best medicine had to offer primary provider roles, the ability to effectively un-
for mechanical low back pain was invasive surgery, derstand care options and advise on overall health
ineffective bed rest, and potentially harmful drugs, strategies takes on increasing importance. Although
the “average” chiropractic approach would have an relicensure requirements ensure exposure to some
obvious advantage. Medicine has actively sought to form of didactic continuing education, oversight to
improve its practice to offer better patient selection quality and value is entirely the province of the spon-
for surgery, early activation instead of bed rest, and soring organizations and the attendees. Staying cur-
better-tolerated nonsteroidal antiinflammatory drugs. rent with professional literature is key. In addition to
Without similar, ongoing self-appraisal and quality the more research-oriented publications, more clinical
improvement within chiropractic, the competition can publications are also available (e.g., Chiropractic Tech-
get the edge. nique). In addition, literature synthesis publications
such as Chiropractic Reports and Chiropractic Research
Needs of Underserved Populations Outreach to under- Review provide a rapid way to be exposed to a variety
served populations is not only the right thing to of relevant articles.
do, it also conveys a social contribution that en-
hances professional credibility. If chiropractic is so
critical to health and well-being, shouldn’t those un- In health care,
Inter- and Intraprofessional Interaction
able to afford it still be able to obtain chiropractic there are few other areas where impacts on pa-
services? Not only might those individuals in need tients can be more problematic than when multiple
benefit from treatment, but regional chiropractic or- providers give conflicting advice to patients. While le-
ganizations might also be well-served by focusing on gitimate areas of disagreement may exist, most prob-
community needs.35 In addition to providing needed lems relate to inadequate communication or under-
services, there is also the opportunity to explore im- standing between caregivers. Disorganization in the
proved efficiencies in delivery where resources are coordination of care (in all fields) has been identi-
scarce. Although examples of altruism and volunteer fied as a key issue in care quality by the Institute
service can readily be found, organized and institu- of Medicine.42 Improving understanding and coor-
tionalized programs regarding health needs of under- dination of care plans is essential, and straightfor-
served or at-risk populations are uncommon. ward strategies can be incorporated into chiropractic
practice.43
Professionalism at the Individual Level
Self-Promotion It is a fascinating observation that eth-
THE STUDY OF ETHICS: CONCEPTUALIZING
ical prohibitions against any advertising promoting a
THE BIG PICTURE
single organization or individual within the medical
fields have disappeared since the economics of prac- Professional ethics is the codified principles and goals
tice have been under attack in recent decades. What that should guide interactions with the patients and
chiropractors were chastised for in the past has now providers’ behaviors as members of society. Ethics
become commonplace in the contemporary business serves as the framework from which difficult choices
of health care. However, chiropractic self-promotion can be made, reviewed, and even changed. The field
and advertising need to remain informative, taste- of ethics, as an academic discipline, is sometimes re-
ful, and professional.31 Issues exciting to chiropractors ferred to as moral philosophy and has three large
domains of inquiry: metaethics, theoretical normative member can countermand the most clear-headed in-
ethics, and applied ethics. tentions of the patient at the eleventh hour. This exem-
Metaethics describes environments of moral deci- plifies how right-versus-wrong dilemmas are some-
sion making, rather than dealing with the decisions times true ethical issues.
themselves. This abstract branch of ethics is distant
from the kinds of the practical day-to-day matters of Right versus Right Right-versus-right ethical dilemmas
professional life. pit options that are all possible against one another,
Theoretical normative ethics delves more intimately but for which only one can emerge as a final choice.
into areas of moral decision making on a conceptual An issue of contemporary interest in chiropractic is
or theoretical level. Three areas within theoretical nor- that of the role of scientific evidence in practice. On the
mative ethics are moral axiology (theory about good one hand, society expects physicians to be well trained
and evil), virtue ethics (describing exemplary moral and to continue their advancement both scholastically
character), and moral obligation theory (requirements and professionally. They are expected to remain cog-
common to all ethical individuals—what they must nizant and generally supportive of advances in health
and must not engage in). science. However, some practitioners eschew scien-
Applied ethics approaches real-life issues from the tific evidence as imperfect and of less importance
constructs provided from the other two branches, than their own experiences and perceptions about
and seeks to find real-world solutions to real-world a patient. As self-centered (as opposed to patient-
problems.44 Although the three areas are highly inter- centered) as the latter seems, there is some validity
related, applied ethics forms the crux of issues con- to the argument. Science is limited by what is studied,
fronted by health care providers. the quality of that investigation, and the myriad of bi-
Applied Ethics ases that permeate every aspect of inquiry. Judgments
are made on a regular basis during scientific studies,
Applied ethical issues can be divided into two cate- judgments that are based on imperfect information be-
gories: right versus wrong and right versus right.45 ing conveyed by imperfect people about imperfectly
understood phenomena. When evidence is in conflict
Right versus Wrong A true right-versus-wrong ethi- with the belief of the physician and the patient, who
cal issue occurs rarely in health care; an example is is right? Should the judgments of well-conducted sci-
physician-assisted suicide. The suffering of patients entific inquiry supersede the individual perceptions
at the end of life is a compelling ethical conundrum of the physician and the patient? The answer to this
with the duty to relieve suffering, especially in the ter- dilemma is not as obscure as the issue of “right to
minal phases of a disease such as cancer or AIDS. The death,” but it illustrates how two virtuous opinions
duty to eliminate suffering is bolstered by the obvious that are opposed should be heard and discussed. To
financial implications of extending life until it sim- fail to do so is to do a disservice to patients.
ply refuses to continue despite all available efforts—
resources that, when spent, will be unavailable for
other patients with a chance to live. This duty was Ethics in Health Care
less contentious when technology and sophistication A discussion of ethics requires distinguishing be-
to support life without the assistance of the patient tween the concepts of ethics and morals. The two
did not exist. However, a physician’s participation in concepts have similarities. Both involve an evalua-
a purposeful agenda to end a patient’s life is usually tion of actions or behavior, both refer to ultimate stan-
prohibited by law. While a physician wrestles with dards, both involve universal standards that should
the ethical dilemma on a case-by-case basis, society be judged in the same way by everybody, both are al-
continues to debate the issue on secular and religious truistic, and in both there should be a publicly defen-
grounds with no clear resolution. sible basis for decisions. The distinction is that morals
Out of this debate has emerged recognition of the refer to specific actions and judgments, while ethics
patient’s autonomy to decide what is or is not accept- refers to systematic codes of conduct. The codes by
able treatment. Advanced directives (documented which judgments are made are the ethics. The actual
wishes of a patient in a care situation) such as “use judgments are moral evaluations.
no extraordinary means,” “do not resuscitate,” and There is also a distinction between what is legal
intervention with medications only (no defibrillators, and what is ethical. An act may be legal but uneth-
respirators, or other mechanical assistive devices ca- ical. Something may be legally within the scope of
pable of replacing normal organ function in the body) practice of chiropractic (e.g., x-rays), but it is unethi-
are all compromises that the law has allowed patients cal to take them if they do not benefit the patient’s care.
and practitioners in this difficult time. Yet even these Conversely, something may be ethical but illegal. For
are fraught with controversy when a reluctant family example, chiropractors may feel an ethical obligation
to treat peripheral joints but may be unable to do so the principle of autonomy is the crucial concept of in-
in certain jurisdictions. formed consent. A patient should be, and has a right
When it comes to patient care, medicine’s tradi- to be, adequately informed of his or her condition
tional ethical adage of nonmaleficence, first do no harm, and the procedures that will be used to evaluate and
is inculcated within the day-to-day care decisions of treat it. In cases where competency of the patient is
typical chiropractors. By training and disposition, the not clearly established (e.g., a child younger than age
least invasive of interventions typically top the list 18 years, mental incapacitation, situations where the
of chiropractors’ care plans. However, one of chiro- judgment of the patient is considered impaired, such
practic’s most valued therapeutic tools, that involving as drug or alcohol intoxication), the physician must
physical touch, can also be a source of ethical profes- attempt to find an agent who can act as counsel on
sional transgression.46 Instead of the vinyl-glove-clad behalf of the patient. In life-threatening situations, of
sterility of medicine and dentistry, physical and man- course, this imperative is significantly more discre-
ual medicine is often rendered in a more casual, re- tionary, allowing the physician to be paternalistic and
laxed setting absent many of the clinical barricades make decisions on behalf of a patient.
that separate other doctors from their patients. Com- Nonmaleficence is the principle of primum non no-
pared to contemporary allopathic medicine, chiro- cere, or “first, do no harm,” found in the Hippocratic
practic care involves far fewer instruments and layers oath. The basic premise entertained by nonmalefi-
of jargonistic isolation. This contributes to a unique in- cence is risk–benefit assessment, suggesting that for all
timacy, which when superimposed on a separate evo- problems, there are solutions that, while helpful, are
lution from the give and take of the mainstream, has not worth the risk or harm to the patient. The premise
contributed to some professional and ethical issues that physicians must operate under is to provide the
unique to chiropractic. greatest good for the least harm, both specifically to
The theoretical underpinnings for ethics can be the condition, and globally to the patient in his or her
found in philosophy (action theory, utilitarianism life context. The axiom “there are some patients that
and consequentialist theories, deontological theories, cannot be helped, but there are no patients that can-
prima facie and duty proper theories, value theory, not be harmed” serves as a powerful illustration of the
virtue theory). In health care, however, there are seven principle of nonmaleficence.
major ethical principles that regulate the interaction Beneficence describes the principle of doing as
between a doctor and a patient: (a) autonomy, (b) non- much good as one can. While this might be viewed as a
maleficence, (c) beneficence, (d) justice, (e) veracity, simple extension of nonmaleficence, there is an impor-
(f) do not kill, and (g) paternalism (Table 11–2). tant difference. Nonmaleficence calls on the physician
Autonomy provides that a patient should be an in- to avoid harm, while beneficence obliges the physi-
formed participant in the decisions that will affect the cian to do as much for the patient as the physician can
patient’s body and health. It obliges a practitioner to and extend the entire latitude of the physician’s abil-
engage the patient as a partner in the assessment and ity and expertise on behalf of the patient. The princi-
management of the patient’s condition. Inherent to ple of beneficence is so strong that society has created
TABLE 11–2. Ethical Principles in Doctor–Patient Relationships
Term Description
Autonomy Recognizes the right of patients to independent judgments about what happens to them, and to have
these choices recognized by the doctor (if not always supported by the doctor, however).
Nonmaleficence Recognizes that at the very least the therapy should not cause harm.
Beneficence Requires that the provider do good.
Justice Delineates that patients have the right to be treated fairly and equitably. It involves giving patients the
care they need, the care they deserve, and the care to which they are entitled.
Veracity Means telling the truth and implies respect for patients, for their autonomy, and for their right to
make independent decisions.
Fidelity Involves keeping promises and commitments and is associated with two key professional
responsibilities: confidentiality of patient information and patient abandonment.
Do not kill Admonishes acts by a health care provider that will foreshorten life.
Paternalism Obligates the doctor to mimic decision making of a parent or guardian when the patient does not
possess the capacity to do so.
special protections for those who would offer their versus an ultrasound-guided biopsy of that same area.
help outside the normal context of care delivery to Even with excellent information provided in a need-
relieve suffering or to save lives (the good samaritan satisfying way over appropriate time, it would be un-
acts). likely that a patient would be able to understand the
Justice is the principle that encompasses fairness variables and their interactions in order to make a re-
to the patient and to the public. It is a principle that sponsible choice without assistance from the physi-
is subject to dilemma as well. The utilitarian theory cian. The physician is granted paternalistic authority
of the “greatest good for the greatest number” may to decide which is best for the patient in that situation.
conflict with the needs of an individual patient. A so- However, despite this authority, there remains an
cialist perspective, such as “from each according to overriding duty to respect the patient’s autonomy. Pa-
his ability, to each according to his needs,” may have ternalism does not alleviate the duty to relate truth-
ethical implications for providing care for noncompli- fully and forthrightly with patients. A physician who
ant patients when care resources are sparse. Fairness feels strongly about a test or treatment might be
is difficult to measure, but the principle is designed to tempted to “simplify” the decision variables to suit the
call to question exactly who benefits from a decision physician’s desired outcome, especially if the physi-
and to what degree. Although it is entirely fair and just cian is concerned that the patient may not be entirely
that a physician should be paid for time and expertise, cooperative or clear about complicated information.
it is not fair that the physician would use his or her au- The temptation to provide a simple lie instead of a
thority to engage the patient for the principal reason of complicated truth is a difficult position, but the prin-
financial benefit, rather than to manage the patient’s ciples of autonomy and justice compel the physician
illness. The issue of fairness becomes complex when to inform to the best of they physician’s ability and to
physicians are asked to consider global fairness (e.g., couch recommendations as such.
cost-effectiveness) over and above individual fairness These seven general principles constitute the most
(e.g., lengthening suffering or incapacity). important codes of conduct within the doctor–patient
Veracity, or being truthful, implies that the patient relationship and typically are the basis for other more
be told the truth about recommended care and alter- specific codes. Lifetime prohibitions against roman-
native options and is also crucial in terms of informed tic or sexual relations with patients by psychiatrists
consent; patients must be apprised of the risks and or psychologists expand from the principle of do no
benefits of the therapies prior to consent. harm. Professions may include additional principles
“Thou shalt not kill” is the principle admonishing as exemplified in the Hippocratic oath, which includes
acts that will foreshorten life. The complexities of eth- “to hold him who taught me this art as equal to my
ical dilemmas in this arena are reflected in contempo- parents.” The American Medical Association code of
rary controversies surrounding a terminal patient’s ethics currently states that a physician shall, in the pro-
right to die and euthanasia, and do not readily apply vision of appropriate patient care, except in the case
to chiropractic. of emergencies, be free to choose whom to serve, with
Paternalism obligates the practitioner to mimic the whom to associate, and the environment in which to
decision making of a parent or guardian in situations provide medical services. The American Dental As-
where the patient does not possess the capacity to do sociation code states that dentists shall be obliged to
so. Paternalism places authority in the hands of physi- seek consultation, if possible, whenever the welfare
cians to decide upon the needs for a patient, or to lead of patients will be safeguarded or advanced by using
a patient substantively to a decision, as long as they those who have special skills, knowledge, and expe-
place the needs of the patient above their own needs rience, and requires a specialist to return the patient
or the needs of others. Paternalism allows a physician to the referring dentist. Dentists are also required to
to coerce a patient into making choices that serve the report instances of gross or continual faulty treatment
patient’s best interests. This tenet of ethical behavior is of other dentists.
usually reserved for situations where patients are not Some professions also expand ethical codes to in-
considered responsible agents for their own interests, clude personal behavior. For example, environmen-
and the physician must intervene on their behalf. tal health practitioners have “Ethical Principles to
Lines of paternalism become less clear when one Guide Environmental Health Practitioners in Their
considers the complex issues related to an esoteric di- Daily Lives.” It includes admonitions to avoid contra-
agnosis, and the complicated and intimidating op- dictions between your lifestyle and your professional
tions for its assessment and/or management. For role, such as owning big and heavily polluting auto-
example, it would be unreasonable to expect a pa- mobiles, keeping your home as clean as feasible, the
tient to be able to distinguish the best choice be- avoiding of creating obvious pollution, and concen-
tween computed tomography (CT)–guided biopsy of trating on living a lifestyle that has less environmental
a neoplasm in the uncinate process of their pancreas impact than the lifestyle of others.
Professional and Ethical Accountability TABLE 11–3.Examples of Ethical Challenges That

The ethical behavior of a practitioner is subject to three Chiropractors Are Likely to Confront
separate bodies of accountability. The first is the ex-
pectation that practitioners will behave in accordance Evidence-based practice
with the general laws of society. These laws are ad- Documentation
judicated by the criminal courts when violated. Civil Accuracy in communication (Simple “statements” versus
courts establish the second process through which the complicated “truths”)
activities of doctors can be judged for compensatory Good samaritan
damages. Administrative law proceedings are a third Professional boundaries
level of legal accountability that practitioners face. Ad- Efficient use of resources
ministrative proceedings are focused on issues relat- Informed consent
ing to a doctor’s access to licensure. All three can be
separately considered for a single offense. They each
employ a different standard of evidence, with crimi- is evidence-based practice. Learned physician opin-
nal courts employing a “beyond a reasonable doubt” ion and customary and prevailing practices of old
standard, civil courts employing a “preponderance of gave way to escalating health care costs and poor
evidence” standard, and administrative law proceed- clinical outcomes in many cases. For example, third-
ings abiding by a “clear and convincing evidence” party reimbursement (insurance) systems did not re-
standard. Thus, it is possible for a practitioner to en- quire doctors to consider cost factors when decisions
dure any or all three of the systems for violating the about medications, surgery, or other interventions
public trust, each establishing its own sanctions and were contemplated. In reaction, limited financial re-
penalties, separate and distinct from the others. Fur- sources spurred the development of managed care
thermore, it is entirely acceptable for evidence in one and its attendant control systems, which attempted
proceeding to be used in another proceeding. to factor cost and resource issues back into treatment
Above the standards of “punishable behavior,” decisions, and may have negatively impacted health
ethical principles implore practitioners to behave care quality in the process.
above reproach, or to avoid the “appearance of im-
propriety.” This standard describes how doctors and
Evidence-Based Practice
other health care workers ought to strive to behave.
Health care practitioners and other professionals are The measurement of patient outcomes and appro-
empowered to assist patients without specific over- priate use of scientific evidence in clinical decisions
sight and to see to their well-being, even when the are behind the current push towards evidence-based
evaluation and cure of the problem places the patient practice.47,48 Yet evidence is subject to variation in
in harm’s way. It is sometimes unavoidable that a availability and quality, and doctor or patient prefer-
doctor could harm a patient in pursuit of a cure for ences and experience may be incongruous with ev-
his or her problem. It is further expected that prac- idence. Social norms and mores have evolved and
titioners will occasionally fail to reverse illness, and delineated professional boundaries that may yield
that despite their best efforts, patients will expire or ethical dilemmas. Obligations to document decisions
be maimed. Physicians are not expected to be per- with clinical data can conflict with efficient use of re-
fect. This power is granted through legal and legisla- sources and a legitimate right to privacy. One’s ex-
tive prerogative, and is judged on an individual basis pertise may clash with a legal scope-of-practice issue
by the standard of care as established by the profes- (as in advising a patient on the appropriateness of
sion, reasonable practitioners, and previous case law a medication prescribed by another provider). How
in similar instances. However, a fourth estate in ethical much one tells patients and family members about
accountability is that of peer oversight. Codes of ethics treatment risks, diagnoses, and lifestyle choices may
and conduct established by professional groups go also be a source of ethical consternation.
above and beyond legal requirements to form the basis For chiropractors, and other physicians who treat
for self-policing competency and behavior by peers. spinal disorders, the challenge regarding evidentiary
practice revolves around the limited availability and
quality of evidence from which to make clinical de-
cisions. One of the greatest issues is reflected in the
ETHICAL ISSUES SPECIFIC TO CHIROPRACTIC
adage “absence of evidence does not equal evidence
Multiple ethical issues currently confront chiroprac- against.” Although high-quality scientific studies spe-
tors and they will require insight and understand- cific to populations for which evidence is to be ap-
ing (Table 11–3). The driving force for health care plied are the gold standard, rarely is such information
delivery in the beginning of the twenty-first century readily available. Scientific literature on manipulation
exemplifies this.49 At least 60 randomized clinical tri- may prompt inquiry and litigation from whoever’s
als have been published on manipulation for neck and interests are affected. Proactive procedures should
back conditions, all suggesting better or equivalent be developed and reconciled with jurisdictional and
outcomes to comparative treatments. What remains community standards.
unstudied are common clinical decisions chiroprac-
tors confront daily, such as how does one treatment Accuracy in Communication
approach compare to another? What is an optimum It is frequently more efficient to convey a simple,
frequency or duration of care? Are there differences yet inaccurate, metaphor instead of a complicated,
for injured worker, pediatric, or elderly populations? comprehensive explanation of difficult concepts, un-
For these questions, one must rely on lesser-quality ev- certainties, and facts for patients. In chiropractic, sim-
idence such as consensus documents, qualitative and plistic (but wrong) explanations of pinched nerves
case report literature, expert opinion, and experience. and philosophical explanations of degeneration and
Should the use of scientific evidence in practice be healing can be much easier to convey than de-
an option, or is it imperative? An argument can be tailed treatises on proprioceptive anomalies, hystere-
made that chiropractors have an ethical duty to resis, biomechanics, and theories on pain behavior. Fur-
port their clinical experience (via publication). At a thermore, patient compliance with a useful care plan
minimum, this should be encouraged, because man- might be more readily engendered with a “simple
dating such requirements would be impractical. There statement” rather than a “complicated truth.” The eth-
is also a minimal requirement to be aware of what ev- ical principles of justice, autonomy, and paternalism
idence is and is not available and be informed about must all be factored into this dilemma and are likely to
it in the decision-making process. Inherent in this is have different outcomes with different patients. The
an obligation to recognize and understand the qual- patient who is an engineering student with a sports
ity of evidence that is available. Last, ethical practice injury may be far better off with complexity than an
asserts a duty to share such information with others, elderly patient with memory problems in a lot of pain.
particularly with patients who could be affected by Judgment and experience must factor into the resolu-
the information. tion of these dilemmas.
Documentation Good Samaritan

There has long been a social expectation that health Doctors can be placed in a unique situation when
care providers document what they do, if for no other knowledge or skills they possess may be of value out-
reason than to document what was done for medicole- side of the typical practitioner–patient environment
gal reasons. Issues of public safety, determination of (such as at the scene of an accident or disaster). In act-
what is or is not of benefit, and the improved accuracy ing under such circumstances, and particularly when
of real-time codification of what transpires in clinical skills and knowledge may be required beyond the
practice reflect legitimate needs for documentation. usual area of expertise, it is necessary to determine
When care is transferred between physicians because whether one is able and willing to help, and what is
of choice or circumstance, documentation should fa- the duty to do so? The fundamental dilemma is the
cilitate continuity of care and preclude revisiting un- risk of potential litigation as a result of expectations
successful or redundant procedures. However, the ad- for trained professionals beyond those of a layper-
ministrative conveniences and needs of third parties son in similar circumstances. The code of ethics for
have factored into documentation requirements with emergency physicians incorporates an expectation for
administrative accountability demands taking physi- behaviors that would normally be placed under the
cian time and resources away from critically needed “good samaritan” concept.51
health delivery priorities. Finding a balance between
needs for reimbursement or professional liability con- Professional Boundaries
cerns and what is essential for assuring quality care Bowers46 provides one of the most practical reviews
can be difficult. Ideally, efficient clinically focused ap- of professional boundary issues available for chiro-
proaches will meet both needs.50 practors. A professional boundary can be defined
More challenging is when documentation conflicts as the expected and accepted physical, psychologi-
with duties to the patient. No issue exemplifies this cal, and social distances that exist between patients
more than when a patient with a condition (say a pos- and providers. Ethics, cultural moral norms, and le-
itive HIV test result) sustains a workplace injury in gal standards define them. Crossing such boundaries
which coverage may require release of past medical may be part and parcel of clinical practice and in and
information to third parties (such as claims adminis- of itself may be acceptable. However, a boundary vi-
trators or employers) who could use the knowledge to olation is unacceptable. A violation is defined as a
the patient’s detriment. Redacting records in such sit- harmful boundary crossing. Table 11–4 summarizes
uations is a ready option, but may be burdensome and boundary issues in chiropractic.
TABLE 11–4. Boundary Issues in Chiropractic
Issue Discussion
Personal space Diagnostic and therapeutic procedures invade personal space by their very nature.
Communication and understanding in advance are key. Crossing into personal space
should be maximally respective of privacy and be done with appropriate verbal consent.
Care of friends and relatives Care of family and friends is common but ethical issues may arise. Doctors should question
themselves regarding their objectivity, training, emotional involvement, ability to sustain
patient compliance, and accountability to standards of care.
Gift exchange Gift giving personalizes relationships and when done by physicians to patients may swing the
balance of power in favor of the doctor’s authority. This can be coercive. Group settings
and clinically relevant low-cost items may be more appropriate (e.g., refreshments in the
reception room during holidays, an exercise pamphlet during an office visit); however, large
individual gifts are best avoided.
Dress Patient and doctor attire does reflect boundaries. Patient draping procedures should be
routinely used and attention to repositioning gowns or drapes that fall or open during
procedures should be standard.
Confidentiality A casual comment from an office staff person may be overheard by another patient. Even
patient charts left within view may be a source of a confidentiality breech. Strict protocols
and training on confidentiality should be standard in health care practices. New US federal
mandates are being implemented, increasing the security in all matters that may impact
privacy and confidentiality protections.
Informed consent When a patient may be at significant risk of harm from a procedure, disclosure must be
made. Not only may legal requirements be in place for particularly serious or frequent
risks, informing patients fosters a useful aura of patient–physician team effort.
Physician self-disclosure Doctors should not routinely reveal their experiences or personal preferences to patients.
This, too, personalizes doctor–patient relationships and may correlate with development of
practitioner–patient sexual relationships. Neutral self-disclosure may be beneficial in some
situations (e.g., relaying an experience with a low back problem or a procedure to be
undertaken).
Physical contact/touching Advance communication regarding clinically correct therapeutic contact should be routine. It
is important to be aware of whose needs are being met by touching and what those needs
are. Touching beyond the clinical encounter can be more sensitive. Handshaking, patting,
embracing/hugging, and kissing are all activities that can personalize relationships, and
even though they may be culturally acceptable in other circumstances, they may be readily
misconstrued in clinical encounters.
Money Transfer of money clearly delineates the business boundaries of therapeutic relationships.
Nonmonetary forms of payment and barter may be ill advised at current times. Boundary
violations regarding billing and insurance are common, and giving away free care may be
construed negatively from a professional liability standpoint. Waiving fees in hardship cases
can be appropriate as long as there is clear intent, documentation, and advance
discussion with the patient.
Language Communication with patients on a first-name basis can personalize doctor–patient
relationships. The use of first names with pediatric patients is typically appropriate, yet a
younger doctor may be better off to default to the use of Mr. or Ms. with an elderly
patient. Tone of voice and choice of words also convey meaning, and attention to these
factors is also important.
Posttherapy personal contact Although patients or doctors experiencing feelings of attraction to one another is neither
abnormal or wrong, choosing to act on such feelings is a boundary violation. Before a
physician initiates any kind of dating or romantic relationship, at a minimum, the
doctor–patient relationship should be terminated and documented in the patient record.
Furthermore, the notation should be signed by the patient.46 Different jurisdictions may
have specific requirements or prohibitions, and some specialties have established
guidelines, such as a 2-year waiting period following discharge. Romantic involvement
between psychiatrists and patients has been considered exploitation of emotions deriving
from treatment and is almost always unethical.
The most visible boundary issue is sexual mis- recommendations in making health care decisions.
conduct associated with making physical or romantic Patients assign authority to a doctor to take their med-
advances to patients. Increasingly, the line has been ical history and some form of examination in order to
drawn in regulations that contain clear prohibitions determine the nature of the problem and establish a
and timelines for any such interactions, and these have treatment plan. The simple act of keeping appoint-
been delineated statutorily or by regulation in practice ments reflects acceptance of this implied covenant to
acts. Sexual or romantic relationships concurrent with treat. It is incumbent upon the caregiver to ensure the
a doctor–patient relationship are clear violations. Re- patient understands what is proposed, as well as what
lations with former patients may also be violations. other care options exist.
For chiropractors, the intimacy of close contact and
touching between doctor and patient during legiti-
CONCLUSIONS
mate treatment procedures can establish a risky lower
threshold of possible violation. Doctors function within a unique position of public
Personal space is central to human relations and trust. While the law may set standards for what is
varies by culture and situation. In business relation- considered intolerable in a doctor’s conduct, it does
ships, several feet of separation are typical, while in- not establish optimal performance and ethics. Disease
timate contact may be less than a foot. In clinical sit- care is not a discretionary purchase and the principle
uations, verbal clarification regarding when and why of caveat emptor may be too harsh an expectation to
personal space is to be crossed can reduce discom- place on consumers. Health care remains one of the
fort. Contact by chiropractors during treatments of- most regulated industries in industrialized nations,
ten involves extensive contact (such as thigh to thigh and most nations fund it out of public dollars. Prac-
in side-posture adjustments). Miscommunication or titioners thus have duties and obligations of profes-
misunderstanding is easy when it is routine and of lit- sionalism and ethics to behave in concordance with
tle concern to a DC, yet is unfamiliar to a new patient. public good, as well as professional good.
Table 11–4 lists areas of potential boundaries chiro- While delineation between what is right and
practors may be at risk of crossing. Physicians should wrong is usually straightforward and frequently gov-
routinely be conscious of, and ask themselves about erned by laws and regulations, distinctions between
appropriateness of, boundary crossings in all of the two competing right answers, actions, or outcomes
areas listed in Table 11–4. are more ambiguous. The domain of ethics and pro-
fessionalism often encompasses such subtleties. Dis-
Efficient Use of Resources tinctions between boundary crossings and boundary
Few can argue that cost containment and resource violations may at times seem clear, while at other times
allocations are legitimate needs for society, pre- be blurred by situational circumstance. Although for-
mium payers, and the insurance business. However, mally adopted professional codes of ethics in chiro-
economic needs should not outweigh quality and practic offer general guidance in patient autonomy
appropriateness-of-care considerations. There exists and help to assure professional interests, such docu-
a tension between cost containment and unfettered ments are rarely revisited and rarely address many
physician autonomy. Some have argued for the need of the specific dilemmas mandated by contemporary
to factor concerns of interests other than those of pa- health care. The chiropractic profession’s ethical com-
tients into the ethical decisions.52 Ideally, demand for pass continues to reside primarily in the hearts of
health care services should be induced by clinical its practitioners. The obligation rests with each prac-
need and patient preference, as opposed to physician- titioner to remain informed, communicate with in-
induced demand. Providers not only have obligations tegrity, and factor the needs, interests, and preferences
to the patients they care for, but to the greater commu- of patients and the community into care recommen-
nity they serve. In the United States, fee-for-service re- dations.
imbursement can provide incentives for care beyond
that which is appropriate, just as risk-sharing models
SUMMARY
may establish incentives to inappropriately withhold
care. 1. Professions are in a unique position of public trust
and receive state sanction in areas such as pro-
Informed Consent fessional autonomy, control of their membership,
By far the most critical issue to patient autonomy and other professional privileges, including self-
is informed consent. While medicolegal and profes- regulation and policing.
sional liability reasons for documenting informed con- 2. In exchange for professional privileges, society ex-
sent are well understood and have been thoroughly pects members of a profession to place the society’s
addressed in chiropractic literature,53 it is easy to interest above their own. When this does not oc-
overlook the fact that patients rely heavily on doctor cur, society may revoke privileges. For example,
the health profession’s failure to consider social A. True

priorities such as the effects of spiraling health B. False
care costs has resulted in diminished physician 3. Which one of the following is the most substan-
autonomy via managed care for clinical decision tive indicator of a unique community sanction as
making. a health profession?
3. Professionals are accountable for their ethical be- A. Health care professionals must obtain a license
havior to the general laws of society as adjudi- to practice.
cated in criminal courts of law (e.g., transgressions B. Health care professionals get to charge for their
such as insurance fraud or rape), civil liabilities as services.
adjudicated in civil courts and proceedings (e.g., C. Health care professionals are required to have
professional malpractice), and to administrative business licenses.
law as adjudicated in administrative hearings (e.g., D. Health care professionals have to carry mal-
suspension of a license to practice because of ro- practice insurance.
mantic involvement with a patient). 4. Which one of the following elements of the chiro-
4. Professions have several characteristics. Members practic profession represents a characteristic of its
of professions typically have skills that flow from professional stature?
a systematic, supportable body of knowledge and A. More than 60,000 chiropractors are in practice
theory. The social authority that is bestowed upon in North America.
professions comes with the expectation that the B. The profession’s knowledge base is increas-
good of the consumer and society prevails over the ingly sustained through its own research ac-
self-interest of the member. Communities in which tivity.
professions work bestow sanctions such as licen- C. It takes specialized education to learn chiro-
sure and monopolistic benefits. Professions typ- practic.
ically codify their ethical standards. Professions D. Chiropractic has prevailed in numerous leg-
may have a unique culture reflected in syntax, islative initiatives and court challenges.
preservation of autonomy, and self-regulation. 5. What should a doctor do if attracted to a patient
5. Ethics are codified principles that guide a profes- before acting on those feelings?
sional’s behavior and interactions with customers, A. Disengage in any pattern of behavior that is
colleagues, and society at large. Morals are re- allowing these feelings to manifest, and strate-
flected in virtuous decisions and behaviors. gize a path to identify the root of situation to
6. Resolution of true ethical dilemmas involves an prevent it in the future.
understanding that identifies a moral issue at B. Explain that you are attracted to the patient and
stake, and that there is an actual right-versus-right the depth of your feelings. Explain that you
ethical dilemma that requires clarification based must refer the patient to someone else before
on ethical principles. pursuing your feelings further.
7. Professional boundaries for physicians are the C. Make a casual reference to your attraction to
expected physical, psychological, and social dis- the patient and assess whether the feeling is
tances between patients and doctors. Crossing mutual. If not, just behave professionally for
the boundaries may be necessary and appropri- the duration of care.
ate (e.g., to touch a patient during an examina- D. Wait until the course of care is completed before
tion); however, violating them is inappropriate asking the patient out.
(e.g., touching a patient in sexual manner during 6. It is unprofessional for a doctor to cease accept-
an examination). ing managed care patients because the doctor is
jeopardizing his or her ability to stay in practice
because of the low reimbursement rates and time
burden created by the managed care hierarchy.
QUESTIONS
A. True
1. A chiropractor touches a patient’s leg with his or B. False
her leg during a side-posture lumbar spine adjust-
ment. This is considered:
ANSWERS
A. A professional boundary violation.
B. A professional boundary crossing. 1. C
C. Nothing, no boundaries are involved with clin- 2. A
ically correct touch. 3. A
2. True ethical dilemmas involve discernment be- 4. B
tween right-versus-right issues rather than be- 5. A
tween right-versus-wrong issues. 6. B
KEY REFERENCES 15. Inglis B. Report of the Commission of Inquiry: Chiropractic

in New Zealand. Wellington, NZ: Government Printer,
American Chiropractic Association. Policies, code of ethics. 1979.
Arlington, VA: American Chiropractic Association, 16. Anderson CA, Beebe M, Dalton JA. Current procedural
1996. terminology: CPT 2002. Chicago: AMA Press, 2001.
American Chiropractic Board of Sports Physicians. Code of 17. Freidson E. Professional dominance. The social structure of
ethics. Estherville, IA: American Chiropractic Board of medical care. New York: Atherton, 1970.
Sports Physicians, 2002. 18. Miles-Trapping C. Physiotherapy and medicine:
Bowers LJ. The “slippery slope”: Boundary issues for Dominance and control. Physiother Can 1985;37:289–
the chiropractic profession. Top Clin Chiropr 1994;1(3): 293.
1–8. 19. Wardwell W. Chiropractic: Challenges to medical dom-
Coulter ID. Conflict between the health professions. ACA J ination. Res Sociol Health 1981;2:207–250.
Chiropr 1994;April:21–26. 20. Willis E. Medical domination. Sydney, Aust: George
International Chiropractors Association. ICA code of ethics. Allen and Unwin, 1983; Coburn D, Biggs CL. Limits
Arlington, VA: International Chiropractors Association, to medical dominance: The case of chiropractic. Soc Sci
1985. Med 1986;22:1035–1046.
Meeker W, Haldeman S. Chiropractic: A profession at the 21. Pratt L. Reshaping the consumer’s posture in health.
crossroads of mainstream and alternative medicine. Ann In: Gallagher EB, ed. The doctor–patient relationship in
Intern Med 2002;136:216–227. the changing health care scene. Washington, DC: DHEW,
O’Neil EH, Pew Health Professions Commission. Recre- 1976:41–71.
ating health professional practice for a new century. The 22. Greenwood E. Attributes of a profession. Social Work
fourth report of the Pew Health Professions Commission. San 1977;2:45–55.
Francisco: Pew Health Professions Commission, 1998. 23. Moreau WJ. The Development of an ethics policy in
a chiropractic specialty. In: Proceedings, Seventh Annual
Conference on the Research Agenda for Chiropractic, New
REFERENCES Orleans. Davenport, IA: Palmer Center for Chiropractic
Research, 2002.
1. Terwilleger K. The view from the outside. Top Clin Chi- 24. Dower C, O’Neil EH, Hough HJ. Profiling the profes-
ropr 2000;7(1):80–83. sions: A model for evaluating emerging health professions.
2. Wardwell W. A marginal professional role: The chiro- San Francisco: Center for Health Professions, Univer-
practor. J Soc Forces 1952:30:339–348. sity of California, 2001.
3. Sternberg D. Boys in plight. A case study of chiropractic 25. Strang VV. The essential principles of chiropractic.
students confronting a medically oriented society [PhD the- Davenport, IA: Palmer College of Chiropractic, 1984.
sis]. University of Missouri, 1972. 26. Sportelli L, Mootz RD. Communicating chiropractic
4. Cowie JB, Roebuck JB. An ethnography of a chiropractic with integrity. Top Clin Chiropr 2000;7(4):25–34.
clinic: Definitions of a deviant situation. New York: Free 27. American Bar Association. Standards for imposing
Press, 1975. lawyer sanctions. Chicago: American Bar Association,
5. McCorkle T. Chiropractic: A deviant theory of disease 1992.
in contemporary western culture. Hum Org 1961;20: 28. McClelland GB. Challenges to trade association, re-
20–23. search organizations, and other “membership” groups.
6. Baer HA. A comparative view of a heterodox health Top Clin Chiropr 2000;7(1):33–38.
system: Chiropractic in America and Britain. Med An- 29. Murray A, Montgomery JE, Chang WH, Inul T, Saran
thropol 1984,8:151–168. DG. Doctor discontent—A comparison of physician
7. Hewitt D, Wood PHN. Heterodox practitioners and satisfaction in different delivery system settings, 1986
the availability of specialist advice. Rheumatol Rehabil and 1987. J Gen Intern Med 2001;16:451–459.
1975:14:191. 30. Kopansky-Giles DR, Decina P, Goldin J, et al. The
8. Wardwell W. Orthodoxy and heterodoxy in medical community-based external clinics program at the
practice. Soc Sci Med 1972;6:759–763. Canadian Memorial Chiropractic College. Top Clin Chi-
9. Anderson RT. Medicine, chiropractic and caste. Anthro- ropr 2002;9(1):62–67.
pol Quart 1981;54:157–165. 31. Christensen MG, Kerkhoff D, Kollasch MW, eds. Job
10. Wiesner D. A caste and outcast system in medicine. Soc analysis of chiropractic: A project report, survey analysis
Sci Med 1983;17:475–480. and summary of the practice of chiropractic in the United
11. Cobb AK. Pluralistic legitimization of an alternative States. Greeley, CO: National Board of Chiropractic Ex-
therapy system. Med Anthropol 1977;1:1–23. aminers, 2000.
12. Cruess SR, Cruess RL. Professionalism must be taught. 32. Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M.
BMJ 1997;315:20–27. A comparative study of chiropractic and medical edu-
13. Cruess SR, Cruess RL. Professionalism: A contract cation. Altern Ther Health Med 1998;4(5):64–75.
between medicine and society. CMAJ 2000;162(5): 33. Janse J. Principles and practice of chiropractic. Lombard,
668–669. IL: National College of Chiropractic, 1976.
14. Wilk et al. vs. American Medical Association et al., 671 F. 34. Manga P, Angus D, Papadopoulos C, Swan W. The effec-
Supp. 1465 (ND Ill. 1987). tiveness and cost effectiveness of chiropractic management of
low back pain. Ottawa, Ontario, Canada: University of the dilemmas of ethical living. New York: Simon and
Ottawa, 1993. Schuster, 1995.
35. Johnson WG, Baldwin ML, Butler RJ. The costs and 41. Sacket DL, Straus SE, Richardson WS, Rosenberg W,
outcomes of chiropractic and physician care for back Haynes RB. Evidence-based medicine: How to practice and
pain. J Risk Insurance 1999;66:185–206. teach EBM. London: Churchill Livingstone, 2000.
36. Hawk C, Killinger LZ, Dusio ME. Perceived barri- 42. Yeomans S, ed. The clinical application of outcomes assess-
ers to chiropractic utilization: A qualitative study us- ment. Stamford, CT: Appleton and Lange, 2000.
ing focus groups. J Am Chiropr Assoc 1995;32(6):39– 43. Mootz RD. Maximizing the effectiveness of clinical
44. documentation. Top Clin Chiropr 1994;1(1):60–61.
37. Institute of Medicine. Crossing the quality chasm: A new 44. American College of Emergency Physicians. Code
health system for the 21st century. Washington, DC, Na- of ethics for emergency physicians. Policy number
tional Academy Press, 2001. 400188. June 1997. Available at: www.acep.org/2,1118,
38. Mootz RD. Interprofessional referral protocols. Top Clin o.html.
Chiropr 2001;8(2):9–12. 45. Montgomery K, Little JM. Ethical thinking and stake-
39. Callahan J, ed. Basics and background. In: Ethical issues holders. Med J Aust 2001;16;174(8):405–406.
in professional life. New York: Oxford University Press, 46. Campbell L, Ladenheim JD, Sherman R, Sportelli L.
1988:3–25. Informed consent: A search for protection. Top Clin
40. Kidder R. How good people make tough choices: Resolving Chiropr 1994;1(3):55–63.
S E C T I O N
INTRODUCTION TO
II
CHIROPRACTIC THEORY
Our understanding and theories of the scientific basis organ. Dr. Polus also synthesizes information from a
of chiropractic are becoming increasingly sophisticated, number of sources to capture an important sentiment
as is clear from the chapters which lie ahead. Each that is discussed by researchers but which has not yet
chapter is written by a recognized authority in the field been emphasized in prior chiropractic writings, the im-
who brings both knowledge and enthusiasm to his or portance of the small, unisegmental paraspinal muscles
her topic. in spinal proprioception. This topic is touched upon by
This section begins with the neurosciences. It has other authors in this section and will no doubt become
been designed to start with sensory input from the an increasingly important focus of research.
spine, moving to central processing, and then talking Having dealt with the structure and function of re-
about reflex output. This is followed by a discussion of ceptors in the spine and paraspinal muscles, we logi-
normal biomechanics and mechanical abnormalities and cally move on to a consideration of the central projec-
spinal pathology. These chapters also frequently discuss tions of these receptors, authored by Xue-Jun Song and
neurological implications. The section finishes with two Ronald Rupert. In tracing connections of nociceptors
topics of special interest to the practice of chiropractic: and mechanoreceptors to the spinal cord and higher
headaches of spinal origin and genetic and environmen- centers, Drs. Song and Rupert do more than simply reit-
tal factors that influence spinal disorders. erate, albeit articulately, the histology of the central ner-
The first chapter deals with sensory innervation of vous system. They deal specifically with the functional
the spine, and is written by Joel Pickar, a respected re- consequences of these connections as they relate to
searcher in this field. Dr. Pickar provides a concise re- such issues of interest as pain sensation, pain control,
view of the structure and function of spinal receptors, somatic reflexes, and somatovisceral phenomena.
and then frames this within the context of chiropractic Much has been made in chiropractic theory of the
theories that relate afferent input from the spine to the effects of nerve compression and stretch. Finally, some
maintenance of homeostasis. This is essential reading clarity of thought is brought to this important area by
for chiropractors who need to know, for example, which Geoffrey Bove. Dr. Bove deals with the biomechanics
tissues are or are not capable of signaling pain, or dis- of peripheral nerves, and explains how disturbances in
turbances in posture or motion. Similarly, discussion of normal biomechanics, either through compression or
the effects of adjustment requires an understanding of stretch, can, for example, compromise blood supply or
possible underlying neurological mechanisms. Dr. Pickar initiate inflammation. These are important topics from
provides excellent groundwork for the chapters which the point of view of diagnosis and treatment. However,
follow. they also have special meaning for chiropractors as we
Dr. Pickar’s theme is picked up by Barbara Polus, revisit concepts such as subluxation and “nerve interfer-
certainly the chiropractor/researcher best qualified to ence.” Dr. Bove arms us with the information needed to
review the topic of muscle spindles and spinal proprio- discuss these topics intelligently and scientifically.
ception. Dr. Polus reviews concepts in proprioception, Historically, chiropractors have argued that “nerve
particularly as they relate to the spine. The integrated interference” caused by subluxation could be an im-
function of receptors in the muscles, joints, skin, and in- portant contributor to visceral disease. In searching
ner ear is acknowledged, but we are quickly introduced for possible neurophysiological mechanisms underlying
to the growing appreciation of the great importance of “spinovisceral disease,” much attention has been fo-
the muscle spindle and its partner, the Golgi tendon cused on the somatoautonomic reflex. Professor Akio
221
222 CHIROPRACTIC THEORY
Sato, the undisputed expert in this field, provides us chapter brings us current on what is and isn’t known
with an authoritative analysis of not just basic scientific about zygapophyseal joint structure and function, and
research involving animals, but also the most recent hu- the role of these joints in spinal pain syndromes. The
man research in this important area. Professor Sato reader will enjoy an interesting discussion of the effects
gives us a robust neurophysiological rationale for what of leg length inequality on the lumbar zygapophyseal
have been some of the most controversial clinical obser- joints and low back pain, and we finish with a consid-
vations of chiropractors, and helps us to move discus- eration of the clinical presentation of “facet syndrome.”
sion of spinovisceral disease to a new intellectual level. From zygapophyseal joints we move to Mark
From the neurosciences, Gary Greenstein takes Finneran’s discussion of the influence of muscles in
us to a consideration of the clinical anatomy, biome- spinal pain syndromes. An illustrated review of the
chanics, and pathomechanics of the cervical spine. anatomy of the paraspinal muscles takes us into a dis-
Dr. Greenstein introduces basic biomechanical concussion of the role of the various muscle groups in
cepts applicable to the entire spine. The focus, however, posture, movement, and proprioception. There is a de-
is the cervical spine, and basic concepts are quickly tailed discussion of the strengths and weaknesses of
and clearly related to important clinical phenomena. The the various methods used to assess the involvement of
chapter concludes with a discussion of whiplash injury, muscle in back pain syndromes. Particular attention is
one of the most challenging and common conditions given to surface electromyography and a newer technol-
confronting chiropractors. ogy, computerized electrophysiological reconstruction of
The fundamental concepts of spinal biomechanics, spinal regions (CERSR).
which were introduced by Dr. Greenstein, are refined Dale Mierau, who coauthored on this topic with
and crystallized for the reader in an excellent chap- David Cassidy in the previous edition of this text, revisits
ter by Partap Khalsa. A review of the structure of the the biomechanics and pathophysiology of the sacroiliac
lumbar spine leads into a clear explanation of regional joint. This is an area of enduring interest to chiroprac-
biomechanics, including coupled motion. Dr. Khalsa dis- tors, and there is much that is new in Dr. Mierau’s chap-
cusses idiopathic juvenile scoliosis as a model of patho- ter. We are treated to an excellent description of the
mechanics, but challenges the concept of the sublux- adaptive changes of the sacroiliac from fetal life to old
ation as a biomechanical lesion, citing the paucity of age. The normal mechanics of the joint are addressed
research to support the hypothesis of the subluxation with refreshing clarity. This is followed by consideration
as a distinct biomechanical entity. of relevant joint disease and dysfunction, with critical
John Triano offers a comprehensive review of the evaluation of the evidence base for commonly used di-
biomechanics of manipulation. His chapter analyzes ev- agnostic techniques.
ery component of the spinal manipulative therapy chi- Simon Dagenais and Scott Haldeman provide a com-
ropractors deliver daily—from tissue properties and prehensive overview of cervicogenic headache, a topic
structural balance to the equilibrium and dynamic in- of special interest to chiropractors. The neuroanatomi-
teractions between the body and its environment. The cal substrate of head pain is precisely reviewed and then
loading of spinal tissues as it applies to manipulation related to current theories of how cervical dysfunction
is discussed, as are the conditions that may require might lead to pain perceived as arising in the head. This
modifying the manipulative technique to optimize treat- provides the context for a discussion of diagnosis of this
ment results. The biomechanical basis for establishing entity, which clearly remains problematic for all health
the safety of manipulation is also reviewed. professions. Notwithstanding the diagnostic challenges,
The most recent findings on the pathophysiology of the authors provide encouraging evidence for the effi-
disc degeneration are synthesized for the reader by cacy of chiropractic care in this relatively common and
Michael Adams, whose own contribution to this field has troublesome complaint.
been significant. This beautifully illustrated chapter, us- The section concludes with Jan Hartvigsen’s highly
ing many photographs by the author, clarifies the normal informative and current look at risk factors for low back
anatomy and physiology of the intervertebral disc. Nor- pain and neck pain. We are given a lucid introduction
mal aging is distinguished from disc degeneration, and to epidemiological methods of particular importance to
the processes of disc degeneration are set out in great chiropractic questions without the unnecessary use of
detail. Disc pathology is related to back pain, and the jargon, which makes so much epidemiological work in-
author concludes with a discussion of the medicolegal accessible to the novice. The reader may be happily sur-
implications of what is now known about disc degener- prised by how much is known, and will be grateful for the
ation, pain, and disability. clarity with which Dr. Hartvigsen has identified gaps in
As in the previous edition of this text, Lynton Giles our knowledge that can now be addressed.
treats us to a lucid discussion of the pathophysiology Previous publications referring to the scientific basis
of the posterior zygapophyseal joints. Extensively ref- of chiropractic have sometimes seemed like disjointed
erenced and well illustrated, this completely revised collections of underreferenced reviews, interspersed
CHIROPRACTIC THEORY 223
with laments about the paucity of research. This text de- inquiry full circle, back to a focus on the integration of
clares that chiropractic has moved beyond that stage. posture, movement, and neurological function.
While much work remains to be done, it is now pos- Our authors on biomechanics present clear but de-
sible to frame important questions as testable hy- tailed analyses of normal and abnormal mechanics, ad-
potheses. Furthermore, what previously seemed to be dressing such issues of interest to the chiropractor
mutually irrelevant research questions, now, with the as coupled motion and whiplash injury. Pathomechan-
richness of information that is emerging, clearly ar- ics are considered in relation to degenerative changes
ticulate an increasingly comprehensive body of knowl- in the facet joints and intervertebral discs. While a num-
edge that is particularly relevant to chiropractic. Re- ber of biomechanical and neurological concepts pre-
viewing the chapter titles in this section, it is reveal- sented in this section seem intuitive to the chiropractor
ing to observe how chiropractor/researchers in the and much of the research in these fields is reassuring,
basic sciences seem to have gravitated toward cer- an exact and comprehensive description of the subluxa-
tain disciplines. There is a natural strength in anatomy tion or manipulable lesion as a biomechanical and neuro-
and pathology with two clear and related streams of logical entity remains elusive. This remains a research
inquiry: biomechanics and the neurosciences. Further- challenge and it is anticipated that future editions of this
more, there is not dichotomy, but rather a great deal of and similar textbooks will provide greater definition of
symbiosis, between researchers in these fields. It is as the lesion that is routinely treated by chiropractors.
if a natural evolutionary process is bringing chiropractic Brian Budgell
C H A P T E R
12
SENSORY INNERVATION OF THE SPINE
Joel G. Pickar
O U T L I N E
INTRODUCTION —Fibrous Joint Capsule
CENTRAL AND PERIPHERAL NERVOUS SYSTEMS —Synovial Membrane
Autonomic Nervous System —Hyaline Articular Cartilage
Primary Afferent Neurons Ligamentum Flavum
Anatomy of a Primary Afferent Intervertebral Disc
Classification of Primary Afferent Fibers Ligaments
ANATOMICAL ORGANIZATION OF THE —Longitudinal Ligaments
VERTEBRAL COLUMN’S INNERVATION —Supraspinous Ligament
Rootlets and Roots Muscles
Spinal Nerves Sacroiliac Joint
MECHANISMS BY WHICH PRIMARY AFFERENTS Meninges, Dorsal Roots, and Ventral Roots
CODE SENSORY INFORMATION Cervical Spine
Sensory Receptors Facet Joints
Sensory Transduction Muscles
Adaptation Cervical Intervertebral Discs
Example 1: Low-Threshold Mechanoreceptors Thoracic Spine
—Muscle Spindles Facet Joints
—Pacinian Corpuscles Costovertebral Joints
Example 2: Chemoreceptors Costotransverse Joints
Example 3: Nociceptors SPINAL MANIPULATION AND SPINAL SENSORY
—Capsaicin Receptor AFFERENTS
—Adenosine Triphosphate Receptors SUMMARY
—Acid-Sensing (pH) Receptors QUESTIONS
TISSUES IN THE VERTEBRAL COLUMN CAPABLE ANSWERS
OF SIGNALING SENSORY STIMULI KEY REFERENCES
Lumbar Spine REFERENCES
Facet Joints
3. To review the mechanisms by which sensory stim-

OBJECTIVES uli elicit changes in the nervous system.
1. To understand the role of the primary afferent neu- 4. To identify those tissues in the vertebral column
ron in mediating the transfer of information from that are capable of signaling the presence of such
the periphery to the central nervous system. stimuli.
2. To review the anatomic organization of the verte- 5. To discuss the impact of spinal manipulation on
bral column. spinal afferent input.
225
Divisions of the Central

TABLE 12–1.
INTRODUCTION
Nervous System
Chiropractic theory has traditionally emphasized the
body’s natural ability to heal from injury, maintain Brain
optimal function, and stay healthy. It has been as- Forebrain
sumed that the body’s inherent recuperative abilities Cerebrum (telencephalon)
include integrative biological mechanisms that main- Cerebral cortex
tain homeostasis. Chiropractic theory, furthermore, Basal ganglia
presumes that an interaction exists between the ver- Diencephalon
tebral column and nervous system and that this in- Epithalamus
teraction has a role in homeostasis. A thread common Thalamus
to many chiropractic theories is that changes in the Subthalmaus
normal anatomical, physiological, or biomechanical Hypothalamus
dynamics of contiguous vertebrae can adversely af- Pituitary
fect this interaction. Chiropractic practice uses spinal Brainstem
manipulative therapy (SMT), which is believed to ben- Midbrain
eficially affect the relationship between the vertebral Pons
column and the nervous system,1,2 and chiropractors Medulla oblongata
deliver more than 90% of SMT in the United States.3 Cerebellum
By its very nature, SMT is a mechanical input to Spinal cord
the tissues of the vertebral column, thought to have
physiological consequences via its effects on neural
communication and processing. The dual role played
divisions (Table 12–2), comprised of individual nerve
by the nervous system in both the biological ratio-
cells (i.e., neurons). Sensory neurons convey informa-
nale and the effects of SMT motivates the need to un-
tion centripetally, from periphery to CNS, and motor
derstand the neural innervation of paraspinal tissues.
neurons convey information centrifugally, from CNS
This chapter contributes to an understanding of the
to periphery. The sensory division of the PNS con-
nervous system by focusing on the processing of sen-
veys information from all tissues, both visceral and so-
sory input from paravertebral tissues. Specifically, this
matic (see Table 12–2). In contrast, the motor division
chapter addresses the mechanisms by which sensory
is subdivided on the basis of the tissue innervated.
stimuli elicit changes in the nervous system, and the
The somatic subdivision of the motor system consists
tissues in the vertebral column capable of signaling
of spinal motor neurons that innervate skeletal muscle
the presence of such stimuli.
cells. This system is responsible for the control of pos-
ture, locomotion, reflex, and voluntary movements of
CENTRAL AND PERIPHERAL NERVOUS the head, trunk, and limbs.
SYSTEMS
Autonomic Nervous System
The organization of the nervous system is presented
only briefly in this chapter to orient the reader to The autonomic subdivision contains motor neurons
that portion of the nervous system upon which this that innervate internal organs: cardiac muscle cells
chapter focuses: the primary afferent neuron inner- of the heart, smooth muscle cells of the blood ves-
vating the vertebral column. For more detailed infor- sels, bladder, and gut, for example, and secretory cells
mation on the structural and functional anatomy of of glands. The autonomic nervous system is further
the nervous system the reader is referred to the rec- divided into the sympathetic and parasympathetic
ommended reading listed at the end of this chapter
(see Key References). Based purely upon gross anatom- Divisions of the Peripheral
TABLE 12–2.
ical considerations the nervous system is divided into Nervous System
two portions: the central nervous system (CNS) and
the peripheral nervous system (PNS). The CNS is con- Sensory
tained entirely within the bony confines of the skull Somatic and visceral information
and vertebral column, and is subdivided into the brain Motor
and spinal cord. The brain, in turn, contains multiple Somatic subdivision to skeletal muscle
subdivisions divisions based partially upon morphol- Autonomic subdivision to nonskeletal muscle tissue
ogy and partially upon function (Table 12–1). The PNS Sympathetic division
extends beyond the confines of the skull and verte- Parasympathetic division
bral column, and contains both sensory and motor
SENSORY INNERVATION OF THE SPINE 227
subdivisions. The sympathetic subdivision arises Spinal

Dendrites
from the thoracic and upper lumbar spinal cord and Cord
the parasympathetic division arises from the cranial
and sacral portions of the CNS. The cell bodies of sym-
pathetic motor neurons originate in the intermediolat-
eral cell column of the spinal cord. Cranial cell bodies Cell
Body
of parasympathetic motor neurons originate in the vis-
ceral efferent column of four cranial nerve nuclei (III, Flow of
VII, IX, and X). Sacral cell bodies of parasympathetic Efferent
motor neurons originate from a position correspond- Information
ing to the intermediolateral cell column of the sympa-
Axon
thetic subdivision but in the middle sacral segments
of the spinal cord (S2-S4).
Primary Afferent Neurons

Neurons comprising the sensory division of the pe-
ripheral nervous system are called primary afferent Neuro-
neurons, primary afferent fibers, or just primary affer- muscular
ents. They are termed primary because they are spe- Junctions
Telodendria
cialized to be the first nerve cell that receives sensory
stimuli from either the external or internal world, and FIGURE 12–1. Nomenclature used to describe the regions of
afferent (from Latin meaning to “bear”) because infor- a neuron. An α-motoneuron is depicted.
mation contained in the sensory stimulus is brought
from the periphery toward the central nervous sys- travels toward somatic or visceral structures. The
tem. Understanding how the nervous system can be stem, central, and peripheral processes appear struc-
affected by the anatomical, physiological, or biome- turally similar to axons, being able to conduct action
chanical conditions in the vertebral column involves potentials. Thus, with reference to the spinal cord, the
understanding the anatomy and physiology of pri- axons of primary afferent fibers convey information
mary afferents that innervate the spine. toward the central nervous system but, unlike nerve
cells of the CNS, the axons of primary afferents con-
Anatomy of a Primary Afferent Primary afferents have a duct action potentials both toward and away from
unique anatomical organization compared with neu- the cell body. Thus, one can consider primary affer-
rons of the PNS and CNS. The prototypical nerve cell ents as having no true dendrites. Instead, their periph-
is divided into four parts: dendrites, cell body, axon, eral processes terminate in telodendria, which receive
and telodendria. An example is given in Figure 12–1, sensory information and convey it to the axon. Telo-
showing a motor nerve (not a primary afferent) origi- dendria are the “receptive endings” of the primary
nating in the spinal cord and terminating at the neuro- afferent.
muscular junction of a skeletal muscle cell. Anatom-
ically, dendrites emerge from the cell body, tapering Telodendria /
into an intricate branching pattern. Functionally, den- Receptive Endings
drites receive information and convey it toward the
cell body in the form of electrotonic potentials. Axons
convey information away from the cell body in the
form of action potentials. Axonal diameter typically
Stem Process
increases in proportion to the length of the axon. At its
termination the axon divides into terminal branches Central Process
called the telodendria. These terminal branches end in Peripheral Process
swellings (in the PNS) or synaptic bulbs (in the CNS). Axon
Primary afferents are pseudounipolar neurons and
have a unique morphology compared with the pro-
totypical neuron described above. The cell body is
generally spherical and is located in the dorsal root
ganglion (Fig. 12–2). A single process, (the “stem pro- FIGURE 12–2. Regions of a primary afferent neuron. Note
cess”) extends from the cell body and splits into two that the primary afferent neuron does not have true den-
branches or processes. The “central process” trav- drites as described for the prototypical neuron depicted in
els toward the spinal cord. The “peripheral process” Figure 12–1.
TABLE 12–3. Classification of Primary Afferent Fibers
Fiber Conduction Classification in

Type of Diameter Velocity Muscle and Classification in
Primary Afferent (μm) (m/s) Deep Tissue Skin
Myelinated
Large 12–20 72–120 I Not present
Medium 6–12 35–72 II A-β
Small 1–6 4–36 II A-δ
Unmyelinated 0.2–1.5 0.4–2 IV C
Classification of Primary Afferent Fibers Primary affer- parent ventral root are comprised of somatomotor
ent fibers are classified using either of two nomencla- and autonomic axons leaving the spinal cord to con-
tures. The Lloyd-Hunt system classifies primary affer- vey motor commands to somatic and visceral struc-
ent neurons from muscle and other deep tissues based tures. Bilaterally, the paired dorsal and ventral roots
upon their axonal fiber diameters and uses Roman pass to the intervertebral foramina where they join
numerals: group I, group II, group III, and group IV to form the spinal nerve, just distal to the dorsal root
(Table 12–3). The Erlanger-Gasser system classifies cu- ganglion.4
taneous primary afferents according to their axonal The spinal cord consists of 31 pairs of spinal nerves
conduction velocity and uses capitalized Arabic let- reflecting the 31 spinal cord segments: 8 cervical,
ters accompanied by Greek letters: A-α, A-β, A-δ, and 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal cord
C fibers. Therefore, strictly speaking, when one uses segment. Each cord segment gives rise to a spinal
the designation group I, II, III, or IV, one is implicitly nerve named for the cord segment. The first seven
referring to the sensory innervation of structures other cervical spinal nerves (C1-C7) exit through the in-
than skin. On the other hand, when one uses the desig- travertebral foramen (IVF) above their corresponding
nation group A-α, A-β, A-δ, or C fibers, one is implic- vertebral segment. The remaining nerves (C8-Co1)
itly referring to cutaneous innervation. However, the exit below their corresponding vertebral segment (or
two classification systems are often used interchange- bony segment in the case of the sacrum and coccyx).5
ably, especially with regards to C fibers (group IV), ir-
respective of the tissues they innervate. Therefore, one
needs to make note of the structure being discussed. Ventral Dorsal
Rootlets Rootlets
The remainder of this chapter will use the classifica-
tion as originally developed. One
Spinal Cord Spinal
Segment Cord
ANATOMICAL ORGANIZATION OF THE
VERTEBRAL COLUMN’S INNERVATION
Rootlets and Roots Nucleus
Pulposus
The external surface of the spinal cord is marked bilat-
erally by the attachments of rootlets to its dorsal and
ventral surfaces (Fig. 12–3). Each of the four groups
of rootlets fans out superior to inferior, subdividing Anulus
the spinal cord into segments of approximately 1-inch Fibrosus
length. The length over which the rootlets enter the
spinal cord defines one spinal cord segment. Within a
short distance of leaving the spinal cord each group of
rootlets separately merges to form bilaterally paired Vertebral
dorsal and ventral roots. The dorsal rootlets and their Body
parent dorsal root are comprised of the central axonal
processes of primary afferents arriving at the spinal FIGURE 12–3. Anatomical relationship of a spinal cord seg-
cord to convey sensory information from somatic ment, with attached dorsal and ventral roots, to a vertebral
and visceral structures. The ventral rootlets and their segment.
Spinal Nerves Each dorsal ramus of the first to fourth lum-

Close to its peripheral exit from the intervertebral fora- bar posterior primary divisions divides into three
men, the spinal nerve divides into the anterior and branches: the medial, intermediate, and lateral. These
posterior primary divisions. The nerves themselves, three branches separately innervate the three multi-
before any further branching occurs, are called the segmental longitudinal muscles of the lumbar region:
ventral and dorsal rami, respectively. The ventral ra- multifidus, longissimus, and iliocostalis, respectively.
mus is larger than the dorsal except for the first to third In addition, the medial branch innervates all other
dorsal rami of the cervical posterior primary divi- medial-most muscles and dorsal tissues of the pos-
sion, which are larger than their ventral counterparts.6 terior compartment. The L5 posterior ramus has only
At all spinal levels two branches divide from the two branches: medial and intermediate. It lacks a lat-
anterior primary division near the intervertebral fora- eral branch because the muscle mass of the iliocostalis
men: an autonomic branch (gray rami communicans) ends superior to the L5 vertebra segment. The first to
and a somatic branch. Primary afferent fibers from third sacral dorsal rami also divide into medial and
somatic and visceral structures reach the spinal cord lateral branches, whereas the fourth to fifth sacral and
through these branches at each spinal level. In con- coccygeal dorsal rami divisions do not.7
trast, white rami communicans are present only in Organization of the vertebral column’s innerva-
the thoracic and upper lumbar segments. This branch tion with respect to the anterior and posterior primary
of the anterior primary division provides the neural divisions of the spinal nerves is best understood by
pathway for motor axons of the sympathetic division longitudinally dividing the vertebral column into two
of the nervous system. The gray rami communicans halves with a coronal plane passing through the mid-
travel ventrally and medially, wrapping around the dle of the intervertebral foramen and the transverse
vertebral body as they travel to the sympathetic gan- processes and passing coplanar with the intertrans-
glia. The somatic branch receives a communicating verse ligaments. Then, when viewed in cross section,
branch from the gray rami communicans and their the vertebral column can be divided into an anterior
union forms the sinuvertebral nerve (also called the and a posterior compartment (Fig. 12–4). The anterior
recurrent meningeal nerve). Therefore, the sinuverte- compartment contains, visualizing from anterior to
bral nerve arises from two sources: a somatic com- posterior, the prevertebral muscles, the anterior lon-
ponent arises from the ventral primary rami of each gitudinal ligament, the vertebral body, the interver-
spinal nerve close to its peripheral exit from the in- tebral disc, the posterior longitudinal ligament, and
tervertebral foramina, and an autonomic component the anterior dura mater. The posterior compartment
arises from the gray rami communicans. The sinuver- contains the neural arch, the posterior dura mater,
tebral nerve re-enters the intervertebral foramen to in- the zygapophyseal joints and their ligaments, and the
nervate structures from within the neural canal where paraspinal muscles.5
the nerve divides into two to four filaments. Thus the Each compartment receives its innervation via one
anterior primary division can provide innervation to of the primary divisions, although some structures
the vertebral column via the gray rami communicans,
the somatic branch, and via the sinuvertebral nerve Dorsal Ventral
after a portion of the gray rami communicans and so- Primary Primary
Rami Rami
matic branch have merged to form it.4,7,8
The dorsal rami initially courses dorsolaterally
and divides into two or three named branches ex-
cept for the first cervical, fourth and fifth sacral, and
coccygeal dorsal rami. The two branches are des-
ignated medial and lateral; when present, the third
branch is designated intermediate. The dorsal rami of
the second to eighth cervical and 12 thoracic poste-
rior primary divisions each have two branches: the
medial and lateral branch. Lateral branches supply Coronal Posterior Anterior
Plane Compartment Compartment
the skin and more superficial muscles, including the
splenius and longissimus. The medial branch inner-
FIGURE 12–4. Organization of the vertebral column’s inner-
vates deeper muscles, including the multifidus and vation. All structures contained within the posterior compart-
semispinalis. However, the specific muscles inner- ment are innervated by the posterior primary division of the
vated by a dorsal ramus depend upon the muscles spinal nerve. All structures contained within the anterior com-
crossing each vertebral motion segment of a given partment are innervated by the anterior primary division of the
spinal region.4,7 spinal nerve.
may receive a dual innervation. Structures in the ante- per second). The peripheral and central processes of
rior compartment receive their nerve supply from the the primary afferent transmit these action potentials
ventral primary rami and the sinuvertebral nerve.7 to the central nervous system and, once they arrive
Structures in the posterior compartment receive their at the spinal cord, sensory coding is based upon ac-
nerve supply primarily from the dorsal primary rami tion potential frequency as well as upon the temporal
and the sinuvertebral nerves.4 The innervation of or phase relationship between action potentials arriv-
some spinal structures is controversial, while others ing from other neurons and upon the spinal pathways
clearly appear devoid of a sensory nerve supply; these activated by the combined primary afferent input.
latter structures include the nucleus pulposus, the car-
tilaginous endplates of the vertebral bodies, and the Sensory Receptors
articular cartilage of the zygapophyseal joints.9 How- Sensory receptors are comprised of the primary af-
ever, vasomotor nerves may course through the car- ferent’s receptive ending (i.e., its telodendria) and
tilaginous endplates. Interestingly, pain in the lower any nonneural tissue associated with the ending.
limbs, spasm of lumbar, gluteal, or hamstring mus- Receptive endings encased in nonneural tissue are
cles, and low back pain can be initiated by stimulation called encapsulated endings and unencased endings
of structures innervated by lumbar dorsal rami and are termed unencapsulated or free nerve endings. A
stopped by dorsal rami nerve block. Thus a dorsal ra- Schwann cell surrounds the free nerve ending but por-
mus syndrome may be differentiated from symptoms tions of the telodendritic membrane are in direct con-
arising from either nerve root compressions or from tact with the extracellular space. The nonneural tissue
structures innervated by the ventral ramus or sinu- portion of the sensory receptor plays a substantial role
vertebral nerve.10 in filtering sensory stimuli, thereby tuning the recep-
tive ending to particular features of the stimulus en-
ergy (see Sensory Transduction and Adaptation: Example
MECHANISMS BY WHICH PRIMARY
1 below).
AFFERENTS CODE SENSORY INFORMATION
The receptive ending of the primary afferent fiber
The nervous system’s ability to receive information is typically enlarged relative to the axon and is spe-
either from the world external or internal to the sur- cialized to receive a particular form of energy. Special-
face of our skin uses two common steps: “receipt” of ization takes the form of proteins embedded within
information in the form of a stimulus, and a set of cel- the cell membrane of the receptive ending. The con-
lular events “transforming” the stimulus into nerve formational state of these embedded proteins is most
impulses or action potentials. A stimulus is a type of sensitive to one form of energy, the energy being trans-
energy. Stimulus energy can take different forms (e.g., mitted directly to the membrane or being filtered by
mechanical, chemical, heat, light, sound). “Receipt” of the ending’s encapsulation. Exposure to that form of
this energy is accomplished by molecular receptors in energy will change the protein’s shape, consequently
the cell membrane of the primary afferent’s teloden- changing the terminal membrane’s ionic permeability.
dria or receptive ending. However, the information Because the resting membrane potential of a neuron
contained within the stimulus energy (e.g., amount of is created by the membrane’s selective permeability
mechanical force, duration of the force, presence of in- to sodium, potassium, and chloride ions, the induced
flammatory chemicals) cannot be directly understood change in ionic permeability will, in turn, change the
by the central nervous system. Action potentials are primary afferent’s resting membrane potential. Thus,
the language of the nervous system and the sensory it is important to note that the receptive ending is re-
information must be converted into this form. “Trans- sponsible for receiving a sensory stimulus and that the
forming” sensory information into action potentials is specificity of the neuron for one type of stimulus is
accomplished by cellular mechanisms that change ion ultimately a result of the receptor proteins in its mem-
conductance of the telodendritic membrane. brane. A primary afferent might be sensitive to more
In general, the transformation or conversion of than one type of stimulus depending upon the popu-
one form of energy to another is called transduc- lation of receptor proteins in the receptive ending.
tion; specifically, sensory transduction is the process The change in resting membrane potential evoked
by which the stimulus energy is transformed into the by receipt of a sensory stimulus is called a genera-
electrochemical energy of action potentials. Action po- tor or receptor potential. Generator potentials are a
tentials produced by a primary afferent neuron are form of electrical activity called electrotonic potentials
identical in size and shape; thus, sensory informa- (Table 12–4), which occur across excitable biological
tion is not encoded based upon qualitative or graded membranes. The generator potential shares many sim-
changes in the form of the action potential. Rather, ilarities with synaptic potentials. The major difference
sensory information is encoded based upon action po- is their location, with synaptic potentials occurring in
tential frequency and is measured in hertz (impulses the postsynaptic cells in the central nervous system,
TABLE 12–4.Comparison Between Action the stimulus. Large-amplitude generator potentials

and Electrotonic Potentials keep returning the axonal membrane to threshold and
evoke action potentials that occur frequently. High-
Action Potential Electrotonic Potential frequency discharges therefore indicate the magni-
tude of the adequate stimulus. Because generator po-
Invariant amplitude Graded with the magnitude tentials can persist for as long as the stimulus (unlike
of the stimulus action potentials, they are not self-terminating), they
Regenerative (initiated and No refractory period will continue to provide a current source for the gener-
recover by themselves) ation of action potentials. The duration of the stimulus
Propagated Stationary and spread is encoded by the duration over which action poten-
passively tials are produced.
Threshold with an all-or-none No threshold of initiation Humans possess four classes of sensory recep-
response tors, usefully named for the form of energy to which
they are most sensitive: mechanoreceptors, chemore-
ceptors, thermoreceptors, and photoreceptors. An al-
ternative but perhaps less useful classification sys-
and autonomic ganglia and generator potentials oc- tem is based upon the source of the stimulus energy.
curring in the receptive ending of primary afferent Interoceptors (primarily located in viscera) monitor
fibers. Generator potentials obey Ohm’s law (volt- the internal milieu of the organism, exteroceptors (lo-
age = current × resistance). They are graded, their am- cated in the eyes, ears, nose, skin, etc.) monitor the
plitude being proportional to current density (mag- external world, and proprioceptors (located in mus-
nitude of ionic current), and current density being cles, joints, ligaments, tendons and skin, semicircular
proportional to stimulus intensity; thus, the greater canals) monitor the position of the body in space, in-
the stimulus intensity, the higher the amplitude of cluding the position of joints, limbs, and muscles.
the generator potential. Unlike action potentials, they A fifth class of sensory receptor is called the noci-
are not actively regenerated by voltage-gated chan- ceptor. In the early 1900s, Sherrington coined the term
nels (see Table 12–4); they spread passively from the “nociception” (from Latin nocere, to hurt or injure)
telodendritic membrane, diminishing in magnitude to describe the organism’s ability to sense injurious
with resistance offered by the intracellular fluid. As stimuli. Therefore, this receptor is sensitive to stimuli
the generator potential spreads into the region of the that signal impending or actual tissue damage. These
axon’s excitable membrane and when it is of sufficient stimuli may be mechanical, chemical, or thermal. No-
magnitude that it depolarizes the axonal membrane to ciceptors typically must be stimulated in order for the
threshold, an action potential will be generated and individual to feel pain, similar to the fact that pho-
propagated to the central nervous system. toreceptors in the eye must be stimulated to experi-
Whether a stimulus is mechanical, chemical, ther- ence vision. However, stimulation of nociceptors does
mal, photic, or nociceptive, the particular form of en- not necessarily evoke pain any more than stimulating
ergy to which the sensory receptor is most sensitive photoreceptors with several photons elicits a visual
is called its adequate stimulus. When the receptive image. Pain, like vision, is a sensation. It is a complex
ending contains more than one type of specialized re- process that requires not only sufficient nociceptive
ceptor protein embedded within its membrane, the input but also appropriate processing by higher brain
neuron may have more than one adequate stimulus. centers, including the thalamus and cortex. For ex-
Sensory receptors responsive to more than one form ample, a quickly executed withdrawal response upon
of stimulus energy are called polymodal receptors. placing a finger on a hot stove is elicited by the no-
The smallest level of energy to which a sensory re- ciceptive heat stimulus, yet pain is not invariably ex-
ceptor will evoke an action potential is called the stim- perienced. The nociceptive stimulus is clearly sensed,
ulus threshold. Threshold is reached when the gener- evoking a withdrawal reflex via the spinal cord level,
ator potential is sufficiently large to evoke an action but it does not necessarily evoke a pain sensation. That
potential. Receptors can respond to types of energy different individuals have different pain thresholds
other than their adequate stimuli, but only at much also demonstrates that nociception and pain are not
higher threshold levels. For example, sensory recep- synonymous.
tors in the retina of the eye are very sensitive to light. Sensory inputs from primary afferent fibers con-
However, a forceful mechanical impact to the eye will vey four types of information about a stimulus:
also evoke the sensation of light as receptors in the modality, location, intensity, and timing. This infor-
retina respond to the mechanical stimulus. mation leads to sensation, either conscious or uncon-
The form and features of the generator poten- scious. Modality defines a class of stimuli determined
tial allow more than encoding the simple arrival of by the sensation elicited. A sensory modality can have
TABLE 12–5. Classification of Sensory Modalities
Modality Submodality Type of Receptor
Smell — Chemoreceptor
Balance Roll Mechanoreceptor
Yaw
Pitch
Vibration
Flutter
Touch Stroke Mechanoreceptor
Pressure
Limb position
Movement
Proprioception Joint angle Mechanoreceptor
Muscle stretch
Muscle force
Rate of change of movement
Temperature Cold Thermoreceptor
Cool
Warm
Hot
Pain Sharp Chemoreceptor
Burning Mechanoreceptor
Freezing Thermoreceptor
Polymodal
Vision Shape Photoreceptor
Color
Movement
Hearing Soft Mechanoreceptor
Loud
Taste Bitter Chemoreceptor
Sweet
Sour
Salty
several submodalities. Table 12–5 shows some of these evoking a reflex response, but the sensation of pain
classifications. The modalities listed in Table 12–5 re- is not necessarily felt. Sensory input does not always
fer only to conscious sensations. For example, pres- reach conscious awareness.
sure receptors in the carotid sinus monitor blood pres- Primary afferent neurons can branch extensively
sure and reflex responses occur in response to pressure at their peripheral ends. As a result, a single primary
changes, yet we are unaware of the mechanical stim- afferent may innervate a large area of tissue (e.g., skin,
ulus. It is likely that similar sensory inputs occur in muscle, or joint). The total area served by the afferent
somatic tissues, including the spine. Terminology dis- is termed its receptive field. Receptive fields may be
tinguishing between sensations that rise to conscious- large or small depending upon the extent of branch-
ness versus those that do not has only been developed ing and the threshold of the ending. The larger the
in the area of body movement. The term kinesthesia receptive field, the less a single primary afferent is
refers to the conscious sensation of body, limb, and able to localize the stimulus. However, the larger the
head position, or to movement and muscle force. Pro- receptive field, the more sensitive the primary afferent
prioception includes kinesthesia but also refers to sen- neuron is to the presence of the stimuli. As is shown
sory inputs that do not reach consciousness, such as below, facet joints of the vertebral column may not
vestibular inputs and some inputs from muscles and have a large number of sensory receptors, and as such,
joints. One may consider a similar situation for no- they could have large receptive fields. It should be rec-
ciception where nociceptors may be stimulated, thus ognized that identification of location, as well as the
exact identity of a stimulus, might require sensory in- transduction for stimuli affecting all cutaneous and
put from a population of primary sensory afferents deep tissues has only recently begun to be understood.
and not simply one afferent. Population responses The examples below provide the framework for un-
may be more important for certain information or sen- derstanding the mechanisms used by sensory neurons
sations. For example, the recognition of an object’s tex- in the vertebral column to respond to the mechanical
ture when placed upon the skin requires population and chemical stimuli they encounter.
coding, whereas identification of a salty taste requires
input from a single neuron on a specific spatial locale Adaptation
on the tongue.
Sensory receptors vary in the degree to which they
maintain the primary afferent’s discharge frequency
Sensory Transduction during continued application of a constant stimulus.
As previously discussed, sensory transduction is the The decline in discharge rate is called adaptation.
process by which the stimulus energy changes the Adaptation is, in large part, a result of changes in the
conformational state of membrane-bound protein and generator potential caused by the nonneural tissue of
elicits a generator potential in the form of electro- the sensory receptor. In addition, inactivation of depo-
chemical energy. Henceforth, the membrane-bound larizing Na+ or Ca2+ channels or activation of the hy-
protein will be called a “receptor,” differentiating it perpolarizing Ca2+ -dependent K+ channel contribute
from a “sensory receptor.” This “molecular” recep- to the mechanisms underlying adaptation.
tor and a sensory receptor have the same broad func- Rapidly adapting sensory receptors cease produc-
tion of receiving stimuli. “Sensory receptor” refers to tion of generator potentials soon after the application
an anatomical portion of the primary afferent neuron, of a constant stimulus. Slowly adapting receptors con-
whereas “receptor” refers to a type of molecule in the tinue to produce a generator potential during appli-
receptive ending of the primary afferent neuron. cation of the stimulus. However, the amplitude of the
Three types of receptors contribute to sen- potential usually declines somewhat with time, even
sory transduction: ion-channel-linked receptors, as the stimulus application is maintained. The rate
G-protein-linked receptors, and enzyme-linked recep- at which the amplitude declines determines the rela-
tors. In turn, ion-channel-linked receptors are com- tive slowness of the slowly adapting receptor. Rapidly
prised of four subtypes: mechanically gated, ligand- adapting receptors are best suited to provide infor-
gated, heat-gated, and voltage-gated (Table 12–6). mation about an immediate change in the environ-
Current knowledge indicates that only ion-channel- ment (a dynamic change; see Example 1: Low-Threshold
linked and G-protein-linked receptors are present on Mechanoreceptors, Pacinian Corpuscles below). The
sensory receptors. The molecular basis of sensory rapidly adapting response often shows dynamic
TABLE 12–6. Sensory Transduction Pathways
Type of Channel Subtypes of Receptors Types of Second Messenger
Ion-channel-linked Mechanically gated channel Probably none

Ligand-gated channel
Heat-gated channel
Voltage-gated channel
G-protein-linked Gs α-subunit cAMP
Golf subunit cGmp
Gi subunit Phospholipase C-β
Go subunit Ca2+
Gt subunit
Gq subunit
Enzyme-linked Guanylyl cyclase cGMP
Tyrosine kinase Ras
Tyrosine-kinase associated ?
Tyrosine phosphatase
Serine/threonine kinase
Key: Ca2+ = calcium; cAMP = cyclic adenosine monophosphate; cGMP = cyclic guanosine monophos-
phate.
sensitivity wherein the magnitude of the generator 26

potential is proportional to the stimulus’s rate of ap-
Afferent Activity from

Muscle Spindle (Hz)
plication. The effect of dynamic sensitivity is that the 20
faster the stimulus is applied (such as a rapid me-
chanical movement during an adjustment or spinal 16
manipulation), the higher the frequency of action
10
potentials.
Slowly adapting receptors provide information 100
(% BW)
Distract
6
about the new status of the environment (a static 60
change) and may provide information about the dy- 0 0
namic change as well (see Example 1: Low-Threshold 0 30 60 90 120 160 180
Mechanoreceptors, Muscle Spindles below). Both rapidly Time (sec)
and slowly adapting receptors are found in tissues
crossing the facet joints, including the fibrous capsule, FIGURE 12–5. The response of a paraspinal muscle spindle
paravertebral muscles, and skin. Rapidly adapting re- to cranial distraction of the L6 vertebra relative to the L7 ver-
ceptors respond when the facet joint is initially moved. tebra in a feline preparation. Electrophysiological recordings
were obtained from fine filaments in the L6 dorsal root. Suc-
They stop responding when the joint stops moving, al-
cinylcholine was used to help identify the muscle spindle af-
though it may be at a new position. Slowly adapting
ferent. The afferent’s receptive field was in the lumbar longis-
receptors, while responding to the initiation of move- simus muscle. Action potentials from the muscle spindle affer-
ment, also continue to respond during the new spinal ents were counted and placed in 0.5s bins (black lines, y-axis at
posture. Thus, the central nervous system is apprised right). The L6 vertebra was linearly translated cranially by apply-
of joint position at the start of movement, about the ing loads at 25%, 50%, 75%, and 100% of body weight (white
rate and direction of movement during its course, and line, y-axis at left). Ramp and hold loads were applied. Note the
about the new joint position. spindle’s dynamic sensitivity, in that it responded more to the
changing load during “up-ramp” than to the static load during
“hold.”
Example 1: Low-Threshold Mechanoreceptors Low-thres-
hold mechanoreceptors have mechanically gated, ion-
the extrafusal muscle fibers, which generate force for
channel-linked receptors embedded in their receptive
posture and movement, both reflexive and voluntary.
endings. Having low thresholds, these sensory recep-
Three types of intrafusal muscle cells can be differ-
tors are sensitive to innocuous stimuli. Being mechan-
entiated histochemically, morphologically, and func-
ically gated, the channels open when they are me-
tionally. They are named for the organization of their
chanically deformed. Stimuli that physically deform
nuclei. Nuclear bag fibers (called bag1 and bag2 fibers)
muscle, facet capsules, ligaments, and skin will, in
bulge near their center or equatorial region and con-
turn, physically deform the receptor and will, in turn,
tain an accumulation of up to 100 nuclei. This ar-
deform the mechanically gated ion channel, conse-
rangement makes the middle of the nuclear bag
quently increasing the cell membrane’s permeability
fiber resemble a bag of marbles. Nuclear chain fibers
to Na+ and possibly to Ca2+ .
contain a chain-like row of nuclei lying single file
along the fiber’s length. Nuclear chain fibers do not
Muscle Spindles These low-threshold mechanorecep- bulge.
tors in skeletal muscle are examples of slowly adapt- Because muscle spindle receptors lie in parallel to
ing receptors with varying degrees of dynamic sen- the extrafusal fibers, they signal the magnitude and
sitivity (Fig. 12–5). The neural portion of the muscle speed of muscle stretch. Muscle lengthening stretches
spindle receptor is comprised of two types of recep- the intrafusal muscle fibers, producing tensile defor-
tive endings: annulospiral endings and flower-spray mation of the annulospiral and flower-spray endings.
endings.11 Group Ia axons parent the annulospiral Conversely, muscle shortening or contraction of the
endings and group II axons parent both annulospiral intrafusal muscle fibers shortens the intrafusal mus-
and flower-spray endings (see Table 12–3). The non- cle fibers, producing compressive deformation of the
neural portion of the muscle spindle receptor is com- annulospiral and flower-spray endings and conse-
prised of a specialized group of muscle fibers, called quently closing their mechanically gated channels.
intrafusal fibers (Latin fusus = spindle; intra = within), Bag1 fibers have dynamic sensitivity responding to
surrounded by the fusiform-shaped capsule. The cap- the rate at which the spindle apparatus is stretched
sule bulges at its middle because of an accumulation as well as the magnitude of the sustained change in
of fluid that may have a protective function. Some of length. Bag2 fibers do not have dynamic sensitivity
the intrafusal fibers extend beyond the ends of the cap- and respond to the magnitude of a sustained change
sule. The entire muscle spindle receptor lies parallel to in length. These filtering characteristics are conferred
in part by elastic fibrils that lie between the primary onset and offset of the mechanical movement. Fig-
afferent’s receptive ending and the muscle membrane ure 12–6B shows that the filtering characteristics of
of bag2 and nuclear chain fibers, but not bag1 fibers. the pacinian corpuscle are conferred by the nonneu-
The elastic fibers provide mechanical coupling that in- ral elements surrounding the primary afferent fiber’s
creases the bag2 fiber’s stiffness relative to its viscos- receptive ending.
ity. Therefore, the response of the mechanically gated
channels in the annulospiral ending around the bag2 Example 2: Chemoreceptors Chemoreceptors have li-
fiber are less time-dependent and do not respond to gand-gated, ion-channel-linked channel receptors,
the rate of change in muscle length. Exactly how the and/or G-protein-linked receptors embedded in their
receptive ending is coupled to the intrafusal muscle receptive endings. The exact signal transduction path-
membrane is not known. way chemoreceptors used to initiate a generator po-
tential is not known. Activation of G-protein-linked
Pacinian Corpuscles These low-threshold mechanore- receptors initiates a set of intracellular events that
ceptors are examples of rapidly adapting receptors. lead to the formation of a set of intracellular sig-
They signal the onset and offset of a mechanical event, naling molecules (second messengers). Activation of
but not the event’s duration. Figure 12–6A shows a one G-protein-linked receptor can lead to the forma-
schematic of the receptor and the electrophysiolog- tion of dozens of second-messenger molecules. This
ical events attributable to the receptive ending and phenomenon leads to amplification wherein a weak
to the nonneural tissue that comprises this ending. sensory signal, such as a low concentration of a par-
Its nonneural, outer layer is bulbous in shape, being ticular extracellular chemical, evokes a large response
comprised of concentric layers of cell membrane alter- as a result of the accumulation of second-messenger
nating with fluid-filled spaces. Viewed in cross sec- molecules. If the second-messenger molecules’ action,
tion, the structure looks much like the layers of an in turn, leads to the opening of other ion channels,
onion with fluid filling the potential spaces between then even the low concentration of a metabolite can
the layers. Near the center of the concentric layers are be signaled by the primary afferent.
collagen fibers that likely attach the inner lamellae Changes in molecular receptor activity do not al-
to the receptive ending of the primary afferent neu- ways lead to generator potentials that depolarize the
ron. Mechanical energy is transmitted through the cell membrane. During repeated or prolonged stim-
lamellae to the collagen and then to the mechanically uli, the sensory receptor can adapt. This form of de-
gated ion channels in the telodendritic membrane. sensitization leads to a diminished response despite
The outer layers of the pacinian corpuscle filter out continued application of the stimulus. Stimulation of
slowly changing mechanical energy (static or quasi- G-protein-linked receptors causes adaptation, typi-
static changes). These layers slide past each other, cally by one of two means. First, second messen-
absorbing and relieving any maintained mechanical gers can induce conformational changes in channel
stress. Slowly changing mechanical forces are pre- proteins via phosphorylating or dephosphorylating
vented from reaching the inner lamellae. The viscos- mechanisms. When the conformational change de-
ity of the lamellae allows the transmission of me- creases the channel protein’s sensitivity to a ligand, the
chanical energy to the receptive ending only at the magnitude of the generator potential will be reduced
A) NORMAL PACINIAN CORPUSCLE B) PACINIAN CORPUSCLE DESHEATHED

FIGURE 12–6. Schematic showing the electrophysi-
ological events attributable to the nonneural and neu- Vm Vm
ral tissue comprising the pacinian corpuscle. Sinu-

soidal indentation (a” and b”) is applied to each of the
two components of the sensory receptor. Column A mechanical
depicts the response of the intact pacinian corpus- mechanical stimulus
stimulus
cle. The top row shows the onion-like appearance of
the intact pacinian corpuscle viewed in cross-section. a b
Receptor Potentials Receptor Potentials
Column B depicts the response of the pacinian cor-
puscle devoid of its concentric layers of cell mem-
brane. Without the filtering characteristics provided
by the nonneural tissue, the prolonged receptor po- a' b'
tential (compare b’ with a’) would allow a prolonged Action Potentials Action Potentials
stimulus of sufficient magnitude to produce continu-
ous firing of the afferent neuron. Vm presents the
a'' b''
intracellular voltage, that is, the voltage measured Indentation Indentation
across the neuronal cell membrane.
or abolished. Second, when the G-protein-linked re- channel. Gating is also accomplished by intracellular
ceptor opens ion channels that stabilize the resting second and third messengers including Ca2+ , inositol
membrane potential (e.g., Cl– channels)or produce a triphosphate (IP3 ), and diacylglycerol (DAG), messen-
hyperpolarizing generator potential (e.g., K+ or Cl– gers associated with G-protein-linked receptors. VR1
channels), the resting membrane is less likely to gen- receptors are thought to contribute to the pain and ten-
erate action potentials. derness associated with ischemia and inflammation
The sensitivity of chemoreceptors to their ade- because tissue damage is accompanied by tissue aci-
quate stimuli can also be increased. Binding of a chem- dosis and extracellular protons are known to activate
ical mediator to a ligand-gated channel receptor can and modulate channel opening in the VR1 receptor.
alter the receptor’s ability to bind another ligand.
Alternatively, the binding of a chemical mediator to a
Adenosine Triphosphate Receptors Adenosine triphos-
G-protein receptor channel can activate an intracellu-
phate (ATP) is the energy currency of the cell. It is nor-
lar signaling pathway that modifies the gating charac-
mally found in the cytosol, enabling chemical work by
teristics of a channel. For example, inflammatory me-
providing energy contained in the phosphate bonds.
diators, such as bradykinin and prostaglandin (PG) E2 ,
ATP can diffuse across cellular membrane but extra-
modulate both heat-gated channels and pH-sensitive
cellular ATP concentration is low, being diluted by
(H+ concentration) ligand-gated channels.
extracellular fluid and degraded by extracellular nu-
cleotidases. However, cell lysis can cause ATP to spill
Example 3: Nociceptors Nociceptors can be subdivided
out and increased intracellular production of ATP can
based upon a number of characteristics. Some noci-
increase the flux of ATP across the membrane by steep-
ceptors belong to group III and some to group IV af-
ening its transmembrane concentration gradient. The
ferents based upon the diameter and conduction ve-
presence of ATP signals present or pending injury.
locity of the parent axon. Nociceptors can be classified
ATP influences nociceptive neurons via ATP-sensitive
according to their respective stimuli. Polymodal no-
receptors. Two families of ATP receptors have been
ciceptors respond to mechanical, chemical, and ther-
identified. When ATP binds to P2Y receptors, sensory
mal stimuli, while other nociceptors respond to sub-
transduction is accomplished via intracellular path-
sets of these stimuli. Another useful classification is
ways linked to G proteins. Thus P2Y receptors are G-
based upon the presence of histochemical markers,
protein-linked receptors. P2X receptors are ATP-gated
a feature that has been used to identify the neu-
ion channels that are opened directly by the binding of
ral innervation of the spine (see below). One group
ATP. These receptors can also be found on cell mem-
of nociceptive neurons produce the proinflamma-
branes containing VR1 receptors because in the pres-
tory peptides calcitonin gene-related peptide (CGRP)
ence of ATP, the temperature threshold for VR1 acti-
and substance P. These peptide-containing neurons
vation is reduced from 42◦ C (107.6◦ F) to 35◦ C (95◦ F).
travel to and synapse in the most superficial layers
The presence of extracellular ATP could allow a nor-
of the spinal cord. Nonpeptide-containing nocicep-
mally nonpainful thermal stimulus (e.g., normal body
tive neurons have been identified by a variety of mea-
temperature, sunlight) to act as a noxious event by ac-
sures including axonal diameters or the presence of
tivating nociceptive endings of group III or group IV
other chemical markers such as isolectin B4 . These
primary afferent fibers.
nonpeptide-containing neurons travel to and synapse
deeper in the spinal cord.
Acid-Sensing (pH) Receptors Acid-sensing receptors be-
Capsaicin Receptor Anyone who has eaten hot chili pep- long to a large family of ligand-gated ion channels
pers understands the consequences of activating cap- permeable to Na+ but also permeable to K+ when the
saicin receptors. Capsaicin is the principal pungent H+ concentration is high (low pH). These channels be-
component of peppers belonging to the genus Cap- long to the extended family of degenerins, also hav-
sicum. Capsaicin and other chemicals that produce a ing members in nonneuronal tissue. In the nervous
response in primary afferent fibers share the chemi- system, unique degenerin family members have been
cal moiety vanillyl. Hence the capsaicin receptor be- found only in nociceptors. These acid-sensing neurons
longs to a family of receptors known as vanilloid re- can also become mechanically sensitive when the pH
ceptors. The first cloned receptor that was responsive surrounding the nerve ending drops. Decreased pH
to capsaicin was labeled the VR1 (representing vanil- changes the mechanical gating characteristics of the
loid receptor 1). VR1 receptors contain an ion channel ion channel. This pH-sensitive increase in mechanical
that produces a depolarizing generator potential via sensitivity is known to exist in C fibers but not A-δ
Na+ and Ca2+ influx. Its gating characteristics are un- or A-β fibers. The same may be true for groups IV,
usual. Heat gates channel opening, but it is not clear III, and II fibers, but it has not yet been demonstrated
whether both moderate and intense heat open the ion experimentally.
reported decreased pain after anesthetic injection of

TISSUES IN THE VERTEBRAL COLUMN
lidocaine into the facet joint space.13 Conversely, low
CAPABLE OF SIGNALING SENSORY STIMULI
back pain and pain referral down the posterior thigh
Conditions in the vertebral column that activate pri- developed in asymptomatic volunteers after saline in-
mary afferent fibers are best understood for mechan- jection into the facet joint.9,14 These injections pre-
ical and chemical changes that occur in paraspinal sumably stretched the facet capsule and activated
tissues of the lumbar spine. Understanding which mechanoreceptors. Whether the source of pain or its
spinal tissues are innervated, the sensory conditions abatement was a result of sensory receptors in the fi-
to which they respond, and the effects of their re- brous joint capsule or the synovial membrane was not
sponses on the central nervous system enables the determined.
development of physiological explanations for the
clinical practice of chiropractic. Fibrous Joint Capsule Human cadaveric dissection re-
veals that group II, group III, and group IV nerve
Lumbar Spine fibers innervate the fibrous portion of the lumbar facet
Facet Joints The facet joints of the vertebral column capsule.15,16 Approximately 75% of the fibers belong
are classified as synovial joints (synovia = “with egg” to group IV, have small diameters (0.5–2 μm), and are
because of the albumin-like consistency of synovial unmyelinated. Approximately 20% belong to group
fluid). A joint capsule encloses the joint cavity ex- III, have small diameters (2–5 μm), and are thinly
cept on its medial-most border where the ligamentum myelinated. The remaining 5% belong to group II,
flavum encloses the cavity. The articulating surfaces of have large diameters (5–10 μm), and are thickly myeli-
the joint are covered with hyaline articular cartilage, a nated.
connective tissue specialized for sliding and shock ab- Although the capsule is considered well inner-
sorption. The facet joint capsule is comprised of three vated, few studies have attempted to determine re-
layers. The outer layer is fibrous, being composed of ceptor distribution either within a facet capsule or be-
collagen. It attaches to the inferior and superior artic- tween segmental levels. It has been noted that more
ular pillars, thereby enclosing the joint. The synovial nerve fibers are visualized than sensory receptors or
membrane comprises the middle and inner layers. The large fascicles (150–200 μm).12,16 These observations
middle layer, called the “subsynovia” or “subintima,” suggest the presence of many neurons innervating the
adjoins the fibrous joint capsule. It is formed of adi- joint capsule and have likely given rise to the con-
pose and areolar tissue in varying proportions. Blood clusion that the lumbar facet joint capsule is richly
vessels and lymphatics course through the subintima. innervated. In actuality, histological studies indicate
The inner layer, the “synovia” or “synovial intima,” that receptor density is between one and seven sen-
lines the joint space and, where the fibrous capsule sory receptors per capsule, with the density decreas-
encloses the articular pillars, lines the both the fibrous ing within the capsule from its inferior to superior
capsule and the periosteum of the articular pillars. poles.12,15,17−19 The small number of receptors might
The synovia is one to five cells deep. Synoviocytes indicate that the endings have large receptive mechan-
are fibroblasts that secrete proteoglycan and phago- ical fields.
cytize foreign matter. Together, the synovial mem- Freeman and Wyke20 classified receptive endings
brane’s two layers produce synovial fluid (a dialysate of articular tissue into four types. Receptive end-
of blood) for lubrication of the joint and nutrition of ings classified as types 1, 2, and 3 are encapsu-
chondrocytes in hyaline articular cartilage.12 lated, whereas type 4 endings are unencapsulated.
Each medial branch of the dorsal ramus from the Mechanoreceptors, some of which aid in propriocep-
two segmental levels comprising each facet joint in- tion, belong to types 1 to 3 and have myelinated par-
nervates each lumbar facet joint. Thus the L2-L3 facet ent axons. Nociceptors belong to type 4 and have
joint, for example, is innervated by the L1 and L2 unmyelinated parent axons. Of the encapsulated re-
spinal nerves. The medial branch from the superior ceptors, the parent axon of the type 3 receptor is largest
segment divides and sends a descending branch along in diameter (13–17 μm), while the parent axon of the
the lamina to innervate the superior portion of the type 1 receptor is the smallest-diameter (5–8 μm).
facet capsule. The medial branch from the inferior seg- Unencapsulated receptors have the smallest-diameter
ment divides, sending a branch to the inferior portion parent axons (< 2 μm). This classification scheme,
of the joint capsule. There appears to be no evidence while potentially useful for classifying receptive end-
in humans that a zygapophyseal joint receives inner- ings in articular tissue, is not related to the numeri-
vation from either the contralateral posterior ramus cal scheme used to classify the parent nerve fiber and
or from a third segmental level. should not be confused with it. Because muscle spin-
Clinically, nociceptors have been demonstrated in dles and Golgi tendon organs are not present in the
human lumbar facet capsule. Symptomatic volunteers facet capsule, group I afferent fibers do not innervate
articular tissue. Thus, group II afferents may parent procedures can be done that cannot otherwise be done
type 2 and 3 receptors, group III afferents likely parent on humans. The work on animals enables hypothe-
type 1 receptors, and group IV afferents parent type 4 ses to be tested on humans to better understand the
receptors. However, there is some evidence that sen- interaction between spinal biomechanics and the ner-
sory neurons have a more heterogeneous relationship vous system. Some primary afferent fibers respond
between the morphology of their receptive ending and to movement of the facet joint within a physiological
the grouping of the primary afferent fiber. For exam- range, while others with higher mechanical thresholds
ple, Vandenabeele et al.,19 using light and electron mi- likely signal the presence of more forceful mechanical
croscopy, reported encapsulated endings in human stimuli. More than 50% of the group III mechanorecep-
lumbar facet capsule as being innervated by small- tors appear to have low thresholds to mechanical stim-
diameter, thinly myelinated group III, as well as small- uli. The action potential discharge frequency of many
diameter, unmyelinated group IV nerve fibers. Thus group III and group IV mechanoreceptive primary af-
group IV afferents may also parent type 1 receptors. ferents is graded with the direction in which a vertebra
In the fibrous capsule, bare, simple, and complex moves, with individual neurons being most respon-
encapsulated nerve endings have been reported; type sive to one or two preferred movement directions.30
1 receptors have been found both with and without These signaling properties are likely related to the
type 2 receptors.15,17,18,21 Type 1 globular Ruffini end- presence of collagen fibers that traverse at variable
ings have been reported in as high as 64% of observa- orientations in the vicinity of encapsulated nerve end-
tions, while type 2 paciniform endings were as high ings. These fibers may link the nonneural encapsu-
as 9%. Methodological issues may contribute to vari- lation to mechanically gated ion channels conferring
ation in the distribution of receptor types, or it may directional sensitivity to mechanoreceptors in the fi-
represent biological variability with not all individ- brous joint capsule.19,21 Coding for direction would
uals having the same distribution of receptive end- arise from the number of mechanically sensitive chan-
ings. Type 4 free nerve endings have been estimated nels opened and the number of action potentials gen-
at 26% of the receptive-ending population, a number erated. High-threshold mechanoreceptors (> 8.5 g) be-
substantially less than the estimated 75% of group IV longing to group III afferents are also present in and
fibers that often terminate in bare nerve endings. Re- around the lumbar facet joints. The presence of no-
ceptive endings have been reported predominately in ciceptive chemicals, such as substance P, can change
middle of the capsule and in the inferolateral portion the mechanical threshold of these sensory receptors.29
of the capsule near the articular recess. Few receptors Both their background discharge and their discharge
have been identified near the superior recess. All four during mechanical stimulation increase in the pres-
receptor types have been found in human facet joint ence of substance P.
capsules.17,18
Substance P, CGRP, and vasoactive intestinal pep- Synovial Membrane Innervation of the synovial mem-
tide (VIP) immunoreactivity have been found in the brane is controversial. While a number of stud-
fibrous capsule.16,22−26 Substance P and CGRP are in- ies found no evidence of neurons in the synovial
tracellular neurochemicals associated with nocicep- membrane,21,26 a small number of small, myelinated,
tive pathways and VIP is a neuromodulator associ- and unmyelinated fibers have been observed cours-
ated with sympathetic vasodilation.27 When found ing through the synovial membrane.12,31,32 Neuropep-
distant from blood vessels, their presence suggests tide Y (NPY, a neuromodulator associated with sym-
a role in sensory reception. Sometimes substance P, pathetic vasoconstriction), substance P, and CGRP
CGRP, and VIP immunoreactivity are found close to have been found in synovial membrane of lumbar
blood vessels, suggesting a vasoregulatory or trophic facet joints. Evidence for the presence of nociceptive
function for these nerves. Not all nerve fibers in the chemoreceptors is more often seen in the subsynovial
lumbar fibrous joint capsule contain immunoreacti- layer than in the synovial layer.
vity, suggesting the presence of a subpopulation of The synovial membrane has redundancies that
neurons with different functions, possibly thermore- form folds of synovial tissue extending into the joint
ceptive or mechanoreceptive. The larger-diameter space. These synovial folds (also called synovial plica)
primary afferent fibers tend not to be stained with sub- are especially well developed in the superior and infe-
stance P, suggesting a purely mechanoreceptive role rior recesses of the lumbar facet joints. Substantial ev-
for these neurons. idence indicates that synovial folds are innervated.12
The anatomical studies described above are sup- Nerves appear most abundant in the subsynovial
ported by electrophysiological studies in animals layer, with hardly any seen in the synovial layer.
showing the presence of groups II and III neurons in Unmyelinated nerve fibers with diameters (0.2–
or near the facet capsule.28−30 Studies using appro- 0.4 μm) within the range of group IV afferents travel
priately anesthetized animals are invaluable because within the folds alongside arterioles, suggesting a
vasoregulatory function. In addition, myelinated one-third of the annulus fibrosus of the healthy disc
nerve fibers with diameters (6–12 μm) within the appears innervated, whereas the inner two-thirds of
range of group III afferents have been observed in the the annulus and the nucleus pulposus are devoid
subsynovial layer but distinct from blood vessels and of nerve endings.38,39 Based upon studies from un-
thereby presumably not vasoregulatory. However, no healthy disc material obtained at surgery, the depth
encapsulated sensory receptors have been observed of neural innervation appears related to the degree of
in the synovial folds suggesting, to the extent the neu- degeneration.37,39 While vascular tissue invades the
rons are mechanically sensitive, the mechanical input disc as it degenerates, it has yet to be determined if
would receive little filtering. These neurons may be neural innervation actually accompanies the angio-
nociceptive mechanoreceptors. genic process. Moreover, the prevalence of innerva-
tion may not be uniform even with disease. In patients
Normally, articular cartilage is
Hyaline Articular Cartilage with low back pain, the discs from only 50% of the
not innervated.12,23 However, nerve fibers may invade individuals were innervated up to the mid-annular
the interface between the articular cartilage and sub- region, as compared with 15% of the discs from indi-
chondral bone during joint degeneration. Excision of viduals with scoliosis.36
the facet joints reveals erosion channels between the Receptive nerve endings indicative of mechanore-
cartilage and subchondral bone in patients with de- ceptor and chemoreceptor function have been identi-
generation of facet cartilage. The channels are accom- fied in the intervertebral disc.36−42 Encapsulated nerve
panied by blood vessels and the blood vessels in turn endings, including pacinian, Meissner, Ruffini, and
are accompanied by nerve fibers with substance P im- Golgi-like tendon organs, have been identified pre-
munoreactivity. In the absence of substantial degen- dominantly on the anterior and anterolateral por-
eration, however, substance P–containing fibers could tion of the disc near the endplate, suggesting the
not be seen. presence of mechanoreceptors that could respond to
stretch during extension, twisting during rotation,
Ligamentum Flavum The ligamentum flavum lines the and compression during flexion. These sensory recep-
medial portion of the facet joint, thus covering the lat- tors would be expected to have mechanically gated
eral surface of the neural canal. The ligament’s elas- channels transducing changes in tension associated
ticity, as well as the fact that it is preloaded, likely pre- with spinal kinematics. In addition, the outer layers
vents it from being nipped by the facet or bulging into of the disc are sparsely innervated by substance P–
the neural canal. Sensory receptors in the ligamentum containing neurons, but CGRP- and VIP-containing
flavum are thought to be rare or nonexistent.16,21 How- neurons appear more abundant.43,44 The presence of
ever, the medial branch of the dorsal ramus and the substance P in the outer layers of the disc has been
sinuvertebral nerve may innervate the ligament’s dor- associated with a trophic influence affecting repair
sal and ventral surfaces, respectively, because CGRP and production of disc matrix because substance P
and VIP immunoreactivity not associated with vascu- can induce proteoglycan production by annular cells
lar structures was recently observed in the ligament.26 in culture.35
However, no substance P immunoreactivity has been
found in the ligamentum flavum, suggesting that it Ligaments
may not be a source of nociceptive information. Phys- Longitudinal LigamentsThe posterior and anterior lon-
iological studies indicate that group II and group III gitudinal ligaments contain both free and encapsu-
afferents might innervate the ligamentum flavum and lated nerve endings.35−37,43 Encapsulated receptors
respond to mechanical movement within the physi- in these ligaments include pacinian corpuscles and
ological range.33 Because of the variability and con- Golgi tendon organs. Neurons containing CGRP im-
tradictory nature of different studies, the exact inner- munoreactivity are also present in the anterior and
vation of the ligamentum flavum is unknown at this posterior longitudinal ligaments. The immunoreactiv-
time. ity appears predominantly in the deeper layers of the
ligaments and its presence is sparse. In addition, a
Intervertebral Disc Clinical experience using hyper- network of small-diameter neurons containing sub-
tonic saline injections into the intervertebral disc and stance P immunoreactivity is present in the posterior
the application of mechanical force to the disc dur- longitudinal ligament. Free nerve endings are more
ing progressive local anesthesia indicates that the abundant than are complex encapsulated receptors.
outer portions of the human annulus fibrosus are In general, the density of neural tissue appears great-
innervated.34 Controversy exists over the extent to est where the ligaments attach to the intervertebral
which annular fibers of the normal intervertebral disc. Mechanoreceptive, nociceptive, and neuromod-
disc are innervated.7,9,35−37 Based upon intervertebral ulatory roles have been suggested for the innervation
discs obtained from organ donors, up to the outer of these ligaments.37
The location and function of these neurons in the quantification and morphological description of the
posterior longitudinal ligament is supported by elec- spindles were not performed. Carlson also noted
trophysiological studies from the lumbar sinuverte- that spindle density appeared higher in the central
bral nerve.45 Group III and group IV neurons with than in the peripheral portions of the longissimus.
mechanosensitivity have been identified. Mechanical The high spindle density in this muscle is consistent
thresholds are above 20 g, suggesting that they re- with the high percentage of slow-twitch fibers also
spond to noxious mechanical stimuli. However, many found.50 Electrophysiological recordings from lumbar
of the receptive endings are located at a segmental paraspinal muscles, the multifidus and longissimus
level where the ligament crosses over the interver- muscles in particular, indicate they are innervated by
tebral disc, thus making it difficult to differentiate groups I to IV afferents and that they respond to me-
endings in the ligaments from endings in the outer chanical changes in vertebral position or movement of
layers of the anulus fibrosus. the facet joint, including spinal manipulation.30,51−53
Supraspinous Ligament Free nerve endings as well

Sacroiliac Joint The innervation of the sacroiliac joint
as paciniform and Ruffini endings are present in
is unclear. Animal studies suggest the joint is mul-
the supraspinous and interspinous ligaments.22 The
tisegmentally innervated, with different segments in-
supraspinous ligament contains large- and small-
nervating the ventral and dorsal surfaces of the joint.54
diameter nerve fibers, with the smaller fibers contain-
When compared with the dorsal surface of the sacroil-
ing substance P. Forceful pulling on the supraspinous
iac joint, the ventral surface is innervated by a higher
ligament elicits a slowly adapting discharge from
number of segments, as well as more cephalad seg-
nerves that innervate paraspinal tissues in gen-
ments in the rat. It is currently unknown if this pattern
eral. The supraspinous ligament itself contains
is similar in humans.
mechanoreceptors with both high and low mechan-
ical thresholds.28 The mechanoreceptor response sat-
urates as ligament tension increases, indicating that Meninges, Dorsal Roots, and Ventral Roots Innervation
the mechanical information is not nociceptive. of the meninges is controversial. Substance P– and
CGRP-containing neurons, as well as sympathetic
Muscles Sensory innervation of muscles attached to efferents, have been identified in the lumbar dura
vertebra of the lumbar spine has received little atten- mater.55 Tracer studies in animals56 show that the dura
tion. It is generally assumed that lumbar paraspinal mater is innervated segmentally and suprasegmen-
muscles are innervated by the full array of known tally (i.e., from three to four segments superior). In-
sensory fibers (i.e., groups I, II, III, and IV afferents). nervation is provided by the sympathetic trunk and
Recent findings in humans demonstrate the impor- sinuvertebral nerve, a pattern similar to the multiseg-
tance of proprioceptive input from paraspinal muscle mental innervation observed for lumbar interverte-
spindles for regional repositioning of the lumbar spine bral discs. It is unknown if the same pattern occurs in
and for normal reflex activity. While healthy individu- humans.
als can accurately reposition their lumbosacral spine, The spinal roots within the intervertebral foramen
their repositioning ability is impaired when muscle (IVF) possess unusual anatomical properties, having
spindle discharge is increased by applying vibration less connective-tissue support and protection than the
to the lumbar paraspinal muscles.46,47 During vibra- peripheral nerve.57,58 As the peripheral nerve trunk
tion, the correct position is consistently undershot be- enters the IVF, its epineurium separates from the
cause of the misperception of vertebral position; facet trunk and becomes continuous with the dura mater.
joint position is “sensed” as being flexed more than it Perineurium surrounding individual fascicles is lost
actually is. Increasing the background discharge from as the fascicles separate into ventral and dorsal roots.
paraspinal muscle spindles affects paraspinal mus- Endoneurium surrounding the individual Schwann
cle reflexes. Vibration-induced stimulation of lum- cells that ensheathe both the myelinated and unmyeli-
bar paraspinal muscle spindles inhibits the short la- nated axons continue into the nerve roots, but the
tency paraspinal electromyelogram (EMG) activity endoneurium’s collagen content becomes less dense
that would otherwise be evoked by tapping the erec- and is no longer organized as a protective sheath. In
tor spinae muscles.48 addition, the density of Na+ channels in the soma
Neurophysiological studies in the cat have pro- and initial segment of dorsal root ganglia cells is rela-
vided a substantial basis for understanding the or- tively high, suggesting these regions may be unusu-
ganization of the human. In the lumbar spine of ally excitable. These properties may render neural tis-
the cat, Carlson49 identified muscle spindles in the sue within the IVF vulnerable to effects of mechanical
longissimus, iliocostalis, sacrocaudalis, intertransver- compression and the chemical environment produced
sarii, multifidus, and interspinalis muscles, but by changes in the intervertebral disc or facet joints.59,60
The dorsal roots (DRs) and dorsal root ganglia where primary afferent neurons comprising the dor-
(DRG) are more susceptible to the effects of mechan- sal root do not increase their discharge in response
ical compression than are the axons of peripheral to mechanical stimulation except in the presence of
nerves.61−64 Impaired or altered function is produced inflammation.
at substantially lower pressures. Compressive loads
as low as 10 mg applied rapidly to the DR slightly in- Cervical Spine
crease the discharge of groups I, II, III, and IV afferents. Typically, individual nerve fascicles comprising the
Slowly repeated loads or gradually increasing loads dorsal ramus of the cervical spinal nerves innervate
produce conduction block. Maintained compressive either the overlying skin or deeper cervical paraspinal
pressures as low as 20 mmHg applied to the DR cause tissues, but not both. Occasionally, a fascicle may
conduction block. While the DR is not as sensitive contain neurons that innervate both deep and super-
as the DRG to mechanical pressure, prior mechani- ficial structures. Deeper tissues of the cervical ver-
cal injury greatly increases resting DR discharge. In tebral column provide the central nervous system
contrast, only slight mechanical compression applied with continuous information because electrophysio-
to the DRG is sufficient to produce large, prolonged logical studies show that nerve fascicles innervating
increases in the discharge of groups I, II, III, and IV af- the deeper tissues contain background neural activity.
ferents, even in the absence of prior mechanical injury. In contrast, neurons innervating the skin are typically
Compression studies, like those described above, quiescent unless the skin is at least touched lightly.73
laid experimental groundwork for investigating how
herniated intervertebral discs affect nerve root func- Facet Joints The posterior primary division of the cer-
tion. Clearly, the idea that a herniated disc could di- vical spinal nerves innervates the cervical zygapophy-
rectly compress the DR or DRG is straightforward. seal joints.5,6 Communicating branches connect the
Recently, pressure between a herniated disc and the dorsal rami of C1, C2, and C3 and form the poste-
nerve root was measured in 34 humans undergoing rior upper cervical plexus. Aside from the communi-
surgery for lumbar disc herniation.65 Mean pressures cating branches, the C1 dorsal ramus (also called the
of 53 mmHg (range: 7–256 mmHg) were measured. suboccipital nerve) does not branch further, whereas
A second idea describing how herniated interverte- C2 and C3 divide into medial and lateral branches.
bral discs could affect nerve root function suggests The C2 medial branch (also called the greater occipital
that its effects are mediated indirectly by the release of nerve) innervates the atlantoaxial facet joints and the
neuroactive chemicals.66 This mechanism would help C3 medial branch (also called the third occipital nerve)
explain the common observation that, even in the ab- innervates the C2-C3 facet joints. The communicating
sence of compression, herniated discs are accompa- branches that join the suboccipital, greater, and third
nied by neurological findings. Recent studies demon- occipital nerves provide the possibility that the C1-C3
strate that the application of nucleus pulposus to a facet joints are innervated multisegmentally.
lumbar nerve root causes mechanical hyperalgesia in The C4-C8 dorsal roots do not have communicat-
the distal limb and causes swelling in and decreased ing branches but do divide into medial and lateral
blood flow to the DRG.67,68 In addition, phospholipase branches. As in the lumbar spine, the zygapophy-
A2 (PLA2 ), an inflammatory mediator associated with seal joints from C4 to C7 are innervated by the me-
disc herniation, is neurotoxic in high doses to groups dial branch from two segmental levels; thus the C4
I, II, III, and IV. In moderate doses, it increases me- medial branch of the dorsal ramus innervates the ip-
chanical sensitivity of the DR, producing long-lasting silateral joint capsule of the C3-C4 facet joint and also
discharge, and it increases the discharge of previously travels inferiorly to innervate the ipsilateral C4-C5
silent DRG cells.66,69−71 Thus, the intervertebral fora- facet joint.
men is a site where the changes in paraspinal tissues Cervical facet joint capsules are organized into
can affect neural signaling independent of activating a three layers similar to those in the lumbar spine. Sen-
neuron’s receptive ending. The pain of sciatica, which sory receptors are found in the outer fibrous cap-
is thought to arise from ectopic firing of injured or sen- sule as well as the synovial membrane. Sensory re-
sitized cell bodies of the DRG or dorsal roots, could ceptor density per facet joint ranges from one to five
also arise from uninjured but mechanically activated receptors with two to three receptors per facet joint
mechanoreceptors. being typical.17 Mechanoreceptors with parent fibers
The meningeal coverings that surround the ventral belonging to groups I and II are found in the outer
root contain receptive nerve endings. These endings fibrous capsule. Low-threshold, rapidly adapting re-
are sensitive to mechanical and chemical stimuli.72 ceptors such as pacinian corpuscles are the most nu-
Stretching the root is the most effective stimulus to merous, followed by low-threshold, slowly adapting
these primary afferent neurons even in the absence receptors. Small, encapsulated receptors, possibly
of inflammation. This contrasts with the dorsal roots, with high mechanical thresholds, are found in the
fibrous capsule and the subintima. Free nerve endings relatively rare but when present, they often lie beside
appear least numerous but are located in both layers Golgi tendon organs.
of the synovial membrane.74 Mechanoreceptors other than muscle spindles,
Golgi tendon organs, and pacinian corpuscles also
Muscles The muscles of the cervical spine are well provide sensory information from cervical paraspinal
innervated.75 Nerves to cervical paraspinal muscles muscles. Group III primary afferent fibers originate in
have a proportionally large number of sensory fibers, mechanoreceptive endings; most have high mechani-
and a proportionally large number of fibers with di- cal thresholds.73 Unlike group III afferents innervating
ameters classifying them as group II and group III af- appendicular muscle, the group III fibers from cervi-
ferents, than do muscles nerves in the limbs. However, cal paraspinal muscles are insensitive to bradykinin
the ratio of unmyelinated to myelinated primary af- and, therefore, are not polymodal.73,85 However, these
ferent fibers (2.5:1) to neck muscles appears similar to group III afferents are sensitive to hypertonic saline,
that in the appendicular skeleton.76 Based upon hu- further indicating their mechanosensitivity, respond-
man and animal studies, the cervical paraspinal mus- ing to changes in tissue tension produced by the
cles are richly supplied with mechanoreceptors, es- change in osmotic pressure. In the superficial cervical
pecially muscle spindles.77,78 Spindle densities range muscles these mechanoreceptors are primarily slowly
from 5 to 45 spindles/g of leg muscle.79 By contrast, adapting. Chemoreceptors are also present in cervical
in superficial cervical muscles spindle density can be paraspinal muscles; their parent axons likely belong
2 to 8 times higher (47–107 spindles/g) and in deep to group IV afferents. These chemoreceptors respond
cervical muscles 10 to 25 times higher (137–460 spin- to inflammation as indicated by the muscle reflexes
dles/g) than in peripheral muscle.73,80−83 The high initiated by intramuscular injection of bradykinin or
spindle density in the cervical and lumbar muscles the inflammatory irritant mustard oil.86,87
is consistent with the high percentage of slow-twitch
fibers found in these muscles. Cervical Intervertebral DiscsLike the lumbar interverte-
Muscle spindle morphology as determined in ani- bral discs, up to the outer one-third of the cervical disc
mal studies has some unique aspects when compared is innervated.74,88 Innervation is provided by the sinu-
with that in the appendicular skeleton, and there is vertebral nerve, which, similar to the lumbar spine, is
reason to believe the situation is similar in the hu- composed of a somatic root and an autonomic root.
man axial skeleton.73,80−83 Muscle spindles in the neck The autonomic root arises from the vertebral nerve,
are smaller than in appendicular muscles. In the cat a branch of the sympathetic trunk in the cervical re-
hindlimb, muscle spindles are described as single region. Nerve filaments can clearly be seen entering
ceptors located both deep in the muscle belly and the cervical discs and the posterior longitudinal lig-
close to the musculotendinous junction. In the cervi- ament. Microscopically, free nerve endings, as well as
cal spine of the human and cat, muscle spindles are pacinian corpuscles and other complex but unencap-
rarely seen as single entities. Cervical spindle com- sulated receptive nerve endings, have been observed
plexes are present wherein two to six spindles are in in the cervical discs. Presumably their function is sim-
close contact with each other or share capsules and/or ilar to that in the lumbar spine. Gross dissection also
intrafusal fibers. They, too, are generally located close reveals nerve fibers entering ligaments in the upper
to musculotendinous junctions. In addition, cervical cervical region, including the transverse and alar lig-
paraspinal muscles have few, if any, bag1 fibers, sug- aments.
gesting the predominant sensory information from
muscle spindles in the neck concerns static changes Thoracic Spine
in muscle length rather than its rate of change. Facet Joints Little is known about the innervation of
Cervical paraspinal muscles are also endowed the thoracic spine. Histological studies indicate the
with Golgi tendon organs.74,78 These receptors are density of sensory receptors in facet joints of the tho-
found at musculotendinous junctions including the racic vertebrae is less than that in either cervical or
numerous tendinous inscriptions that compartmen- lumbar vertebrae. Some thoracic facet joint capsules
talize cervical paraspinal muscles. Studies of cervi- may be devoid of innervation.18 Group I and group II
cal paraspinal muscle in cross section indicate that afferents appear to predominate in the innervation of
the Golgi tendon organs are often found lying be- the thoracic spine.
side muscle spindles, more so than in appendicular
muscle.84 Most Golgi tendon organs and spindles are Costovertebral Joints The costovertebral joints receive
located in parts of muscle that contribute most to pos- an articular branch from the ventral ramus. Articular
tural support, that is, the portions of these muscles branches can arise directly from the ventral rami just
having the highest percentage of slow-muscle fibers. distal to the intervertebral foramen. Alternatively, ar-
Pacinian corpuscles in cervical paraspinal muscles are ticular branches may arise from the somatic branch of
the ventral ramus before it courses medially to re-enter interplay between these sensory inputs and the result-
the intervertebral foramen and neural canal as the sin- ing changes in the central nervous system, including
uvertebral nerve.89 Mechanoreceptors in the capsule segmental, intersegmental, and suprasegmental neu-
of the costovertebral joints have been implicated in ral pathways, will enable us to improve the delivery
the perception of resistance to breathing. It is esti- of care to patients.
mated that each facet capsule contains two sensory
receptors. Most of these sensory receptors are slowly
SUMMARY
adapting. They are active over the entire range of rib
cage movement during breathing. They have a resting 1. Primary afferent neurons are the first nerve cells
discharge and are sensitive to changes in rib position. that receive sensory stimuli. Primary afferent neu-
Their sensitivity is graded with both the magni- rons from muscle and other deep tissues can be
tude and the direction of rib movement. Distension classified based upon their axonal fiber diameters
of the joint capsule increases the activity of these using Roman numerals (group I, group II, group
mechanoreceptors.90 III, and group IV) or according to their axonal con-
Other mechanoreceptors in the capsule of the cos- duction velocity (A-α, A-β, A-δ, and C fibers). Pri-
tovertebral joints have rapidly adapting characteris- mary afferents are pseudounipolar neurons and
tics. They are silent when the rib cage is stationary but have a unique morphology compared with the
give a burst of activity during movement, becoming prototypical neuron. The cell body is generally
silent again when movement is terminated. The com- spherical and is located in the dorsal root ganglion.
bined input from these rapidly and from the slowly A single process (the “stem process”) extends from
adapting sensory receptors likely signals changes in the cell body and splits into two branches or pro-
joint position, as well as the velocity of the positional cesses. The “central process” travels toward the
change. Biomechanical changes in this joint would al- spinal cord. The “peripheral process” travels to-
ter the discharge of these mechanoreceptors and con- ward somatic or visceral structures.
tribute to the perception of difficulty with the work of 2. When viewed in cross section, the vertebral col-
breathing.90 umn can be divided into an anterior and a poste-
rior compartment. The anterior compartment con-
Costotransverse Joints The posterior primary division tains, visualizing from anterior to posterior, the
of the spinal nerve innervates the costotransverse prevertebral muscles, the anterior longitudinal lig-
joints. Articular branches arise from the dorsal ramus ament, the vertebral body, the intervertebral disc,
and can also arise from the medial branch as it travels the posterior longitudinal ligament, and the ante-
to innervate the thoracic multifidi. In addition, inner- rior dura mater. The posterior compartment con-
vation can be multisegmental, arising from the spinal tains the neural arch, the posterior dura mater, the
nerve above and below.89 zygapophyseal joints and their ligaments, and the
paraspinal muscles.
3. Stimulus energy can take different forms (e.g., me-
SPINAL MANIPULATION AND SPINAL
chanical, chemical, heat, light, sound). Sensory
SENSORY AFFERENTS
transduction is the process by which the stim-
The mechanical effects of spinal manipulation likely ulus energy changes the conformational state of
have direct effects on mechanoreceptors. Spinal ma- membrane-bound proteins and elicits a generator
nipulation’s therapeutic effects may arise, at least in potential in the form of electrochemical energy.
part, from its capacity to silence and/or activate the Both rapidly and slowly adapting receptors are
inflow of sensory information. The long-lasting effects found in tissues crossing the spinal facet joints,
of spinal manipulation may arise from normaliz- including the fibrous capsule, paravertebral mus-
ing the biomechanical relationship between individ- cles, and skin. Thus, the central nervous system is
ual vertebrae, consequently changing the mechani- apprised of joint position at the start of movement,
cal conditions “seen” by these mechanoreceptors. The about the rate and direction of movement during
mechanical effects of spinal manipulation may also its course, and about the new joint position. Low-
affect nonmechanoreceptive endings, that is, noci- threshold mechanoreceptors include the muscle
ceptors, chemoreceptors, or thermoreceptors. Biome- spindles and pacinian corpuscles. These are dif-
chanical changes in paraspinal tissues may change ferentiated from chemoreceptors and the nocicep-
the chemical milieu of the spine. For example, re- tive capsaicin receptor, ATP receptors, and acid-
moval of a mechanical irritation or redistribution of sensing (pH) receptors.
stresses or strains within paraspinal tissues may re- 4. Tissues in the vertebral column capable of sig-
duce subacute inflammation and/or alter blood flow naling sensory stimuli include the facet joints, fi-
and the washout of metabolites. Understanding the brous joint capsule, synovial membrane, hyaline
articular cartilage, ligamentum flavum, interver-

ANSWERS
tebral disc, ligaments, longitudinal ligaments,
supraspinous ligament, muscles, sacroiliac joint, 1. Primary afferent neuron or primary afferent.
costotransverse joints, costovertebral joints, and 2. The Erlanger-Gasser system classifies cutaneous
meninges. primary afferents according to their axonal con-
5. Spinal manipulation’s therapeutic effects may duction velocity. The Erlanger-Gasser classifica-
arise, at least in part, from its capacity to silence tion uses capitalized Arabic letters accompanied
and/or activate the inflow of sensory information. by Greek letters: A-α, A-β, A-δ, and C fibers. The
Removal of a mechanical irritation or redistri- Lloyd-Hunt system classifies muscle primary af-
bution stresses or strains within paraspinal tis- ferents according to their axonal diameter. The
sues through manipulation may reduce subacute Lloyd-Hunt system classification uses capitalized
inflammation and/or alter blood flow and the Roman numerals: groups I, II, III, and IV.
washout of metabolites and in this way reduce 3. B. The frequency with which action potentials
symptoms. occur.
4. Mechanically gated ion channels.
5. The outer layer is called the fibrous joint capsule
and is composed of collagen. It attaches to the infe-
QUESTIONS rior and superior articular pillars, thereby enclos-
1. All somatosensory information from the spinal ing the joint. The middle and inner layers form
column is conveyed to the central nervous system the synovial membrane. The middle layer is called
via what general classification of neuron? the “subsynovia” or “subintima” and lines the fi-
2. Using either the Erlanger-Gasser system or Lloyd- brous joint capsule. It is formed of adipose and are-
Hunt system, into what named categories can sen- olar tissue. Blood vessels and lymphatics course
sory neurons be subdivided? through the subintima. The inner layer is called
3. Sensory signals that convey information about a the “synovia” or “synovial intima” and lines the
stimulus (either its quality or quantity) are en- joint space. The synovia is a cellular layer one to
coded by which aspect of the action potential? five cells deep. These synoviocytes are fibroblasts
A. The amplitude of the action potential. that secrete proteoglycan and phagocytize foreign
B. The frequency with which action potentials oc- matter.
cur. 6. A, B, G, H, I, J, L, M, O, and P.
C. Both A and B.
D. None of the above.
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Physiol Ther 1998;21:553. fects of capsaicin and bradykinin on afferent fibers
76. Richmond FJR, Anstee GCB, Sherwin EA, et al. Motor with endings in skeletal muscle. Circ Res 1982;50:133.
and sensory fibres of neck muscle nerves in the cat. 86. Bolton PS, Holland CT. An in vivo method for study-
Can J Physiol Pharmacol 1975;54:294. ing afferent fibre activity from cervical paravertebral
77. Amonoo-Kuofi HS. The number and distribution tissue during vertebral motion in anaesthetised cats.
of muscle spindles in human intrinsic postvertebral J Neurosci Methods 1998;85:211.
muscles. J Anat 1982;135:585. 87. Hu JW, Yu X-M, Vernon H, et al. Excitatory effects
78. Richmond FJR, Abrahams VC. Physiological proper- on neck and jaw muscle activity of inflammatory
ties of muscle spindles in dorsal neck muscles of the irritant applied to cervical paraspinal tissues. Pain
cat. J Neurophysiol 42:604, 1979. 1993;55:243.
79. Chin NK, Cope M, Pang M. Number and distribution 88. Bogduk N, Windsor M, Inglis A. The innervation of
of spindle capsules in seven hindlimb muscles of the the cervical intervertebral discs. Spine 1988;13:2.
cat. In: Barker D, ed. Symposium on muscle receptors. 89. Wyke B. Morphological and functional features of
Hong Kong: University Press, 1962:241–248. the innervation of costovertebral joints. Folia Morphol
80. Richmond FJR, Abrahams VC. Morphology and dis- (Warsz) 1975;23(4):296.
tribution of muscle spindles in dorsal muscles of cat 90. Godwin-Austen RB. The mechanoreceptors of the cos-
neck. J Neurophysiol 1975;38:1322. tovertebral joints. J Physiol 1969;202:737.
C H A P T E R
13
MUSCLE SPINDLES AND SPINAL
PROPRIOCEPTION
Barbara I. Polus
O U T L I N E
INTRODUCTION SPINAL PROPRIOCEPTORS
Proprioception: A Historical Perspective Intervertebral Disc
Role of Sensory Input in Regulating Movement Spinal Ligaments
and Posture: A Contemporary Perspective Zygapophyseal Joints of the Spine
PROPRIOCEPTIVE SENSORY SYSTEM Proprioception and the Paraspinal Muscles
INTRAMUSCULAR RECEPTORS Encapsulated Receptors of the Neck
Anatomy and Physiology of Muscle Spindles FUNCTION OF SPINAL PROPRIOCEPTORS
Structure Assessment of Position and Movement Sense
Sensory Innervation of the Spine
Motor Innervation Effect of Mechanical Spinal Injury on Spinal
Comparative Anatomy Proprioception and Postural Stability
Excitation Proprioceptors of the Neck
Response to Stretch and Postural Stability
Response to Fusimotor Stimulation JOINT STABILITY: THE ROLE OF NEUROMUSCULAR
Resting Discharge CONTROL
Muscle Stretch Reflex: Tonic and Phasic Components Ligamento-Muscular Synergism in the Spine
Anatomy and Physiology of the Golgi Effect of Mechanical Spinal Injury
Tendon Organs on Ligamento-Muscular Synergism
Structure SUMMARY
Dynamic and Static Responses QUESTIONS
Reflex Actions ANSWERS
ANATOMY AND PHYSIOLOGY OF JOINT KEY REFERENCES
MECHANORECEPTORS REFERENCES
position sense and movement sense in the spine,

OBJECTIVES as well as region-specific differences.
1. To define proprioception. 6. To explain the effect of injury on spinal proprio-
2. To describe the major proprioceptive inputs of the ception.
body: labyrinth, muscles, tendons, joint tissues, 7. To explain the role of spinal proprioceptors in
skin, and eyes. ligamento-muscular synergism.
3. To explain the physiological anatomy of muscle
spindles.
INTRODUCTION
4. To describe the physiological anatomy of proprio-
ceptive mechanoreceptors in joints and tendons. Proprioception refers to the sense of the static (posi-
5. To describe the tissues that are responsible for tion sense) and dynamic (kinesthetic sense) position
249
of the limbs and the body in space. Proprioception servocontrolled movement where spindle afferent dis-
forms one part of a set of complex somatic sensory charge provided the stimulus for excitation of syner-
modalities that inform us about our external and in- gistically connected motoneuron pools. Postural sta-
ternal environments. Contact with the external world bility was therefore thought to be maintained by the
and within our bodies occurs through the transduc- reflex excitation of α-motoneuron pools of antigrav-
tion of various forms of natural stimulation into neu- ity/extensor muscles secondary to activation of mus-
rally relevant signals. This is achieved through spe- cle spindles by stretch of these antigravity muscles.
cialized neural structures, the sensory receptors. From This servo control was deemed to be the way that
here the neural signals are transmitted via peripheral posture was controlled. Position and movement sense
nerves into the central nervous system. Transmission were thought to be signaled primarily by joint recep-
to higher brain centers occurs in anatomically dis- tors. Muscle receptors were thought not to make any
crete pathways to equally discrete processing areas contribution. This was based partly on the belief that
within the brain. In this way, humans have the ability spindle afferent pathways did not reach higher brain
to sense many kinds of mechanical, thermal, chemical, somatosensory centers.
and electromagnetic events. Proprioceptors consist of
a large number of sensory terminals chiefly located Role of Sensory Input in Regulating Movement
in muscles, joints, ligaments, fascia, the skin, and the and Posture: A Contemporary Perspective
labyrinth. In addition to the specialized receptors of Current thinking maintains Sherrington’s initial con-
the labyrinth, the intramuscular receptors and slow- cept that reflexes (and therefore somatosensory input,
and fast-adapting mechanosensitive units of the skin including proprioceptive inputs) play an important
and joint tissues are also responsible for our proprio- role in the patterning of motor behaviors. However,
ceptive sense. Not only does our proprioceptive sense reflexes are now considered to be integrated with cen-
provide us with continuously updated information trally generated motor commands that together pro-
about body position and movement, but propriocep- duce highly adaptive movement patterns. The role
tors are also responsible for initiating a variety of re- that muscle spindles and joint receptors play in move-
flex responses that serve to ensure appropriate mus- ment and position sense has also undergone major
cle control of movement and the provision of joint revision. It is now widely accepted that muscle spin-
stability. dles make a powerful contribution to our position and
This chapter identifies the sensory receptors re- movement sense, and it is probable that all proprio-
sponsible for proprioception in the spine, and explores ceptors act in concert to provide our total appreciation
the role of the different spinal proprioceptors in gen- of the position and movement of our body parts.
erating our perception of the position and movement
of the trunk in space. It also examines the role that the
PROPRIOCEPTIVE SENSORY SYSTEM
epaxial (i.e., located on or above the axis) propriocep-
tors have in regulating the body’s static and dynamic The three types of sensory receptors that are respon-
postural stability, and the critical role of mechanore- sible for articular proprioceptive sense are located in
ceptors in providing local spinal stability. This chapter muscles, joint tissues, and overlying skin. The contri-
examines the effect of injury to spinal structures on bution that each makes to our final kinesthetic sense
proprioceptive sense and the consequences thereof. is dependent on the joint being studied, but gener-
Finally, this chapter examines the role of propriocep- ally speaking, each receptor is thought to play a role
tors in initiating muscular reflex responses to optimize in kinesthesia, particularly when this relates to move-
spinal stability. ment sense. For the more distal joints, skin and joint
receptors provide a major contribution, while for
Proprioception: A Historical Perspective proximal joints, muscle receptors are thought to be
The term proprioception comes from the Latin pro- most important.1 The slowly adapting skin and mus-
prius, which translates as belonging to one’s own self. cle receptors have been implicated as the major con-
Charles Sherrington was one of the first neurophys- tributors to position sense.2
iologists to recognize the importance of sensory in- Kinesthetic sense of the trunk and its significance
put for regulating movement, maintaining posture, in health and disease have come under investigation
and providing an appreciation of the position of the only relatively recently. As with appendicular joints,
body in space. Sensory input from muscles, joints, the same types of receptors, primarily of muscles and
the skin, and the labyrinth were considered to be joint tissues, are responsible for spinal propriocep-
involved in muscle control and body movement, as tion. Of particular importance is the neuromuscular
well as the perception of body position and kines- control of spinal motion and spinal segment stability
thesia. Early concepts of the role that propriocep- that occurs not only through activation of movement
tors played in movement included the mechanism of synergies by higher brain centers, but also through a
MUSCLE SPINDLES AND SPINAL PROPRIOCEPTION 251
complex reflex activation of local musculature initi- thought to be the most important fiber type because
ated by various proprioceptive paraspinal structures. the primary sensory ending associated with this fiber
Therefore, spinal proprioceptors serve two impor- dominates the pattern of sensory information gener-
tant functions: (a) position sense and kinesthesia, and ated from the spindle.3 It is the largest of the intra-
(b) neuromuscular control, where afferent input ini- fusal fibers, its length extending beyond the edges of
tiates reflex activation of local musculature to guide the muscle spindle capsule. Each end of the intrafusal
movement and produce spinal stability. fiber contains the muscle proteins myosin and actin.
At its center, the intrafusal fiber loses its myofilament
components and becomes enlarged. Here, the myofil-
INTRAMUSCULAR RECEPTORS
aments are replaced by a collection of nuclei.
The muscle receptors contributing to proprioception For both the bag1 and bag2 fibers, the central nu-
include the muscle spindles and Golgi tendon organs. clei are congregated together to form a “bag” of nu-
Muscle spindles are stretch-sensitive mechanorecep- clei (Fig. 13–1). The bag1 fiber is similar in structure
tors sensitive to muscle length and changes in mus- to the bag2 fiber except that it is slightly shorter. It
cle length. They lie in parallel with ordinary skeletal also extends beyond the limits of the spindle capsule.
muscle fibers. Muscle spindles are found in virtually Functionally, bag1 and bag2 fibers are differentiated
all skeletal muscles. Golgi tendon organs signal mus- by their speed of muscle contraction.4 Bag1 fibers con-
cle tension or force. These receptors lie in series with tract most slowly, followed by bag2 fibers. Chain fibers
skeletal muscle fibers and are located most often at the have the fastest contraction speed. (The stimulation
musculotendinous junctions. frequency of γ axons necessary to produce a maxi-
mal contraction of the different intrafusal fibers ranges
Anatomy and Physiology of Muscle Spindles from 75 to 100/s for the bag1 fiber to 100/s for the
Structure Muscle spindles lie in parallel with extra- bag2 fiber and 150 to 200/s for the chain fiber.) Mor-
fusal muscle fibers. The length of the muscle spindle phologically, the bag2 fiber is closer to the bag1 fiber.
is approximately one-third the length of the extrafusal However, its histochemical (myofilament type) and
fiber and each muscle spindle is anchored at its ends mechanical (contraction speed) properties are much
to extramysial connective tissue. The muscle spindle closer to those of the chain fibers.
consists of approximately six to nine specialized stri- The third type of intrafusal fiber is the chain fiber.
ated muscle fibers called intrafusal fibers that are en- Its length is about half that of the bag fibers; it has a
closed within a connective tissue capsule. The capsule smaller diameter; and it resides completely within the
becomes swollen at its central region to form a fluid- muscle spindle capsule. Its central portion is also de-
filled space. The intrafusal muscle fibers are of three void of contractile proteins, the region being replaced
types: bag1 , bag2 , and chain fibers. The bag2 fiber is by a row of nuclei (see Fig. 13–1). There are usually two
FIGURE 13–1. The main elements that make up the structure of the mammalian muscle spindle in summary form: The spindle
contains three types of fibers. Two large muscle fibers are expanded in their middle region to accommodate a collection of nuclei.
These are the bag1 and bag2 fibers. Notice that the bag2 fiber is slightly longer than the bag1 fiber. The third fiber of the muscle
spindle is the chain fiber. This fiber is completely enclosed within the spindle capsule while both bag fibers extend beyond the limits
of the capsule. A large Ia afferent fiber enters the capsule and makes annulospiral terminals around the nucleated portions of all
three types of intrafusal muscle fiber. A second, smaller, afferent group II fiber makes its terminations to one side of the Ia endings
and supplies predominantly the bag2 and chain fibers. The bag1 fiber is innervated by a γD (dynamic) axon, whereas bag2 and chain
fibers are innervated by γS (static) axons. The diagram only shows γ innervation and omits the skeletomotor system. (Figure adapted
from Proske U. The mammalian muscle spindle. News Physiol Sci 1997;12:37–42.)
bag fibers and four to seven chain fibers for each spin- average of approximately 14 intrafusal fibers per spin-
dle. Each muscle spindle is innervated by a spindle dle comprising all three types of fiber; motor inner-
nerve that leaves a nearby intramuscular nerve trunk vation is also similar. Structural differences between
to enter the equatorial region of the muscle spindle. human and cat muscle spindles, however, do exist.
Human spindles tend to contain more intrafusal mus-
Sensory Innervation Two different types of sensory af- cle fibers than those of other mammals. This increase
ferent fibers innervate muscle spindles: the large- in number of intrafusal fibers is largely accounted for
diameter Ia afferent fiber and the group II fiber. The by an increase in the number of chain fibers. Hulliger
large-diameter Ia afferent fiber enters the muscle spin- suggests that static fusimotor action of chain fibers
dle via its capsule and branches repeatedly, each might therefore be more powerful in humans than in
branch remaining myelinated. Eventually, the nerve cats.4 Also, there appears to be a closer topograph-
fiber terminates in an unmyelinated primary ending on ical relationship between muscle spindles and extra-
the central portion of each and every intrafusal fiber. fusal motor units in humans. In some cases, it has been
The terminals of these primary endings have a charac- found that the spindle capsule can enclose neighbor-
teristic annulospiral appearance.3 Generally speaking, ing extrafusal fibers.5 This suggests that the spindle
most mammalian spindles are supplied by a single afferent fiber in humans might be more responsive to
Ia axon, although significant variations to this pat- individual extrafusal motor unit contractions than in
tern of innervation may occur in some muscles (see the cat. The consequence of this arrangement may be
Fig. 13–1). The group II fiber enters the muscle spindle an increased sensitivity to force and length modula-
along with the Ia afferent. From its point of entry into tion by the muscle spindles of human skeletal muscle.
the capsule, the group II afferent branches and eventu-
ally terminates in spray-like structures called secondary Excitation There are two ways in which the muscle
endings located to one side of the annulospiral end- spindle afferents may be excited: by stretching of the
ing. Group II endings predominantly innervate the whole muscle or by contraction of its intrafusal mus-
bag2 and chain fibers3 (see Fig. 13–1). cle fibers. When the muscle is stretched, the stretch
is transmitted to the central portion of the intrafusal
Motor Innervation Muscle spindles receive a dual mo- fibers where the sensory terminals lie. In this way, the
tor supply from the γ or fusimotor system and the muscle spindle responds to changes in muscle length.
β or skeletomotor system. The fusimotor system ex- Likewise, contraction of the two ends of the intrafusal
clusively innervates the intrafusal fibers. Fusimotor fiber causes an elongation of the central portion of the
neurons are small, their axons having a diameter in intrafusal fiber, resulting in excitation of the sensory
the Aγ -diameter range of nerve fibers (approximately terminal.
5 μm). The skeletomotor (β) system innervates both It is important to remember that each afferent
extrafusal and intrafusal fibers. The diameter range of fiber that innervates a muscle spindle branches before
this fiber system is similar to that of α motor axons. finally terminating on each intrafusal fiber of the mus-
Each motor system contains two functionally differ- cle spindle. In other words, for each muscle spindle
ent types of motor axon known as static and dynamic a single afferent fiber innervates several morphologi-
motor axons. Stimulation of each type of axon pro- cally and functionally distinct intrafusal fibers. The ac-
duces different effects on the response of the primary tivity generated in each sensory terminal in response
afferent ending (see Fig. 13–1). to a stimulus (either stretch or intrafusal fiber contrac-
Dynamic axons, both γ and β, exclusively inner- tion) must therefore combine in some form before it is
vate bag1 fibers. Static (γs ) axons innervate bag2 and propagated to the parent group Ia or group II axon.
chain fibers. There is some controversy over the static
(γs ) innervation. Proske suggests that both bag2 and Response to Stretch When a muscle is stretched, the
chain fibers may be innervated by branches of the muscle spindle which lies parallel to the extrafusal
same γs axon.3 However, there is also the suggestion muscle fibers is also stretched, resulting in a charac-
that some γ axons may innervate bag2 and chain fibers teristic response from muscle spindle afferents. The
separately.3 muscle stretch opens the primary annulospiral end-
ings of individual intrafusal muscle fibers, which, in
Comparative Anatomy The most studied muscle spin- turn, is thought to open stretch-operated cation (Na+ )
dles are those of the hindlimb of the cat. These spindles channels. This results in depolarization of the annu-
typically contain one of each of the bag fibers and a lospiral membrane and ultimate initiation of the ac-
varying number of chain fibers, usually four, but there tion potential.
are many variations to this pattern. Morphologically, There are two types of sensory discharge from
human muscle spindles seem quite similar to those of spindle afferents: the static and the dynamic responses
the cat, having the same sensory innervation and an that occur as a result of muscle stretch. The static
response of the muscle spindle ending occurs when continues to occur even when the length change of the
the de-efferented muscle is slowly stretched. The slow muscle is very small, provided that the rate of change
stretch excites both the primary and secondary spin- is fast. The dynamic response occurs only when the
dle endings. The response of these endings is to in- change in length is actually occurring. This also works
crease their rate of discharge approximately in direct in reverse. If muscle length is suddenly decreased, the
proportion to the length of the muscle. Therefore, dur- primary ending momentarily stops its discharge. At
ing passive muscle stretch, the muscle spindle behaves the new, shorter length, the primary ending begins its
as though it consisted of a single intrafusal muscle discharge again.
fiber with a single primary and secondary ending. The The dynamic response of the spindle may be de-
intrafusal fiber thought to initiate the static response fined and studied during a ramp-and-hold stretch of
is the bag2 fiber3 (Fig. 13–2). the de-efferented muscle. When this stretch is applied,
The dynamic response occurs when the length of the primary ending fires a short, high-frequency burst
the muscle and, therefore, its spindle, is suddenly of impulses (the initial burst) at the start of the ramp.
changed. This stimulus preferentially excites primary As the ramp continues, the primary ending increases
spindle endings. The dynamic response is very sen- its rate of discharge until a peak is reached at the end
sitive to the rate of change in muscle length and it of the ramp. During the hold phase of this stretch, the
primary ending shows an initial adaptation in rate of
discharge, which consists of an initially rapid, then
slower decline in impulse frequency. This then set-
tles to a new steady-state discharge rate. The differ-
ence between the peak rate at the end of the ramp
and the steady-state discharge during the hold part
of the stretch can be measured and is known as the
dynamic response of the spindle afferent ending. Note
that the new steady-state spindle afferent discharge is
the static spindle response (see Fig. 13–2).
As the velocity of the stretch increases, the fre-
quency of the initial burst increases and the slope of
increase in impulse frequency during the ramp also
increases. This, of course, results in an increase in
the dynamic response of the primary ending. How-
ever, the length sensitivity (the static response) is un-
affected. The intrafusal fiber mainly responsible for
the dynamic response is the bag1 fiber, although there
is evidence to suggest that primary afferent activity
from bag2 and chain fibers can demonstrate passive
dynamic behavior.
Response to Fusimotor Stimulation The muscle spindle

FIGURE 13–2. The response of a primary ending to a ramp-
responds to fusimotor stimulation in characteristic
and-hold stretch with and without fusimotor stimulation. The ways and these response patterns are specific for the
top panel shows the length change of the muscle associated type of intrafusal fiber that is stimulated as well as
with the ramp-and-hold stretch. The middle panel shows the re- the type of motor fiber stimulated. Fusimotor activ-
sponse of the primary ending with no stimulation. Notice that ity results in either a stiffening or a shortening of the
prior to any change in muscle length, the primary ending is polar ends of the intrafusal fibers. The bag1 fiber is
silent. At the beginning of the stretch, the primary ending be- unique in that motor stimulation results in stiffening
gins its discharge and the frequency of discharge increases of the polar ends rather than actual shortening. At the
during the ramp. At the end of the ramp, discharge frequency other end of the intrafusal fiber spectrum, chain fibers
is maximum, and this then settles to steady state (lower state)
shorten in response to a motor stimulus. The end re-
at the new muscle length. Stimulation of the γS axon start-
sult is a stretch of the noncontractile central portion
ing near the beginning of the bottom panel causes a steady
increase in the rate of discharge of the primary ending. Stim-
of the intrafusal fiber where the sensory endings are
ulation of the γD axon causes a large increase in sensory dislocated.
charge during the ramp stretch. (Adapted from Crowe A, Matthews Stimulation of the static γ motor axon enhances
PB. The effects of stimulation of static and dynamic fusimotor fibres on the the static response of the muscle spindle, that is, the
response to stretching of the primary endings of muscle spindles. J Physiol amount by which spindle firing increases when the
1964;174:109–131.) muscle is stretched from one length to the other. Static
γ fibers innervate both chain and bag2 fibers. Static causing the stretch. The static reflex is elicited by im-
motor stimulation has no effect on the dynamic re- pulses transmitted from both primary and secondary
sponse of the spindle. endings.
Stimulation of dynamic γ motor axons activates The size (amplitude) of the phasic stretch reflex
the bag1 fiber. This results in only a modest rise in im- or tendon jerk is influenced by a number of factors
pulse activity of the primary ending when the muscle that have their origin both in the periphery as well
is held at a steady length. However, if the muscle is si- as within the central nervous system (CNS). Central
multaneously stretched, the dynamic response of the factors include the level of excitability of the motoneu-
primary ending is dramatically increased. Therefore, ronal pool of the stretched muscle. For instance, dur-
stimulation of the dynamic γ axon greatly enhances ing sleep, when CNS excitability is low, the tendon
the dynamic sensitivity of the primary ending to a jerk is absent or its size is very small. Peripheral fac-
change in muscle length (see Fig. 13–2). tors also contribute to changes in the size of the tendon
jerk. One notable factor that has an important influ-
Resting Discharge Muscle spindles exhibit a resting ence on reflex size is a property of muscle known as
discharge or tonic discharge, and can respond to muscle thixotropy. The term thixotropy has been used
length changes either by lengthening the muscle by for gel-like substances that, when stirred, become less
increasing the rate of discharge or shortening the mus- viscous; if left to rest, these gels return to their original
cle by decreasing the rate of discharge. This is a feature high viscosity. The stiffness of a thixotropic substance
of both primary and secondary endings, although pri- is dependent on its past history of movement. It is
mary endings have a resting discharge at shorter mus- thought that the stirring forces disrupt bonds between
cle lengths. molecules, which then reform when the substance is
left alone. Thixotropy is thought to be responsible for
Muscle Stretch Reflex: Tonic and Phasic Components Im- the phenomenon of aftereffects that spindles exhibit.7
pulses from muscle spindles provide the afferent limb Aftereffects are thought to occur in passive muscle
of the stretch reflex. The stretch reflex is divided into from the formation of a small number of stable cross-
two components: phasic and tonic. The phasic com- bridges between the myosin and actin myofilaments
ponent is caused by a rapid increase in length of the within the intrafusal fibers. These stable cross-bridges
muscle, which evokes a dynamic response of the pri- will also form in extrafusal fibers. Either stretch of
mary ending (the tendon jerk). This afferent signal is the muscle or muscle contraction will break stable
transmitted to the spinal cord and produces mono- cross-bridges. However, as soon as the muscle is left
synaptic excitation of the α motoneurons, resulting undisturbed, the stable cross-bridges reform and this
in a reflex contraction of the homonymous mus- occurs at whatever length the muscle happens to be at
cle. The phasic stretch reflex (tendon jerk) is a very when it is left at rest. If a muscle comes to rest at a long
transient response, occurring in less than 1 second length, stable cross-bridges form at this length. When
(Fig. 13–3).6 the muscle is subsequently passively brought back to a
The tonic component of the stretch reflex oc- shorter length, the intrafusal fibers, now stiffened by
curs after the muscle has been stretched to its new the presence of the stable cross-bridges, have a ten-
length. Here a weaker static stretch reflex contin- dency to fall slack. The central region of the muscle
ues as long as the muscle is held at the stretched spindle where the sensory endings lie will therefore
length; that is, the static stretch reflex will continue to also be slack, reducing the sensitivity of the muscle
cause a muscle contraction opposing the force that is spindle to stretch (Fig. 13–4).
FIGURE 13–3. Diagrammatic rep-

resentation of the monosynaptic
component of the phasic stretch
reflex (tendon jerk). Quick stretch
of the muscle excites primary end-
ings of muscle spindles. Ia affer-
ent fibers signal this brief change in
muscle length by sending impulses
into the spinal cord. These fibers
make monosynaptic contact with α
motoneurons of the same muscle.
The motor fibers then send impul-
ses back to the muscle to produce
a twitch contraction of the muscle.
FIGURE 13–4. An illustration of the effect of a muscle-conditioning protocol (used to alter the movement and activation history of
the muscle) on the mechanical sensitivity of the muscle spindle. The diagram shows length changes of the muscle associated with
the muscle-conditioning procedure. Stretching (illustrated by an upward change in the length record) and contracting the muscle
will break stable cross-bridges. The muscle is then left at rest at this stretched length and cross-bridges form at this new length.
When the muscle is passively shortened to the test length, the intrafusal fibers, now stiffened by the presence of these stable
cross-bridges, will not shorten. The central portion of the spindle goes slack. This results in a decreased mechanical sensitivity
of the spindle. Downward movement of the length trace is associated with shortening of the muscle. Contraction at this length
will again break any cross-bridges formed in intrafusal fibers. If the muscle is left at rest at this short length, cross-bridges will
again reform. Stretching of the muscle to the longer test length results in stretching of the stable cross-bridges, resulting in a taut
intrafusal fiber and an increased mechanical sensitivity of the spindle. The muscle-conditioning protocol was developed by Gregory,
Morgan, and Proske.8
The phenomenon of aftereffects has important im- tendon jerk in humans. To do this, they developed a
plications clinically. If the tendon jerk is elicited when specific muscle-conditioning regime (see Fig. 13–4).
the muscle spindle is in a slack state, the tendon jerk They found that if the muscles were shortened from a
may be erroneously considered to be diminished or stretched length before eliciting the tendon jerk, then
even absent. It is therefore important clinically to de- the size of the reflex would always be small. Con-
fine the length and contraction history of the muscle versely, stretching the muscle from a shorter length
before drawing conclusions about the presence or ab- where stable cross-bridges had formed resulted in taut
sence of the tendon jerk. intrafusal fibers and a taut central sensory region.
Gregory, Morgan, and Proske8 studied the effects Thus, muscle-conditioning regimes are a method of
of systematically altering the length and activation systematically altering the sensitivity of the muscle
history of the triceps surae muscles on the Achilles spindle (Fig. 13–5).
FIGURE 13–5. Effects on the

size of the tendon jerk of sys-
tematically altering the movement
and activation history of the tri-
ceps surae muscle. The tendon
jerk was elicited by a rubber-tipped
reflex hammer, which delivered a
tap of reproducible size to the
Achilles tendon. The reflex mus-
cle response was measured as
the surface EMG. The size of the
reflex after hold-short condition-
ing was almost twice as large as
the reflex response after hold-long
conditioning.
Anatomy and Physiology of the Golgi as the dynamic response of tendon organs. The rate of
Tendon Organs discharge then settles down to a lower steady-state
Golgi tendon organs are highly sensitive mechanore- level that is proportional to the amount of tension in
ceptors activated by skeletal muscle contraction. They the muscle—the static response. The tendon organ is
are distributed in variable numbers in different skele- therefore very efficient in signaling rapid variations
tal muscles. Together with muscle spindles, the Golgi of contractile force and this information is conveyed
tendon organs govern muscle stiffness and provide back to the central nervous system.
for smooth muscle contraction.
Reflex Actions Tendon organ afferents excite an in-
hibitory interneuron in the spinal cord that then in-
Structure Golgi tendon organs are spindle-shaped hibits the α motoneuron of the same and synergistic
structures made up of a bundle of collagen strands muscles. This reflex acts to prevent the development
enclosed in a connective tissue capsule. The collagen of too much tension in the muscle. The function of ten-
strands of the capsule are derived from compact bun- don organ discharge during muscle contraction may
dles of collagen that have left the main tendon. The be to equalize activity between different motor units
afferent axon (8–15 μm in diameter, Ib afferent axon) during contraction, inhibiting the activity of one mo-
that innervates the Golgi tendon organ penetrates the tor unit through the inhibitory reflex described above,
capsule and then divides into a number of smaller while enhancing the activity of another motor unit as
branches before losing its myelin sheath and mak- a result of the absence of activity of the tendon or-
ing contact with the collagen strands. At the muscle gan. In this way, the tendon organ is able to monitor
end of the tendon organ the collagen strands rejoin and regulate muscle force and aid in the production
to form tendinous attachments for muscle fibers. This of smooth muscle contraction during movement.
means that the tension developed by muscle fibers
contracting is directly transmitted to the collagen
strands that underlie the nerve endings. Each tendon ANATOMY AND PHYSIOLOGY OF JOINT
organ is connected to a muscle fascicle consisting of MECHANORECEPTORS
about 5 to 25 muscle fibers derived from several dif- Four types of sensory endings with distinctive mor-
ferent motor units.9 phological characteristics and physiological respon-
The majority of tendon organs are found at muscle- siveness are recognized to reside within and around
tendon junctions. For pennate (i.e., resembling a joint tissues. Three of these are encapsulated endings
feather) muscles, the muscle-tendon junction may be and are involved in mechanoreception. The fourth
in the belly of the muscle where the intramuscu- type (type IV ending) is the free nerve ending involved
lar portions of the tendon are located. Golgi tendon primarily in pain sensation. This receptor type is not
organs are often found in association with other dealt with further in this chapter.
encapsulated sensory end organs including muscle The encapsulated mechanoreceptors are thought
spindles and paciniform corpuscles. The functional to have both mechanoreceptive and nociceptive func-
significance of this arrangement is unknown but there tions. Joint mechanoreceptors are also thought to have
has been speculation that this is a developmental phe- a reflex influence on muscle tone, which may be either
nomenon or that the positioning of mechanoreceptors phasic or tonic10 (Table 13–1). Within the joint capsule,
may reflect the optimum site for monitoring length Ruffini-like endings or spray endings (type I) are most
and force changes, and tissue distortion. Finally, it is commonly found. Type 1 endings are termed Ruffini
interesting to note that most muscles contain more because of their morphological similarity to Ruffini re-
muscle spindles than tendon organs. ceptors located in the skin. Type I endings are slowly
adapting and have a low threshold to stimulation. It is
Dynamic and Static Responses The twitch contraction thought that there are both static and dynamic types
of muscle fibers that are attached to the tendon organ of type I endings, which are capable of signaling me-
provides sufficient tension to excite the tendon organ. chanical stress, joint position, and movement. Type I
Remember that the muscle fibers attached to the ten- endings are also thought to have a continuous influ-
don organ are derived from a number of motor units. ence on local muscle tone.10
This indicates that a twitch contraction of an individ- Pacinian (paciniform) corpuscles (type II) are com-
ual motor unit is an adequate stimulus to activate the monly found in the fibrous periosteum near articu-
tendon organ, which is, therefore, a highly sensitive lar or ligament attachments. These endings are fast-
mechanoreceptor for signaling tension. When mus- adapting and have a low threshold to stimulation.
cle tension is suddenly increased, as occurs during a Because of their fast-adapting quality, these receptors
twitch contraction of a motor unit, the tendon organ serve a dynamic function, responding to changes in
responds with a brief burst of impulses. This is known joint position—that is, they are capable of signaling
TABLE 13–1. Classification of Joint Receptors*
Morphological Physiological
Type Receptor Name Features Location Characteristics
1 Ruffini ending Globular receptors, thinly Superficial layers of Slowly adapting, low
(spray ending) encapsulated fibrous capsule of joint, threshold; mid-range units
periarticular ligaments, signal joint position,
and tendons pressure, and velocity of
movement; have
continuous influence on
muscle tone
2 Pacinian corpuscle Cylindrical, thick, multilayered Deeper layers of fibrous Rapidly adapting, low
structure with dense, capsule; at junctions threshold; respond to
central axon core sudden changes in stress;
have brief, reflex influence
on muscle tone
3 Golgi ending Fusiform corpuscle with thin Found most commonly in Very slow adapting, high
(Golgi-Mazzoni capsule surrounding an ligaments; also found threshold; completely
corpuscle) arborizing neural in tendons, dense inactive in immobile joint;
meshwork connective tissue of only become active when
joint capsule, and the joint is at the extremes of
intervertebral disc its range of motion; have
reflex influence on muscle
tone
4 Free nerve Unmyelinated and Found in all periarticular Nonadapting; nociceptive
endings unencapsulated tissues except cartilage
* Based on Roberts et al.,10 Freeman and Wyke,11 Yahia and Newman,16 and McLain and Pickar.20
joint movement. Type II endings have a more phasic have been identified within a number of specific spinal
influence on local muscle tone. tissues including interspinous, supraspinous, and
Endings similar to Golgi tendon organs are lo- flaval ligaments, the thoracolumbar fascia, paraspinal
cated within the ligaments surrounding the joint and muscles, lumbar intervertebral discs, and spinal facet
these are referred to as Golgi-type endings or type III joints.
endings. They are slowly adapting and have a high
threshold to stimulation.11 The Golgi-type receptors Intervertebral Disc
are thought to measure tension and only become ac- Historically, the intervertebral disc (IVD) was not con-
tive when the joint is at the extreme of its range of sidered to be innervated because early histological
motion. studies failed to demonstrate nervous tissue within
The anatomical location of each receptor within the discs.12 However, more recent studies10 have pro-
the capsular, ligamentous, or connective tissues per- vided strong evidence that the IVD does have nerves
mits individual receptors to be stimulated when that associated with it. Mechanoreceptors morphologi-
particular part of the tissue undergoes distortion. cally resembling Golgi tendon–like endings (type III),
Ruffini endings (type I), and pacinian corpuscles
(type II) have all been found. Of these, the most com-
SPINAL PROPRIOCEPTORS
mon type found in the IVD is the type III ending.10,13
It is well known that the spine and paraspinal tissues Pacinian corpuscles are the least common receptor
receive extensive innervation from the dorsal and ven- type. All receptor types are most commonly located
tral rami of spinal nerves. In the last 10 to 15 years, in the outermost regions of the annulus and the lon-
histological and physiological evidence has accumu- gitudinal ligaments. Their distribution density varies
lated that provides strong evidence that spinal tis- throughout the disc, with the highest density occur-
sues are richly endowed with a number of different ring at the lateral margins of the disc, decreasing pos-
encapsulated nerve endings capable of detecting mo- teriorly, with the lowest receptor density of all in the
tion and tissue distortion. Mechanoreceptor afferents anterior aspect of the annulus.12
Spinal Ligaments zones occur mainly in the superficial parts of the ex-
The spinal ligaments receive a rich sensory in- tensor muscle mass of the cervical spine. In contrast,
nervation. Nervous elements have been located in the zones of high density of spindles in the suboccip-
spinal ligaments including the ligamentum flavum, ital muscles are located in the deeper portions of the
supraspinous and interspinous ligaments,14−16 and muscle mass.
the longitudinal ligaments.10 These nerve fibers ter- A number of authors have suggested that the
minate as both encapsulated (mechanoreceptor) and small, unisegmental muscles of the spine may pri-
free endings (nociceptors). The encapsulated end- marily serve a proprioceptive rather than a mechan-
ings correspond morphologically with the types I ical function. The basis of this speculated function
(Ruffini), II (pacinian corpuscles), and III (Golgi ten- comes from the high spindle densities found in these
don organ/Ruffini corpuscles) endings of Freeman muscles relative to their polysegmental neighbors.25
and Wyke11 (see Table 13–1 for classification). The Whether spindle density is actually higher in the
presence of these mechanoreceptors in the posterior smaller, unisegmental muscles has been questioned
ligamentous system of the spine indicates that the by Barker and Banks.26 They provide evidence that
CNS keeps the mechanical state of this system under suggests that as spindle density is traditionally calcu-
surveillance. The thoracolumbar fascia contains two lated by counting the number of spindle capsules per
types of encapsulated nerve endings: pacinian corpus- gram of skeletal muscle, smaller muscles will neces-
cles and Golgi endings.17 In addition, free nerve end- sarily produce a higher spindle density count. As an
ings (serving a nociceptive function) are also present. example, they cite the case of the lumbrical III muscle
in both cat and human. This muscle has often been
Zygapophyseal Joints of the Spine regarded as an example of a small muscle with a high
spindle density. In fact, when the assumption of its
The zygapophyseal joints of the spine also receive small size is taken into consideration, lumbrical III is
an extensive innervation from the dorsal rami of found to have a less-than-average number of muscle
spinal nerves. A number of studies have demon- spindles.
strated the presence of all four types of receptors in The argument that increased spindle density is
both the facet joint capsule of spinal facet joints18–20 associated with an increased kinesthetic sensibility
and synovial folds.21 Of particular interest is the den- appears to be based on the tactile system, where in-
sity of mechanoreceptor endings in the facet joints of creased numbers of mechanoreceptors are clearly as-
different spinal regions. McLain and Pickar20 found sociated with tactile acuity (e.g., fingertips). This is
the highest density of receptors per capsule in the cer- not necessarily the case for the kinesthetic system,
vical spine, as compared with the thoracic and lumbar where the total number of receptors is far lower than
facet joint capsules. The density of receptors was least in the tactile system, and there is no clear associa-
in the thoracic spine. The changing density of reception between increased numbers of receptors and in-
tors in each region of the spine is consistent with the creased kinesthetic sensibility. What appears to be im-
degree of mobility of the spinal region and may well portant to the CNS with regard to the muscle spindles
also reflect the role that the cervical spine plays in pos- is whether their location in the muscle can provide the
tural control (see below). most up-to-date and accurate information regarding
muscle length, changes in muscle length, and the ve-
Proprioception and the Paraspinal Muscles locity of change. Evidence now suggests that higher
The paraspinal muscles, like most other skeletal densities of muscle spindles are associated with ox-
muscles, have a complement of intramuscular idative extrafusal fiber types.26 This seems to be func-
mechanoreceptors, including both muscle spindles tionally appropriate, because these motor units would
and Golgi tendon organs. Of the two types of recep- be recruited first in any movement performed and are
tor, muscle spindles have received the most attention also more continuously active during postural con-
in the literature and this review primarily focuses trol/stability tasks.26
on their distribution and role in spinal propriocep- There is no question however, that some of the
tion. Only a few studies have examined the segmental unisegmental muscles of the spine—notably the cer-
distribution of muscle spindles in humans.22,23 What vical intertransversarii—have an unusually high spin-
is known is that muscle spindles are found in the dle density.5 Furthermore, Bogduk and Twomey27
paraspinal muscles throughout the spine. The neck suggest that for at least some of the unisegmental
contains by far the highest density of muscle spindles muscles, such as the intertransversarii, their anatom-
and, in fact, the intervertebral muscles of the neck are ical location and dimensions make it highly unlikely
considered amongst the most spindle-rich muscles of that they would be capable of contributing any ap-
the body.24 Throughout the neck, spindles appear to preciable force to joint movement. Therefore, regard-
be arranged in zones of high concentration.22,24 These less of whether or not spindle density is high for the
unisegmental spinal muscles, the evidence is that to detect a change in the position of a joint most com-
paraspinal muscles throughout the spine contain monly assesses movement sense. A number of recent
these receptors and it is argued convincingly that spin- studies have investigated spinal position and move-
dles are critically important for kinesthesia through- ment sense specifically related to the cervical spine
out the spine’s range of motion. and trunk in both health and disease. What these re-
Descriptions of the distribution of Golgi tendon ports establish is that position sense in healthy indi-
organs in paraspinal muscles are lacking in the liter- viduals is accurate to within a few degrees.29–32 Com-
ature. The only studies available have focused on the paring children with adolescents, spinal positioning
cervical spine of the cat. In this species, the neck mus- accuracy increases with age33 and position sense may
cles are apparently rich in tendon organs. They are be impaired by vibration,34 muscle fatigue,35 and low
found at the ends of the muscles and along tendinous back pain.36,37
insertions as in other skeletal muscles.28 Afferent inputs from the vast array of spinal pro-
prioceptors may contribute to spinal position and
Encapsulated Receptors of the Neck movement sense. The role that each of the major pro-
The cervical spine receives a rich and highly complex prioceptors plays in the perception of spinal kinesthe-
innervation. Encapsulated nerve endings are located sia has been the subject of a number of recent investi-
in all of the major intervertebral structures includ- gations (e.g., references 31, 34, and 38).
ing the intervertebral muscles, zygapophyseal joints, Ligamentous and capsular mechanoreceptors
and intervertebral discs. It is particularly interesting to have been previously identified as being most active
note the observation that the encapsulated receptors at the limits of joint movement.39 These joint recep-
including muscle spindles, tendon organs, and pacini- tors monitor joint excursion and capsular tension.
form corpuscles (i.e., corpuscles that have the appear- The ability to detect passive movements of periph-
ance of a pacinian corpuscle that has been stripped of eral joints is not abolished by skin and joint afferent
its multilayered outer coating) are commonly found anesthesia, which suggests that these receptors do not
in association with each other in the dorsal mus- make a major contribution to kinesthetic sense. How-
cles of the neck. Here they appear to be arranged in ever, if the muscles crossing the particular joint under
what Richmond et al. refer to as “complicated recep- study are disengaged, there is a significant impair-
tor arrays.”28 This anatomical arrangement suggests ment of both position and movement sense.2 In this
that the neck proprioceptors signal a “matrix of infor- respect, the Golgi tendon organs signal muscle force or
mation” to provide the CNS with a multidimensional tension so their role in position sense would be ex-
view of events of movement and position of the head pected to be limited.
and neck in space.28 This leaves afferent input from muscle spindles
as most likely to provide proprioceptive information
over most of the physiological range of spine move-
FUNCTION OF SPINAL PROPRIOCEPTORS
ment. Spindle afferents discharge over almost the en-
Two major functions of spinal proprioceptors have tire physiological length range of a muscle. However,
been identified in the literature. The first role that the difficulty the CNS has with interpreting spindle
spinal proprioceptors play is to provide the CNS with afferent traffic is that the muscles of the spine are com-
information about paraspinal tissue distortion, length, plex in terms of their length and orientation, as well
and changes in length, providing us with our percep- as the number and orientation of muscle fascicles that
tion of the position and movement of the spine. The cross a particular spinal joint. Furthermore, spindle
second major function of spinal proprioceptors is in discharge is itself influenced by a variety of factors in-
the initiation of spinal reflexes that serve to provide cluding muscle length and velocity of length changes,
stability to the spine and protect the spinal joints and fusimotor drive, and the movement and activation
paraspinal tissues. history of the muscle (see discussion on aftereffects in
spindles and Fig. 13–4). All of these factors might be
Assessment of Position and Movement Sense expected to affect the proprioceptive signal received
of the Spine by the CNS.
To examine our proprioceptive sense, proprioception It appears that one of the ways that the CNS
needs to be resolved into its two components: position copes with these variables is by a central subtrac-
sense and movement sense. Position sense is investi- tion process.40 When a centrally ordered movement
gated by assessing an individual’s ability to reproduce command is generated by the motor cortex, both α
preselected target positions. The degree of error asso- and fusimotor neurons are eventually activated. The
ciated in reproducing the target position provides a movement signal generated by motor cortical centers
measure of position sense accuracy. Determining the is not only fed to the motoneuron pools responsible for
threshold velocity at which an individual is first able actuating the movement, but the same central signal
small amplitude changes in muscle length. Vibration

of the muscle drives the muscle spindle afferents to
discharge at the frequency of the vibratory signal.41
If this frequency is higher than the resting discharge
of the spindle afferent, it gives the illusion that the
muscle length is longer than it actually is. Vibration
has been used as a stimulus to distort spindle afferent
input from the multifidus muscles of the lumbosacral
spine in healthy volunteers.34 The vibratory stimu-
lus was found to significantly increase the reposition-
ing error during a pelvic–lumbosacral repositioning
task. The direction of this error suggested that muscle
vibration induced a muscle-lengthening illusion. This
finding suggests that accurate spindle signals from
the paraspinal muscles are essential for precise posi-
tion sense. Similar vibration experiments carried out
on the posterior neck muscles also lead to position
sense inaccuracies, as well as disturbances in postu-
ral stability.44,45 The role of paraspinal muscle spin-
dles in providing our awareness of body and head
position and in maintaining postural stability is dra-
matically illustrated by vibratory experiments that
significantly distort the spindle signal received by
the CNS.
Effect of Mechanical Spinal Injury on Spinal

FIGURE 13–6. Diagram to illustrate how afferent information Proprioception and Postural Stability
relevant to kinesthesia may be extracted from the response of Spinal position sense is altered in patients with chronic
a muscle spindle that is subjected to inputs from both mus- low back pain36,37 and after a whiplash injury.46 In par-
cle length changes and fusimotor activity. When a movement ticular, it is apparent that patients suffering chronic
command is generated, there is coactivation of α and γ mo- spinal pain or injury have a decreased ability to re-
toneurons. The efference copy of the signal to α motoneurons
produce a target position. This results in a deficit in
generates a sense of effort. The efference copy of γ motoneu-
the proprioceptive acuity of these patients. The propri-
ron activity is used to subtract fusimotor-evoked impulses from
the spindle signal to extract the kinesthetic signal. (Reproduced
oceptive acuity of injured peripheral joints has been
with permission from Proske U, Wise AK, Gregory JE. The role of mus- similarly studied and has also been found to be de-
cle receptors in the detection of movements. Prog Neurobiol 2000;60(1): ficient. (See Swanik et al.47 for a review of the ef-
85–96.) fect of injury to the anterior cruciate ligament of the
knee.) It is interesting to note that despite the vast ar-
ray of proprioceptors available to monitor kinesthetic
is also fed to the sensory cortex. This is known as the sense, particularly in the spine (joint mechanore-
efference copy of the central signal.40 In this way, spindle ceptors, mechanoreceptors of ligaments, fascia and
afferent signals from the peripherally activated mus- muscles), compensation for deficits in proprioceptive
cle can be compared to fusimotor-generated spindle sense by structures unaffected by injury does not
activity, which can then be subtracted out of the total seem to occur. One may speculate that this lack of
spindle afferent signal. In this way, the CNS is able to compensation occurs because of an abnormally high
extract spindle information relevant to actual muscle fusimotor drive to muscle spindles of the injured tis-
length changes40 (Fig. 13–6). sue and, indeed, this has been suggested. Tissue injury
Despite the difficulties that the CNS may have in results in the formation of a blend of inflamma-
extracting accurate information from the spindle af- tory chemicals that activates and sensitizes chemosen-
ferent signal, proprioceptive inputs from muscle spin- sitive nociceptors. Recent evidence presented by
dles have been shown to contribute to spinal position Johansson’s group shows that introducing bradykinin
and movement sense. Data supporting this view are (a pain-producing agent) intramuscularly has the ef-
derived primarily from experiments involving mus- fect of increasing muscle spindle afferent discharges
cle vibration.34,41−43 Vibration of a muscle is known from both the leg48 and the neck.49
to preferentially excite muscle spindles, particularly Muscle tissue contains an abundance of chemosen-
the Ia endings. These endings are very sensitive to sitive nociceptors in both the group III and group
IV range. Apart from their supraspinal connections, establish whether the tonic neck reflex, which acts
these afferents also make reflex connections to the to maintain postural stability with changes in head
fusimotor neurons of homonymous and heterogenous and neck position by adjusting extensor muscle tone,
muscles.49 Consequently, activity in the group III and could be observed in the awake human adult. The
IV fibers has the capacity to excite fusimotor neurons tonic neck reflex is readily observed in an animal
which, in turn, increase the sensitivity of the muscle model, as well as in newborn infants, as an ex-
spindles and their rate of discharge for a given muscle tension of the limbs with ipsilateral head rotation
length. Because this increased fusimotor activity is a and flexion of the limbs on the opposite side. How-
locally driven response, sensory cortical areas might ever, with neurological maturation, overt expression
be expected to receive an inaccurate efference copy of of the reflex is inhibited. Establishing that the tonic
fusimotor activity levels. This, in turn, will result in neck reflex can be observed in conscious adults pro-
an inaccurate subtraction process of fusimotor-driven vides a noninvasive method to study the impact that
spindle activity from the total spindle signal received changes in somatosensory proprioceptive inputs from
from the periphery. the neck have on neck-evoked postural responses
Another condition that has been found to de- (Fig. 13–7).
crease proprioceptive acuity is muscle fatigue. This Injuries of the neck are associated with a number of
has been demonstrated for the shoulder (where fa- disabling symptoms, including local pain, headache,
tigue increased the threshold for detection of move- radiating pain and numbness, vision dysfunctions,
ment of the shoulder joint by approximately 70%),50 dizziness, and disturbances in balance. Clinically, the
the knee,51 and the lumbar spine.35 In the Taimela structures involved in injury include the cervical mus-
et al. study,35 the effect of lumbar fatigue on the abil- cles, ligaments, and joints, as well as neural tissues.
ity to sense a change in lumbar position was exam- Recent studies show that people who have suffered
ined in both healthy controls and in patients suffering neck injury demonstrate a deficit in their position and
nonspecific recurrent low back pain of greater than kinesthetic sense.46,55 These data suggest that injury
3 months’ duration. Induced lumbar fatigue impaired to the neck structures containing proprioceptors re-
the ability to sense a change in lumbar position in sults in inaccurate and inappropriate information be-
both the healthy and the low back pain group. How- ing conveyed to the CNS. This, in turn, leads to a
ever, impairment of proprioceptive sense was worse decline in function and the appearance of symptoms
among the low back pain group and lasted for a longer such as those described above. What remains to be
duration. The mechanism underlying the reduction in determined is whether neck injury is also associated
proprioceptive acuity following muscle fatigue is still with changes in the pattern of lower limb motoneu-
unclear, but there is evidence to suggest that muscle fa- ron excitability that occurs with tonic neck reflex. This
tigue is associated with a reduction in the transmission may give an indication of the extent to which damage
of sensory information from spindle afferents.52,53 The of neuromusculoskeletal structures of the neck affects
fact that the low back pain group of the Taimela et al. CNS integration of kinesthesia and postural stability
study35 faired significantly worse after fatigue than and movement.
the healthy group points to the added effect that in-
jury to spinal tissues has on diminishing propriocep-
JOINT STABILITY: THE ROLE OF
tive acuity.
NEUROMUSCULAR CONTROL
Proprioceptors of the Neck What are the consequences of a reduction in proprio-
and Postural Stability ceptive acuity for the spine? Adequate neuromuscu-
An important function of the proprioceptors of the lar control is essential to dynamically stabilize joints.
neck is to maintain postural stability. Neck proprio- Jonsson et al.47 have defined neuromuscular control
ceptors act in concert with afferent inputs from the as the efferent response to sensory information. The pas-
vestibular system to stabilize the position of the head, sive spine (spinal motion segment including IVD,
stabilize the eyes in the moving head, and stabilize the spinal ligaments, joint capsules, and passive muscle) is
head relative to the position of the trunk. Neck pro- inherently unstable.56 Well-coordinated muscle sup-
prioceptors also provide essential sensory input that port provides the spine with the stability required for
allows appropriate postural adjustments to the trunk optimum function.56 Muscular support is provided by
and limbs to be made in response to head movement. the neuromuscular control system. The neuromuscu-
A recent study conducted in the author’s laboratory lar control system regulates the degree of muscle tone
demonstrated that changes in somatosensory inputs around the joint so that there is appropriate muscle
from neck structures are indeed capable of influenc- stiffness to dynamically restrain the joint and protect it
ing the excitability of motoneuron pools of the lower from injury. Neuromuscular control mechanisms have
limb in awake humans.54 The aim of this study was to been extensively studied in various peripheral joints
FIGURE 13–7. Effect of right longitudinal body rotation against a head maintained in the straight-ahead position on the size of
the Hoffman (H) reflex for one subject. Longitudinal body rotation was produced by having a subject sit in a chair that could be
rotated about its base. The head was placed loosely into a helmet, which served to prevent rotation of the head during rotation
of the body in the chair. The H reflex was measured as surface EMG measured from the triceps surae muscles after a hold-short
muscle-conditioning procedure (see Fig. 13–4). Reflex size was measured as the peak-to-peak amplitude of the triphasic EMG
signal. The protocol was as follows: First the size of the reflex after hold-short conditioning was obtained. This served as the control
reflex. The posterior neck muscles were then conditioned by asking the subject to produce an isometric contraction of the neck
muscles with the head in the straight-ahead position, against the resistance of the experimenter’s hand positioned over the right
maxilla/mandible. The neck was then left at rest, and 5 seconds later the chair was rotated to the right (inducing, in effect, left
head rotation). After 30 seconds, the right triceps surae muscles were conditioned as above. At the end of the triceps surae
muscle-conditioning procedure, the H reflex was elicited by transcutaneous electrical stimulation of the tibial nerve in the popliteal
fossa. The figure shows the EMG signal before and after right longitudinal body rotation. The dotted trace refers to the reflex
response evoked after the control triceps surae muscle conditioning sequence. Note that the direct (M) response is the same in
both cases, indicating stability of stimulating conditions between trial pairs.
in both health and after injury (e.g., the knee joint; the CNS, including motor cortical areas. Both feed-
see Jonsson et al.47 for a review of this topic). Neuro- forward and feedback neuromuscular control are used
muscular control in the spine has only recently come by the CNS to dynamically stabilize joints in the face
under investigation and research in this area is still of changing external loading conditions.
very much in its infancy.
Two mechanisms of neuromuscular control coor-
dinate efferent responses to afferent information. Feed- Ligamento-Muscular Synergism in the Spine
forward neuromuscular control involves the planning It is clearly established that both passive and active
of movements based on sensory information derived spinal tissues are supplied by a family of mechanore-
from past experiences. What occurs here is that mus- ceptors that together monitor proprioceptive and
cle activation patterns are preprogrammed in antic- kinesthetic information. Evidence has now accumu-
ipation of specific movements and joint loads. The lated, particularly from peripheral joints, of the exis-
advantage of feed-forward neuromuscular control is tence of a reflex arc linking mechanoreceptors of joints
that centrally generated motor commands originating and the muscles associated with the joint. The pres-
from higher brain centers allow muscles to be preten- ence of these reflexes has been established for the knee,
sioned so the joint is proactively protected from the shoulder, ankle, and elbow (for a review of references,
anticipated loading stress to be placed on the joint. see Stubbs et al.57 ). Sensory receptors within the var-
The centrally generated motor commands are con- ious joint tissues monitor joint stress and strain and
structed and updated on the basis of proprioceptive transmit this information into the CNS. The efferent
and kinesthetic information previously supplied from response is the contraction of muscles surrounding
the local joint tissues. This method of neuromuscular the joint, resulting in an unloading of the joint capsule
control is thought to be critical for dynamic joint sta- or ligament.
bility. Feedback neuromuscular control encompasses What is becoming evident now is that signals gen-
the more traditional view of how the CNS processes erated by the various spinal proprioceptors are also
afferent signals. Efferent responses are constructed on capable of initiating reflex responses in muscles cross-
local reflex pathways and are activated on the basis of ing the vertebral joints. The proprioceptors serve as
ongoing afferent input (past experiences) in concert the afferent limb of reflex pathways which result in
with motor commands initiated from higher levels of local muscle contractions that serve to stiffen the joint
and minimize mechanical disturbances to the natural of the chiropractic manual thrust in reducing segmen-
alignment of the spinal joint. tal muscle tone or muscle spasm.
Indahl’s group58,59 has established that neural con- The results of these studies point to the complexity
nections exist between (a) mechanoreceptors and their of reflex pathways that are activated through stimu-
connecting afferent fibers of the IVD, (b) zygapophy- lation of the various proprioceptors in spinal tissues.
seal joints, and (c) local fascicles of the multifidus However, electrical stimulation is only capable of es-
muscle in the porcine. They used electrical stimu- tablishing the existence of a neural pathway. When
lation, the parameters of which were sufficient to an electrical stimulus is applied to neural tissue, the
excite low-threshold afferents of the disc annulus and signal generated may not necessarily be very mean-
facet joint capsule to establish the existence of the neu- ingful to the CNS. Therefore, the response generated
ral pathway. Bipolar needle electrodes were used to may likewise not be one that would normally be gen-
record the electrical (EMG) response from fascicles erated by a more natural stimulus. For instance, the
of the multifidus muscles. Motor unit action poten- natural stimulus necessary to evoke the muscular re-
tials (MUAPs) were recorded from multiple vertebral sponse recorded in the Indahl et al. experiments might
levels, as well as contralaterally, after electrical stim- range from mechanical pressure or tension to crush-
ulation of the lateral periphery of the annulus at the ing of the stimulated tissue. For this reason, exper-
level of L1-L2. The latency between electrical stimulus iments designed using natural stimulation provide
and detection of the MUAP was usually in the order of an important insight into the functioning of spinal
3–5 ms. In contrast, electrical stimulation of the facet reflex pathways. Solomonow’s group conducted a
joint capsule at the same vertebral level produced a series of investigations, in both the cat and in hu-
more localized response restricted to the same ver- mans, in which both electrical stimulation and nat-
tebral segment and ipsilateral to the side of electrical ural stimulation were used to establish the existence
stimulation.58 Again, detection of the MUAP occurred and significance of reflex pathways activated by stim-
between 3 and 5 ms after the electrical stimulus. ulation of spinal proprioceptors (e.g., see Stubbs et
This study was an important landmark in our al.57 and Solomonow et al.60 ). Their studies focused
understanding of ligamento-muscular synergism in on stimulation of the supraspinous ligament—using
the spine because it demonstrated the existence of electrical stimulation in humans—which established
a neural connection between sensory signals gener- the existence of a ligamento-muscular reflex in peo-
ated in the spinal facet joint and outer annular fibers ple, and in cats, where mechanical deformation of
of the IVD and the multifidus muscle. However, the the supraspinous ligament was used to activate the
study did not identify the types of natural stimuli that ligamento-muscular reflex.
would normally activate such a reflex. The most important finding of these studies
Another important finding of these studies was was that mechanical activation of receptors of the
that injection of lidocaine (a local anesthetic) into the supraspinous ligament was capable of reflexively acti-
L1-L2 facet joint significantly reduced the MUAP re- vating segmental paraspinal muscles.60 The end result
sponse to electrical stimulation of both the facet joint of this reflex activation was to produce a local stiffen-
and anulus fibrosus.58 This finding was further devel- ing of the motion segments in the vicinity of the lig-
oped in Indahl et al.’s second study.59 In that study, ament deformation. Functionally, such a reflex serves
instead of using a local anesthetic injected into the to unload the passive ligament and shift load and sta-
facet joint, physiologic saline was used. Once again, bilization duties back to the active muscle. The active
after the injection of physiological saline into the joint muscle is capable of dynamically altering its stiffness
capsule, multifidus muscle activation induced by elec- to adjust to the changing stabilization requirements of
trical stimulation of afferents originating in either the the joint.
peripheral anulus fibrosus or facet joint capsule was What all of these investigations suggest is that
reduced. The introduction of physiologic saline into there is complex load sharing between active and
the facet joint capsule most likely acted to stretch passive elements of the spine and that this is under
the capsule, thereby mechanically activating sensory the control of the CNS. Vast arrays of sensory trans-
receptors. Their activation presumably activated in- ducers (mechanoreceptors of the ligaments, joint cap-
hibitory interneurons within the spinal cord which sules, fascia, and, of course, muscle) participate, in
ultimately inhibited the anterior horn cells (α concert, to provide the CNS with proprioceptive and
motoneurons) innervating the multifidus muscle. kinesthetic information. In this way, neuromuscular
Stretch of the articular capsule therefore modified the control is afforded to the spine so that continuous sta-
reflex activation of the multifidus muscle induced by bility is maintained.
electrical stimulation of the IVD and facet joint cap- The descriptions above provide supporting evi-
sule. This finding is important clinically because it dence for the model of spinal stabilization that has
points to a possible mechanism underlying the effect been proposed by Panjabi.56,61 In his model, Panjabi
describes the spine as consisting of three basic ele- with information about the length of the muscle,
ments. First, the passive musculoskeletal spine, the changes in muscle length, and the rate at which
structures of which contain sensory transducers; sec- these changes occur. Sensory information is also
ond, the active musculoskeletal spine; and third, the obtained from receptors in the joints, tendons, and
neural feedback system—the control unit. In this skin with significant input from the labyrinthine
model, the various transducers of the spine monitor system and the eyes. From all these signals comes
changes in spinal position, motion, and loading. They our awareness of where our different body parts
relay this information to the control unit. The control are in space and where and how fast they are mov-
unit detects challenges to spinal stability. It then is ing. The extent to which different receptors con-
able to activate appropriate reflex responses to restore tribute to our overall awareness of joint position
spinal stability. and movement is determined to some extent by
the joint under consideration.
Effect of Mechanical Spinal Injury 3. Muscle spindles are major contributors to our pro-
on Ligamento-Muscular Synergism prioceptive sense. These receptors are located in
Most patients suffering acute mechanical low back most skeletal muscle and, most importantly, they
pain will usually recover within a 2–4-week period. are located throughout the paraspinal muscula-
However, recurrence of episodes of low back pain may ture. Muscle spindles are complex sensory end
be as high as 60–80%. One mechanism that is thought organs that receive both a sensory and motor in-
to play a part in ongoing episodes of low back pain nervation. Muscle spindles signal muscle length
is lumbar spine segmental instability.62 Panjabi61 pro- and are very sensitive to changes in muscle length,
posed that lumbar instability might be a result of a loss even when these changes are very small, provided
of control and excessive movement around the neutral the velocity at which the change occurs is fast
zone of the spinal segment brought about by injury to enough.
spinal tissues, degenerative changes in spinal joints, 4. Mechanoreceptors of joints are of three basic types,
disease, or muscle weakness. (The neutral zone has including the type 1 Ruffini endings, which are
been defined as that part of the intervertebral range low-threshold, slow-adapting units that are ca-
of motion measured from the neutral position. Within pable of monitoring joint movement in the mid-
the region of the neutral zone, spinal motion is pro- range of the joint’s range of motion. Type 2 recep-
duced with a minimum of internal resistance, where tors are known as pacinian corpuscles. These are
the overall stresses in the spinal column and the mus- fast-adapting, low-threshold units that monitor
cular effort required to maintain joint alignment are changes in joint position. Type 3 receptors (Golgi
minimal.61 ) end organs) are high-threshold, slow-adapting
The multifidus muscle plays a significant role in units. These receptors signal the end range of the
maintaining stability of lumbar spinal segments (e.g., joint’s range of motion. They are most commonly
Wilke et al.63 and Quint et al.64 ). This muscle under- located in ligaments.
goes significant pathological change after episodes of 5. Mechanoreceptors have been found in a num-
acute low back pain, including atrophy that does not ber of spinal tissues including the interspinous,
recover after resolution of symptoms. This lack of re- supraspinous, and flaval ligaments, the interver-
covery of local musculature is presumed to lead to tebral disc, the thoracolumbar fascia, and spinal
an increased vulnerability of the lumbar spine to fur- facet joints. With regard to the latter, the density
ther injury and risk of recurrence of acute episodes of mechanoreceptors is greatest in the cervical re-
of low back pain.65 The role that the proprioceptors of gion and least in the thoracic region. The density of
the muscles and joints and the ligamento-muscular re- mechanoreceptors within the facet joints of the dif-
flexes play in this unfolding situation requires further ferent spinal regions is consistent with the degree
investigation. of mobility present in these joints.
6. Position and movement sense in the spine are
highly developed in humans. Position sense is
SUMMARY
accurate to within a few degrees and may be
1. Proprioception is the perception of position and impaired by vibration, muscle fatigue, and low
movement of the different parts of the body, back pain. The fact that spinal position sense
including the spine. It is sometimes more broadly significantly deteriorates during vibration points
defined to also cover the sense of force and to the major role that muscle spindles play in
effort. the kinesthetic sense of the spine. For all spinal
2. These sensory perceptions originate primarily regions, at the end of the spine’s range of mo-
from intramuscular receptors, in particular, mus- tion joint receptors are major contributors. In
cle spindles. Muscle spindles provide the CNS this respect, the receptors contributing to spinal
proprioception are similar to those involved in pe- system innervates both extrafusal and intrafusal
ripheral joints. muscle fibers. Each motor system consists of two
7. The normal sensory property of proprioception functionally different types of motor axon known
is not only important for position and movement as the static and dynamic motor axons. Stimulation
sense but is also critical for normal joint function. of each type of motor axon produces a characteris-
Awareness of joint position is necessary to limit tic response from the spindle afferent (group I and
the loads placed on joints and to allow optimum group II) fibers.
sharing of load between the passive and active el- 3. Vibration preferentially excites the primary end-
ements of the spine. ings of muscle spindles. The group I afferent fiber
is activated and sends action potentials into the
spinal cord. The reflex motor response is a reflex
QUESTIONS contraction of the muscle. Because the muscle spin-
dle is also responsible for our position and move-
1. Define proprioception and list the different propri-
ment sense, vibration of the tendon of the mus-
oceptors of paraspinal tissues.
cle also produces two illusions: one, that the body
2. Describe the sensory and motor innervation of the
part is actually moving (lengthening), and two,
muscle spindle.
that the muscle length is actually longer than it
3. Describe the effects that vibration applied to the
really is.
muscle tendon has on the intramuscular receptors.
4. Three joint receptors are responsible for helping to
4. Describe the role that each type of joint receptor
apprise the CNS of joint position and movement.
plays in apprising the CNS of joint position and
The type II pacinian corpuscles are fast-adapting
movement.
receptors and alert the CNS when the joint is ac-
5. Describe the role that each spinal proprioceptor
tually changing position. The type I Ruffini end-
plays in signaling the position of the spine and its
ings are slow-adapting receptors. These receptors
movement.
are activated whenever the part of the joint cap-
6. Describe ligamento-muscular synergism. What is
sule where they are situated is under stretch or
its significance for spinal stability?
tension. Therefore, different populations of Ruffini
endings will be active throughout a joint’s range of
motion. The Golgi-type endings (type III endings)
ANSWERS
are chiefly located in ligaments. They are higher-
1. Proprioception is the sense of the static (position threshold slow-adapting receptors and are active
sense) and dynamic (kinesthetic sense) position of whenever the joint is placed under significant ten-
the body and limbs in space. The proprioceptors sion, that is, when the joint is at the extreme of its
of the paraspinal tissues include the intramuscular range of motion.
receptors (muscle spindles and Golgi tendon or- 5. All spinal proprioceptors play a role in signal-
gans; pacinian corpuscles are also present in skele- ing the position of the spine and spinal move-
tal muscles and act as pressure detectors) and the ment throughout the full range of spinal motion.
receptors of the joints, including the type 1 Ruffini The receptors of the joints (zygapophyseal joints
endings, the type II pacinian corpuscles, and the and the IVD) and ligaments are thought to be ac-
type III Golgi-type endings. These receptors are tive towards the extremes of the regional spine’s
also present in other spinal tissues, including the range of motion. The intramuscular receptors—
ligaments and the IVD. primarily the muscle spindles—are thought to be
2. Two different types of sensory afferent fibers inactive throughout the full range of the spine’s
nervate muscle spindles. The first type is the large- range of motion.
diameter Ia afferent fiber. This nerve terminates as 6. Mechanical activation (changed loading condi-
an unmyelinated, annulospiral primary ending on tions) of receptors located in the paraspinal tis-
the central portion of every intrafusal muscle fiber sues of the joints and ligaments evokes a reflex
of the muscle spindle. The second afferent fiber response of the local segmental muscles of the ac-
type is the group II fiber. The group II fiber ter- tivated spinal joint. The purpose of this response is
minates as a spray-like ending located to one side to produce a local stiffening of the motion segment
of the primary ending. Group II endings predom- in the vicinity of the mechanical deformation of
inantly innervate the bag2 and chain fibers. the joint. The reflex thus serves to unload the pas-
Muscle spindles receive a dual motor supply sive ligament and joint structures and shift load
from the fusimotor (γ ) system and the skeletomo- bearing and stabilization back to the muscle sys-
tor (β) system. The fusimotor system exclusively tem. The muscle system, in turn, is more able
innervates the intrafusal fibers. The skeletomotor to cope with changes in loading of tissues by
dynamically altering its stiffness to adjust to the 8. Gregory JE, Morgan DL, Proske U. Changes in size of
changing stabilization requirements of the joint. the stretch reflex in cat and man attributed to aftereffe-
cts in muscle spindles. J Neurophysiol 1987;58:628–640.
9. Jami L. [Functional properties of the Golgi tendon or-
gans]. Arch Int Physiol Biochim 1988;96(4):363–378.
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C H A P T E R
14
CENTRAL PROJECTIONS OF
SPINAL RECEPTORS
Xue-Jun Song and Ronald L. Rupert
O U T L I N E
INTRODUCTION Spinomesencephalic Tract
SPINAL RECEPTORS Cervicothalamic Tract
Dorsal Root Ganglion Neuron Spinohypothalamic Tract
Characteristics of the Dorsal Root Ganglion FUNCTIONAL CONSEQUENCES OF CENTRAL
Neuron CONNECTIONS
—Nociceptors Central Responses to Nociceptive Information
—Nonnociceptors General Arousal and Sensory Focusing
—Cutaneous and Subcutaneous Mechanoreceptors Emotional Response
—Muscle and Skeletal Mechanoreceptors Establishment of the Memory Engram
—Warmth and Cool Receptors Visceral–Hormonal Response
Spinal Dorsal Horn Neurons Motor Responses: Flexor and Crossed Extensor
Anatomy of the Spinal Cord Reflexes
Spinal Dorsal Horn Neurons Relay the Primary Hyperalgesia
Afferent Fibers Central Mechanisms for Pain Control
CENTRAL PROJECTIONS OF THE SPINAL —Gate Control in the Spinal Cord
RECEPTORS —Descending Nociceptive Control Pathways to the
Ascending Systems Conveying Sensory Information to Spinal Cord
the Cerebral Cortex —Contributions of Opioid Peptides to Endogenous
Dorsal Column–Medial Lemniscal System Pain Control
Anterolateral System SUMMARY
Ascending Pathways Conveying Nociceptive QUESTIONS
Information ANSWERS
Spinothalamic Tract KEY REFERENCES
Spinoreticular Tract REFERENCES
OBJECTIVES 7. To list and briefly describe the responses to noci-

ceptive information.
1. To describe the characteristics and functions of 8. To explain the central mechanisms for pain control.
dorsal root ganglion neurons.
2. To describe the different types of nociceptors.
INTRODUCTION
3. To describe nonnociceptive receptors.
4. To identify the major structures of the spinal cord. The dorsal root ganglion neurons are the common
5. To discuss two systems used to convey somatic class of sensory neurons that transmit a variety of
sensory information to the cerebral cortex. modalities including discriminative touch, proprio-
6. To list and describe the ascending pathways used ception, nociception, and temperature sense from the
to convey nociceptive information. peripheral receptive fields to the spinal cord and the
269
brain. Individual dorsal root ganglion neurons re- connections between the spinal receptors and the
spond selectively to specific types of stimuli because brain will be presented. Central responses to nocicep-
of morphological and molecular specialization of their tive input and central mechanisms for pain control are
peripheral terminals. Some dorsal root ganglion neu- examined in detail.
rons project directly to the higher levels in the brain,
and some form synapses with the neurons in the dor-
SPINAL RECEPTORS
sal horn of the spinal cord, which is the first relay
point for peripheral information traveling to the brain. The spinal receptors, dorsal root ganglion (DRG) neu-
The gray matter of the spinal cord can be divided into rons, and the dorsal horn neurons of the spinal cord
10 layers, and the neurons in each layer are distinct convey peripheral information to the brain. The DRG
in both cytoarchitecture and function. The spinal re- neurons conduct impulses from peripheral terminals
ceptors include the dorsal root ganglion neurons and to the spinal cord and then directly, or relayed by
the dorsal horn neurons of the spinal cord. The dor- spinal dorsal horn neurons, to the higher levels of the
sal root ganglion neurons are the presynaptic recep- central nervous system (CNS). The spinal dorsal horn
tors and the dorsal horn neurons are the postsynaptic neurons receive input from the central branches of ax-
receptors. ons of the DRG neurons and transfer the information
This chapter focuses on the central projections to the brain or other higher regions of the nervous sys-
of the spinal receptors and the possible functional tem through their axons. The distinct cytoarchitecture
consequences of these connections. The first material and function of these spinal receptors are discussed in
presented examines the spinal sensory receptors, the detail.
dorsal root ganglion neurons, and the dorsal horn neu-
rons of the spinal cord. The different types of noci- Dorsal Root Ganglion Neuron
ceptors and nonnociceptors, which transfer somatic Dorsal
Characteristics of the Dorsal Root Ganglion Neuron
sensory information from the periphery to the spinal root ganglion neurons are pseudo-unipolar primary
cord and to the higher levels of the central nervous sensory neurons, which convey somatosensory infor-
system, and the functional organization of the dor- mation from the body to the CNS. The morphology
sal horn neurons are discussed. Central projections of of the DRG neuron is well suited to its principal func-
the spinal receptors, including the ascending systems tions: stimulus transduction and transmission of en-
and the pathways and terminations in the brainstem coded stimulus information to the central nervous sys-
and cortex, are then considered. Finally, a descrip- tem (Fig. 14–1). The DRG neurons differ in a variety of
tion of the possible functional consequences of the ways that reflect their distinct roles in sensation. Each
FIGURE 14–1. The morphology of a dorsal root ganglion cell. The cell body lies in a ganglion on the dorsal root of a spinal nerve.
The axon has two branches: the peripheral one, which projects to the peripheral receptive fields where its specialized terminal is
sensitive to a particular form of stimulus energy, and the central axon, which projects to the spinal cord or higher levels of the
central nervous system. (Adapted from Martin JH, Jessell TM. Anatomy of the somatic sensory system. In: Kandel ER, Schwartz JH, Jessell TM, eds.
Principles of neural science, 4th ed. New York: McGraw-Hill, 2000:353–365.)
CENTRAL PROJECTIONS OF SPINAL RECEPTORS 271
FIGURE 14–2. The location of various receptors in hairy and hairless (glabrous) skin of primates. Receptors are located in the
superficial skin, at the junction of the dermis and epidermis, and more deeply in the dermis and in subcutaneous tissue. The
receptors of the glabrous skin are: Meissner’s corpuscles, located in the dermal papillae, Merkel’s receptors, also located in
the dermal papillae, and bare nerve endings. The receptors of the hairy skin are hair receptors, Merkel’s receptors (having a
slightly different organization than their counterparts in the glabrous skin), and bare nerve endings. Subcutaneous receptors,
beneath both glabrous and hairy skin, include pacinian and Ruffini’s corpuscles. (Reproduced with permission from Martin JH, Jessell TM.
Anatomy of the somatic sensory system. In: Kandel ER, Schwartz JH, Jessell TM, eds. Principles of neural science, 4th ed. New York: McGraw-Hill,
2000:353–365.)
cell can be distinguished by (a) the morphology of its Two distinct classification systems exist for affer-
peripheral terminal, (b) its sensitivity to a stimulus en- ent fiber innervation of skin versus muscle. The alpha-
ergy, (c) the presence (or absence) of a myelin sheath, betical scheme is used for cutaneous nerves, while the
and (d) the diameter of its axon and cell body. numerical classification typically is used for muscle
The cells can be divided into three groups based on afferents. Both nomenclatures are based on conduc-
the sizes (diameter) of the cell body: large (≥50 μm), tion velocity (or axonal diameter). The muscle affer-
medium (30–50 μm), and small (10–30 μm). The pe- ent fibers include four types of axons: large myeli-
ripheral branches and the central branches (dorsal nated (I), medium myelinated (II), small myelinated
roots) of the axons of DRG cells are called the primary (III), and unmyelinated (IV) fibers. The A-α, A-β, A-
afferent fibers, and transmit the encoded stimulus in- δ, and C-fiber classification scheme is also used. The
formation to the CNS. The terminal of the peripheral cutaneous nerves have three groups: A-β, A-δ, and C-
branch is the only portion of the DRG cell that is sen- fiber groups.1 In general, A-α and A-β fibers are the
sitive to stimulus energy. The peripheral terminal is axons of the large-size cells, the A-δ fibers are axons of
either a bare nerve ending or an end organ consisting the medium-size cells, and the C fibers are axons of the
of a nonneural capsule surrounding the axon terminal small-size cells.3−5 Table 14–1 lists the DRG cells, fiber
(Fig. 14–2). The dorsal roots enter and terminate in the diameters, and conduction velocities for the four types
spinal cord or brainstem. of axons. According to responses to different stimuli,
The axons of the DRG cells conduct action poten- the DRG neurons can be divided into nociceptive and
tials to the CNS. The speed at which an afferent fiber nonnociceptive receptors.
conducts action potentials is related to the diameter
of the fiber: The bigger the diameter, the faster the Nociceptors Nociceptors are the receptors that respond
speed, and the sooner the central nervous system can selectively to stimuli that can damage tissue. They re-
act on the information. The conduction velocity (m/s) spond directly to some noxious stimuli and indirectly
is approximately six times the axon diameter (μm) for to others by means of one or more chemical interme-
the large fibers and five times the diameter of thinly diaries released from cells in the damaged tissue. Four
myelinated fibers. The factor for converting axon di- types of nociceptors are distinguished on the basis of
ameter to conduction velocity is smaller (1.5–2.5) for properties of the stimuli6−12 : mechanical, heat, cold,
unmyelinated fibers.1,2 and polymodal. Mechanical nociceptors are activated
TABLE 14–1. Characteristics of the Dorsal Root Ganglion Neurons and Their Axons
Axon Myelinated Peripheral Axon

Diameter of Cutaneous Muscle Diameter (M) or Unmyelinated Conduction Velocity
Cell Body (μm) Nerve Nerve (μm) (UM) Axon (m/s)
Large cell ≥50 A-α I, II 6 ∼ 20 M ≥16

A-β
Medium cell 30 ∼ 50 A-δ III 1∼6 M 2 ∼ 15
Small cell ≤ 30 (usually 10 ∼ 30) C IV 0.2 ∼ 1.5 UM 0.4 ∼ 2
only by strong mechanical stimulation, most effec- thermal and cool receptors. Virtually, all of these sen-
tively by sharp objects. Mechanosensory visceral af- sations are mediated by the fast, myelinated A-α or
ferents, which are similar to mechanical nociceptors A-β fibers.
in the skin, are activated by distension and stretch-
ing of visceral muscle, which may evoke sensations Cutaneous and Subcutaneous Mechanoreceptors There are
of pain. Heat nociceptors respond selectively to heat. three types of mechanoreceptors located either cu-
Heat nociceptors in humans respond when the tem- taneously or subcutaneously18−20 : hair-follicle recep-
perature of their receptive field exceeds 45◦ C (113◦ F), tors, Meissner corpuscles, and pacinian corpuscles.
the heat pain threshold. Both mechanical and ther- Hair-follicle receptors are the principal mechanore-
mal nociceptors have small-diameter, thinly myeli- ceptors of the hairy skin, which covers most of the
nated A-δ or III fibers. Activation of these nociceptors body. There are three separate classes of receptors in-
is associated with sensations of sharp, pricking pain. nervating different types of hair follicles: hair-guard,
Cold nociceptors respond to noxious cold stimuli be- hair-tylotrich, and hair-down receptors. Meissner cor-
low 5◦ C (41◦ F) and have small-diameter, unmyeli- puscles and Merkel receptors are the two principal
nated C fibers. Polymodal nociceptors respond to types of mechanoreceptors in the superficial glabrous
several different kinds of noxious stimuli, such as (hairless) skin. The Meissner corpuscle is a rapidly
high-intensity mechanical, hot, cold, and chemical adapting receptor, which responds at the onset, and
stimuli. often also at the termination, but not through the
Some naturally occurring agents, such as the duration of the stimulus. The Merkel receptor is a
chemical mediators released from the cells in dam- slowly adapting mechanoreceptor, which responds
aged tissues—potassium, serotonin, bradykinin, his- continuously to a persistent stimulus. Both receptors
tamine, prostaglandins, leukotrienes, and substance have specialized accessory structures that are thought
P—can activate or sensitize these nociceptors.6,12,13 to be mechanical filters that confer the dynamic or
Polymodal nociceptors have small-diameter, un- static response specificity. Glabrous skin is a remark-
myelinated C fibers. Activation of these nociceptors ably discriminating organ, and this sensitivity is most
results in slow-onset burning pain. Both A-δ and C developed at the tips of the fingers. Pacinian corpus-
fibers are widely distributed in skin, as well as in cles are rapidly adapting receptors, while Ruffini cor-
deep tissues. The viscera are innervated by dorsal root puscles are slowly adapting receptors. Both receptors
ganglion neurons with free nerve endings and have are located in subcutaneous tissue beneath hairy and
mechanosensory and chemosensory receptors.6,14,15 glabrous skin. The receptive fields of pacinian and
The mechanosensory visceral afferents are similar to Ruffini corpuscles are larger than those of Meissner
those in the skin and can be activated by distension corpuscles and Merkel receptors in superficial skin
and stretching of visceral muscle, which may evoke (see Fig. 14–2).
sensations of pain.14−16 Chemosensory nerve endings These mechanoreceptors can be activated by a
are very important for monitoring visceral function long-lasting stimuli, such as a steady skin indenta-
and provide the afferent limb for many autonomic tion. This stimulus first evokes the sensation of con-
reflexes.17 tact or tap, which may be mediated by both rapidly
and slowly adapting receptors. Rapidly adapting re-
NonnociceptorsNonnociceptors are those responding ceptors stop firing after several hundred milliseconds.
to nonnoxious stimuli, such as touch, warmth, cold, Meanwhile, the slowly adapting receptors remain ac-
and limb proprioception. These receptors can be di- tive, and a steady skin indentation is felt. The pure
vided into cutaneous and subcutaneous mechanore- sensory experiences of steady skin indentation, flut-
ceptors, muscle and skeletal mechanoreceptors, and ter, and vibration are quite different from the complex
tactile sensations evoked by natural stimuli that hu-

mans usually encounter. Natural stimuli usually ac-
tivate different combinations of mechanoreceptors
rather than a single type of receptor.10,21,22
Muscle and Skeletal Mechanoreceptors There are four

main types of peripheral receptors that signal limb
proprioception: mechanoreceptors in joint capsules;
muscle spindle receptors that signal the length, speed,
and stretch of the muscle; stretch-sensitive receptors
that help control the excess stretch or force; and Golgi
tendon organs involved in muscle contraction. These
receptors are important in limb proprioception, which
is essential for maintaining balance, controlling limb
movements, and for evaluating the shape of a grasped
object.21,23
FIGURE 14–3. The columnar organization of the white matter
and the butterfly-shaped gray matter of the spinal cord. The
Warmth and Cool Receptors Thermal sensations consist
white matter is organized into three columns—dorsal, lateral,
of the separate senses of warmth and cool. Warmth and ventral—which run parallel to the long axis of the spinal
is mediated by thermal receptors that are selectively cord. The central gray matter is divided into 10 layers (I to X)
activated by a range of temperatures between approx- of functionally distinct nuclei. Laminae I–VI and VII comprise the
imately 32◦ C (89.6◦ F) and 45◦ C (113◦ F). With progres- dorsal horn and intermediate zone, respectively. Laminae VIII
sively warmer stimuli, warmth receptors discharge and IX are equivalent to the ventral horn. Lamina X envelops
at a greater rate. Discharge rate and perceived mag- the central canal.
nitude of warmth increase in parallel.18,21 At tem-
peratures greater than approximately 45◦ C (113◦ F), Lamina VII corresponds to the intermediate zone,
warmth is not perceived; rather, pain is felt. In this which contains the autonomic preganglionic neurons
range of painful thermal stimuli—the range over and mediates a variety of visceral control functions,
which thermal nociceptors are active—the discharge as well as neurons that transmit afferent information
of warmth receptors is actually reduced. Hence, to the cerebellum. The laminae VIII and IX are equiv-
warmth is mediated by warm receptors, which have alent to the ventral horn, which contains interneurons
unmyelinated C fibers,7,11 whereas heat pain is medi- and motor neurons that control muscles of the trunk
ated by nociceptors as described above. Cool receptors and the limbs. Lamina X consists of the gray matter
discharge intensely when a cool stimulus (around 20– surrounding the central canal.26
25◦ C [68–77◦ F]) is delivered to the receptive field, and The discussion now turns to the detailed func-
the frequency of firing is proportional to the rate and tions of each lamina and the corresponding nuclei.25,27
degree at which temperature is lowered. Cool is medi- Lamina I, the marginal zone, is located in the most
ated by cool receptors, which have A-δ or II fibers.21,24 superficial region of the dorsal horn. Many A fibers
and C fibers from muscles terminate in this area and
Spinal Dorsal Horn Neurons synapse with spinal neurons which are nociceptive-
Anatomy of the Spinal Cord The spinal cord is the first specific.27,28 This area is an important sensory relay
relay point for somatic sensory information conveyed for pain and temperature. Lamina II is also called the
to the brain. The spinal cord consists of a butterfly- substantia gelatinosa (SG). The unmyelinated cuta-
shaped central gray area and a surrounding region of neous C fibers terminate in this area.27−29 This area
white matter. The central gray area contains the cell is isolated from the others because all the SG cells are
bodies of spinal neurons and the white matter con- interneurons and no axons project to other areas.6,7,30
tains axons that ascend to or descend from the brain The axons of the cells in lamina I and the dendrites
(Fig. 14–3). Raxed proposed that the gray matter of of the cells in the deeper laminae project to the SG
the spinal cord could be divided into 10 layers (lam- area and synapse with the SG neurons. The substantia
inae) based on their neural cytoarchitecture.25 Subse- gelatinosa is the most important area for integrating
quently, the neurons were found to be functionally dis- nociceptive information, as described later in refer-
tinct and to have different patterns of projections.6,25 ence to gate-control theory.31 Laminae III, IV, V, and
Laminae I–VI are equivalent to the dorsal horn, which VI contain the nucleus proprius, which integrates sen-
contains interneurons and ascending projection neu- sory input with information that descends from the
rons that relay the peripheral sensory information brain, and this region encompasses the base of the
to the higher levels of the central nervous system. dorsal horn where many of the neurons that project
to the brainstem are located. Many A-δ and C fibers

terminate in this area.27−29 The wide dynamic range A-β
neurons that receive and transmit both nociceptive
and nonnociceptive information are located mainly A-δ
in laminae I, IV, V, and VI.27−29,31 Lamina VII contains
the Clarke nucleus or cell column, which is present C
only in the thoracic and upper lumbar spine and re-
lays information about limb position and movement
to the cerebellum. This region also contains the inter-
mediolateral nucleus columns, which house the au-
tonomic preganglionic neurons. Lamina VIII and IX
receive input from many receptors related to propri-
oception; this region also contains the cell bodies of
motor neurons serving skeletal muscle. Lamina X, al-
though it envelops the central canal, receives afferent
input similar to that of laminae I and II. The nocicep-
tive neurons receiving nociceptive input from joints
are mainly located in this area.6,31
Spinal Dorsal Horn Neurons Relay the Primary Afferent

FIGURE 14–4. Termination of nociceptive and nonnocicep-
Fibers The primary afferent fibers have their cell bod-
tive afferent fibers in the dorsal horn of the spinal cord. The
ies in the DRG. The central axons enter the spinal
large-diameter myelinated A fibers mainly project to the deeper
cord through the dorsal roots. The spinal dorsal horn layers, laminae III and IV. The small-diameter myelinated noci-
neurons relay information from the primary afferent ceptive A fibers project to the superficial layer, lamina I, and
fibers to the brain or higher levels of the central ner- the deeper layer, lamina V. The small unmyelinated C fibers
vous system. The different classes of primary afferent mainly synapse with the neurons in lamina II. (Adapted from
fibers that convey somatosensory modalities take spe- Fields HL. Pain. New York: McGraw-Hill, 1987; and Basbaum A, Jes-
cific routes and end in different regions of the spinal sell TM. The perception of pain. In: Kandel ER, Schwartz JH, Jessell TM,
cord.27−29 Collaterals of large-diameter A-β fibers, in- eds. Principles of neural science, 4th ed. New York: McGraw-Hill, 2000:
volved in tactile sense and limb proprioception, enter 477–479.)
the lateral dorsal columns and ascend to the medulla.
Large-diameter fibers also give off collaterals that en-
ter the dorsal horn from its medial aspect, and termi- referred pain, which originates in deep visceral struc-
nate in the deeper laminae (III–VI) of the gray matter. tures but is perceived in superficial tissues (Fig. 14–5).9
Both A-δ and C nociceptive fibers, which mediate pain Indeed, referred pain from particular visceral struc-
and temperature sense, ascend or descend for a few tures produces characteristic pain patterns, testifying
segments as part of the tract of Lissauer, while axon to the importance of the anatomical substrate of this
collaterals synapse with neurons in the dorsal horn. phenomenon.9,32
Nociceptive fibers terminate primarily in the superfi-
cial dorsal horn, laminae I and II. Some A-δ nocicep-
tive fibers also project more deeply and terminate in CENTRAL PROJECTIONS OF
lamina V (Fig. 14–4). Nociceptive afferents form direct THE SPINAL RECEPTORS
or indirect connections with three major classes of neu-
rons in the spinal dorsal horn: (a) projection neurons The spinal sensory receptors convey impulses from
that relay incoming sensory information to higher cen- peripheral terminals to the spinal cord and then di-
ters in the brain, (b) local excitatory interneurons that rectly, or relayed by dorsal horn neurons, to the higher
relay sensory input to projection neurons, and (c) in- levels of the CNS. The following is a discussion of the
hibitory interneurons that regulate the flow of noci- ascending pathways, which convey somatic sensory
ceptive information to higher centers.6,31 As described information related to pain, thermal sense, touch, and
above, the projection neurons that process nociceptive proprioception.
information are mainly located in laminae I and IV–VI
and convey primary input to the higher levels of the
brain, as explained in more detail below. Ascending Systems Conveying Sensory
Knowledge of the distribution of afferent input Information to the Cerebral Cortex
to dorsal horn neurons facilitates the understand- The dorsal column–medial lemniscal and the antero-
ing of important clinical pain syndromes such as lateral systems (Fig. 14–6) are the major ascending
FIGURE 14–5. A model for accounting for referred pain: convergence of visceral and somatic afferents on the projection neurons
in the dorsal horn of the spinal cord. Both visceral and somatic afferents fibers synapse with the same projection neurons, which
convey the information to the higher levels of the brain. In this case, the brain has no way of knowing the actual source of the noxious
stimulus and mistakenly identifies the sensation with the peripheral structure. (Adapted from Fields HL. Pain. New York: McGraw-Hill,
1987; and Basbaum A, Jessell TM. The perception of pain. In: Kandel ER, Schwartz JH, Jessell TM, eds. Principles of neural science, 4th ed. New York:
McGraw-Hill, 2000:477–479.)
systems conveying somatic sensory information to the There are somewhat different pathways for pro-
cerebral cortex.9,21,26,33 prioceptive information from the arms and legs to the
medulla. The axons in the cuneate fascicle, providing
Dorsal Column–Medial Lemniscal System This system proprioception from the arm, synapse on neurons in a
mediates the somatosensory modalities of discrimi- portion of the cuneate nucleus whose axons project in
native touch, joint position, and vibration. The system the contralateral medial lemniscus. The propriocep-
starts with the dorsal column, which originates from tive information from the leg is transmitted by neu-
the ascending axons of large-diameter primary affer- rons in the Clarke nucleus, which, in turn, synapses
ent fibers, the central branches of DRG cells, and the on neurons that are located in the contralateral medial
axons of neurons in laminae III and IV of the dorsal lemniscus in the caudal medulla.
horn. Initially, this pathway runs ipsilaterally in the The thalamus relays all sensory pathways, with
spinal cord. At upper spinal levels the dorsal column the exception of the olfactory system, to the cerebral
separates into the gracile fascicles and the cuneate fas- cortex. Somatic sensation is mediated by the ventral
cicles. The gracile fascicle ascends medially and con- posterior nucleus, and projected to the primary so-
tains fibers from the ipsilateral sacral, lumbar, and matic sensory cortex through the posterior limb of the
lower thoracic segments, while the cuneate fascicle internal capsule. The axons from the thalamus termi-
ascends laterally and includes fibers from the upper nate on pyramidal cells and also on the interneurons
thoracic and cervical segments. The two bundles ter- in the primary somatic sensory cortex. The primary
minate in the lower medulla in the gracile nucleus and and secondary somatic sensory cortices and posterior
cuneate nucleus, respectively. The cuneate and gracile parietal cortex are the main regions of the cortex for
nuclei are located at about the same level in the caudal the terminations of the fibers from the dorsal column–
medulla. These two nuclei together are referred to as medial lemniscal system. The cortical neurons are ori-
the dorsal column nuclei. The fibers from the dorsal ented in columns, and this columnar organization is
column nuclei arch across the midline and form the an important feature of the cortical neurons, helping
medial lemniscus and ascend to synapse on neurons to limit the horizontal spread of afferent input to the
in the thalamus. cortex.
FIGURE 14–6. The dorsal column–medial lemniscal and anterolateral systems convey somatic sensory information from the
spinal cord to the thalamus and cerebral cortex. The dorsal column–medial lemniscal system conveys tactile sensation and limb
proprioception, and the anterolateral system transmits painful and thermal sensations to the thalamus. The anatomy of the pathways
is shown on a series of brain slices. The top slice is a schematic oblique section through the postcentral gyrus, which is the location
of the primary somatic sensory cortex. The bottom five slices are schematic transverse sections through the brainstem and spinal
cord at levels marked on the neuraxis. (Reproduced with permission from Gardner EP, Martin JH, Jessell TM. The bodily senses. In: Kandel ER,
Schwartz JH, Jessell TM, eds. Principles of neural science, 4th ed. New York: McGraw-Hill, 2000:430–432.)
TABLE 14–2. Comparison of the Dorsal Column–Medial Lemniscal and Anterolateral Systems
Dorsal Column–Medial Lemniscal Anterolateral
Origin Large-diameter primary afferent fibers (central The neurons in laminae I and IV–VI of spinal dorsal
branches of DRG neurons); the neurons in horn
laminae III and IV of spinal dorsal horn;
caudal medulla
Level of decussation Thalamus Spinal cord (within two to three segments)
Terminations in brainstem None Thalamus; hypothalamus; reticular formation of
the pons and medulla; primary and secondary
somatic sensory cortices and posterior parietal
cortex
Terminations in cortex Primary and secondary somatic sensory None
cortices and posterior parietal cortex
Modalities Tactile (discriminative touch, the sense of Pain; temperature sense; crude touch
vibration), proprioception (arm and joint
position)
Effects of hemisection of Loss of tactile sense and limb proprioception Loss of pain and temperature sense in a few
spinal cord in ipsilateral arm and leg segments below the lesion in the contralateral
arm and leg
Anterolateral System This is a phylogenically older sys- systems are opposed to one another in a more lateral
tem that carries pain and temperature, and some less position. Fibers of the anterolateral system synapse on
discriminative forms of touch sensation. The system neurons in three thalamic regions: the ventral poste-
originates predominantly from neurons in lamina I rior lateral nucleus, the intralaminar nuclei, and the
and in deep laminae of the dorsal horn. The axons of posterior nuclei. Neurons of the ventral posterior lat-
these neurons cross the midline to the contralateral eral nucleus project only to the somatic sensory corti-
side of the spinal cord, usually within two to three cal areas. The intralaminar nuclei project more widely
segments above the level of entry of the peripheral to areas of the cortex and to the basal ganglia. The
fibers. This crossing occurs in the anterior white mat- posterior nuclei project to regions of the parietal lobe
ter, and then information ascends in the anterolateral outside the primary somatic sensory area. Table 14–2
portion of the lateral column. The reticular formation compares and summarizes the essential differences
of the pons and medulla, the midbrain, and the tha- between the dorsal column–medial lemniscal and an-
lamus are the main brain regions where most of the terolateral systems.
axons of the anterolateral system terminate.
The anterolateral system is composed of three as- Ascending Pathways Conveying
cending pathways: spinothalamic, spinoreticular, and Nociceptive Information
spinomesencephalic tracts. The spinothalamic and Nociceptive information is carried from the spinal
spinoreticular tracts mediate noxious and thermal cord to the higher centers in the brain through five
sensations relayed from the periphery to the spinal major ascending pathways that originate in different
cord by A-δ and C fibers. Axons in the spinoreticu- laminae of the dorsal horn as described by Willis (Fig.
lar tract end on neurons in the reticular formation of 14–7) and others.32,34 The ascending pathways trans-
the medulla and pons, which relay information to the mitting pain are mainly located in the anterolateral
thalamus and other structures in the diencephalon. system.
The spinomesencephalic (or spinotectal) tract termi-
nates primarily in the tectum of the midbrain. The Spinothalamic Tract The spinothalamic tract is the most
spinomesencephalic tract also projects to the mesen- important of the nociceptive pathways ascending the
cephalic periaqueductal gray, the region surrounding spinal cord. It originates from the nociceptive-specific
the cerebral aqueduct. In the medulla the axons of the and wide-dynamic-range neurons in laminae I, V, and
anterolateral system are located on the lateral mar- VI of the dorsal horn.35 The axons of the dorsal horn
gin and separated from the medial lemniscus. In the neurons cross the midline and ascend in the antero-
pons, the anterolateral system and medial lemniscus lateral white matter on the contralateral side and ter-
move closer together, and in the midbrain the two minate in the thalamus. Experimental and clinical
FIGURE 14–7. Three of the major ascending pathways that transmit nociceptive information from the spinal cord to the higher
centers. (Reproduced with permission from Gardner EP, Martin JH, Jessell TM. The bodily senses. In: Kandel ER, Schwartz JH, Jessell TM, eds. Principles
of neural science, 4th ed. New York: McGraw-Hill, 2000:430–432.)
evidence have clearly shown that electrical stimula- which is involved in emotion. Therefore, this pathway
tion of the spinothalamic tract results in pain, and is thought to be involved in the affective component
lesions of this tract result in marked deficits in pain of pain. It is important to note that many of the axons
sensation. of this pathway project in the dorsal part of the lateral
funiculus, but not in the anterolateral quadrant.
Spinoreticular TractThe spinoreticular tract originates
from the axons of nociceptive neurons in laminae VII Cervicothalamic Tract This tract begins with the neu-
and VIII, and accompanies the spinothalamic tract, rons in the lateral cervical nucleus, located in the lat-
as part of the anterolateral system, terminating in eral white matter of the upper two cervical segments
both the reticular formation and the thalamus. Most of the spinal cord. Most neurons in laminae III or IV
spinoreticular fibers project ipsilaterally, unlike the of the dorsal horn respond to tactile stimuli, but some
spinothalamic tract, in which almost all the fibers cross also respond to noxious stimuli. These neurons project
the midline. through the spinocervical tract, which runs in the dor-
solateral spinal cord to the lateral cervical nucleus. The
Spinomesencephalic Tract The spinomesencephalic tra- cervicothalamic tract crosses the midline and ascends
ct originates from the nociceptive neurons in laminae in the medial lemniscus in the brainstem to midbrain
I and V, and projects to the mesencephalic reticular nuclei and to the ventroposterior lateral and posterior
formation, the lateral periaqueductal gray, and the medial nuclei of the thalamus.
parabrachial nuclei, via the spinoparabrachial tract.
The neurons of the parabrachial nuclei project to the Spinohypothalamic TractThis pathway originates from
amygdala, a major component of the limbic system, the axons of the neurons in laminae I, V, and VIII, and
projects directly to supraspinal autonomic control cen- ascending pathways and systems to brain. The pri-
ters. The spinohypothalamic tract has been thought mary somatic sensory cortex (S-I), the secondary so-
to be involved in the complex neuroendocrine and matic sensory cortex (S-II), and the posterior parietal
cardiovascular responses that follow noxious stimu- lobe are the most important areas for receiving, pro-
lation. cessing, and integrating different somatic sensory af-
Nociceptive information is conveyed by the as- ferent information necessary for perception. The basic
cending pathways from the spinal cord to the tha- function for these pathways is to carry sensory-
lamus. Of the nuclei of the thalamus processing no- discriminative, as well as motivation-affective, com-
ciceptive information, the lateral and medial nuclear ponents of pain sensation. In addition, impulses in
groups are the most important. The nuclei of the lat- these pathways trigger both reflex motor and auto-
eral nuclear group receive input via the spinothalamic nomic responses through their connections with spe-
tract, primarily from nociceptive-specific and wide- cific nuclei. Furthermore, impulses in these pathways
dynamic-range neurons located in laminae I and V appear capable of activating the descending pain con-
of the dorsal horn. However, the nuclei of the medial trol or analgesic system. There are central responses to
nuclear group receive input primarily from neurons pain stimulation, and neurophysiological and neuro-
in the laminae VII and VIII. The lateral thalamus is chemical mechanisms for pain control. In this context,
thought to mediate information about the location of touch is a complex topic and has been discussed in
an injury because the neurons have small receptive detail by Gardner and Kandel.39
fields, as do the dorsal horn neurons that project to
them. This information is then conveyed to conscious- Central Responses to Nociceptive Information
ness as acute pain. The neurons in the medial nuclear
The response of the brain to painful stimulation is
group respond optimally to noxious stimuli and also
extremely complex. There are very few higher func-
have widespread projections to the basal ganglia and
tions that are not influenced to a greater or lesser ex-
many different cortical areas. Therefore, the medial
tent by this powerful sensory stimulation. Some of the
nuclear group may be involved in not only process-
major areas of the brain affected by nociceptive input
ing the nociceptive information but also in activating
are the reticular formation, thalamus, hypothalamus,
a nonspecific arousal system.
limbic system, general cortex, parietal and temporal
The thalamic nuclei then send the nociceptive in-
lobes, and the primary somatosensory cortex. These
formation to the different regions of the somatosen-
affected areas, in turn, influence the response to pain
sory cortex. It is still unknown where and how the no-
stimulation.
ciceptive information is processed in the cortex. Using
the imaging techniques of positron emission tomog-
raphy (PET), Craig et al.36−38 found that the cingulate General Arousal and Sensory Focusing Being awake and
gyrus and the insular cortex are involved in the re- alert is necessary for the cerebral cortex to analyze sen-
sponse to nociception. The cingulate gyrus is a part of sory stimuli and bring the sensation into conscious-
the limbic system and may be involved in processing ness. The brainstem reticular formation plays very
the emotional component of pain. The insular cortex important roles in maintaining the state of general
receives direct projections from the medial thalamic wakefulness to focus attention on a particular painful
nuclei and from the ventral and posterior medial tha- stimulus. The reticular formation is the name of a
lamic nuclei, and may contribute to the autonomic group of neurons found throughout the brainstem.
component of the overall pain response. In addition, In a ventral view of the brainstem, the reticular for-
some neurons in the somatosensory cortex have small mation occupies the central portion or core area of the
receptive fields and respond selectively to nociceptive brainstem from midbrain to medulla.26 Fibers from
input, but they might not contribute to most clinical the reticular formation ascend to the thalamus and
pain.32 Similar to nociceptive pain information, tem- project to various nonspecific thalamic nuclei. From
perature sense is conveyed to the cortex in the antero- these nuclei, fibers are distributed diffusely to the
lateral system. cerebral cortex, which is concerned with conscious-
ness, and so this system has been called the ascending
reticular activating system. Activation of this system
FUNCTIONAL CONSEQUENCES OF
causes generalized cerebral arousal. The reticular for-
CENTRAL CONNECTIONS
mation may also, at least in part, be responsible for
Complex connections exist among the primary affer- the focusing of attention on specific sensations.31,40,41
ent fibers, the second-order neurons, the different lev- This arousal response can be obtained by stimulating
els of the brainstem, and the somatic sensory cortex. the peripheral sensory receptors that connect directly
The varieties of somatic sensory inputs are con- with neurons in the reticular formation. The arousal
veyed from the periphery to the brain along different response is the basis for the further responses of the
individual to any nociceptive or nonnociceptive stim- of the major centers involved in controlling sympa-
ulation. thetic and parasympathetic activity, as well as hor-
monal function. The three motivational–affective pain
Emotional Response The hallmark of pain is the dis- pathways—paleospinothalamic tract, spinoreticular
tinctly unpleasant emotional experience. Emotion is tract, and the multisynaptic ascending and descend-
defined as a strong feeling, aroused mental state, or ing propriospinal systems—are also involved in reg-
intense state of drive or unrest directed toward a defi- ulating the visceral–hormonal responses.14,17
nite object, evidenced by both behavioral and psycho-
logical changes. The limbic system has been thought Motor Responses: Flexor and Crossed Extensor Reflexes
to be responsible for the emotional component of pain. As well as the responses described above and acti-
The limbic system is the phylogenetically older part of vated by noxious stimulation, the motor responses
the brain, and includes cortical and noncortical (sub- are also important so that the individual can escape
cortical, diencephalic, and brainstem) structures. The from injury. There are several spinal reflexes directly
paleospinothalamic tract, the spinoreticular tract, and involved in the responses of escaping from pain stim-
the multisynaptic ascending and descending pro- ulation, such as the cutaneous reflexes, flexor reflex,
priospinal systems are the three pathways of the non- and crossed extensor reflex.44,45 For example, when
specific motivational–affective system that pass infor- the skin of one foot of an individual is stimulated
mation to the hypothalamus and limbic system. This by a noxious mechanical or thermal stimulus, the
contributes to emotional responses to noxious stim- lower extremity undergoes a coordinated withdrawal.
uli. Destruction of pathways or nuclei within the lim- The flexor muscles contract and the extensor mus-
bic circuit results in a loss of the affective component cles relax, facilitating the flexion of the joints so as
of pain. When these connections have been surgically to escape injury. This coordinated reflex is termed the
destroyed in humans through procedures such as or- flexor reflex. Meanwhile, there is also extension of the
bitofrontal leukotomy (i.e., removal of white matter) contralateral leg termed the crossed extensor reflex.
or stereotactic surgery in attempts to reduce pain, pa- This reflex makes the contralateral leg bear the body’s
tients have noted that they are still aware of the fact weight while the ipsilateral flexor reflex occurs. Both
that something is wrong with the body and can lo- reflexes are mediated by polysynaptic pathways, and
calize the sensation (through an intact somatosensory the integrative centers are in the local spinal cord.
cortex). These patients, however, no longer complain These spinally mediated withdrawal reflexes can be
of discomfort or pain.40−42 reduced or blocked by the descending systems from
higher levels of the brain, such as that from the peri-
Establishment of the Memory Engram aqueductal gray region as discussed later in this chap-
The storage and retrieval of memory are of major im- ter. In addition, the voluntary motor cortex can also
portance in the interpretation of sensory input and be involved in regulating the spinal reflexes. The corti-
allow an individual to correlate the nature, intensity, cospinal neurons terminate on both spinal motor neu-
and associated sensations of the immediate stimulus rons and the interneurons in the spinal cord. These
with previous sensory experiences. This, in turn, al- connections can gate reflex circuits, allowing volun-
lows for an appropriate response to the sensation. The tary movements to take advantage of spinal circuits, as
major storage site for memory engrams appears to be these circuits can link local sensory input to output.46
in the temporal lobes, which receive thalamocortical
projections from the medial thalamic nuclei.40,41 Al- Hyperalgesia Hyperalgesia is an increased response to
though the exact mechanisms still remain unclear, the a stimulus that is normally painful. It has both pe-
establishment of memory engrams for painful experi- ripheral and central origins. Changes in nociceptor
ences has been noted to be a function of the intensity sensitivity underlie primary hyperalgesia, while the
of the stimulus, the length of time the stimulus lasts, hyperexcitability of spinal dorsal horn neurons under-
and the frequency with which it is repeated.43 lies centrally mediated hyperalgesia.47 Hyperalgesia
is one of the major responses of the nervous system to
Visceral–Hormonal Response The visceral–hormonal re- repetitive noxious stimulation.
sponses to pain include cardiovascular, gastrointesti- Upon repeated application of noxious stimuli,
nal, and hormonal changes, and are manifested as in- nearby nociceptors that were previously unrespon-
creases in, for example, respiratory and heart rates, sive to the stimuli become responsive. This phe-
blood pressure, and movement of the gastrointesti- nomenon is called sensitization. The sensitization of
nal tract. Many of the cardiovascular and gastroin- nociceptors after injury or inflammation results from
testinal responses are mediated through spinal or the release of a variety of chemicals by the dam-
lower brainstem reflexes, and are modified and co- aged cells and tissues in the vicinity of the injury.
ordinated, in turn, by higher centers in the cortex These substances include bradykinin, histamine, sero-
and the hypothalamus. The hypothalamus is one tonin prostaglandins, substance P, leukotrienes, and
acetylcholine.9,47 Under conditions of severe and per- hypothesis focuses on the interaction of four classes
sistent injury, the nociceptive C fibers fire repeti- of neurons in the spinal dorsal horn: nonmyelinated
tively and the response of spinal dorsal horn neurons nociceptive afferents (C fibers); myelinated nonnoci-
increases progressively. This phenomenon is called ceptive afferents (A fibers); projection neurons, mainly
“wind-up.”48,49 Wind-up is dependent on the relocated in laminae I and V, whose activity results in the
lease of glutamate from C terminals and the conse- sensation of pain; and inhibitory interneurons in lam-
quent opening of postsynaptic ion channels gated by ina II. The projection neuron is excited by both noci-
the N-methyl-d-aspartate (NMDA)-type glutamate ceptive and nonnociceptive neurons, and the balance
receptors.48 Consequently, noxious stimuli can induce of these inputs determines the intensity of pain. The
long-term changes and produce hyperexcitability in inhibitory interneuron is spontaneously active and
the dorsal horn neurons. The profound alterations in normally inhibits the projection neuron, thus reduc-
the biochemical properties and excitability of the dor- ing the intensity of pain. This inhibitory interneuron
sal horn neurons, as well as the dorsal root ganglion is excited by nonnociceptive afferents but inhibited by
neurons, can lead to spontaneous pain and can de- nociceptive afferents. Therefore, nociceptive afferents
crease the threshold for the production of pain.4,5,50−52 turn on and nonnociceptive afferents turn off a gate to
the central transmission of noxious input. This circuit
Central Mechanisms for Pain Control One of the remark- is potentially modulated by several central descend-
able discoveries of pain research is that pain can be ing pathways.
controlled by central mechanisms. The nociceptive in- Gate-control theory provides a neurophysiological
formation is modulated by special circuits, nuclei, or basis for the observations that, for example, a vibra-
pathways at different levels of the brain, whose main tory stimulus that selectively activates large-diameter
function is to regulate the perception of pain. nonnociceptive afferents can reduce pain, and that
transcutaneous electrical stimulation (TENS) and dor-
sal column stimulation may be effective for the relief
Nociceptive inputs from
Gate Control in the Spinal Cord of pain.47,53
peripheral nociceptors to the dorsal horn neurons of
the spinal cord are regulated by the activity in other Descending Nociceptive Control Pathways to the Spinal Cord
myelinated afferents that are not directly concerned Gate-control theory proposes that pain perception is
with the transmission of nociceptive information. This sensitive to levels of activity in both nociceptive and
idea that pain results from the balance of activity in nonnociceptive afferent fibers. It is also important to
nociceptive and nonnociceptive afferents was pro- understand that nociceptive signals can also be mod-
posed by Melzack and Wall in 1965, and was called ulated at successive synaptic relays along the central
the “gate-control theory” of pain (Fig. 14–8).31 This pathway. In experimental animals, stimulation of the
periaqueductal gray region that surrounds the third
ventricle and the cerebral aqueduct produces a pro-
C fiber found and selective analgesia.34,53 In human patients,
stimulation of the periventricular gray region, the ven-
trobasal complex of the thalamus, or the internal cap-
sule reduces the severity of pain.9,54 This stimula-
- + tion produces a profound suppression of activity in
- nociceptive pathways, but does not change the tac-
Inhibitory tile sensations. The neural pathways mediating this
interneuron stimulation-produced analgesia have been defined as
+ follows (Fig. 14–9): The neurons in the periaqueductal
+ gray matter, which usually do not directly project to
the dorsal horn neurons of the spinal cord, make exci-
tatory connections with neurons of the rostroventral
medulla, in particular with serotonergic neurons in
A-β fiber
the midline of the nucleus raphae magnus. Neurons
of this nucleus project to the spinal cord via the dorsal
FIGURE 14–8. Gate-control theory is one explanation for the
part of the lateral funiculus and make inhibitory con-
modulation of pain in the spinal cord. The nociceptive and non-
nociceptive afferents turn on and off, respectively, the gate to
nections with the neurons in laminae I, II, and V of the
the central transmission of noxious input. The balance of the dorsal horn. Stimulation of the rostroventral medulla
nociceptive and nonnociceptive afferent inputs determines the inhibits dorsal horn neurons, including neurons of
intensity of pain. (Adapted from Gardner EP, Martin JH, Jessell TM. the spinothalamic tract that respond to nociceptive
The bodily senses. In: Kandel ER, Schwartz JH, Jessell TM, eds. Principles inputs. The other descending inhibitory systems orig-
of neural science, 4th ed. New York: McGraw-Hill, 2000:430–432.) inating in the noradrenergic locus ceruleus and other
the dorsal horn.47,56−59 The periaqueductal gray re-

gion is among the most sensitive sites for eliciting such
analgesia. This opiate-induced analgesia involves the
same descending pathways, which originate from the
periventricular gray region and the noradrenergic lo-
cus ceruleus and other nuclei of the medulla and pons
as described above (see Descending Nociceptive Control
Pathways to the Spinal Cord). The brain contains spe-
cific receptors for opiates. Three major classes of opi-
oid receptors have been identified: mu (μ), delta (γ ),
and kappa (κ).60
The mu receptors are the most important in me-
diating analgesia and are highly concentrated in pe-
riaqueductal gray matter, the ventral medulla, and
the superficial dorsal horn of the spinal cord, all of
which are very important in the regulation of pain.61,62
Naloxone, an antagonist of the opiate receptors, can
bind the mu receptors and block the analgesia in-
duced by morphine, an agonist of opiate receptors.54,55
Three major classes of endogenous ligands for these
receptors have been identified: enkephalins, beta-
endorphins, and dynorphins. Enkephalins are ac-
tive at both mu and delta receptors, and dynor-
phins are a relatively selective agonist of the kappa
receptor.47,54,56,57,59,63 Acupuncture or TENS may act
by activating this endogenous opiate system to reduce
the intensity of pain.
FIGURE 14–9. Two descending pathways regulate nociceptive There are several other important neurochemical
neurons in the spinal cord. The pathways of serotonergic pe- agents, such as serotonin and norepinephrine, which
riaqueductal gray region–nucleus raphae magnus–spinal dor-
serve as primary neurotransmitters in both ascending
sal horn and the noradrenergic locus ceruleus–spinal dorsal
and descending spinal pathways involved with the
horn are involved in suppressing the activity of nociceptive neu-
rons in the dorsal horn of the spinal cord. The former pathway
modulation of pain sensation.60,64
arises in the midbrain periaqueductal gray region and projects
to the nucleus raphae magnus and other serotonergic nuclei
(not shown), then via the dorsolateral funiculus to the dorsal
SUMMARY
horn of the spinal cord. The second pathway arises from the
noradrenergic cell groups in the pons and medulla and from 1. Based on cell body size, dorsal root ganglion neu-
the nucleus paragigantocellularis, which also receives input rons can be divided into small, medium, and
from the peripheral aqueductal gray region. In the spinal cord, large cells. Dorsal root ganglion neurons medi-
these descending pathways inhibit nociceptive projection neu- ate afferent information, including discriminative
rons through direct connections, as well as through interneu-
touch, proprioception, nociception, and temper-
rons in the superficial layers of the dorsal horn. (Reproduced with
ature sense from the peripheral receptive fields
permission from Gardner EP, Martin JH, Jessell TM. The bodily senses,
In: Kandel ER, Schwartz JH, Jessell TM, eds. Principles of neural science,
to the spinal cord and the higher levels of the brain.
4th ed. New York: McGraw-Hill, 2000:430–432.) They are pseudo-unipolar primary sensory neu-
rons and respond selectively to specific types of
stimuli because of morphological and molecular
nuclei of the medulla and pons are also involved in specialization of their peripheral terminals. The
suppressing the activity of nociceptive neurons in the central branches of the dorsal root ganglion neu-
dorsal horn.47,55 rons directly, or relayed by the dorsal horn neurons
of the spinal cord, project to the brain.
Contributions of Opioid Peptides to Endogenous Pain Control 2. Four types of nociceptors respond directly to nox-
It is known that opiates such as morphine and codeine ious stimuli and indirectly to others by means of
are effective analgesic agents. Microinjection of mor- one or more chemical intermediaries released from
phine, codeine, or other opiates directly into specific cells in the traumatized tissue: mechanical (strong
regions of the rat brain produces a powerful analge- mechanical stimulation, most effectively by sharp
sia by inhibiting the firing of nociceptive neurons in objects); heat (>45◦ C [113◦ F]); cold (<5◦ C [41◦ F]);
and polymodal (high-intensity mechanical, hot, an older system that carries pain and temperature
cold, and chemical stimuli). Both mechanical and and some less discriminative forms of touch sen-
thermal nociceptors have small-diameter, thinly sation. The system originates predominantly from
myelinated A-δ or III fibers; cold nociceptors have neurons in lamina I and in deep laminae of the
small-diameter, unmyelinated C fibers; and poly- dorsal horn. The anterolateral system is composed
modal nociceptors have small-diameter, unmyeli- of three ascending pathways: the spinothalamic,
nated C fibers. spinoreticular, and spinomesencephalic tracts. Ta-
3. Nonnociceptive receptors are those responding ble 14–2 summarizes the essential differences be-
to nonnoxious stimuli, such as touch, warmth, tween the dorsal column–medial lemniscal and an-
cold, and limb proprioception. These receptors terolateral systems.
can be divided into cutaneous and subcutaneous 6. Nociceptive information is carried from the spinal
mechanoreceptors (such as hair-follicle receptors, cord to the higher centers in the brain through five
Meissner corpuscles, Merkel receptors, pacinian major ascending pathways that originate in dif-
corpuscles, and Ruffini corpuscles), muscle and ferent laminae of the dorsal horn: the spinothala-
skeletal mechanoreceptors (such as the joint cap- mic tract, spinoreticular tract, spinomesencephalic
sule mechanoreceptors, muscle spindle receptors, tract, cervicothalamic tract, and spinohypothala-
stretch-sensitive receptors, and Golgi tendon or- mic tract. The spinothalamic tract is the most im-
gans), and thermal and cool receptors (selectively portant.
activated by a range of temperatures between ap- 7. The primary somatic sensory cortex (S-I), the sec-
proximately 32◦ C [89.6◦ F] and 45◦ C [113◦ F]). Vir- ondary somatic sensory cortex (S-II), and the pos-
tually, all of these sensations are mediated by the terior parietal lobe are the most important areas for
fast-myelinated A-α or A-β fibers. receiving, processing, and integrating different so-
4. The spinal cord is the first relay point for peripheral matic sensory modalities necessary for perception.
information to the brain. It consists of a butterfly- The response of the brain to painful stimulation is
shaped central gray area and a surrounding region extremely complex. Some of the major areas of the
of white matter. The central gray area contains the brain affected by nociceptive input are the retic-
cell bodies of spinal neurons and the white matter ular formation, thalamus, hypothalamus, limbic
contains axons that ascend to or descend from the system, general cortex, parietal and temporal lobe,
brain. Based on neural cytoarchitecture, the gray and the primary somatosensory cortex. These af-
matter of the spinal cord can be divided into 10 lay- fected areas in turn influence the response to pain
ers. Laminae I–VI are equivalent to the dorsal horn, stimulation.
which contains interneurons and ascending pro- 8. The “gate-control theory” of pain offers one ex-
jection neurons that relay peripheral sensory infor- planation for the modulation of pain in the spinal
mation to the higher levels of the central nervous cord. The nociceptive and nonnociceptive affer-
system. Lamina VII corresponds to the intermedi- ents turn on and off the gate to the central trans-
ate zone, which contains the autonomic pregan- mission of noxious input, respectively. The bal-
glionic neurons and mediates a variety of visceral ance of nociceptive and nonnociceptive afferent
control functions, as well as neurons that trans- input determines the intensity of pain. The noci-
mit afferent information to the cerebellum. Lami- ceptive signals can also be modulated at successive
nae VIII and IX are equivalent to the ventral horn, synaptic relays along the central pathways. Stimu-
which contains interneurons and motor neurons lation of the periaqueductal gray region produces
that control muscles of the trunk and the limbs. a profound and selective analgesia. The descend-
Lamina X consists of the gray matter surrounding ing pathways, such as the serotonergic periaque-
the central canal. ductal gray region–nucleus raphae magnus–spinal
5. The dorsal column–medial lemniscal and antero- dorsal horn and the noradrenergic locus ceruleus–
lateral systems are the two major ascending sys- spinal dorsal horn pathways, are involved in sup-
tems conveying somatic sensory information from pressing the activity of nociceptive neurons in the
the spinal receptors to the cerebral cortex. The dorsal horn of the spinal cord. It is important to
dorsal column–medial lemniscal system is a phy- understand that opioid peptides make great con-
logenically new system for the somatosensory tributions to the endogenous pain control system.
modalities of discriminative touch, joint position,
and the sense of vibration. It starts with the dor-
sal column, which originates from both the as-
QUESTIONS
cending axons of large-diameter primary afferent
fibers and the axons of neurons in laminae III and 1. What are the functionally distinct characteristics
IV of the dorsal horn. The anterolateral system is of the spinal dorsal horn neurons?
2. What are the essential differences between the involved in conveying nociceptive information to
dorsal column–medial lemniscal and anterolateral the brain. (a) The spinothalamic tract is the most
systems? prominent ascending nociceptive pathway in the
3. What are the origins and terminations of the main spinal cord. It originates from the nociceptive-
ascending pathways conveying nociceptive infor- specific and wide-dynamic-range neurons in lam-
mation from the spinal dorsal horn to higher levels inae I and V–VII. The axons of the dorsal horn
in the brain? neurons cross the midline and ascend in the an-
4. How is nociceptive information modulated in the terolateral white matter on the contralateral side
spinal dorsal horn? and terminate in the thalamus. (b) The spinoretic-
5. What are the immediate physiological responses ular tract originates from axons of nociceptive neu-
and the possible neural pathways mediating the rons in laminae VII and VIII. This tract ascends in
responses when your foot is accidentally stabbed the anterolateral quadrant of the spinal cord and
by a sharp needle? terminates in both the reticular formation and the
thalamus. Of the thalamus nuclei processing no-
ciceptive information, the lateral and medial nu-
clear groups are the most important. The lateral
ANSWERS
thalamus is thought to mediate information about
1. The gray matter of spinal cord can be divided into the location of an injury. The medial nuclear group
10 layers (laminae) based on the neural cytoarchi- may be involved in processing the nociceptive in-
tecture. The neurons in each laminae are function- formation, as well as in activating a nonspecific
ally distinct and have different patterns of projec- arousal system. (c) The spinomesencephalic tract
tions. Laminae I–VI are equivalent to the dorsal originates from the nociceptive neurons in lami-
horn of the spinal cord and contain interneurons nae I and V. It projects to the mesencephalic retic-
and ascending projection neurons that relay the ular formation and to the parabrachial nuclei. The
peripheral sensory information to the higher lev- neurons of the parabrachial nuclei project to the
els of the central nervous system. Lamina I, the amygdala, a major component of the limbic sys-
marginal zone, is located in the most superficial tem, which is involved in emotion. Therefore, this
region of the dorsal horn. This area is an impor- pathway is thought to be involved in the affective
tant sensory relay for pain and temperature. Many component of pain.
A-δ and C fibers from muscles terminate in this 4. The nociceptive inputs from peripheral nocicep-
area and synapse with nociceptive-specific cells. tors to the dorsal horn neurons of the spinal cord
Lamina II is also called the substantia gelatinosa are modulated by the local balance of activity in
(SG). The unmyelinated cutaneous C fibers termi- nociceptive and nonnociceptive afferents—as pro-
nate in this area. The axons of the cells in lamina I posed by the “gate-control theory” of pain—and
and the dendrites of the cells in the deeper laminae by descending inhibitory systems from the higher
project to the SG area and synapse with the SG neu- levels of the brain. The gate-control theory of pain
rons. The substantia gelatinosa is the most impor- focuses on the interaction of four classes of neurons
tant area for integrating nociceptive information. in the spinal dorsal horn: nonmyelinated nocicep-
Laminae III, IV, V, and VI contain the nucleus pro- tive afferents (C fibers); myelinated nonnocicep-
prius, which integrates sensory input with infor- tive afferents (A fibers); projection neurons whose
mation that descends from the brain and the region activity results in the sensation of pain, which are
of the base of the dorsal horn, where many of the mainly located in laminae I and V; and inhibitory
neurons that project to the brainstem are located. interneurons in lamina II. The projection neuron
Many A-α, A-β, and C fibers terminate in this area. is excited by both nociceptive and nonnocicep-
The wide-dynamic-range neurons that receive and tive neurons, and the balance of these inputs de-
transmit both nociceptive and nonnociceptive in- termines the intensity of pain. The inhibitory in-
formation are located mainly in laminae I, IV, V, terneuron is spontaneously active and normally
and VI. inhibits the projection neuron, thus reducing the
2. See Table 14–2. intensity of pain. This inhibitory interneuron is
3. Nociceptive information is carried from the spinal excited by nonnociceptive afferents but inhibited
cord to the higher centers in the brain through by nociceptive afferents. Therefore, nociceptive af-
three major ascending pathways that originate in ferents turn on and nonnociceptive afferents turn
different laminae of the dorsal horn. They are off a gate to the central transmission of noxious
the spinothalamic tract, spinoreticular tract, and input. The nociceptive signals can also be modu-
spinomesencephalic tract. In addition, the cervi- lated at successive synaptic relays along the central
cothalamic and spinohypothalamic tracts are also pathways. Stimulation of the periaqueductal gray
region produces a profound and selective analge- Kandel ER, Schwartz JH, Jessell TM, eds. Principles of neural
sia. The descending pathways, such as the seroton- science, 4th ed. New York: McGraw-Hill, 2000.
ergic periaqueductal gray region–nucleus raphae Korczyn AD. Handbook of autonomic nervous system dysfunc-
magnus–spinal dorsal horn and the noradrener- tion. New York: Marcel Dekker, 1995.
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C H A P T E R
15
PERIPHERAL NERVE BIOLOGY
AND CONCEPTS OF NERVE
PATHOPHYSIOLOGY
Geoffrey Bove
O U T L I N E
INTRODUCTION Nerve Dynamics
NERVE ANATOMY Adhesions as a Sequel of Inflammation
NERVE BIOMECHANICS POTENTIAL SENSORY CONSEQUENCES OF NERVE
Longitudinal Movements of Nerves COMPRESSION AND INFLAMMATION
Lateral Movements of Nerves SUMMARY
Relative Nerve Movements QUESTIONS
Factors Affecting Biomechanics ANSWERS
MECHANISMS OF NERVE INJURY KEY REFERENCES
Nerve Compression REFERENCES
Nerve Stretch
subluxation, which relieved pressure on a nerve.

OBJECTIVES This allowed the nerve to recover and the system to
1. To understand nerve anatomy. return to its normal balance (homeostasis). Symp-
2. To understand nerve biomechanics. toms such as pain in the sciatic distribution were
3. To understand mechanisms of nerve injury. thought to be generated by pressure on nerves as
4. To understand how nerve pathologies induce in- they passed through confined areas, such as the inter-
flammation of the nerve. vertebral foramina. Terms such as “nerve pressure”
5. To learn the effects of inflammation on nerves and and “nerve interference” were commonly used to de-
axons. scribe the pathology caused by subluxation. These
6. To understand possible sensory consequences of concepts were not widely accepted at the time outside
nerve inflammation. of the profession because there was little supportive
research or proof that such lesions occurred and could
be documented.
To appreciate these concepts, a detailed under-
INTRODUCTION
standing of nerves and their response to changes in
Since the early stages of the chiropractic profession, it their environment is necessary. For example, a study
has been maintained that nerves are critical elements of the axon of one sensory neuron whose cell body
to human health. The initial observations that spinal resides in the fifth lumbar dorsal root ganglion and
manipulation had beneficial effects on patients with a innervates the dorsum of the foot will introduce the
wide variety of symptoms generated many hypothe- reader to peripheral nerve anatomy. In the interver-
ses about the possible mechanisms of action. One such tebral foramen, the neuron is associated with the L5
mechanism was that the manipulation removed a intervertebral disc, the facet joint margins, pedicles,
289
and various ligaments that traverse the IVF.1 The neu- mechanical stressors from bone, joint, muscle, fascial,
ron extends one axon, which travels in the dorsal root and even skin pathologies. In this chapter, the adapta-
ganglion before branching to send one process toward tions to protect nerves in normal and pathological sit-
the spinal cord and one toward the periphery. The cen- uations are discussed, focusing on the potential ram-
trally projecting axon travels toward the spinal cord ifications of somatic dysfunction on sensory input.
in the L5 dorsal root, within the spinal canal. Here, the
dorsal root is in contact primarily with cerebrospinal
NERVE ANATOMY
fluid, but the axon also interfaces loosely with the in-
tervertebral discs, vertebral bodies, pedicles, laminae, Nerves are highly specialized structures, from their
facet joint margins, and ligamentum flavum. The pe- connective-tissue layers to their blood supply, and
ripherally extending axon travels in the ventral ramus even innervation. Nerves are best understood by start-
of the L5 spinal nerve, which passes underneath the ing at their smallest structural level and building out-
psoas muscle, over the anterior aspect of the sacroil- ward.
iac joint, and finally joins the sciatic nerve just prior There are many kind of axons within a peripheral
to leaving the pelvis underneath the piriformis mus- nerve. Besides the functional classes such as sensory,
cle. From here, the axon freely courses within the sci- motor, and autonomic axons, there is a large range of
atic nerve in a fascial plane below the hamstring mus- axon sizes. So-called unmyelinated axons are smaller
cles, before entering the peroneal branch of the sciatic than 2 mm in diameter. Numerous axons invaginate
nerve. The common peroneal nerve winds posterior a single Schwann cell, and the resulting structure is
to the head of the fibula, where it pierces and then called a Remak bundle, which is not myelinated. Larger
runs below peroneus longus. The nerve carrying the axons, up to 20 mm, are surrounded by a Schwann cell
axon then appears above the lateral ankle in the super- that eventually wraps numerous layers of cell mem-
ficial peroneal nerve, piercing the dense crural fascia brane around it, which is called myelin. This myelin
to reach the skin on the dorsum of the foot. sheath can be up to 6 mm thick. Each myelinated
The course that an axon takes is somewhat pre- axon or Remak bundle is covered by a layer of con-
carious, especially considering that the axon in ques- nective tissue called the endoneurium (Fig. 15–1). The
tion may be only 1–2 mm in diameter. The axon is endoneurium contains the intraneural fluid, which re-
potentially subjected to adverse environmental and sembles cerebrospinal fluid, and gives the nerve some
FIGURE 15–1. Peripheral nerve

anatomy. Endoneurium-covered ax-
ons (end) are bundled by peri-
neurium ( p) into fascicles. These
fascicles are in turn covered by
epineurium (epi). Specializations of
the Schwann cells that surround
for unmyelinated (B) and myeli-
nated (C) axons. Numerous unmye-
linated axons (ax) are embedded by
invagination into the cytoplasm of
a single Schwann cell (Schw). Each
myelinated axon has multiple lay-
ers of Schwann cell wall wrapped
around it, forming myelin (my), in-
terrupted at regular intervals by
nodes of Ranvier (nR).
PERIPHERAL NERVE BIOLOGY AND CONCEPTS OF NERVE PATHOPHYSIOLOGY 291
Besides providing a framework for the fascicles, the

epineurium pads the nerve, providing substantial re-
sistance to compression. It also allows relative move-
ment of the fascicles to adapt to compressive forces.
Surrounding the nerve trunk is a conjunctiva-like
adventitia that facilitates smooth movements of
the entire nerve in relationship to the surrounding
tissue.
The dorsal and ventral roots do not have a per-
ineurium or epineurium. Therefore, these structures
have much less resistance to stretch and compression,
and are also more susceptible to chemical stimuli that
may be present during inflammation or infection.
The blood supply of nerves is quite special. The
nutrient arteries to nerves are numerous and appear
somewhat coiled. This feature facilitates the normal
longitudinal movements of the nerve (Fig. 15–3). The
epineurium contains a network of longitudinal ves-
sels that are highly anastomotic, making it difficult to
render a section of a nerve ischemic (i.e., if one ves-
sel is blocked by compression, blood flow will con-
FIGURE 15–2. Peripheral nerve axons follow an undulating
tinue through other pathways). The longitudinal ves-
course, seen upon gross inspection of a rat sciatic nerve (A)
sels send smaller vessels through the perineurium
as stripes perpendicular to the axons. Parallel wavy nature of
the axons can also be appreciated in sectioned nerve tissue
that pass through at an acute angle. This arrangement
(B; rat sciatic nerve, 60 μm thick). may allow compartment syndromes to occur in nerves.
These may occur if increased pressure forms within a
fascicle, causing the penetrating vessels to close like
support and resistance to stretch and bending. The a flap-valve, preventing venous return and allowing
axons, with their myelin and endoneurium, travel in pressure to escalate.2 Finally, the intrafascicular ves-
parallel and follow an undulating course. This is eas- sels form a capillary network. These capillaries are
ily appreciated on a gross level, especially when a specialized like those in the central nervous system
nerve is transilluminated (Fig. 15–2). The wavy course (the blood–brain barrier) and prevent most macro-
they run indicates that axons are longer than the nerve molecules, especially proteins, from passing. This spe-
within which they run; the importance of this fact will cialization is referred to as the blood–nerve barrier. This
be clear later. diffusion barrier, however, is thought to be easily dis-
Bundles of these axons are encased in a thin but rupted during pathology.
tough layer of perineurium. The perineurium is an ep- The innervation of the nerves is referred to as
ithelial tissue, composed of flattened cells with tight the nervi nervorum. The sensory modalities of this
junctions. Within this layer, axons are relatively free to innervation include nociception, general mechanore-
slide longitudinally to meet the movement demands ception, and vasomotor actions.3−5 The nociceptors
of the body. The perineurium maintains the intraneu- are sensitive to mechanical, thermal, and chemical
ral fluid pressure (axons will herniate through any stimuli3 and are distributed primarily along the blood
defect) and forms a diffusion barrier that helps pro- vessels,6 but also terminate freely, although somewhat
tect the nerve from infection and inflammation. The sparsely, in all connective-tissue layers.7 Like other no-
perineurium is strongest in tension, limiting stretch ciceptors, they release vasoactive neuropeptides upon
of the nerve. The perineurium also forms divisions stimulation.8 Nervi nervorum branch repeatedly, and
of the nerves, called fascicles. Fascicles branch and receptive fields of individual neurons also branch to
merge repeatedly, forming a plexus within the nerve. other deep tissues, such as muscle. One could pre-
Thus, one cannot follow any individual fascicle for sume that stimulation of the nervi nervorum would
much distance without encountering a branch point. lead to poorly defined sensations somewhat related to
The fascicles are bound together by a relatively the course of the affected or innervated nerve; this is
soft and thick connective-tissue layer called the an exceedingly common presentation in chiropractic
epineurium. It can make up a large percentage of the practice. There is limited information regarding the
cross-sectional area of a nerve, maintaining its thick- other sensory modalities, but histologically the struc-
ness between fascicles into the center of the nerve. tures resemble mechanoreceptors.9 The vasomotor
FIGURE 15–3. In vivo pho-

tographs of a rat sciatic nerve
demonstrate the undulating na-
ture of the blood vessels. When
the nerve is slightly stretched
distally (to the left in this view), the
vessels straighten and glide over
each other. The vessel indicated
by the solid arrow (A-B) follows
the movement, and the vessel
indicated by the arrowhead (A-B)
elongates. One can also discern an
epineurial (A-B, open arrow) from
a perineurial blood vessel (A-B,
solid arrow) in these photo-
graphs by their relative move-
ments: the perineurial blood vessel
moves underneath and further
than the epineurial blood ves-
sel. Also note that the waves
normally seen on the axons are
removed with stretch (A, white
arrow).
fibers are from the sympathetic nervous system and joints must withstand potential buckling and com-
control the blood flow through the nerve.10 pressive forces (e.g., median nerve at elbow). Even
the sympathetic chain, loosely affixed anterolaterally
to the spinal column, must adapt to flexion and ex-
NERVE BIOMECHANICS tension of the spine, and to movements that cause the
peripheral nerves to stretch and thus pull the rami
The concept of nerve biomechanics is somewhat ob-
scure. When one considers that each part of the
nervous system spans numerous joints, one must ap-
preciate that in order to avoid damage, nerves must
adapt to the large ranges of motion that the body is
capable of. Consider that the brain is connected to the
spinal cord, which is connected to the dorsal and ven-
tral roots, which traverse the intervertebral foramina
and become nerves, which extend to the ends of the
fingers and toes. The brain is not directly tethered to
the cranial vault, and the spinal cord is somewhat del-
icately suspended by the denticulate ligaments. The
nerve roots are suspended in the cerebrospinal fluid.
While there are semifirm connections of the cervi-
cal spinal nerves to the bottom of the intervertebral
foramina, these are negligible in the rest of the spine.
Peripheral nerves are not tethered in their course, but
are restricted only at branch points and where they
are buried into their target tissues. This arrangement FIGURE 15–4. Responses of nerves to bending (A) and com-
pression (B). A. When a nerve is bent around an immovable
allows considerable mobility of the central and pe-
structure, such as bone, tension gradients are formed in the
ripheral nervous systems.
nerve, being greatest furthest from the interface between the
Peripheral nerves must adapt to mechanical nerve and the immovable structure. In addition, compression
stresses placed on them as they run through foram- occurs perpendicular to the structure. B. When compression
ina formed by bone, muscle, and fascia. Bending is applied to a monofascicular nerve (left), the fascicle must de-
around the outside of joints places stretching and com- form. In a multifascicular nerve (right), the fascicles are free
pressive forces on them (e.g., ulnar nerve at elbow) to move without deformation, thus accommodating the com-
(Fig. 15–4A). Nerves that are located in the inside of pression.
communicantes laterally. The connective-tissue layers the median nerve moves at least one nerve thickness
of the nerves help disperse these forces. Multiple fas- side to side during the opening and closing of the fist.
cicles, present in the larger peripheral nerves, disperse In doing so, it slides over and around tendons passing
compressive forces by allowing movements of the fas- with it into the hand (Fig. 15–5). Although such move-
cicles relative to each other (Fig. 15–4B). ments of other nerves have not been evaluated, it is
likely that similar nerve movements occur elsewhere
Longitudinal Movements of Nerves as well.
The loose connection of nerves to surrounding tis-
sue allows substantial longitudinal excursion, or slid-
ing, of the nerves. These movements are normally Relative Nerve Movements
as smooth as the movements of tendons in their Nerve movements must be considered in relation to
synovium. For example, longitudinal movements of the surrounding tissue. A rule of thumb is that the
nerves during full ranges of motion of the upper limb nerve always moves toward the axis of rotation of the
are 11–17 mm for the brachial plexus and median joint being moved. Movement of the sciatic nerve dur-
nerve, and 5–9 mm for the common digital nerves.11 ing the straight-leg raise is a good example. Imagine
The sciatic nerve at the sciatic notch moves 6–10 mm that one marker is placed in the sciatic nerve above
during a straight-leg raise,12 and although not mea- the hip joint, and another is placed in the sciatic nerve
sured systematically more distally, may in fact move in the middle of the thigh. During a straight-leg raise,
more than this in the mid-thigh. both markers will move toward the hip joint. On the
other hand, if the hip is left stationary and the knee is
Lateral Movements of Nerves extended, both markers will move toward the knee.
Reports of lateral movements of nerves are limited. In Figure 15–6 demonstrates this concept, which applies
the carpal tunnel, in addition to longitudinal sliding, to all nerves that must adapt to movement.
FIGURE 15–5. Ultrasonogram of author’s left wrist just proximal to the carpal tunnel. Left is lateral, top is anterior. Outline of the
median nerve (MN) and the tendons of flexor pollicis longus (FPL) and the long flexors (FLEX) are to right. A. Neutral wrist. The
median nerve is relatively medial. B. Finger extension without movement of the wrist. The median nerve has slid laterally over the
long flexor tendons. The dark spaces are flexor muscles which change in dimension with arm joint positions.
comparable to that which occurs in carpal tunnel syn-

drome causes paresthesia and loss of sensation.14,15
Although it is typically assumed that nerve compres-
sion causes pain, there is no support for such claims.
For example, we have all experienced the sensory
loss following short-term compression of the sciatic
nerve from sitting too long at the wrong angle. The
development of such symptoms is imperceptible, but
such compression does not typically cause pain, and
symptoms from such transient pressure are readily re-
versible. Slow-growing tumors that compress nerves
FIGURE 15–6. Relative nerve movements. Consider the line
with solid circles in A. When the system is bent, the circles will
do not typically manifest with pain, but rather with
move toward the axis of the movement, relative to the moving numbness and/or paralysis of the innervated tis-
parts (solid circles in B). From flexion to extension, the same sue. Acute compression of the spinal nerves during
relationship holds true: The shaded circles on the inside of the surgery causes reversible paresthesia, but not pain. A
system in B move closer to the axis of rotation (shaded circles critical case series reported pain and conclusive evi-
in A). This can be demonstrated by using a rubber band to dence of compression of relevant neural structures in
bridge the reader’s elbow, with reference marks on the band a group of patients with radiating pain.16 After their
and the skin. symptoms had fully abated, either spontaneously or
with conservative care, the imaging was repeated and
Factors Affecting Biomechanics the neural compression remained. This observation
Because nerves are intimately associated with vari- supports the theory that compression per se is proba-
ous tissues as they course toward their target, such bly not the cause of symptoms other than numbness
associations impact nerve biomechanics. Rigid struc- and paresthesia. We know, however, that many pa-
tures such as bone will not yield to the nerve, and can tients with compression syndromes have pain. What
act as a tethering point, restricting nerve movements is the origin of such adverse symptoms?
(discussed further below). Softer structures, such as The answer may be that in many cases, temporary,
muscle, can also affect nerves, especially with hyper- intermittent, or maintained nerve compression leads
trophic changes. Nerve branches often pierce fascial or to inflammation, which may then lead to pain. Within
travel through bony foramina, which may also focus hours of temporary experimental compression, the in-
forces on nerves. Finally, the nerves bury themselves flammatory cascade begins, marked by edema and in-
into target organs, becoming tethered. This final teth- creased numbers of macrophages, lymphocytes, and
ering is the primary means for body movements to act fibroblasts.17 Such compression also leads to myelin
upon the nerve. destruction and axonal disruption and degeneration.
These changes may also follow nerve ischemia and/or
hindered nerve movements. In either case, the result
MECHANISMS OF NERVE INJURY
is cellular debris that must be cleared by the immune
Nerves can be injured in numerous ways, includ- system. The immune cells respond by releasing an ar-
ing stretching, compression, constriction, and cutting. senal of chemicals (e.g., prostaglandins, leukotrienes,
Nerves are often involved in processes such as infec- histamine, substance P, bradykinin) that can activate
tions and space-occupying lesions solely as a result or affect axons. The sensory consequences of this im-
of their proximity to the diseased environment. The mune reaction may include pain and paresthesia, to
symptoms resulting from nerve injury depend on the be discussed below.
time it takes for the disease to occur and the pathology
it produces. Nerve Stretch
During normal movements, nerves are designed to ac-
Nerve Compression commodate changes in the length of their path from
Nerve compression has historically been held as the origin to insertion. For instance, when the arm is hang-
primary cause of nerve injury, and much is known ing by one’s side, the nerves of the brachial plexus
about the effects of compression on nerve function, are relatively loose. As the shoulder is abducted, in-
vasculature, axoplasmic flow, and repair (for a review, ferior brachial plexus nerves are first straightened,
see Rempel et al.13 ). Carpal tunnel syndrome and sim- then stretched. This stretching removes the normal
ilar conditions are very common and typically result undulations of the axons. With the arm abducted to
from narrowing of the tunnel through which the nerve 90 degrees, if the wrist is extended, a further load
travels, or from swelling of the structures within the is placed on the nerve. Laterally bending the neck
tunnel. It is known that experimental compression to the contralateral side further increases this load.
At this point, the brachial plexus, and especially the

median nerve, reaches its stretch limit. Even asymp-
tomatic individuals placed in this position experi-
ence paresthesia in the median nerve’s distribution
to the hand. Further stretch can lead to nerve dam-
age. When stretched 8% or more, blood vessels feeding
nerves may start to close and the nerve may become is- FIGURE 15–7. Adhesions change the length of nerve avail-
chemic. With 15% elongation of the nerve, blood flow able for movement adaptation. A. The stretch is distributed
and nerve conduction cease.18,19 If maintained, this throughout the nerve. B. With an “adhesion”, the same move-
ischemia can lead to axonal damage and perineurial ment must be accommodated by a shorter effective length of
scarring.20,21 Further stretching of the nerve can rup- nerve.
ture these taut blood vessels, resulting in bleeding or
axonal breakage. Bleeding will activate the immune string become slack again, and then put another piece
system to remove the products of blood degradation, of tape at its midpoint. Try pulling until it straightens
attracting macrophages, lymphocytes, and fibroblasts again—you may not be able to. If you watch the new
to the area. anchor point, it will be carrying the load, while the
The sensory consequences of stretch injuries are section between the two anchors remains loose. If your
often debilitating, and may seem out of proportion second anchor is too loose to prevent movement, you
to the initial injury. While the exact reason for this will note tension in the part you are pulling on and
phenomenon is unknown, it may indicate that dam- resisted sliding through the second anchor, until you
age secondary to nerve stretching occurs in multiple fully stretch the other segment.
areas, especially where the forces were somewhat dis- This is a conceptual model of adverse nerve biome-
tributed to begin with. Individual anatomic variation chanics: Anything that changes the anchoring point
of nerves, nerve branches, and the fascicular pattern (e.g., adhesions) focuses the forces on the anchor dur-
within the nerve may play an important part in deter- ing movements of the nerve. This is illustrated in Fig-
mining the location of the damage, and may be diffi- ure 15–7. In both panels, the nerve needs to move, by
cult to predict. If the damage is more diffuse, the re- stretching about 10% of its original length. In Figure
sultant inflammatory and immune response will also 15–7A, this stretch is distributed throughout the nerve.
be more diffuse. This may be partly responsible for In Figure 15–7B, note the “adhesion” at the nerve’s
the greater levels of sensory symptoms seen following midpoint. The same movement now will require the
traction injuries of nerves, such as complex regional right segment of this nerve to stretch 20%, while the
pain syndrome types I and II.22,23 left segment does not adapt at all.
While adhesions are common in human nerve
Nerve Dynamics pathologies, restrictions in movement occur without
Two general concepts related to nerve dynamics need frank adhesions. Compression by surrounding struc-
to be understood: nerve gliding and nerve anchor- tures or nerve swelling will effectively cause a limita-
ing. Consider that nerves are slippery structures in- tion of movement similar to an adhesion. Entrapment
side a tube. There are numerous ways to compromise syndromes are secondary to either of these processes,
smooth gliding in this system (e.g., decrease the slip- and are often referred to as “friction injuries” to re-
pery nature of the nerve, increase the nerve diame- flect the concepts presented above.25 With movement
ter or decrease the tube diameter, or simply overload restrictions, the affected nerve is potentially damaged
the system through repeated motion cycles). All of each time the body part is moved.
these potential nerve injuries routinely occur, and all
increase the nerve’s resistance to further movements. Adhesions as a Sequel of Inflammation
Repetitive motion may therefore be a cause of nerve In both compressive and stretch injuries of nerves, fi-
irritation, leading to tenosynovitis or other repetitive broblasts are recruited to the injured area and deposit
motion syndromes. This theory is supported by an- fibrous tissue between the nerve and the surround-
imal studies showing that rats made to repeatedly ing tissue, causing adhesions. Adhesions secondary
reach for their food developed a repetitive motion dis- to nerve injury are likely to be an under-recognized
order not unlike that of humans who perform similar source of pain,26 and immune-mediated inflammation
tasks, characterized by thickening and scarring of the and perineurial fibrosis have been implicated in radi-
median nerve at the carpal tunnel.24 ating pain.27,28 There is strong evidence that nerve ad-
To understand nerve anchoring, place a length of hesions can be symptomatic.26 Distinguishable adhe-
string on your desk parallel to a ruler. Tape one end sions with no other evident pathology have been cited
of the string to the desk. Measure how far you have to as causing radiating sciatic pain.29−31 In a somewhat
pull the other end to straighten the string. Now let the serendipitous finding during postmortem studies
and paresthesia can either occur spontaneously, with-

out added stimulus, or can be provoked mechanically.
The nature of these symptoms usually correlates to the
fiber type that is being affected or to known patho-
physiological mechanisms. It is important to remem-
ber that sensations (e.g., pain, numbness) felt in one
area may originate from another. For example, when
we bump our ulnar nerve at the elbow the resulting
numbness is felt in the medial palm.
Paralysis and lack of light touch are the first symp-
toms to occur during experimental nerve compres-
FIGURE 15–8. Magnetic resonance imaging of sciatic nerves sion, and arise when the conduction in large-diameter
in nerve injury. This patient suffered a fall and stuck her left axons is blocked. These axons are the most sensitive
sciatic nerve 3 years prior to this study, and had unremitting to pressure.
radiating leg pain made worse by approximately 5◦ straight- Paresthesia can occur as a result of spurious dis-
leg raise testing, and any other movements that stressed her charge of axons that normally subserve whichever
left sciatic nerve. Images are taken from identical levels, near sensation is evoked. Paresthesias are usually sensa-
the insertion of gluteus maximus (c). Note in B that the sci-
tions of buzzing and/or tingling, and are a result
atic nerve (in outline and enlarged in inset) has a hyperintense
of fast-axon discharge. While such symptoms can
margin, representing the fascial plane within which it courses.
This plane is indistinct on the symptomatic side (A), where the
be transient, and typically occur following removal
nerve appears embedded within the muscle tissue. Legend: a of a short-lived compressive insult, they can per-
= femur; b = vastus lateralis; d = adductor magnus. sist as a consequence of at least two other patholo-
gies. First, demyelination will cause ectopic discharge
from myelinated axons. Demyelination can follow is-
of sciatic nerve biomechanics, the sciatic nerves ad- chemia, compression, friction trauma, toxins, and au-
hered to the anterior sacral margin in two cadav- toimmune reactions, all of which involve nerve in-
ers who had documented history of sciatic pain with flammation. If the axon is left intact, it can become
painfully limited straight-leg raise tests.12 Such lum- remyelinated, and thus recover. Second, if axons are
bosacral plexus abnormalities have recently been pro- cut or caused to degenerate, their tips may remain sen-
posed as causative factors in cases of lumbar pain with sitive to mechanical stimulus and their cell bodies may
radicular symptoms.32 Figure 15–8 demonstrates such produce discharge in the absence of any added stimuli
an example, where posttraumatic sciatic pain was as- (e.g., spontaneous discharge). Mechanically sensitive
sociated with an area of scar tissue that encased the axon tips from cut nerves are probably responsible
sciatic nerve. Although a promising area for research, for positive Tinel tests, where the nerve is tapped and
the importance of adhesions in nerve pathology sensations are felt distal to the tapping. The type of
remains somewhat obscure because definitive diag- sensation expected from demyelinated or damaged
nosis relies on invasive methods such as nerve biopsy axons would not change (e.g., nerves that normally
or direct observation. participate in light touch or pressure would continue
to produce light touch or pressure).
Pain is more difficult to explain. While demyeli-
POTENTIAL SENSORY CONSEQUENCES OF
nation is unlikely to affect unmyelinated axons, it has
NERVE COMPRESSION AND INFLAMMATION
been stressed that demyelination leaves debris that
We have presented mechanisms through which nerve can induce an immune and inflammatory reaction.
compression and stretch can cause inflammation, This reaction within a nerve can lead to spontaneous
immune activation, and possibly axonal damage. For activity in nociceptors,33−35 potentially causing pain
example, when transient compression causes edema, in the area to which the affected neurons project. If
this can lead to conduction block. With prolonged or the activity is induced in nociceptors that innervate
extreme compression, axonal loss can occur. Stretch in- leg muscles, for instance, the sensation would likely
jury can cause bleeding and axonal damage, depend- be pain in the leg muscles. Furthermore, gross inflam-
ing on the severity. Of particular importance to clini- mation of a nerve renders deep-innervating nocicep-
cians are the consequences of such pathologic changes tor axons mechanically sensitive.35 Whether less se-
(e.g., how the patient reacts to such an injury). vere levels of inflammation, such as that occurring
Symptoms give general clues to the pathology oc- following demyelination, cause mechanical sensitiv-
curring at the axonal and neuronal level. Symptoms ity has yet to be tested. Although less sensitive to com-
of nerve damage can include motor paralysis, numb- pression, unmyelinated axons are perhaps more sen-
ness to light touch, paresthesia, and pain. Both pain sitive to damage by direct trauma. As for myelinated
axons, when unmyelinated axons are broken or are will be perceived within the target tissue. Isolated
otherwise caused to degenerate, their cut ends and nerve compression leads to paresthesia and incites
cell bodies in the dorsal root ganglia generate activity. inflammation, which can then cause pain.
This seems to be limited to nociceptors innervating
deep targets such as muscle.36 The regenerating tips
of damaged nociceptor axons are mechanically sensi- QUESTIONS
tive, at least transiently.37 Again, spontaneous or me- 1. What is the anatomy of the connective tissues of
chanically evoked activity will be perceived as coming nerves?
from the tissue that used to be innervated by the dam- 2. What are potential causes of nerve inflammation?
aged axons, and this activity is likely to be perceived 3. A friendly scientist recruits you for an experiment.
as pain. The scientist places an electrode into your com-
The previous information gives possible peripheral mon peroneal nerve, just below your fibular head.
mechanisms for symptoms. There is strong evidence A connected machine runs electricity through the
to support that the nervous system changes during electrode, and activates fast-conducting axons in
pathology, usually becoming more sensitive, by in- the nerve. What do you feel and where?
creasing the effectiveness of sensory input or decreas- 4. A black pellet is placed in the sciatic nerve in
ing normal pain inhibitory mechanisms. For instance, the mid-thigh. The subject is lying supine, with
following sunburn the affected skin is more sensitive, straight legs. Which way do you expect the pellet
and a nonnoxious stimulus such as light touch be- to move when the
comes painful. This is termed allodynia, and is proba- A. Hip is flexed?
bly not transduced by nociceptors, but rather by light B. Ankle is flexed?
touch receptors, and is most likely mediated by the C. Lumbar spine is flexed?
central nervous system. A thorough discussion of such 5. Based on this chapter, do you think that der-
pain mechanisms is beyond the scope of this chapter, matomes or myotomes are more important for di-
and the reader is referred to the Key References for fur- agnosis of nerve-related pathology?
ther information on the topic.
SUMMARY ANSWERS
1. Nerves are anatomically complicated structures 1. The connective tissues of nerves include, in order
that are somewhat loosely affixed to the rest of the from most inner to most outer, the endoneurium,
body. The layers of the nerve sheaths provide me- the perineurium, and the epineurium. The en-
chanical and chemical protection for the enclosed doneurium covers each axon and contains the
axons. intraneural fluid. The perineurium bundles the
2. Nerves are also biomechanically complicated and axons into fascicles, and provides substantial ten-
move substantially during many bodily move- sile strength as well as a diffusion barrier. The
ments. Nerves move in general toward the joint epineurium is relatively thick, covering each fas-
that is effecting the movement, and can also move cicle, cushions the nerve from compressive force,
laterally within their bed. and allows free movement.
3. Nerves are predominantly injured mechanically, 2. Nerve inflammation can be caused by trauma, in-
by compression and/or stretching. Stretching infection, toxins, systemic processes leading to de-
juries to nerves tend to have worse prognoses. myelination, diabetes, and autoimmune reactions.
4. Alterations of nerve biomechanics can be expected 3. Paresthesia will be felt in the distribution of the
to induce inflammation. Conversely, inflammation common peroneal nerve.
that affects the nerve can be expected to lead to 4. A. Toward the hip; B. toward the ankle; C. toward
alterations in nerve biomechanics. the spine.
5. Inflammation affecting a nerve can lead to fibrotic 5. Myotomes.
changes in the nerve or its vicinity (adhesions),
which can cause biomechanical alterations. Adhe-
sions can act to focus forces, leading to or perpetu- KEY REFERENCES
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damage. Rev Pain 2000;4:451.
6. Nerve inflammation can lead to pain, which can be Bove GM, Light AR. The nervi nervorum: Missing link for
perceived by local receptors (nervi nervorum) and neuropathic pain? Pain Forum 1997;6:181.
also signaled by certain axons within the nerve. Butler D, Gifford L. The concept of adverse mechanical ten-
When passing axons are affected, the sensation sion in the nervous system. Physiotherapy 1989;75:622.
Cervero F. Spinal cord mechanisms of hyperalgesia and al- 14. Gelberman RH, Szabo RM, Mortensen WW. Carpal
lodynia: Role of peripheral input from nociceptors. Prog tunnel pressures and wrist position in patients with
Brain Res 1996;113:413. Colles’ fractures. J Trauma 1984;24:747.
Quintner JL, Bove GM. From neuralgia to peripheral neuro- 15. Szabo RM, Gelberman RH. The pathophysiology
pathic pain: Evolution of a concept. Reg Anesth Pain Med of nerve entrapment syndromes. J Hand Surg Am
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Lancet 1999;353(1092):3–27. ropathy of spinal nerve roots: A compressive or bio-
Watkins LR, Maier SF. The pain of being sick: Implications logical problem? Spine 1991;16:162.
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pain. Annu Rev Psychol 2000;51:29. nerve compression. Lab Invest 1986;55:91.
Zimmermann M. Pathobiology of neuropathic pain. Eur J 18. Brown R, Pedowitz R, Rydevik B, et al. Effects of acute
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spine. Melbourne: Churchill Livingstone, 1987. grafting of the median and ulnar nerves. J Bone Joint
2. Lundborg G, Myers R, Powell H. Nerve compression Surg Am 1972;54:727.
injury and increased endoneurial fluid pressure: A 21. Starkweather RJ, Neviaser RJ, Adams JP, et al. The effect
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surg Psychiatry 1983;46:1119. peripheral nerves: An experimental study. J Hand Surg
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C H A P T E R
16
SOMATOAUTONOMIC REFLEXES
Akio Sato and Brian Budgell
O U T L I N E
INTRODUCTION ANATOMICAL BASIS OF SEGMENTALLY
WHAT IS A SOMATOAUTONOMIC OR ORGANIZED SPINOVISCERAL REFLEXES
SPINOVISCERAL REFLEX? OBSERVATIONS FROM HUMAN SUBJECTS
EARLY MODELS OF THE SOMATOAUTONOMIC Spinovisceral Research in Humans
REFLEX Studies on Blood Cells and Blood Chemistry
OBSERVATIONS FROM ANIMAL EXPERIMENTS Studies on Blood Pressure, Heart Rate, and Autonomic
Mechanical Stimulation of the Spine Output to the Heart
Noxious Chemical Stimulation of the Spine Studies on Regional Blood Flow
Sciatic Nerve Blood Flow Summary of Findings from Human Experiments and
Blood Pressure and Heart Rate Future Directions
Adrenal Function SUMMARY
Urinary Bladder Function QUESTIONS
Gastric Function ANSWERS
Summary of Findings from Animal Experiments KEY REFERENCES
REFERENCES
OBJECTIVES mechanisms, including, for example, the psychologi-

cal effects of the patient–clinician interaction and the
1. To review the relevance of physiological investiga- direct transmission of mechanical force to the spine
tions of somatoautonomic reflexes. or viscera.1 Because the exact mechanism of action of
2. To define the terms “somatoautonomic reflex” and SMT is unknown, it is not unreasonable to think that
“spinovisceral reflex.” several mechanisms might be in play simultaneously.
3. To explain why chiropractic clinical experience Research into the reported beneficial effects of SMT on
was inconsistent with early models of the soma- nonmusculoskeletal complaints has been the primary
toautonomic reflex. stimulus to focus attention on one such mechanism,
4. To explain the significance of the discovery of the somatoautonomic reflex. This area of neuroscience
segmental, spinal-mediated, somatoautonomic re- is very promising and raises the possibility that treat-
flexes. ment approaches, such as SMT, directed at the muscu-
5. To review basic physiological investigations of loskeletal system may also have an impact on visceral
spinovisceral reflexes in animals. organ disorders.
6. To review basic physiological studies of spinovis- It is important for clinicians to understand how
ceral reflexes in humans. spinal manipulation may affect the nervous system,
and therefore achieve clinical results. Such under-
standing aids clinicians in the application of diagnos-
INTRODUCTION
tic and therapeutic techniques, as well as in the design
Spinal manipulative therapy (SMT) is thought to and interpretation of clinical trials. Within this con-
affect human physiology through several different text, the basic sciences have a wealth of knowledge to
301
offer clinicians. However, to date, this knowledge has and in the organs they serve.2 Alexander was the first
not been well synthesized. This chapter provides read- to actually record reflex sympathetic discharges fol-
ers with information concerning somatoautonomic re- lowing somatic stimulation,3 and his work was soon
flexes that will improve their understanding of the ef- confirmed by others.4–6 Most early animal studies of
fects of SMT on the autonomic nervous system (ANS). somatoautonomic reflexes share three common fea-
tures of experimental design:
WHAT IS A SOMATOAUTONOMIC OR
1. Investigators most often chose to stimulate the eas-
SPINOVISCERAL REFLEX?
ily accessible limb tissues, rather than more central
A somatoautonomic reflex is elicited when stimula- sites, such as the trunk, which are often obscured
tion of somatic tissue (the musculoskeletal system and by monitoring and support equipment (e.g., tra-
the dermis of the skin) is manifested as an alteration cheal cannulas or catheters into the neck vessels).
in ANS function. A spinovisceral reflex is a type of 2. Cardiovascular responses were frequently mea-
somatoautonomic reflex in which stimulation of the sured and cited because they are relatively easy
spinal column alters visceral function. to obtain and of clinical importance.
There are numerous clinical examples of soma- 3. Most experimental models used anesthetized ani-
toautonomic reflexes. One is the paralytic ileus, a con- mals in order to reduce the influence of emotional
dition marked by abdominal tenderness and disten- factors on their results.
sion, absence of bowel sounds, and flatus, as well as
nausea and vomiting. This condition may be an im- These three aspects of experimental design were es-
portant clue to the existence of an occult spinal injury, sential to the successful investigation of somatoau-
such as a fractured vertebra, impairing the function tonomic phenomena, but also introduced biases that
of the ANS. Another example of a somatoautonomic need to be considered when extrapolating their results
reflex is the ciliospinal reflex, in which the pupillary to clinical practice. Additionally, these aspects of de-
response to painful stimulus is used as a diagnostic sign favored results that were not supportive of the
procedure for verifying the integrity of the cervical many espoused clinical observations following SMT.
sympathetic fibers. Specifically, in early investigations it had fre-
In the absence of pain, the presence of ANS- quently been observed that transection of the cervi-
associated signs and symptoms may also be a useful cal spinal cord eliminated somatosympathetic reflex
indicator of disease, especially in patients with spinal discharges. Consequently, it was assumed that these
cord injuries. Somatoautonomic reflexes have been reflexes were mediated at the supraspinal level and
used with some success in the management of mic- interrupted if the connection between the spinal cord
turition and defecation in infant and spinal cord injury and brain was severed. This would argue against the
patients. The presence of somatoautonomic reflexes is concept of segmentally organized reflexes causing lo-
well established, both on the basis of clinical phenom- cal visceral dysfunction in response to local spinal dys-
ena and on physiologic experiments in animals and function. Later, however, Beacham and Perl were able
humans.2 A review of modern neurophysiologic stud- to demonstrate somatosympathetic reflex discharges
ies shows that many of the reported effects of spinal of spinal origin in spinalized cats.7,8 Since then, many
manipulation on visceral disorders—previously dis- investigators have confirmed the existence of both
missed as impossible—in fact may be related to so- spinal and supraspinal reflex centers (Fig. 16–1) in
matoautonomic reflexes and are deserving of further central nervous system (CNS)-intact preparations.9–11
investigation. In particular, it is reasonable to propose As we now understand, the ability to demonstrate
that noxious stimulation of spinal tissues may disturb spinally mediated reflexes depends most importantly
visceral function and, conversely, relief of spinal dys- upon recording from the appropriate segment—
function may have a therapeutic effect on the func- specifically, recording from an efferent nerve at or
tion of internal organs. Additionally, there is growing close to the same segmental level as the afferent nerve
evidence from animal experiments to support the hy- which is being stimulated.
pothesis that dysfunction at particular levels of the In general, it remains a common observation that
spine may provoke dysfunction of related organs. stimulation of forelimb tissues produces much the
same results as stimulation of hind limb tissues. This
occurs despite differences in their levels of spinal
EARLY MODELS OF THE SOMATOAUTONOMIC
innervation. It would therefore appear natural to
REFLEX
conclude that spinally mediated somatoautonomic re-
Numerous investigations have revealed that both in- flexes are indifferent to the segmental level of the stim-
nocuous and noxious stimulation of somatic tissues ulation. This, in turn, would argue against the hypoth-
evoke reflex responses in autonomic efferent nerves esis that biomechanical dysfunction at a particular
SOMATOAUTONOMIC REFLEXES 303
FIGURE 16–1. In the CNS-intact cat, electrical stimulation of the L2 spinal nerve produces two reflex responses in the L2 white ra-
mus: an early, spinally mediated response and a late, supraspinally mediated response. Stimulation of the superficial peroneal nerve
(SP ), a hind limb nerve, produces only the late supraspinally mediated response. In spinalized animals, the supraspinally mediated
reflex is abolished, and only local stimulation of the L2 spinal nerve continues to produce the spinally mediated reflex discharge.
(Modified with permission from Sato A, Schmidt RF. Spinal and supraspinal components of the reflex discharges into lumbar and thoracic white rami.
J Physiol 1971;212:839–850; and Sato A. Spinal and medullary reflex components of the somatosympathetic reflex discharges evoked by stimulation of the
group IV somatic afferents. Brain Res 1973;51:307–318.)
level of the spine is likely to be associated with vis- mediated spinovisceral reflex. Although intriguing,
ceral dysfunction at approximately the same level. whether these results are applicable to articular struc-
However, when one examines in detail stimulation tures, and especially to tissues of the spine itself, re-
of paraspinal tissues, a different picture emerges. mains to be seen.
A seminal work in this regard is that of Kimura
et al.12 who demonstrated that in CNS-intact anes-
OBSERVATIONS FROM ANIMAL EXPERIMENTS
thetized rats, noxious mechanical stimulation of the
skin elicited significant responses in both heart rate Far and away the majority of animal studies have
and blood pressure (Fig. 16–2). As would be predicted involved stimulation of limb tissues, particularly su-
from previous research, these responses showed a perficial tissues. In general, it has been found that nat-
clear segmental tendency, with the strongest re- ural stimulation of nociceptors, or electrical stimula-
sponses coming approximately equally from stimulation sufficient to recruit unmyelinated C fibers, has
tion of the hind paws or forepaws. It should be noted been most effective in eliciting consistent somatoau-
that pinching virtually anywhere produced some re- tonomic reflex responses.13 Reflex effects have been
sponse. In spinalized animals, however, the segmen- demonstrated throughout the cardiovascular system,
tal tendency was altered but exaggerated. Thus, in as well as in the digestive system, urinary system, en-
spinalized animals, limb stimulation still gave signif- docrine system, and immune system.2 Not surpris-
icant but relatively weak responses in, for example, ingly, in anesthetized animals, innocuous stimulation
heart rate, while stimulation in the thoracolumbar produces either weak, inconsistent responses or no re-
region produced much-enhanced reflexes. Further- flex at all. In particular, stimulation of group Ia fibers
more, stimulation on the right side gave a significantly (from muscle spindles) or group Ib fibers (from Golgi
greater response in heart rate than stimulation on the tendon organs) has normally shown virtually no effect
left side. This work still stands as the most convincing on ANS activity or visceral function.14 Beyond these
demonstration of a segmentally organized, spinally generalizations, it must be recognized that tissues
FIGURE 16–2. In the CNS-intact anesthetized rat, noxious mechanical stimulation of virtually any body area produces a reflex
response in heart rate. With spinalization, it becomes obvious that stimulation of areas served by afferents entering the cord
at or adjacent to the level of sympathetic outflow to the heart produces the most profound responses. Left panels show sample
recordings from a single animal, right panels show averages of six trials. (Reprinted with permission from Kimura A, Ohsawa H, Sato A,
Sato Y. Somatocardiovascular reflexes in anesthetized rats with the central nervous system intact or acutely spinalized at the cervical level. Neurosci Res
1995;22:297–305.)
differ in their sensitivities to stimulation and may also or lower thoracic spine produces changes in the mon-
differ in their propensities to elicit reflex responses. itored parameters that outlast the length of stimula-
This has particular relevance to the stimulation of limb tion. These effects are the result of activation of spinal
tissues. afferents. However, it is unclear whether the forces
In anesthetized cats, it has been shown that move- applied, from 0.5 to 3.0 kg, should be characterized as
ment of the knee joint within its normal physiolog- noxious or innocuous.
ical range (Fig. 16–3) has no effect on blood pres- A study of the effects of mechanical spinal stimu-
sure or heart rate.15 However, forced movement, for lation on gastrointestinal myoelectric activity in con-
example, forced rotation beyond the normal physio- scious rabbits revealed that displacement of a mid-
logical range, produces significant increases in these thoracic vertebra could have inhibitory effects on
parameters. Furthermore, these responses are greatly gastrointestinal activity.17 Interestingly, there ap-
exaggerated in the acutely inflamed joint, where even peared to be a segmental organization to the reflex
movement within the normal range produces reflex response, with smaller effects achieved by upper tho-
increases in blood pressure and heart rate. racic or thoracolumbar stimulation. Heart rate was ap-
parently unaffected, suggesting that the stimulation
Mechanical Stimulation of the Spine was not particularly painful.
Because limbs and peripheral joints are easily accessi-
ble, relatively little work has been conducted on spinal Noxious Chemical Stimulation of the Spine
and paraspinal tissues. The first physiologic study of An alternative animal model that has proven quite
the effects of spinal joint stimulation on autonomic useful involves injecting a small volume of capsaicin,
function was conducted by Sato and Swenson, who in- a pungent component in hot peppers that specifically
vestigated the effects of mechanical stimulation of the excites polymodal nociceptors, into interspinous tis-
spine on blood pressure, heart rate, and renal sympa- sues of the anesthetized rat. Because injection of the
thetic nerve activity in anesthetized rats (Fig. 16–4).16 same volume of saline normally produces no sig-
The application of lateral stress to the lower lumbar nificant reaction, researchers can be confident that
FIGURE 16–3. In the normal knee joint of the anesthetized cat, flexion and extension within the physiological range (rFE) have
no effect on heart rate or blood pressure in these sample recordings. Forced internal and external rotation (OR/R) cause reflex
increases in these parameters. In the inflamed knee, the response to noxious mechanical stimulation is exaggerated, and even
previously innocuous movement causes reflex increases in heart rate and blood pressure. (Reproduced with permission from Sato A,
Sato Y, Schmidt RF. Changes in blood pressure and heart rate induced by movements of normal and inflamed knee joints. Neurosci Lett 1984;52:516–560.)
FIGURE 16–4. Mechanical deformation of the spine causes reflex alterations in renal nerve activity, heart rate, and blood pressure
in the anesthetized rat. The responses are qualitatively and quantitatively different in CNS-intact, as opposed to spinalized, animals.
(Modified from Sato A, Swenson R. Sympathetic nervous system response to mechanical stress of the spinal column in rats. J Manipulative Physiol Ther
1984;7:141–147.)
injection of capsaicin provides a pure and natural (a) an increase in systemic blood pressure, which ini-
form of painful stimulation in the absence of mechan- tially leads to a passive increase in sciatic nerve blood
ical stimulation. With this model it has been possi- flow, and (b) constriction of the sciatic vasa nervorum
ble to demonstrate spinovisceral reflex effects on car- and a decrease in sciatic nerve blood flow. It would ap-
diac function and sciatic nerve blood flow,18 adrenal pear that, with the long-lasting noxious spinal stim-
nerve activity and catecholamine secretion,19 bladder ulation of capsaicin injection, the reflex constriction
motility,20 and gastric motility.21 Furthermore, partic- of the vasa nervorum becomes fully manifested and
ularly in spinalized animals, it appears that the reflex overpowers the effect of systemically increased blood
response is facilitated when stimulation involves af- pressure.
ferents entering the spinal cord at or close to the level
of sympathetic efferent outflow to the target organ. Blood Pressure and Heart Rate
Blood pressure and heart rate are routinely moni-
Sciatic Nerve Blood Flow tored in animal experiments to ensure adequate anes-
With regard to effects on sciatic nerve blood flow, elec- thetization and well-being. Hence, cardiovascular
trical stimulation of the lumbar sympathetic trunk can effects of noxious paraspinal stimulation are well char-
induce constriction of the vasa nervorum and result acterized, as numerous studies have indicated that
in decreased blood flow.22 Conversely, in CNS-intact noxious stimulation, especially pinching of the paws,
animals, pinching of the forepaws or hind paws nor- leads to increases in heart rate, as one would ex-
mally induces an increase in blood pressure and a pas- pect from a generalized sympathetic response.2 The
sive increase in sciatic nerve blood flow.23 This is con- effects of capsaicin injection of the interspinous tis-
sistent with the general observation that nerve blood sues are distinctly different. In CNS-intact animals,
flow manifests little local autoregulation but rather is capsaicin injection produces an especially sharp and
enslaved to mean arterial pressure. However, in an- transient drop in heart rate.18,23 There is often also
imals spinalized above the lumbar cord to eliminate a brief drop in blood pressure, followed by signif-
supraspinal influences, hind paw pinching produces icant and prolonged hypertension. Vagotomy abol-
no change in blood pressure, but rather a reflex de- ishes the heart rate response, while the blood pres-
crease in sciatic nerve blood flow.23 This suggests that sure response is preserved. Here we apparently have
noxious mechanical stimulation of the hind paw elic- a dramatic parasympathetic reflex that obscures the
its two competing reflexes: (a) a supraspinal reflex expected reflex increase in heart rate due to an ex-
that increases systemic blood pressure and thereby pected increase in sympathetic nerve activity. These
sciatic nerve blood flow, and (b) a spinal reflex that responses are quite different from those reported for
induces constriction of the sciatic vasa nervorum and noxious stimulation of limb tissues.
in this manner produces a decrease in sciatic nerve
blood flow. Normally, in the CNS-intact animal, the Adrenal Function
supraspinal influence predominates and obscures the In both CNS-intact and spinalized animals, noxious
reflex tendency of vasa nervorum constriction. Hence, stimulation of the interspinous tissues also normally
the reflex constriction of the sciatic vasa nervorum leads to increases in adrenal sympathetic nerve ac-
only expresses itself in the spinalized animal. In CNS- tivity and catecholamine secretion.19 It has been pos-
intact animals, saline injection of either the L4-L5 facet sible to confirm both supraspinal and spinal reflex
joints or interspinous tissues produces only slight and responses to stimulation of A and C fibers, with a rel-
transient decreases in systemic blood pressure and sci- atively greater response to thoracic stimulation in the
atic nerve blood flow. Injection of the facet joint with spinalized animal (Fig. 16–6). In this regard, it should
capsaicin produces results that are no different from be noted that the bulk of preganglionic sympathetic
those induced by saline. On the other hand, capsaicin neurons serving the adrenal gland in the rat are lo-
injection of the interspinous tissues produces qualita- cated between the T7 and T10 level of the cord.24
tively and quantitatively different responses, resem-
bling those elicited by noxious mechanical stimulation Urinary Bladder Function
of the hind limb (Fig. 16–5). Specifically, there was Physiologic studies have shown that the resting blad-
an immediate, profound increase in systemic blood der can be made to contract by noxious stimulation
pressure and a matching increase in nerve blood flow. of the perineal skin. Noxious stimulation of other ar-
However, although blood pressure remained elevated eas has proven ineffective.25 This suggests that the
for perhaps 20 minutes or more, nerve blood flow reflex depends upon stimulation within the territory
quickly dropped well below prestimulus levels and of afferent fibers entering the spinal cord at the level
remained there for approximately 20 minutes. This of parasympathetic outflow to the bladder. Microin-
suggests that noxious chemical stimulation of the jection of the interspinous tissues with capsaicin has
interspinous tissues evokes two competing reflexes: shown that stimulation at either the thoracic or lumbar
FIGURE 16–5. Injection of capsaicin into the interspinous tissues of the anesthetized rat causes an increase in blood pressure
(MAP) and thus an initial increase in sciatic nerve blood flow (NBF). However, after several minutes, reflex constriction of the vasa
nervorum becomes completely expressed, causing nerve blood flow to drop even though blood pressure remains elevated. The
dashed line indicates the point of capsaicin injection. (Modified with permission from Budgell B, Hotta H, Sato A. Spinovisceral reflexes evoked
by noxious and innocuous stimulation of the lumbar spine. J Neuromuscul Syst 1995;3:122–131.)
level can produce a brisk response in bladder tone, a spinally mediated, segmentally organized inhibition
this response being mediated at the supraspinal level, of gastric motility that is principally dependent upon
with the efferent limb of the reflex within the pelvic sympathetic fibers traversing the celiac ganglion.
nerves that provide parasympathetic innervation to
the bladder.20 Summary of Findings from Animal Experiments
The experimental model employed in the foregoing
Gastric Function investigations (i.e., capsaicin injection of the inter-
Previous physiologic studies showed that noxious spinous tissues) is in several ways a useful model of
mechanical stimulation of the skin, particularly the back pain. The stimulation is intense and fairly long
abdominal skin, is capable of inhibiting gastric lasting, and can be targeted to specific levels and tis-
motility.26,27 Similarly, noxious chemical stimulation sues. It would certainly be useful to apply this model
of lower thoracic interspinous tissues (Fig. 16–7) re- to other physiological functions, including endocrine
sults in a substantial increase in gastric sympathetic and immune activity. Already, however, we can see
nerve activity and a decrease in gastric tone.21 Signifi- several important generalizations regarding spinovis-
cantly weaker effects are achieved with lower lumbar ceral reflexes. First is that spinal pain is different from
stimulation. The reflex response to thoracic stimula- pain in other structures. It appears that certain struc-
tion is preserved in spinalized animals, somewhat ditures of the spine are acutely sensitive to certain types
minished by vagotomy, and abolished by extirpation of noxious stimulation, and so elicit responses that are
of the celiac ganglion, the principal source of sympa- different from those arising from stimulation of other
thetic innervation to the stomach. This suggests that body parts. It is therefore axiomatic that the bulk of re-
noxious stimulation of interspinous tissues produces search to date into the physiological responses to pain
FIGURE 16–6. Injection of capsaicin into the lower thoracic interspinous tissues of the CNS-intact anesthetized rat causes an
increase in adrenal sympathetic nerve activity and adrenal catecholamine secretion. Although absolute values drop with spinalization,
on a proportional basis, the responses are facilitated in the spinalized animal. The bars under the recordings of nerve activity indicate
the period during which capsaicin was being injected. Nerve activity was recorded as impulses per 5-second period. Adrenal venous
plasma catecholamine levels were recorded as a percentage of preinjection levels. (Reproduced with permission from Budgell B, Sato A,
Suzuki A, Uchida S. Responses of adrenal function to stimulation of lumbar and thoracic interspinous tissues in the rat. Neurosci Res 1997;28:33–40.)
FIGURE 16–7. Injection of saline into the thoracolumbar interspinous tissues of the anesthetized rat produces no significant effect.
However, injection of the same tissues with capsaicin produces a significant increase in gastric sympathetic nerve activity, and a
significant decrease in gastric tone. Significantly weaker responses were obtained with lower lumbar stimulation but, as would be
expected in a segmentally organized reflex, responses were unaffected by spinalization. (Modified with permission from Figure 1 in Budgell
B, Suzuki A. Inhibition of gastric motility by noxious chemical stimulation of interspinous tissues in the rat. J Auton Nerv Syst 2000,80:162–168.)
has limited relevance to pain from spinal structures.

The second important finding from the work we have
described is that in some instances, stimulation of dif-
ferent segmental levels of the spine produces quanti-
tatively different responses.
ANATOMICAL BASIS OF SEGMENTALLY

ORGANIZED SPINOVISCERAL REFLEXES
Early experiments employing limb stimulation
tended to elicit massive generalized sympathetic re-
sponses, with no profound differences between hind
limb and forelimb stimulation. More modern exper-
iments, especially using thoracolumbar stimulation,
show a segmental organization to some somatoauto-
nomic reflexes. This dichotomy is explained by the
cytoarchitecture of the spinal cord.
In general, the soma of preganglionic sympathetic
neurons are located within the intermediolateral and
intermediomedial columns of the spinal cord.28 How-
ever, these cell columns are displaced from the cervi-
cal and lumbar enlargements of the cord that house
the somatomotor neurons serving the limbs. Hence,
afferent information from the limbs has little oppor-
tunity to synapse directly with preganglionic sym- FIGURE 16–8. Afferent information entering the spinal cord
pathetic neurons in the spinal cord. Rather, this in- in the thoracolumbar and sacral regions has the opportunity to
formation must be relayed to supraspinal structures synapse directly with local preganglionic fibers and so produce
that produce an integrated reflex response. Afferent localized reflex responses in, for example, the heart, stomach
information entering the thoracolumbar cord has the and urinary bladder. At the cervical and lumbar enlargements,
opportunity to synapse directly with local pregan- the preganglionic autonomic neurons are displaced, possibly
glionic sympathetic neurons and therefore the poten- to accommodate neurons serving the limbs, and so stimula-
tial to produce a localized response (Fig. 16–8). This tion of limb afferents is unlikely to produce localized spinal re-
flexes. (Reproduced with permission from Figure 95 in Sato A, Sato Y,
tendency is manifested most strongly when moder-
Schmidt RF. The impact of somatosensory input on autonomic functions.
ating descending influences are eliminated by sever-
Rev Physiol Biochem Pharmacol 1997;130:1–328.)
ing the cervical spinal cord. The potential for spinal-
mediated somatoautonomic reflexes is further en-
hanced by the central convergence of afferent input more limited divergence of spinal afferents.31 Labeling
from somatic and visceral structures.29 experiments provide a different perspective in that
In general, the autonomic outflow to organs afferents entering the cord at a particular level may
is organized in a segmental fashion. For example, be seen to diverge quite widely. However, such stud-
with some species variation, parasympathetic pregan- ies indicate the absolute anatomical limit of diver-
glionic neurons serving the bladder are located at the gence without indicating functional importance. Fur-
lumbosacral junction, and preganglionic sympathetic thermore, the bulk of internal projections normally
neurons serving the adrenal glands are localized be- terminate within one or two segments of the entrance
tween T7 and T10.25 Thus, afferent information enter- to the spinal cord. Therefore, of all of the tissues in the
ing the cord at a particular level has a greater potential human body, it is the spinal structures that are most
to elicit reflex responses in a particular organ or set of likely to elicit a segmentally organized (i.e., organ-
organs. The segmental anatomy of the sympathetic specific) reflex response.
nervous system is mirrored to a degree by the obvi- Nonetheless, such logic is a poor substitute for
ously segmental anatomy of the spinal column and its evidence obtained in scientific, controlled clinical in-
afferent innervation. vestigations. Studies in anesthetized animals may be
It was recently demonstrated that the functional viewed as confirming the neuroanatomy of spino-
sensory innervation of the lumbar spinal column from visceral reflexes. However, anesthesia obviously al-
each spinal nerve is limited to no more than three ters at least the supraspinal component of auto-
vertebral levels in the rat.30 In humans, anatomical nomic reflexes and, because of the limits of anes-
evidence suggests a similar or perhaps somewhat thesia, investigations are restricted to acute effects.
Furthermore, anesthetics are generally chosen to pre- or innocuous mechanical stimulation, and the exist-
serve sympathetic activity at the expense of cardiac ing research is primarily phenomenological. That is to
parasympathetic activity. The responses that we elicit say, there are reports of what happens in the clinical
in such models are, therefore, distant from the inte- setting, but little insight into the underlying mecha-
grated phenomena seen in the conscious animal or nisms. While this situation is improving, the student
human. of chiropractic is still currently deprived of credible
The clinical significance of these findings remains human spinovisceral research that might otherwise
unknown. If we wish to explore the physiological sig- illuminate his or her clinical studies.
nificance of relatively innocuous spinal stimulation Not surprisingly, as with early animal experi-
such as those that may result from SMT, or more in- ments, autonomic function in the majority of human
tense chronic noxious stimulation that occurs in most somatoautonomic studies concerns cardiovascular re-
spinal pain syndromes on spinal autonomic reflexes, sponses, with very few references at all to other or-
it is necessary to develop experimental models that gan systems. A brief survey of human spinovisceral
more closely resemble the clinical situation. In partic- studies follows, with specific reference to the effects
ular, it will be necessary to encourage studies in con- of spinal manipulation on human physiology.
scious animals and clinically meaningful human stud-
ies. Such investigations could aid substantially in the Studies on Blood Cells and Blood Chemistry
refinement of diagnostic and therapeutic techniques, Two studies have looked at the effects of spinal ma-
and would be a valuable contribution to the body nipulation on plasma beta-endorphin levels. One35
of scientific knowledge common to all health care demonstrated a short-term increase in beta-endorphin
practices. levels in an asymptomatic group receiving cervical
SMT, when compared to subjects receiving no treat-
ment or sham treatment. However, the cohorts in
OBSERVATIONS FROM HUMAN SUBJECTS
this study were very small, and no further stud-
In conscious humans, cardiovascular responses to ies concerning beta-endorphin have emerged. A sec-
noxious somatic stimulation are well documented32,33 ond study36 used similarly small cohorts and demon-
and understood to be mediated principally by way of strated no response to lumbar SMT, when compared
the autonomic nervous system. In otherwise healthy to no treatment and sham treatment, in patients with
individuals, as in experimental animal models, rela- low back pain. Again, this line of research has not
tively innocuous stimulation normally does not pro- been repeated by other authors. A small, nonrandom-
duce particularly profound physiological responses. ized study37 looked at the effects of cervical SMT on
On the other hand, in patients who have suffered plasma catecholamine levels in asymptomatic young
spinal cord injuries, as in experimental animals that males with mild asymmetry of cervical ranges of mo-
have been surgically spinalized, quite a different pic- tion. This study found no effect of authentic ver-
ture presents itself. High spinal cord injury causes sus sham manipulation on plasma levels of nore-
a net decrease in sympathetic activity below the pinephrine, epinephrine, or dopamine. Two studies
level of injury. Hyperreflexia may develop such have examined effects on plasma substance P lev-
that relatively mild stimulation, for example from a els following thoracic SMT. One study, with credible
distended bladder, may induce even life-threatening numbers of subjects and randomization to treatment,
reflex hypertension.34 These unfortunate clinical phe- demonstrated no response to SMT.38 A second,
nomena confirm that, in humans, both supraspinal smaller study without randomization did demon-
and spinal centers exist to mediate somatoautonomic strate statistically significant changes in substance
reflexes, and that spinal reflex centers are, under some P and tumor necrosis factor with SMT.39 However,
circumstances, capable of eliciting physiologically sig- in this study, the researchers were obliged to dis-
nificant responses to relatively mild stimuli. What re- card data from several subjects because of techni-
mains unclear is whether physiological responses of cal difficulties with their assays. A single study has
any consequence can be elicited in patients without se- looked at the effects of SMT on cortisol levels.40 While
rious cord injuries. It is also unclear whether these re- the cohorts were rather small, overall cortisol levels
flexes occur in response to such stimuli as might arise fell throughout the course of the experiment, regard-
from biomechanical problems of the spine, or such less of whether the subjects received SMT or sham
therapeutic methods as may be directed at biomechan- manipulation.
ical lesions, such as spinal manipulation. Two studies cited above38,39 also examined the ef-
fects of SMT on the activity of phagocytic cells col-
Spinovisceral Research in Humans lected from blood samples taken at intervals prior
Unfortunately, there is almost no physiologic research to and following sham and authentic manipulation.
concerning responses in humans to either spinal pain One study, using an adequate number of subjects,
did demonstrate an enhanced respiratory burst in function, and many studies in animals illustrate the
polymorphonuclear neutrophils and monocytes with neurological and humoral mechanisms that might un-
SMT, as compared to sham manipulation.38 The effects derlie these effects.2 Furthermore, a reliance on in-
on neutrophil activity were confirmed in a subsequent appropriate technology, such as the use of sphygmo-
study.39 manometry to record changes in blood pressure, has
dampened enthusiasm over these results. The move-
Studies on Blood Pressure, Heart Rate, and ment toward continuous measurement of physiologi-
Autonomic Output to the Heart cal parameters, as, for example, with ECG and arterial
At present, only two convincing cohort studies have tonometry, is much more likely to yield results that
examined the effects of SMT on blood pressure, heart are valid within the context of physiologic studies, as
rate, and autonomic output to the heart.41,42 A recent well as being more relevant to the clinical situation.
study employed arterial tonometry to continuously The use of power spectrum analysis of ECG, as cited
measure heart rate and blood pressure responses in above,42 has opened the door to exploration of under-
conscious humans undergoing cervical SMT.41 Previ- lying neurological mechanisms, and this technology
ously, investigators have used sphygmomanometry is being explored by a number of investigators with
to take discrete measures of blood pressure before an interest in SMT. Similarly, studies of responses in
and after treatment. This methodology is flawed be- pupil cycle time (PCT) could provide a productive re-
cause heart rate and blood pressure continually os- search strategy for investigating the effects of SMT on
cillate, both in harmony with the respiratory rhythm, ANS activity (Fig. 16–9).45
and at lower frequencies. Unlike conventional sphyg-
momanometry, arterial tonometry is appropriate for
SUMMARY
the continuous measurement of cardiovascular func-
tion during SMT.43 By using arterial tonometry, instan- 1. Research into the reported beneficial effects of SMT
taneous heart rate and blood pressure changes have on nonmusculoskeletal complaints has been the
been demonstrated in response to chiropractic SMT, primary stimulus to focus attention on the soma-
as opposed to a sham procedure. The effects mea- toautonomic reflex. This area of neurophysiology
sured, however, were in the short term, the subjects in presents a theoretical framework that might ex-
this pilot study were normotensive, and the underly- plain how treatment approaches, such as manipu-
ing physiological mechanisms remain to be resolved. lation, directed at the musculoskeletal system may
An additional controlled study,42 using electrocardio- also have an impact on visceral organ disorders.
gram (ECG) monitoring and power spectral analysis, 2. A somatoautonomic reflex is elicited when stimu-
reported significant changes in both heart rate and lation of somatic tissue (the musculoskeletal sys-
autonomic output to the heart in a cohort of healthy tem and the dermis of the skin) is manifested as
young adults in response to authentic versus sham an alteration in autonomic nervous system func-
upper cervical manipulation. Specifically, SMT was tion. A spinovisceral reflex is a type of somatoau-
associated with a decrease in heart rate and a shift in tonomic reflex in which stimulation of the spinal
the balance of autonomic output to the heart in favor column alters visceral function.
of sympathetic tone. 3. It remains a common observation that stimulation
of forelimb tissues produces much the same results
Studies on Regional Blood Flow as stimulation of hind limb tissues. This occurs
While some degree of autoregulation of blood flow ex- despite differences in their levels of spinal inner-
ists in various tissues, most notably the brain, regional vation. It would therefore appear natural to con-
blood flow must necessarily be influenced by systemic clude that somatoautonomic reflexes are indiffer-
blood pressure. Hence, studies of regional blood flow ent to the segmental level of the stimulation. This
may reflect the net effects of both systemic and local argues against the hypothesis that biomechanical
regulatory mechanisms. A single study has examined dysfunction at a particular level of the spine is
the effects of thoracolumbar SMT on pulse wave ve- likely to be associated with visceral dysfunction
locity in the posterior tibial artery44 and demonstrated at approximately the same level.
no significant effect. The treatment and control cohorts 4. In spinalized animals, limb stimulation results in
were quite small, and no further studies along these significant but relatively weak responses in, for ex-
lines are likely forthcoming. ample, heart rate. Stimulation in the thoracolum-
bar region produces much-enhanced reflexes and
Summary of Findings from Human Experiments stimulation on the right side of the body results
and Future Directions in a significantly greater response in heart rate
Limited human studies therefore indicate that, in than stimulation on the left side. The discovery of
some circumstances, SMT can affect cardiovascular segmental somatoautonomic reflex responses has
FIGURE 16–9. Central reflex pathways of somatosympathetic reflexes induced by stimulation of myelinated (A) and unmyelinated (B)
somatic afferents. The various classes of somatic afferents differ in their propensities to elicit autonomic reflexes. The potencies of
pathways are indicated by the thicknesses of lines in the accompanying figure. Afferent input may lead to facilatory (+) or inhibitory (–)
reflexes of different potencies mediated at supramedullary, medullary, and spinal reflex centers. Basic scientific research necessarily
studies components of this complex system, but recognizes that it is an integrated response that occurs in the human organism.
(Reproduced with permission from Figure 1 in Sato A, Schmidt RF. Somatosympathetic reflexes: Afferent fibers, central pathways, discharge characteristics.
Physiol Rev 1973;53:916–947.)
increased the possibility that treatment directed at

QUESTIONS
one level of the soma can have a unique impact on
visceral function. 1. What is a somatoautonomic reflex?
5. Reflex effects have been demonstrated in animals 2. What is a spinovisceral reflex?
to occur throughout the cardiovascular system, as 3. Why is it that in animal experiments stimulation
well as in the digestive system, urinary system, of limb tissues most often produces generalized
endocrine system, and immune system. Far and rather than segmentally organized (organ-specific)
away the majority of animal studies have involved responses?
stimulation of limb tissues, particularly superfi- 4. Why is it that in animal experiments stimulation
cial tissues. There have, however, been investiga- of somatic tissues served by thoracolumbar affer-
tions on the effects of mechanical stimulation of ents is capable of producing segmentally orga-
the spine on blood pressure, heart rate, and renal nized (organ-specific) reflexes?
sympathetic nerve activity in anesthetized rats. 5. In which organ systems have somatoautonomic re-
6. Unfortunately, there is almost no physiologic reflexes been demonstrated?
search concerning responses in humans to either
spinal pain or innocuous mechanical stimulation,
and the existing research is primarily phenomeno-
ANSWERS
logical. Limited human studies therefore indicate
that, in some circumstances, spinal manipulation 1. A somatoautonomic reflex is a reflex elicited by
may have some effect on cardiovascular func- stimulation of somatic tissue (strictly speaking, tis-
tion and various immune responses. These stud- sue of the musculoskeletal system and the dermis
ies, however, remain controversial, and in many of the skin) and manifesting as an alteration in au-
cases, there is conflict between results from differ- tonomic nervous system function.
ent studies. Until further studies are carried out, it 2. A spinovisceral reflex is a somatoautonomic reflex
is not possible to extrapolate the neurophysiolog- in which stimulation is directed towards tissues
ically demonstrated somatoautonomic reflexes to associated with the spinal column, and the effect
the clinical setting. is manifested in an alteration of visceral function.
3. Where limb afferents enter the spinal cord, there 5. Schaefer H. Central control of cardiac function. Physiol
are few autonomic neurons with which to commu- Rev 1960;40(Suppl 4):213–231.
nicate and elicit local reflexes that might be organ- 6. Weidinger H, Fedina L, Kehrel H, Schaefer H. Uber
specific. Hence, incoming information must first die Lokalisation des “bulbaren sympathischen Zen-
be relayed to the brain in order to elicit a reflex trums” und seine Beeinflussung durch Atmung und
blutdruck. Z Kreisl Forsch 1961;50:229–241.
response. Reflexes originating in the brain tend to
7. Beacham WS, Perl ER. Background and reflex dis-
be generalized. charge of sympathetic preganglionic neurones in the
4. Afferents serving the thoracolumbar tissues enter spinal cat. J Physiol 1964;172:400–416.
the spinal cord in a region where there are many 8. Beacham WS, Perl ER. Characteristics of a spinal sym-
clusters of autonomic neurons providing output to pathetic reflex. J Physiol 1964;173:431–448.
specific organs. Consequently, the potential exists 9. Coote JH, Downman CBB. Central pathways of
to generate segmentally organized reflexes. some autonomic reflex discharges. J Physiol 183:714–
5. In animal models, somatoautonomic reflexes have 729.
been demonstrated in the cardiovascular system, 10. Sato A, Tsushima N, Fujimori B. Reflex potentials of
digestive system, urinary system, endocrine sys- lumbar sympathetic trunk with sciatic nerve stimula-
tem, and immune system. In humans, the best ev- tion in cats. Jpn J Physiol 1965;15:532–539.
11. Sato A, Schmidt RF. Spinal and supraspinal compo-
idence of somatoautonomic reflexes, particularly
nents of the reflex discharges into lumbar and thoracic
spinovisceral reflexes, is seen in the cardiovascu- white rami. J Physiol 1971;212:839–850.
lar system. 12. Kimura A, Ohsawa H, Sato A, Sato Y. Somatocardio-
vascular reflexes in anesthetized rats with the central
nervous system intact or acutely spinalized at the cer-
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C H A P T E R
17
CLINICAL BIOMECHANICS
AND PATHOMECHANICS OF
THE CERVICAL SPINE
Gary Greenstein
O U T L I N E
INTRODUCTION Ligaments of the Cervical Spine
BIOMECHANICAL PROPERTIES OF THE Ligament Biomechanics
CERVICAL SPINE Intervertebral Disc
Range of Motion Biomechanics of the Intervertebral Disc
Intersegmental Motion KINETICS OF THE CERVICAL SPINE
Flexion/Extension Axioscapular Muscles
Cervical Spine Clinical Anatomy and Its Relationship Trapezius
to Motion Levator Scapulae
Vertebral Processes Cervical Spine Intrinsic Muscles
Transverse Foramen and Vertebral Artery Splenius Cervicis and Capitis
Articular Processes of the Typical Cervical Spine Lateral and Anterior Cervical Musculature
(Facet Joints) Cervical Spine Muscular Function
Cartesian Coordinate System and Cervical PATHOMECHANICS OF THE CERVICAL SPINE
Spine Motion Soft-Tissue Injuries
Atypical Cervical Vertebrae Pathomechanical Effects on Soft Tissues
Atlas Whiplash Injuries
Axis SUMMARY
Zygapophyseal Joints and Uncovertebral Cleft QUESTIONS
(Luschka Joints) ANSWERS
Instantaneous Axis of Rotation of KEY REFERENCES
the Cervical Vertebrae REFERENCES
BIOMECHANICS OF THE SOFT TISSUES
IN THE CERVICAL SPINE
3. To discuss the different anatomic structures that

OBJECTIVES
contribute to the biomechanical properties of the
1. To introduce the basic principles and nomencla- cervical spine.
ture of importance in studying cervical biome- 4. To review the kinematics and kinetics of the cervi-
chanics, including concepts such as elasticity, load- cal spine with reference to global range of motion
ing, and range of motion. and intersegmental ranges of motion.
2. To discuss the different methods and their short- 5. To examine the role of intrinsic and extrinsic mus-
comings for measuring global range of motion of cles in the normal biomechanics of the cervical
the cervical spine. spine.
315
6. To discuss the basic concepts of cervical spine path- of these forces are measured by load–deformation
omechanics, with particular reference to whiplash curves. The effects of the loads on the microstruc-
injury. ture (internal forces) of the material being evaluated
are described by stress/strain curves. Stress is de-
pendent upon the force applied per unit area. Cal-
INTRODUCTION culation of this term requires that the researcher be
able to determine the cross-sectional area of the ma-
The cervical spine may be considered the pillar for the terial as loads are being applied. Strain is defined
head. Its extensive ranges of motion permit the head in terms of the change in length of a material ver-
to position in space the motor and sensory appara- sus its original length, and is measured as a percent-
tuses for hearing, vision, smell, taste, and related lin- age of change. Damping is the internal response of
gual and labial sensations, and contend with the sur- viscoelastic materials to load rates. Human tissues
rounding environment.1 The cervical spine’s global respond differently to loads applied over long peri-
ranges of motion determine head position. The ranges ods versus loads applied quickly. The purpose of the
of global motion and intersegmental motion that occur tissue response is to disperse loads and prevent in-
in the cervical spine are governed by the interplay of creases in stress that can cause tissue rupture or bone
the shape and structure of the cervical vertebrae, discs, fracture. Loads applied over long periods allow fluid
zygapophyseal joints, and muscles. Cervical spine dispersion, whereas loads quickly applied cause an
function is an interplay of neurological programming, increase in tissue stiffness.2 An example of the re-
muscle response, and joint motion that produces hu- sponse of a viscoelastic tissue to loads applied over
man motion. a long period is seen in the intervertebral disc. Early
This chapter presents the current knowledge on in the day, a person is slightly taller than at the end
the normal and abnormal biomechanics of the cervi- of the day. The fluid within the disc relocates over the
cal spine. It begins with a general overview of com- course of the day in response to the loads applied, and
mon biomechanical terminology and an examination so the height of all the intervertebral discs decreases
of how science approaches the complexity of cervical slightly. This phenomenon is called creep. Relaxation
spine motion and function. Following this synopsis is the tissue response to prolonged tensile loads and
is a presentation of the kinematics and kinetics of the is measured by the length–tension curve. Initially, tis-
cervical spine and a discussion of how these two areas sue stiffness is high, producing a steep slope. Over
of biomechanics have contributed to the understand- time, the tissue fluid redistributes and the stiffness
ing of its function. The pathomechanics of the cervical
spine are presented in the last section of this chapter.
Tensile
Force
BIOMECHANICAL PROPERTIES OF THE Plastic C
CERVICAL SPINE
Failure
All soft-tissue and bony structures are viscoelastic ma- B
terials, meaning they possess both elastic and fluid
Elastic
properties. All external forces (e.g., compression, ten-
sion, and shear) affect the tissues they are applied
to. These effects are described in load–deformation
curves that explain the elastic, plastic, and failure
properties of the tissue being evaluated. The exter-
Toe
nal loads applied by the environment cause internal
property changes that are measured by stress/strain A
O
curves, damping, creep, relaxation, and hysteresis.
Three types of external loads are applied to the cer- Displacement
vical spine by the surrounding muscular structures:
FIGURE 17–1. Typical force/displacement curve of a vis-
compression, tension, and shear. Compression is de-
coelastic material during tensile forces. Incorporated into the
fined as equal loads applied toward each other and
graph is the stiffness displacement during tensile forces (dot-
perpendicular to the cross-sectional area of the tissue ted line). Between O and A the curve is nonlinear and is named
being studied. Tension is the application of equal and the toe region (neutral zone) and shows a gradual increase in
opposite forces that are applied perpendicular to the stiffness. AB is the linear phase (elastic phase) with constant
tissue’s cross-sectional area, and shear is the applica- stiffness; BC is the plastic phase (traumatic phase) and de-
tion of equal and opposite loads (forces) that are par- notes a decrease in material stiffness; and C denotes material
allel to the cross-sectional area. The external effects failure with zero stiffness.
CLINICAL BIOMECHANICS AND PATHOMECHANICS OF THE CERVICAL SPINE 317
TABLE 17–1. Average Global Ranges of Motion radiography, the mean ROM for flexion/extension
in the Cervical Spine was 93 degrees and total left-to-right lateral flexion
was 90 degrees.5 This suggests that some of the motion
Motion Normal Value (Degrees) that Dvorak reported occurred in the thoracic spine.
The thoracic spine contributes to cervical spine mo-
Flexion 45–75 tion and should be evaluated by the clinician.
Extension 35–70 Cervical spine rotation occurs primarily at the C1-
Lateral flexion 35–50 C2 segment. Clinically, this motion can be isolated
Rotation 70–90 from that of the rest of the cervical spine by full cer-
vical spine flexion.5 Full flexion locks the zygapophy-
seal joints of the lower cervical spine, preventing ro-
tation. In this position, Dvorak and coworkers found
dissipates. Therapeutic stretching techniques use this that average rotation at C1-C2 ranged from 66 to 75
biomechanical phenomenon to lengthen muscle (e.g., degrees and that the range increased with age to 77–85
hamstring stretch). Hysteresis measures the change in degrees.4
energy that is produced by work and is determined
by the area under the curve. Stiffness is the measure- Intersegmental Motion
ment of stress/strain. The more internal stress applied Scientific evaluation of intersegmental motion has
by external forces and the less response of the tissue been difficult. Yet, in the chiropractic profession, this
to strain, the higher the stiffness. The reciprocal of information is valued far more than gross ranges of
stiffness is flexibility that is measured as strain/stress. motion and helps the clinician determine where cer-
Figure 17–1 illustrates a common stress/strain curve vical spine adjustment is needed. Sophisticated sci-
of a viscoelastic material in tension. entific tools have been developed that evaluate the
intersegmental motion (e.g., flexibility machine that
Range of Motion produces a pure moment). Their shortcoming has
A physician’s clinical evaluation of the cervical spine been the use of the functional spinal unit (FSU) as
includes assessment of global ranges of motion, and the factor that is measured. The FSU is an in vitro seg-
the most important consideration in the evaluation ment of the cervical spine composed of the vertebrae
of global kinematics is total range of motion (ROM). and discs from which the muscles and tendons have
Table 17–1 illustrates these ranges for the cervical been removed. The data collected from these studies
spine. Common measuring devices used in clinical illustrate only part of the true intersegmental cervical
practice are the goniometer and inclinometer. Data spine range of motion because the role of muscle is
presented in Table 17–1 are the accepted values for not considered.
ROM. The usefulness of the goniometer depends on Recently, in vivo evaluation with motion magnetic
the proficiency of the examiner. Using more sophis- resonance imaging (MRI) and computed tomography
ticated equipment, Dvorak et al.3,4 found that ROM (CT) has helped to resolve the discrepancies in inter-
decreases with age and active ROM is usually smaller segmental range of motion data. Table 17–3 presents
than passive ROM (5–10%) (Table 17–2). Their re- data that give a clearer picture of intersegmental mo-
search also found that the repeated measures’ variance tion. What should be apparent to the reader is that
was larger in active than in passive measurements intersegmental motion has many variables and that
(12–17 degrees vs. 8–14 degrees). By using motion the data sometimes have standard deviations that are
TABLE 17–2. Changes in global Range of Motion with Age*
Flexion/Extension Lateral Bending Rotation
Age (Years) Male Female Male Female Male Female
20–29 153 149 101 100 184 182

30–39 141 156 95 106 175 186
40–49 131 140 84 88 157 168
50–59 136 127 88 76 166 152
60+ 116 133 74 80 146 154
* In the males evaluated, ranges were consistent until the seventh generation.
Adapted from Dvorak et al.3
Cervical Spine Intersegmental

TABLE 17–3. 2
Range of Motion* 3
Level Flexion Extension
C0/C1 −0.82 ± 4.63 13.97 ± 6.51

C1/C2 5.76 ± 4.44 5.56 ± 4.38
C2/C3 5.10 ± 2.81 3.86 ± 3.20
C3/C4 7.20 ± 3.46 6.10 ± 4.13
C4/C5 7.39 ± 3.65 8.08 ± 4.60
C5/C6 7.49 ± 3.96 7.25 ± 4.74
C6/C7 8.46 ± 4.03 4.32 ± 3.73
* Average and standard deviation are shown. Note the negative number 1
for occiput-C1 during cervical spine flexion. This indicates that extension
occurs at this level during cervical spine global flexion.
Adapted from Kraemer and Patris.6
larger than the mean. This information should alert

the reader that further research is needed. This exam- FIGURE 17–2. The axes of rotation of the saddle-type
ple illustrates the need for clinicians to evaluate both joint formed by the vertebral bodies and uncinate processes.
methodology and results to determine if the informa- (Adapted from Bogduk and Mercer.1 )
tion obtained from a research paper or journal article
is of value to the clinician’s patients. slope anteriorly. This slope is conducive to flexion–
extension of the cervical vertebrae.1 At the superior-
Flexion/Extension lateral borders of each cervical vertebral body there is
Most of the in vivo kinematic studies of interseg- a superior slope (uncinate process) that meets with
mental motion in the cervical spine have focused a convex curvature at the inferior endplate of the
on flexion–extension. The planar motion of flexion– vertebra above. This forms an ellipsoid saddle joint
extension is easier to evaluate scientifically than are that allows a rocking motion in the transverse plane1
lateral bending and rotation. Therefore, plain-film x- (Fig. 17–2). The inferior lip of the upper vertebra and
ray is well suited to studying these motions. Kraemer the uncinate processes join to form the uncovertebral
and Patris6 found that 52% of their subjects displayed joints (Luschka joints). The configuration of the supe-
paradoxical motion at the occiput-C1 level during cer- rior endplate at the anterior and lateral aspects leads
vical spine flexion. At full cervical spine flexion, the to coupling of rotation with translation in the sagittal
occiput-C1 motion ranged from –26 degrees to +13 plane, and coupling of rotation in the horizontal plane
degrees. In addition, they found that the paradoxi- with rotation in the coronal plane. Clinically, cervical
cal motion decreased with age. For subjects younger spine flexion is composed of rotation and translation
than 20 years of age, the average C0-C1 angle on cer- in the sagittal plane as the primary and secondary
vical spine flexion was –9 degrees, with the extension motions. Cervical spine rotation is rotation in the hor-
angle decreasing to nearly zero for ages 40–69 years, izontal plane as the primary motion, with ipsilateral
and converting to flexion for subjects age 70 years and rotation in the coronal plane as the secondary motion.
older. Lateral bending is rotation in the coronal plane with
coupled ipsilateral horizontal rotation.
Cervical Spine Clinical Anatomy and Its
Relationship to Motion Vertebral Processes
There are seven cervical vertebrae: four typical (C3- Seven processes or structures combine with the ver-
C6) and three atypical (C1, C2, and C7). All typical tebral body to make up the bony vertebra: two pedi-
cervical vertebrae have a vertebral body. The cervi- cles, two transverse processes, two laminae, and one
cal vertebrae have the smallest vertebral bodies in the spinous process. The pedicles are oval-shaped struc-
spine and are considered “short-long bones.”1 The su- tures that have a thick medial cortex.7 The pedicles
perior endplate of the cervical vertebral body is gent- extend to form the transverse processes and laminae.
ly curved in the sagittal plane at its anterior aspect to The transverse processes are trough-shaped with an-
form a groove that fits with the inferior lip of the verte- terior and posterior tubercles located on their borders.
bral endplate above. This gentle slope of the endplates The transverse processes face lateral, anterior, and in-
in the sagittal plane causes the intervertebral disc to ferior. Traveling within the trough of the transverse
process is the spinal nerve that is made up of the a subject of ongoing research. Haldeman et al.,10 after
dorsal and ventral primary rami. The laminae extend a retrospective study of the vertebrobasilar dissection
from the pedicle–laminar junction posteriorly and me- literature, were unable to find any variable that identi-
dially to join together to form the spinous process. fied the patient at risk. They were also unable to iden-
The spinous processes are bifid bony structures that tify any specific mechanical trauma, neck movement,
increase the surface area for connection of the thick or type of manipulation that was more likely to precip-
nuchal ligament. The spinal canal is bordered by the itate vertebrobasilar artery dissection. Terrett11 states
posterior aspect of the vertebral body and its inter- that the incidence of vertebrobasilar insufficiency in-
vertebral disc, as well as by the pedicles and laminae. duced by spinal manipulation is very small. The ratio
In the cervical spine, the spinal canal is triangular in is probably around 1 in 1 million cervical chiropractic
shape. The spinal cord, spinal nerve roots, dorsal root adjustments. There may be genetic or environmental
ganglia, lymphatics, and blood supply lie within the factors that make a patient vulnerable to dissection
spinal canal. either occurring spontaneously or during head and
neck motion.
Transverse Foramen and Vertebral Artery
The transverse foramina are located at the lower an- Articular Processes of the Typical Cervical
terior aspect of the transverse groove. The vertebral Spine (Facet Joints)
artery, an extension of the subclavian arteries, ascends There are four articular processes (facets) located at
through the transverse foramina starting at C6, pass- the pedicle–laminar junction. The superior articulat-
ing anterior to the spinal nerves. At C1 the vertebral ing facets of the typical cervical vertebrae are flat struc-
arteries wrap around the posterior aspect of the supe- tures that face 45degrees to the horizontal plane in a
rior articular facet and at the superior vertebral notch posterior direction.12 The inferior articular facets of
enter the foramen magnum and form the basilar artery the vertebra above join with the superior articular
that joins the circle of Willis. Rotation of the head to facets of the vertebra below to form the zygapophyseal
one side has been reported to reduce blood flow in joint (synovial–diarthrodial joint). Along with the in-
the contralateral vertebral artery. There is, however, tervertebral disc, the intervertebral joint surface deter-
conflicting data in this literature that makes an ab- mines the direction and the amount of intersegmental
solute statement about the effect of head movement motion that occurs between the vertebrae.
on vertebral blood flow difficult, and further research The zygapophyseal joint surfaces of the cervical
is needed on this topic. Attempts to assess vertebral spine are covered with hyaline articular cartilage. Be-
artery blood flow using various clinical tests where tween the facets and their hyaline cartilage cover is
the patient’s head is rotated and extended have not synovial fluid secreted from cells within the articu-
shown any predictive value in determining the likeli- lar capsule. The cellular morphology of the hyaline
hood of vertebral injury from neck movement.8 articular cartilage is determined by the stresses ap-
Anatomists have described the vertebral artery as plied by joint motion. From its tidemark to its tan-
having four sections.9 Section 1 runs from the artery’s gential layer, the cells change shape according to the
origin at the subclavian artery to its tortuous path imposed loads. At the tidemark the cells are cuboidal
through the C6 transverse foramen. Section 2 of the in shape. Closer to the tangential layer of the joint
vertebral artery is from the transverse foramen of C6 surface, cellular structure is flatter. The purpose of
to the transverse foramen of C2. The vertebral veins the hyaline cartilage and synovial fluid is to reduce
and sympathetic nerve plexus accompany the artery friction on the joint surface. The coefficient of fric-
in this region. Section 3 begins at the transverse fora- tion in some diarthrodial joints ranges from 0.01 to
men of C2, and makes an acute angle of 45 degrees 0.04. By comparison, the coefficient of friction for ice
as it approaches the C1 transverse foramen. The ver- sliding on ice at 0˚C (32˚F) ranges between 0.01 and
tebral artery at this point wraps around the superior 0.10.13
articular pillar of the atlas to pass through the supe- Two mechanisms, boundary and fluid film, have
rior notch of the posterior arch of C1. The artery sub- been described as the basis for joint lubrication.
sequently passes under the posterior atlanto-occipital Boundary lubrication is adherence of a thin layer of
membrane to begin section 4. It then runs medially synovial fluid sitting on the hyaline articular cartilage.
and pierces the dura and arachnoid mater and travels This thin layer (lubricin) prevents the joint surfaces
through the foramen magnum. Once within the base from ever making contact. Fluid-film lubrication oc-
of the skull, it travels in the subarachnoid space along curs during joint motion. When two nonparallel sur-
the clivus and joins with the opposite vertebral artery faces are moving past each other, a fluid wedge is
to form the basilar artery. formed that is trapped between the two moving sur-
The relationship of cervical manipulation or faces. The two moving surfaces do not make contact
trauma and dissection of the vertebral artery remains because of the lubricant.
Hyaline articular cartilage is deformable and an Y

elastohydrodynamic lubrication is present. During
zygapophyseal joint motion, hyaline cartilage is elas-
tic, producing a wave-type action around the moving
facet. The “wave” increases the cartilage surface area, +Ry
dispersing loads. As deformation of the hyaline ar-
ticular cartilage occurs, fluid is forced into the space
between the surfaces, increasing the fluid’s viscosity.
This mechanism is called boosted lubrication and is
used to further cushion the moving facets to assist in
minimizing the coefficient of friction.
Immature hyaline articular cartilage is relatively
thick. As it matures, its thickness decreases. The X
+Rz
causes for the decrease in thickness are many. One +Rx
can consider normal wear and tear and the change in
the proteoglycan structure to be contributing factors.
The relative water content and collagen concentration Z
vary inversely with age: Water content decreases and
collagen concentration increases.13 Water is held in FIGURE 17–3. The right-handed cartesian coordinate system
place within the cartilage matrix by proteoglycans. is used to define the coupled motion in the spine either around
The proteoglycan protein core and glycosaminogly- or along an axis. The x, y, and z coordinates are presented.
Rotation around an axis to tighten the screw is described as a
cans are longer in young articular cartilage. With ag-
positive direction (+R). Movement along an axis in the direction
ing, the proteoglycan core decreases in length and
of the arrows is positive translation (+T).
the “bottle-brush” appearance of the glycosaminogly-
can becomes dissipated, possibly causing a change
in the biomechanical properties and resilience of the the same direction as the primary motion. However,
cartilage.13 in the atypical cervical spine (occiput-C2) the coupled
Encircling the zygapophyseal joint is the capsule. motion in rotation and lateral bending are contralat-
The fibrous joint capsule consists of two layers. The eral. This coupled motion reversal serves to keep the
deepest layer is perpendicular to the facet plane and eyes level during these motions.
attaches the superior facet to the inferior facet. The
more superficial layer attaches to the ligamentum Atypical Cervical Vertebrae
flavum on both sides. Synovium, an extension of the The atlas (C1) is a unique vertebra in terms of ap-
capsule that produces synovial fluid, is located within pearance and function. The atlas’s superior articular
the joint capsule as a fold or tab that may cover part processes are cup-shaped and meet with the concave
of the hyaline articular cartilage.14 occipital condyles and resemble a cup and saucer. This
cradle-type joint structure allows for minor flexion–
Cartesian Coordinate System and Cervical extension motions (nodding). Flexion is achieved by
Spine Motion the coupled motion of anterior rotation and poste-
In biomechanics, an object’s movements may be de- rior translation. Extension occurs by posterior rotation
fined by a coordinate system. Each coordinate sys- and anterior translation. The concave–convex rule ex-
tem is used to define specific properties of motion. plains this motion. The rule states that rotation and
The most commonly used system is the right-handed translation will be in the same direction when a con-
cartesian coordinate system. The x, y, and z axes are cave structure moves on a fixed convex structure,
perpendicular to each other and can be used to de- and rotation and translation will be in opposite direc-
fine translational motions along the axes or rotational tion when a convex structure moves on a fixed con-
motions around an axis (Fig. 17–3). The coordinate cave structure. If the atlas cradles the occiput, rota-
system clearly identifies the intersegmental primary tion of the occiput on a fixed atlas (i.e., nodding) will
and coupled motions that occur during clinical global be coupled with translation in the opposite direction
ranges of motion in the cervical spine. The literature (Fig. 17–4). Translation in the opposite direction pre-
has focused on cervical spine intersegmental motion vents the condyles from dislocating from the supe-
and the study of spinal kinematics. Table 17–4 presents rior articulating facets of the atlas. Flexion is limited
data on the primary and secondary coupled motions by tensile forces produced by the posterior cervical
of the cervical spine. As noted earlier, during global musculature and by impaction of the submandibular
motions of rotation and lateral bending of the typi- tissues. Extension is limited by the anterior cervical
cal cervical spine vertebrae, the coupled motion is in musculature and the contact of the occiput and C2.
TABLE 17–4.Cervical Spine Intersegmental Muscles of the upper cervical spine cannot physio-
Primary and Coupled Motions logically produce axial rotation or lateral bending of
the occiput on the atlas.1 The deep concavity of the
Primary Motion Coupled Motion atlas superior articular process and the joint capsule
also prevent these motions from occurring.1 No more
Flexion than 2–3 degrees of rotation and lateral bending occur
Occiput-C1 +Rx −Tz in the occiput-C1 joint. These motions are limited by
C1-C2 +Rx +Tz the joint angle of the superior facets of C1. The facets
C2-C3 +Rx +Tz are kidney-shaped and elevated on the lateral aspect,
C3-C4 +Rx +Tz preventing lateral bending and rotation.
C4-C5 +Rx +Tz
C5-C6 +Rx +Tz
Atlas
C6-C7 +Rx +Tz The atlas does not have the same anatomical structure
as the other vertebrae and is a transitional vertebra
Extension
between the skull (occiput) and the second cervical
Occiput-C1 −Rx +Tz
vertebra. The first 25 degrees of flexion–extension oc-
C1-C2 −Rx −Tz
curs between occiput-C1. At C1-C2, the zygapophy-
C2-C3 −Rx −Tz
seal joints are arranged so that more than 50% of cer-
C3-C4 −Rx −Tz
vical spine rotation occurs at this joint. Because the
C4-C5 −Rx −Tz
atlas lacks a vertebral body and contains a large ver-
C5-C6 −Rx −Tz
tebral arch, rotation can easily occur at this level with-
C6-C7 −Rx −Tz
out neural compromise. The shape of the facets also
Left rotation assists in this rotational component and limits flex-
Occiput-C1 +Ry +Rz ion/extension and lateral bending. The axis (C2) is
C1-C2 +Ry ±Ty+Rz just that; it acts as an axis of rotation for C1 during
C2-C3 +Ry −Rz cervical spine rotation. Again, a transitional vertebra,
C3-C4 +Ry −Rz C2 is more like the typical cervical vertebrae at its in-
C4-C5 +Ry −RZ ferior articular facets, with the intersegmental motion
C5-C6 +Ry −RZ between C2-C3 being similar to the typical cervical
C6-C7 +Ry −RZ vertebrae.
Right rotation
Axis
Occiput-C1 −Ry +Rz
C1-C2 −Ry ±Ty−Rz
The atlantoaxial joint provides the majority of axial
C2-C3 −Ry +Rz
rotation of the cervical spine. Rotation of the atlas on
C3-C4 −Ry +Rz
the axis occurs about an instantaneous axis of rota-
C4-C5 −Ry +Rz
tion (IAR) located at the odontoid process.15 Trans-
C5-C6 −Ry +Rz
lation along the y axis and lateral bending in the
C6-C7 −Ry +Rz
opposite direction (z axis) are coupled with rotation
at C1-C2. Evaluation of axial rotation demonstrates
Left lateral flexion that at neutral position the atlas is at its lowest point; it
Occiput-C1 −Rz −Ry then translates upward and reaches its highest point at
C1-C2 −Rz −Ry approximately the mid-range of its total uniaxial mo-
C2-C3 −Rz +Ry tion. At the end of axial rotation it translates slightly
C3-C4 −Rz +Ry downward and snuggles onto the axis1,12 (Fig. 17–5).
C4-C5 −Rz +Ry During rotation of C1 on C2, the coupled motion of
C5-C6 −Rz +Ry axial translation corresponds to the motion of tighten-
C6-C7 −Rz +Ry ing and loosening a screw and is known as the screw-
Right lateral flexion home mechanism of the spine. The coupled motions are
Occiput-C1 +Rz +Ry present because of the shape and orientation of the
C1-C2 +Rz +Ry facet joints. The joint surfaces of the zygapophyseal
C2-C3 +Rz −Ry joint at C1-C2 are biconvex. The superior articulating
C3-C4 +Rz −Ry facets of the atlas are flat but their hyaline articular car-
C4-C5 +Rz −Ry tilage is thickest in the middle, making the contact sur-
C5-C6 +Rz −Ry face convex. Filling the anterior and posterior spaces
C6-C7 +Rz −Ry of the C1-C2 zygapophyseal joints are intraarticular
meniscoids.14 Normal aging causes the meniscoids to
Extension Neutral Flexion
Occiput
C1
FIGURE 17–4. During nodding, the occiput rotates in a +Rx/–Rx direction and is coupled with –Tz/+Tz translation, respectively.
This prevents occiput-C1 dislocation during nodding. The center figure depicts the occipital condyle in the neutral position on the
superior articular facet of C1. On flexion, the head rotates forward and the occipital condyle translates posteriorly. The opposite
rotatory and translatory motions occur on extension.
become fibrotic. The pinching of the meniscoid may alar ligament did not show an increase in axial rota-
be one cause of cervical spine pain. Its release may be tion. Their conclusions state that functional loss of the
one cause of the relief some patients feel after manip- alar ligaments could lead to rotatory instability.
ulation.
During motion, the atlas acts as a passive washer Zygapophyseal Joints and Uncovertebral Cleft
between the head and the rest of the cervical spine.1 (Luschka Joints)
Generally, motions of the atlas are caused by the forces The zygapophyseal joint consists of a joint capsule,
applied to the occipital condyles, the axis, and the rest synovial membrane, synovial fluid, articular cartilage,
of the cervical spine. During cervical spine rotation, and intraarticular meniscoids.14 The material proper-
the sternocleidomastoid concentrically contracts. Its ties of the cervical spine zygapophyseal joints have
insertion is the mastoid process. Forces applied to the not been well investigated. Data is extrapolated from
head cause the occiput to rotate on the atlas, which the material properties of the lumbar spine. The zy-
then applies forces to the rest of the cervical spine. gapophyseal joints respond to multiple load vectors.
Other motions of the atlas are limited by the sur- The zygapophyseal joints play a complementary role
rounding ligamentous structures, the articular cap- with the intervertebral disc, sharing the loads applied
sules, and the lateral masses. Panjabi et al.16 subjected to the cervical spine. Because of the facet direction
an occiput-C3 FSU to axial torque. Using stereopho- of the zygapophyseal joint (45 degrees from the hori-
togrammetry, they sequentially transected the alar lig- zontal), compression, tension, and shear forces are al-
aments and studied the relative motions of occiput-C1 ways present. Any change in joint structure can cause
and C1-C2. After transection of the left alar ligament, the nociceptive fibers located in the capsule and sub-
they found that axial torque increased in both direc- chondral bone to respond, causing pain in the neck,
tions at both joints. Subsequent cutting of the right shoulders, and head.17 The uncovertebral clefts are
not present at birth. They arise late in childhood and
increase in size with age. As they develop, they ex-
tend to meet in the midline to produce a transverse
fissure across the posterior aspect of the intervertebral
disc.18 The cleft forms next to the uncinate processes
and allows for a large degree of movement between
Atlas the vertebral bodies in axial rotation. The clefts also
assist the zygapophyseal joints with the coupling of
lateral bending and axial rotation.
Instantaneous Axis of Rotation of

Axis
the Cervical Vertebrae
The instantaneous axis of rotation is derived from
FIGURE 17–5. Motion of atlas on axis during cervical spine reliable and consistent measurements that define
rotation. At least 45 degrees of cervical rotation occurs at this the axis of rotation of cervical spine motion.19
joint. The translatory coupled motion (±Ty) is depicted by the The IAR is calculated from neutral and full-range
connected dots. (Adapted from White and Panjabi.12 ) radiographs. The IAR is most accurately measured for
seems to be no correlation between the IAR and the

symptomatic segment found by discography and zy-
gapophyseal joint blocks.21,22
Data extrapolation suggests that pain can cause
the intersegmental motion to change, indicating a cor-
responding change in the compression, tension, and
shearing properties of the cervical vertebrae. An in-
crease in posterior muscle tension can cause a pos-
terior and downward displacement of the IAR. The
change in location of the IAR could reduce rotation,
changing intersegmental motion.1
BIOMECHANICS OF THE SOFT TISSUES

IN THE CERVICAL SPINE
The biomechanics of the soft tissues of the cervical
spine are assessed by applying external loads and
measuring the internal load responses of the desig-
nated tissues. Load–deformation curves are used to
evaluate the external load, while stress–strain curves
are used to evaluate the internal response of the tis-
sues. Experimental studies have focused on the exter-
nal load–deformation characteristics of the ligaments,
motion segments, head and neck complex, and whole-
body cadavers. This type of research has been limited
in that the correlation between load sharing of the
disc and stresses and strains of the surrounding tis-
sues during motion in the cervical spine could not be
performed. Research on live human subjects to obtain
FIGURE 17–6. The location of the instantaneous axis of rota- the necessary biomechanical information is ethically
tion (IAR) during flexion–extension motion. Note that descend- problematic. Research has focused on biomechanical
ing the cervical spine, the IAR moves superior. data that would help develop mathematical models
of the cervical spine (finite element modeling). The
finite element model can correlate external loads ap-
flexion–extension because these motions occur along plied to the spine with internal tissue responses and
one plane and the measurements are consistent over has good repeatability and reproducibility.23 This sec-
time.20 During flexion–extension of C3–C7, the IAR tion focuses on data from finite element mathematical
is located progressively higher and closer to the inter- models of the cervical spine ligaments, intervertebral
vertebral disc of that segment (Fig. 17–6). The height of disc, zygapophyseal joints, and uncovertebral joints
the articular pillars seems to be a critical determinant in normal and pathologically functioning tissue.
of the height progression. The IAR is relatively low
at C2-C3 and progressively moves toward the in- Ligaments of the Cervical Spine
tervertebral disc as it descends the cervical spine. How these ligaments function during motion is de-
The ratio between the amount of rotation and trans- termined by their fiber direction, fiber type (col-
lation that occurs in intersegmental motion during lagen:elastin ratio), IAR, and fiber length (origin–
flexion–extension defines the location of the IAR.20 insertion distance). The ligaments of the cervical spine
The IARs for other cervical spine motions are not as share the general function of limiting motion. They
well defined. consist of varying amounts of collagen and elastin
The IAR has been used to determine the qual- that are arranged in a uniaxial direction. Aligned
ity of cervical spine motion. IARs have been evalu- along the y axis, the collagen and elastin fibers of the
ated in patients with cervical headache21 and post- anterior–posterior longitudinal ligaments, ligamen-
traumatic neck pain.22 These studies indicate that the tum flavum, supraspinous ligament, and nuchal lig-
IAR is abnormal in neck pain patients when com- ament resist and limit the global motion of flexion–
pared to normative data, at least at one intervertebral extension in the cervical spine. The ligament matrix
segment. Further analysis revealed that the abnormal content also determines how the ligament responds
IARs are located at the upper cervical levels, yet there to applied loads. The proportion of collagen to elastin
TABLE 17–5. Stress–Strain and Stiffness Characteristics of

the Cervical Spine Ligamentous Structures
Stress (MPa) Strain (%) Stiffness (N/mm)
C2-C5
ALL 8.36 (1.76) 30.8 (5.0) 16.0 (2.7)
PLL 6.29 (2.28) 18.2 (3.2) 25.4 (7.2)
LF 2.64 (0.79) 77.0 (12.9) 25.0 (7.0)
ISL 2.97 (0.76) 60.9 (11.2) 7.74 (1.6)
C5-T1
ALL 12.0 (1.41) 35.4 (5.9) 17.9 (3.4)
PLL 12.8 (3.38) 34.1 (8.8) 23.0 (2.4)
LF 2.64 (0.34) 88.4 (13.1) 21.6 (3.7)
ISL 2.88 (0.74) 68.1 (13.8) 6.4 (0.7)
Key: ALL = anterior longitudinal ligament; LF = ligamentum flavum; ISL = interspinous ligament; PLL =
posterior longitudinal ligament.
determines the stiffness and elastic properties of that ligaments are in tension and limit the amount of cervi-
ligament. The ligamentum flavum has a high propor- cal flexion. During lateral bending the intertransverse
tion of elastin fibers, and this makes the ligament far ligaments limit intersegmental and global motions.
more elastic than the other ligaments of the cervical During left lateral bending the right intertransverse
spine. Being elastic prevents ligamentous buckling. ligament experiences tensile forces and limits motion.
The ligamentum flavum is located in the spinal canal Table 17–5 presents the stress–strain characteris-
(from lamina to lamina) and buckling of this ligament tics of the ligamentous structures between C2 and T1.
would impinge on the adjacent neural tissues. Data depicting the force/deformation characteristics
Ligaments whose fibers are situated along the y from the occiput to C2 are not available in the litera-
axis limit flexion–extension motions in the cervical ture. The table shows that between C2 and T1 the liga-
spine. Their location relative to the IAR and per- mentum flavum (LF) has the highest strain-to-failure
pendicular distance from the IAR will determine the characteristics. This is a result of the high elastin fiber
type and amount of compressive and tensile discontent. Conversely, the interspinous ligament (ISL) is
placement produced during flexion–extension. Dur- the most flexible (lowest stiffness properties). Load–
ing flexion the anterior longitudinal ligament com- deformation properties of the cervical vertebral liga-
presses and buckles and the posterior longitudinal ments are rate-dependent. With an increase in tensile
ligament, ligamentum flavum, intertransverse liga- loading rate, the ligaments develop increased stiffness
ments, interspinous ligament, and nuchal ligament (increase in the slope of the curve). This is a typical
are in tension. During flexion, the greatest amount of characteristic of all viscoelastic tissues and is charac-
resistance occurs in the interspinous ligament.18 Dur- terized as damping.
ing lateral bending the contralateral intertransverse
ligaments produce the most tension. The disc and the Intervertebral Disc
zygapophyseal joints limit rotation in the typical cer-
The intervertebral disc is designed to resist all global
vical vertebrae. From occiput to C2 there are no discs
ranges of motion, including vertebral compression
and the limitations of rotation are governed by the
and tension. The diagonal fiber direction of the an-
capsules, alar ligaments, and tectorial membrane.
ulus fibrosus permits tensile forces to occur during
torque and moment forces. Torque is the application
Ligament Biomechanics of force around the long axis of a structure. All other
Ligaments most often limit tensile forces and are most rotational forces not along the long axis of the struc-
effective when distracted along their fiber direction.24 ture are called moment. The application of rotational
During extension of the cervical spine, the anterior forces (torque/moment) to the soft tissues and bone
longitudinal ligament is in tension and limits the produces compression, tension, and shear stresses and
amount of cervical spine extension. During flexion, strains (Fig. 17–7).
the axis of rotation is between the applied force and the Figure 17–1 illustrates a typical stress–strain
posterior longitudinal ligament, ligamentum flavum, curve during application of tensile forces. This
interspinous ligament, and nuchal ligament. These graph demonstrates typical stiffness characteristics of
causing the cervical disc to be involved with compres-

sion and moment forces.18
Geometric properties of the cervical intervertebral
disc are different from those of the lumbar spine. The
anulus fibrosus does not traverse around the total
perimeter of the disc.25 The disc is well developed an-
Tension
teriorly but tapers posteriorly and laterally toward the
uncinate processes on each side. Also, the criss-cross
Compression arrangement of collagen fibers with each lamella, as
Shear seen in the lumbar spine annulus, is not seen in the cer-
vical annulus. Instead, the anterior fibers run upward
and anterior from the inferior vertebra to the superior
vertebra. Posteriorly, the anulus fibrosus is described
as consisting of a few fibers near the median plane
that are longitudinally oriented. They are gathered in
a lamella approximately 1 mm thick. The posterior
longitudinal ligament covers the thin lamella. Aging
FIGURE 17–7. Presence of compression, tension, and shear
of the cervical intervertebral disc produces transverse
loads applied during torque–moment forces.
fissures at the posterior aspect of the disc. The fissures
commence as clefts from the uncovertebral region,
viscoelastic tissues (soft and hard tissues). The non- progressing medially across the disc and ultimately
linearity of the stress–strain curve is apparent. Point forming transverse fissures by the third decade.26
OA denotes the toe region, representing a highly non- In terms of its biomechanical properties, under
linear curve corresponding to low stiffness. This is pure tension or compression the disc displays the
commonly called the neutral zone in that stress is same stress–stain curvature as other ligamentous
occurring, but there is little if any strain present. In structures. Table 17–6 presents the failure loads of
this phase, there is little motion resistance. AB marks the cervical intervertebral disc under compressive and
the linear phase and is the elastic phase (physio- tensile loads. Extrapolation of the tensile failure load
logic phase) of tissue deformation. BC is the plastic data indicates that the C5-C6 disc fails at low forces
phase, showing a decrease in stiffness characteristic and least stiffness. The significance of this data cannot
of trauma or tissue injury. C is tissue failure (tissue be determined because of the lack of mean and stan-
rupture) and is represented by zero stiffness. Nor- dard deviation data, but further investigation may
mal physiological stresses applied to the tissues of the help to explain the common findings of C5-C6 disc
body are located in the physiological (elastic) phase. changes on MRI in patients with, and without, cervi-
This signifies that viscoelastic tissues will return cal spine pain.
to their original length when loads (stresses) are re- Under laboratory conditions, the vertebral end-
moved. When injury to tissues occurs, the viscoelastic plate ruptures without significant injury to the disc
material enters the plastic deformation part of the material itself during excessive compressive loads.23
stress–strain curve and permanent length changes are The load–displacement and stress–strain characteris-
produced. The injured tissue, when loads are released, tics of the cervical spine are not readily available. The
will not return to its original resting length. However, information provided in this chapter is taken from
in the human body, tissues can heal. Healing con- data recently published in the literature and has not
sists of an inflammatory phase, a reparative phase, gone through the rigors of repeatability.
and a remodeling phase. The biomechanical purpose
of the healing process is to return the injured tissues KINETICS OF THE CERVICAL SPINE
to their original histological structure and mechanical
function. The study of kinetics evaluates the forces that apply
motion to the spine. In the present discussion of mus-
cle activity, the terms proximal and distal attachment
Biomechanics of the Intervertebral Disc sites are used, rather than origin and insertion, in or-
This section discusses the geometric uniqueness and der to emphasize that motion may occur at both ends
some of the biomechanical properties of the cervical of a muscle and that synergist muscle activity is nec-
intervertebral disc. Because of the weight of the head, essary to stabilize an area. Muscle activity is classified
the cervical intervertebral disc is always involved in according to muscle location relative to the axis of rota-
some type of compressive loading. The head load is ec- tion (perpendicular distance—moment arm), the lever
centrically placed with respect to the cervical column, system, and muscle fiber type (slow oxidative, fast
TABLE 17–6. Force, Deformation, and Stiffness Quantities to

Failure During Compressive and Tensile Loads of the Cervical
Intervertebral Disc
Force (N) Deformation (mm) Stiffness (N/mm)
Compressive load
C2-C3 602 1.4 637.5
C3-C4 683 1.5 765.3
C4-C5 777 1.6 784.6
C5-C6 664 1.6 800.2
C6-C7 673 1.7 829.7
C7-T1 910 1.6 973.6
Tensile loads
C2-C3 636 11.4 63.5
C3-C4 636 12.1 69.8
C4-C5 571 9.3 66.8
C5-C6 391 12.7 22.0
C6-C7 505 10.0 69.0
C7-T1 535 11.3 82.2
glycolytic). Muscle-force generation and its relation to Axioscapular Muscles

gravitational pull are classified as concentric (muscle Trapezius The trapezius, the most superficial of the
shortening—forces against gravity), eccentric (mus- cervical spine muscles, is divided into upper, middle,
cle lengthening—forces resisting gravitational accel- and lower sections. The upper fibers have the greatest
eration), and static (force produced without change in effect on the cervical spine. Their concentric action will
muscle length) activities. produce ipsilateral bending, cervical spine extension,
This section discusses the normal biomechanics of and contralateral head rotation. Contralateral head ro-
muscle function in the cervical spine. The discussion tation occurs because of the muscle’s attachment to the
begins with the presentation of the effects of mus- cervical spinous processes. The effect on the scapula is
cle concentric activity studied in anatomy. Further to cause elevation of the shoulder girdle and scapular
discussion focuses on normal muscle activity during protraction during shoulder abduction. During shoul-
active cervical spine motion as evaluated in a physical der abduction, the effect of the trapezius at its proxi-
examination performed by the chiropractic physician. mal attachment sites must be counterbalanced by an-
Muscles rarely, if ever, work alone—they function tagonistic muscles that stabilize the cervical spine. The
in groups to stabilize structures and produce moments middle and lower parts of the trapezius are recruited
in joints (in our case, vertebral joints). Cervical spine during shoulder abduction to help the serratus an-
function depends on muscles working as groups, pro- terior stabilize the scapula against the thoracic cage.
ducing accurate moments and torques, and agonists The greater trapezius activity occurs with upper limb
and antagonists working in patterns to stabilize struc- elevation and contralateral head rotation.
tures and allow proper joint function. Combined mus-
cle activity and proper neurophysiological program- Levator Scapulae The levator scapulae cause shoulder
ming produce coordinated human motion. girdle elevation with some protraction, and internal
The following are general considerations of cervi- rotation of the scapula (glenoid down rotation).27 This
cal spine concentric muscle actions. All neck muscles muscle’s participation during shoulder elevation is
have the action of lateral bending toward the ipsilat- controversial. However, it is generally accepted that
eral side; muscles of the upper cervical spine that cross activity does occur and that its effect on scapular in-
the axis of the atlantoaxial joint have more rotating ternal rotation is counterbalanced by the high activity
functions than the muscles of the lower cervical spine. of the serratus anterior.28 The levator scapulae are in-
There are intrinsic muscles (muscles that are involved volved in cervical spine ipsilateral rotation, in lateral
in cervical spine motion) and other muscles that act on flexion, and, to a degree, in extension. During shoul-
the axioscapular area (shoulder girdle), and some ax- der motions the proximal attachment sites of the lev-
ioscapular muscles affect the cervical spine and head ator scapulae to the cervical spine assist in stabilizing
during motion of the shoulder and upper limb.27 the cervical spine.
The other axioscapular muscles have little effect the nuchal muscles are the six pairs of interspinalis
on cervical spine motion. The rhomboideus minor at- cervicis muscles. These small muscles do not seem
taches to the lowest part of the nuchal ligament and to cause motion but are believed to be cervical spine
to the spinous processes of C7 and T1. Along with proprioceptors.
middle and lower trapezius activity, the rhomboids
seem to be most active during forced scapular retrac- Lateral and Anterior Cervical Musculature
tion and are involved with stability of the thoracic The concentric actions of the sternocleidomastoid
spine during shoulder elevation. During overreach of (SCM) muscles allow flexion, lateral bending, and con-
the shoulder, the thoracic spine develops a lateral C tralateral rotation of the head and neck. The action on
curve toward the ipsilateral side. This is most likely the shoulder girdle is to elevate the clavicle and the
caused by rhomboid attachments to this area and the entire rib cage.27 The SCM muscle is an ipsilateral lat-
excessive protraction motion of the scapula. eral flexor and contralateral rotator, but as the mastoid
process passes medial to the clavicular attachment, the
Cervical Spine Intrinsic Muscles SCM muscle losses its rotation action.
Splenius Cervicis and Capitis Concentric action of the The scalene muscles are divided into the anterior,
splenius cervicis and capitis produces ipsilateral ro- middle, and posterior bellies. Passing between the
tation, lateral bending, and extension of the cervical anterior and middle scalenes are the brachial plexus
spine. The lever arms of the splenius capitis are gener- and subclavian artery. During concentric action, the
ally greater than those of the splenius cervicis and so scalenes are ipsilateral lateral flexors and weak neck
produce more moment. However, the splenius cervi- flexors (anterior scalene).
cis has a rotational influence on the atlas equal to that The longus colli and capitis are small muscles that
of the splenius capitis. Ipsilateral recruitment in the produce flexion and ipsilateral lateral bending of the
splenius capitis muscle occurs with almost all head cervical spine, stabilize the spine, and give proprio-
rotations, but not during lateral bending.27 ceptive feedback.27
The girth of the erector spinae in the cervical spine The cervical intertransversarii muscles consist of
is far less than in the lumbar spine. The iliocostalis cer- seven pairs of muscles connecting transverse pro-
vicis, longissimus cervicis and capitis, and the spinalis cesses from the atlas to T1. These muscles surround
cervicis have short lever arms and are used to pro- the proximal portion of the ventral rami. Because of
duce lower cervical spine stability during neck and their location, they are considered cervical spine lat-
head motions. The cervical transversospinalis muscle eral flexors. Homologous to the anterior intertransver-
group consists of the semispinalis capitis, semispinalis sarii is a small muscle between the anterior arch of the
cervicis, multifidus cervicis, and rotatores cervicis. atlas and the occiput called the rectus capitis anterior.
During global range of motion of both the head–neck Its location and fiber direction suggest that its con-
and shoulder girdle, these muscles act as neck exten- centric action is head flexion and ipsilateral rotation.
sors, contralateral rotators, and cervical spine stabiliz- Homologous to the posterior intertransversarii mus-
ers. There is a low level of electromyographic activity cles is the rectus capitis lateralis. Its attachments are
of the semispinalis capitis with the head in the neutral on the transverse processes of atlas and the occiput.
position. This activity prevents head flexion.27 Passing medial to rectus capitis lateralis is the ventral
Located deep to the semispinalis capitis is the sub- ramus of the C1 spinal nerve.
occipital triangle. The muscles that make up the trian- Other muscles in the neck area are typically not
gle are the obliquus capitis superior and inferior and involved in cervical spine motion. For example, the
the rectus capitis posterior major. Alongside the rectus suprahyoid and infrahyoid muscles are involved in
capitis posterior major is the rectus capitis posterior motions of the tongue, mandible, larynx, pharynx, and
minor. The minor attaches to the dura mater of the oral cavity.27 However, these muscles may produce
spinal cord. It is thought that during upper cervical electromyelogram (EMG) activity during forceful cer-
spine extension the rectus capitis posterior minor pre- vical spine flexion.
vents the dura from buckling and folding into the ver-
tebral canal and spinal cord.29,30 The upper aspect of Cervical Spine Muscular Function
the nuchal ligament also appears to have fibers that The clinician is more interested in the normal function
attach to the dorsal aspect of the dural sheath.31 The of the cervical spine muscles during global ranges of
greater occipital nerve (major branch of the dorsal ra- motion than in concentric muscle action. During the
mus of C2) passes inferior to the obliquus capitis infe- physical examination the physician tries to determine
rior. This muscle’s only action seems to be ipsilateral what anatomical structures are involved in the in-
rotation at the atlantoaxial joint. The obliquus capitis jury with which the patient presents. This information
superior is a weak extensor and a contralateral rota- guides diagnosis and treatment/management proto-
tor of the head at the atlantoaxial joint. The last of cols. Biomechanically, muscle function in the cervical
Posterior in either direction, the contralateral muscle groups

Cervical Resistance
Force produce eccentric activity to lower the head to the
Musculature (Face)
opposite shoulder.
Axis
PATHOMECHANICS OF THE CERVICAL SPINE
(Cervical spine)
One goal of clinical biomechanics is to develop math-
FIGURE 17–8. A type 1 lever system. This system is common ematical models that will describe the reaction of soft
during flexion–extension and lateral bending maneuvers of the tissues, joints, and the intervertebral disc to injury.
spine. The use of mathematical models obviates the need
for human volunteers and attempts to help the clini-
spine follows certain principles. First, muscles work cian develop treatment protocols for different condi-
in groups. Moment arms determine the amount of tions. The use of human volunteers to study cervical
torque that will be applied during a certain motion; spine trauma is ethically problematic and, in practice,
the lever system determines the relationship of the very limited. Research is therefore constrained in the
muscles’ torque to the motion. Hence, the small mus- amount of force that can be applied to human subjects.
cles close to the center of rotation are probably used The major focus of research on cervical spine injuries
as spinal stabilizers and proprioceptors. The amount concerns whiplash forces applied to the neck.
of force produced by these muscles is small and the
moment arms are short, producing little torque. The Soft-Tissue Injuries
larger muscles that have longer moment arms produce Landmark studies in animals have shown that lesions
higher torques and probably play large roles in spinal at the myotendinous junction repair within 1 week,
movement. An important precept would also include and develop nearly normal tension by 7 days after
that any cervical spine motion requiring resistance to injury.32 However, it has proven difficult to develop
gravitational pull will require eccentric muscle activ- a research model that produces a consistent injury.33
ity and synergistic muscles to stabilize the cervical Present data collected by mathematical modeling has
spine joints. For example, when the patient lowers his been used to depict the kinematic behavior of the cer-
or her chin to his or her chest (neck flexion), initial vical spine in response to abnormal forces, obviating
concentric activity in the anterior cervical musculature the need for animal models, cadavers, and human
lasts only a few milliseconds and is followed by eccen- volunteers.34
tric activity of the posterior cervical musculature to
slowly lower the head to the chest. This muscle activ- Pathomechanical Effects on Soft Tissues
ity can be considered similar to the flexion–relaxation Finite element models have been developed to study
phenomenon that occurs in the lumbar spine.31 the effects of facet change and the corresponding re-
There are three basic types of levers, classified ac- sponse of the internal mechanical behavior of the ad-
cording to axis of rotation, force generation of the mo- jacent intervertebral discs. Kumaresan et al.35 and Voo
tion and the load. A type 1 lever system, for exam- et al.36 used mathematical modeling to determine the
ple, in a child’s seesaw (Fig. 17–8) is most commonly effect of facet resection on range of motion and stresses
used during cervical spine motion and explains the on the superior and inferior intervertebral disc. Using
use of eccentric muscle activity. Rotational motion in a C4-C5-C6 model, they found that unilateral and bi-
the sagittal plane (flexion–extension) and the coronal lateral facet resection caused the greatest change in
plane (lateral bending) of the cervical spine are exam- total range of motion and disc stress.
ples of a type 1 lever system. With the patient upright, Other research has evaluated the load sharing
the posterior cervical musculature applies a force that capabilities of the intervertebral disc, longitudinal lig-
resists gravity to lower the head toward the chest. aments, ligamentum flavum, and interspinous liga-
The posterior cervical musculature is applying an ec- ments. Using a C4-C5-C6 finite element model, the re-
centric action to resist gravity. During cervical spine sults indicate that with laminectomy or ligamentous
extension, the posterior cervical musculature applies transection the stresses applied to the surrounding tis-
concentric forces. As the center of mass passes beyond sues increase. The external loads increase to such a
the axis of rotation of the cervical spine, the anterior degree that instability of the cervical spine occurs and
cervical musculature produces an eccentric action at fusion is required.35 Other authors have indicated that
the end of extension. In the coronal plane, moments the ventral region of the disc experiences higher axial
are again generated by the musculature on the oppo- forces in all loading modes; and the dorsal region of
site side of the axis of rotation to the center of mass of the disc–uncovertebral joint experiences higher shear
the object being moved. As the clinician instructs the forces. It has been suggested that the difference in axial
patient to laterally bend the patient’s cervical spine forces between the disc regions is an important factor
in osteophyte formation and disc herniation.23 Using adjustable seats,40 harness belts,41 and collapsible
a nonlinear finite element model, Kumarsen et al.37 steering wheels.
found that segmental and global stiffness increased Modern studies of whiplash biomechanics have
with increasing levels of disc degeneration. They also used high-speed photography and high-speed cinera-
found that stiffness was higher at the degenerated diography to determine the kinematics of the cervical
level than at adjacent levels, and that loads at the disc spine. By using cadavers and human volunteers, these
increased while the loads transmitted through the zy- studies found that posterior rotation of the head oc-
gapophyseal joint and facet pressure decreased. Disc curs between 60 and 100 ms after rear-end impact.
bulge, annulus stress, and fiber strain at the degen- These studies also showed that at no time did the head
erated disc also decreased with increasing severity rotate beyond its physiological limit.42,43
of disc degeneration. The increased load was cen- Agreement also exists between high-speed pho-
tered at the disc–bone interface. This may facilitate tographs and cineradiography of cervical segmental
bony growth leading to osteophyte development. The and intersegmental motion in human volunteers and
changes in the facet loads with degeneration may ex- cadavers.44,45 These studies provide detailed informa-
plain the structural compromise that leads to facet tion on the neck and body motions during rear-end
arthritis in the cervical spine. impact whiplash movements of the body. Between 0
and 50 ms after impact there is no response by the
Whiplash Injuries body. At 60 ms the hips and low back thrust upward
A seminal paper published on whiplash mechanics and forward, forcing the upper trunk to move up-
by Severy et al. in 1955 used human volunteers in ward and forward. The trunk’s upward movement
two rear-impact tests at 13 and 15 kilometers (8.1 and compresses the cervical spine and the forward move-
9.3 miles) per hour.38 They demonstrated the phas- ment displaces the neck and trunk ahead of the line of
ing of acceleration of the volunteer and the vehicle. gravity of the head. Between 50 and 75 ms, the com-
Peak acceleration of the vehicle preceded that of the pression of the cervical spine by the trunk causes the
volunteer’s torso, which, in turn, preceded peak ac- cervical spine to undergo a sigmoid deformation.46 At
celeration of the volunteer’s head. As the torso accel- this time, the lower cervical segments undergo exten-
erated, the head remained relatively stationary, and sion and the upper segments flex. At 120 ms, the center
torso acceleration peaked at approximately 250 ms af- of gravity of the head drops, causing the head to rotate
ter impact. These findings indicated that, as the torso backwards, reaching its peak extension of 45 degrees
moved under an initially stationary head, whiplash and producing a C-shape curve in the cervical spine.
involved inertial loading of the neck. Further research The torso’s upward motion peaks at 200 ms with an
has shown that the maximum neck torque, shear amplitude of 9 cm (3.5 inches).
forces, and axial compression forces during a rear- At 160 ms after the collision, the torso pulls the base
end collision are below levels that might cause ra- of the neck forward, and tension on the cervical spine
diographic evidence of injury.39 Other investigators brings the head forward. At 250 ms, the trunk, neck,
have exposed cadavers and volunteers to rear-end im- and head are descending and descent is complete by
pacts and have found tears in the anterior longitudinal 300 ms. By 400 ms, the head achieves its maximum for-
ligament and zygapophyseal joint capsule, and frac- ward flexion and begins to settle into its original po-
tures in the posterior vertebral body and spinous pro- sition between 400 and 600 ms (Fig. 17–9). With more
cess. These findings have led to the advancement of forceful rear-end impacts the events are the same, but
passenger safety and the initiation of head rests and the magnitude of movement is greater.47
0 MS ~75 MS ~ 120 MS 400 MS
FIGURE 17–9. Events during a rear-end collision. The hashed circles are the centers of rotation (flexion–extension). Arrows depict
the direction of the resultant forces on the head and neck. The spine structures represent the C and S cervical spine curves that
occur at 75 ms and 120 ms, respectively.
Further evaluation of cervical spine motion dur- consider when a rear-end collision occurs. At best,
ing rear-end collision reveals that the mean global one can only estimate soft-tissue injury potential
motion of the cervical spine does not exceed its ro- caused by the automobile and its many uncontrollable
tational physiological limit. However, intersegmental factors.
posterior rotation of the lower cervical spine exceeds
physiological limits at about 100 ms after the colli-
sion. Posterior rotation normally consists of rotation
SUMMARY
around the x axis and posterior translation. However,
translation is not present at this time because the axis 1. All soft-tissue and bony structures are viscoelastic
of rotation has moved superior to its normal location. materials, meaning they possess both elastic and
As the vertebra posteriorly rotates about this high axis, fluid properties that respond to external loading,
its anterior elements rotate superior and the posterior such as compression, tension, and shear. These ef-
elements rotate inferior, causing the vertebral bodies fects are described in terms of load–deformation
to separate anteriorly and the zygapophyseal joints to curves.
jam together.35 The inferior articular processes chisel 2. Several methods are used to determine range of
into the superior articular processes (see Fig. 17–9). motion. Range of motion of the cervical spine de-
The jamming of the facets is caused by the upward creases with age. Active ROM is usually smaller
motion of the torso. This motion may cause injury to than passive ROM and repeated measures vari-
the disc at the endplates and to the facet surfaces of ance is larger in active range measurements than
the zygapophyseal joints, producing neck pain and in passive measurements. Plain-film x-ray is well
headaches.48,49 suited to studying the planar motion of flexion–
Epidemiological studies have reported occupant extension.
head position at the time of impact to be a deter- 3. The primary soft-tissue structures that contribute
minant of injury severity and symptom persistence to the biomechanics of the cervical spine include
in whiplash injury. Axial pretorque of the head and the ligaments, muscles, and the intervertebral
neck increases facet capsular strain, making the cap- discs. Each of these tissues has unique anatom-
sule more susceptible to whiplash injury,50 and head ical structures with their own biomechanical
rotation is the only accident feature that has a statisti- properties.
cally significant correlation with symptom duration.51 4. The coordinate system clearly identifies interseg-
Patients may incur soft-tissue injuries even in a mental primary and coupled motions that occur
low-impact rear-end motor vehicle collision, defined during global ranges of motion in the cervical
as a crash that occurs below 10 miles per hour. Auto- spine. During global motions of rotation and lat-
mobiles are made primarily to withstand high-impact eral bending of the typical cervical spine vertebrae,
collisions. The automobile industry has developed car the coupled motion is in the same direction as the
fenders and bumpers that, at certain velocities, will de- primary motion. However, in the occiput-C2 area,
form (crush, plastic phase). The deformation of these the coupled motion in rotation and lateral bend-
materials allows for energy absorption, which protects ing are contralateral. This coupled motion reversal
the passengers from high rebound (bounce) forces. serves to keep the eyes level during these motions.
Automobile fenders are standardized to withstand 5. All neck muscles have the action of lateral bending
anywhere from 5 to 10 mile-per-hour collisions with- toward the ipsilateral side; muscles of the upper
out permanently deforming. In low-impact collisions cervical spine that cross the axis of the atlantoaxial
there is usually no fender or bumper crush, because of joint have more rotating functions than the mus-
the elastic properties of the automobile, and so there is cles of the lower cervical spine. There are intrin-
greater transfer of energy to the passengers, produc- sic muscles (muscles that are involved in cervical
ing soft-tissue injuries.47 spine motion) and other muscles that act on the
Other variables involve seat and head rest posi- axioscapular area (shoulder girdle), and some ax-
tion. The seat back is made to collapse at certain colli- ioscapular muscles affect the cervical spine and
sion velocities. In the low-impact collision, seat-back head during motion of the shoulder and upper
collapse does not occur and so the seat’s elastic prop- limb.
erties (bounce) needs to be considered in the equa- 6. Cervical spine motion during rear-end collision re-
tion. Headrest position is also of concern. The head- veals that the mean global motion of the cervical
rest should not be more than 2 inches from the head. spine often does not exceed its rotational physi-
Any further distance will cause the headrest to be in- ological limit. However, intersegmental posterior
effective. If the headrest is too low, it will produce rotation of the lower cervical spine exceeds phys-
a fulcrum for the head and may cause further cervi- iological limits at about 100 ms after the collision.
cal spine injury. Hence, there are many variables to This motion may cause injury to the disc at the
endplates and to the facet surfaces of the zy- cervical segments, severely limits the amount of
gapophyseal joints, producing neck pain and torque that they can apply to the vertebrae.
headaches.
KEY REFERENCES
QUESTIONS
Bogduk N, Mercer S. Biomechanics of the cervical spine.
1. Name and describe the physical phenomenon I: Normal kinematics. Clin Biomech (Bristol, Avon)
by which intervertebral disc height normally de- 2000;15:633.
creases throughout the course of the day. Bogduk N, Yoganandan N. Biomechanics of the cervical
spine. Part 3: Minor injuries. Clin Biomech (Bristol, Avon)
2. Why is it difficult to extrapolate from experimental
2001;16(4):267.
models that use functional spinal units (FSUs) to Cramer GD. The cervical region. In: Cramer GD, Darby SA,
in vivo movement of the human spine? eds. Basic and clinical anatomy of the spine, spinal cord, and
3. What is the origin of the coupled motions that oc- ANS. St. Louis: Mosby, 1995.
cur at individual motion segments? Cusick JF, Pintar FA, Yoganandan N. Whiplash syn-
4. During global or intersegmental motion, what de- drome: Kinematic factors influencing pain patterns.
termines the magnitude of compressive or tensile Spine 2001;26(11):1252.
forces acting on an adjacent ligament? Kumaresan S, Yoganandan N, Pintar FA, et al. Contribution
5. Why are the smallest and deepest intersegmental of disc degeneration to osteophyte formation in cervi-
muscles of the cervical spine unlikely to play a cal spine: Biomechanical model. J Orthop Res 2001;19(5):
significant role in creating cervical motion? 977.
Murphy DR. Conservative management of cervical spine syn-
dromes. New York: McGraw-Hill, 2000.
Panjabi MM, White AA. Biomechanics in the musculoskeletal
ANSWERS system. Philadelphia: WB Saunders, 2000.
1. The physical phenomenon is called creep. In the in- Weinkelstein BA, Nightingale RW, Richardson WJ, Myers
BS. The cervical facet capsule and its role in whiplash
tervertebral disc, it refers to the gradual movement
injury. Spine 2000;25(10):1238.
of fluid, principally from the disc into the vertebral Whiting WC, Zernicke RF. Biomechanics of musculoskeletal in-
body, as a result of the pressure applied to the disc jury. Champaign, IL: Human Kinetics, 1998.
when a person is in the upright position. Yoganandan N, Kumaresan S, Pintar FA. Biomechanics of
2. The FSU consists of vertebrae, intervertebral discs, the cervical spine. Part 2. Cervical spine soft tissue
and spinal ligaments. However, other tissues that responses and biomechanical modeling. Clin Biomech
affect spinal movement, most importantly the (Bristol, Avon) 2001;16:1.
muscles and tendons, have been removed. Hence,
data from FSUs cannot account for the actions of
these other tissues, and it is well understood that REFERENCES
muscles in particular have significant effects on
spinal biomechanics. 1. Bogduk N, Mercer S. Biomechanics of the cervical
3. Coupled motions are a product of (a) the anatomy spine. I: Normal kinematics. Clin Biomech (Bristol, Avon)
2000;15:633.
of the vertebrae and adjacent tissues and (b) forces
2. Panjabi MM, White AA. Biomechanics in the muscu-
applied by muscles. As an example of (a), because loskeletal system. Philadelphia: WB Saunders, 2000.
the facet joint surfaces are neither perfectly flat nor 3. Dvorak J, Antinnes JA, Panjabi MM, Loustalot D,
perfectly aligned in any one plane, rotation about Bornomo M. Age and gender related normal motion
any axis cannot be perfectly symmetrical—a sec- of the cervical spine. Spine 1992;17(10S):S393.
ondary “coupled” motion is introduced. As an ex- 4. Dvorak J, Panjabi MM, Grob D, Novotny JE, Antinnes
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6. Kraemer M, Patris A. Radio-functional analysis of the
ament connecting two or more moving elements
cervical spine using the Arlen method. Part II. Para-
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C H A P T E R
18
CLINICAL BIOMECHANICS
AND PATHOMECHANICS OF THE
LUMBAR SPINE
Partap S. Khalsa
O U T L I N E
INTRODUCTION Intervertebral Disc
BIOMECHANICAL DEFINITIONS Posterior Structures
AND TERMINOLOGY Functional Characteristics of Facet
Force and Force Vectors Capsule
Torque (Moment) Facet Joint and Capsule Loading
Loading Longitudinal Ligaments
Bending Moments Muscles
Stiffness LUMBAR BIOMECHANICS
Elasticity Functional Spinal Motion Units
Strain Regional Lumbar Biomechanics
Stress LUMBAR PATHOMECHANICS
Material Properties (Relationships Between Stress Scoliosis
and Strain) SUMMARY
Viscoelasticity QUESTIONS
Fatigue ANSWERS
LUMBAR SPINE ANATOMY AND KEY REFERENCES
BIOLOGY REFERENCES
Vertebra
1. To develop basic understanding of key concepts in Biomechanics is the science that examines forces
biomechanics. acting upon and within a biological structure and
2. To present structure–function relationships of the effects produced by such forces.1
lumbar spine.
3. To explain biomechanical interactions of the lum- While the origins of biomechanics certainly traverse
bar vertebra, intervertebral disc, ligaments, facet millennia, arguably the “Father of Spine Biomechan-
capsule, and muscles. ics,” Giovani Alfonso Borelli, hails from the seven-
4. To describe generic biomechanical testing meth- teenth century.2–4 It was Borelli who published, in
ods for intact spines and functional spinal his 1680 classic text, De Motu Animalium, the concept
units. that movement was the result of muscles using the
5. To explore issues in pathomechanics. bones as levers (Fig. 18–1). The ideas of force and
335
chapter and typically involves sequential studies of

applied calculus, linear algebra, engineering statics,
engineering dynamics, fluids, continuum mechanics,
mechanics of materials, viscoelasticity, biomechanics
itself, and advanced topics typically taught only at the
graduate level. Nonetheless, this chapter should serve
as a good overview of the subject.
BIOMECHANICAL DEFINITIONS
AND TERMINOLOGY
A patient walks painfully into your examining room.
She is antalgic, bent slightly forward and to the left,
and is averse to attempts to straighten up because
of increased pain. Clearly, her lumbar spine must be
loaded differently than if she were standing straight.
By examining the biomechanics of her situation, we
can gain insights into potential causes of her condi-
tion, and help formulate diagnoses and possible treat-
ment approaches.
Force and Force Vectors

In the scenario described above of the antalgic pa-
tient, it is intuitively obvious that her spine must be
loaded differently (Fig. 18–2A). But what is meant by
load and how is it defined? In this case, by personal
FIGURE 18–1. A figure from Giovanni Borelli’s classic text, De and clinical experience, it is clear that her weight has
Motu Animalium, published in 1680. (Reproduced with permission been distributed differently and hence she must ac-
from Maquet P. Iatrophysics to biomechanics. From Borelli (1608–1679) commodate for it or she would risk falling over. Intrin-
to Pauwels (1885–1980). J Bone Joint Surg Br 1992;74:335–339.) sically, some sort of force is acting that she must coun-
terbalance. The force is developed as a consequence of
displacement still characterize our current concepts the influence of earth’s gravity, and clearly would not
of biomechanics. In chiropractic, both the lesion that be present if she were in outer space, away from any
we describe as a vertebral subluxation and the spinal large masses (such as planets). Furthermore, it is in-
adjustment by which it is treated are fundamentally tuitive that if she were larger in size (i.e., had greater
described by biomechanics. Hence, it behooves chiro- mass), then she would have to exert a greater counter-
practic clinicians and students to develop a working balancing force. Force, then, is a function of the mass
knowledge, if not expertise, in spinal biomechanics as of the object (in this case, the woman’s torso) and the
it relates to the chiropractic discipline. magnitude of its acceleration (in this case because of
This chapter presents general concepts of biome- gravity). For the simplest case, where there is only one
chanics applied to the lumbar spine to facilitate un- possible line of action for a force to operate upon, the
derstanding of clinical disorders that can affect the magnitude of force can be described as:
lumbar spine. Mechanics itself is a subset of physics,
F = ma (18.1)
and the language of physics is mathematics. Mechan-
ical concepts are rigorously defined, most commonly where m is the mass, in standard international (SI)
using calculus. Even though calculus is a required sub- units of kilograms (kg), and a is the acceleration in SI
ject for all chiropractic students, experience has shown units of meters per second squared (m/s2 ).
that it is quickly forgotten when not regularly used. This, of course, is the mathematically trivial case
Hence, its nomenclature can obscure rather than il- of Newton’s second law of motion, which states that
luminate. Therefore simpler approaches will be used an object with a net force on it will accelerate along
herein to present spinal biomechanics. The interested the line of action of that force and proportional to the
reader who desires a more rigorous mathematical ap- magnitude of the acceleration. The SI units of force are
proach is encouraged to examine texts listed in the Key newtons (N) in honor of Sir Isaac Newton, who for-
References, as well as the peer-reviewed literature ex- mulated three basic laws of mechanics. Recalling that
tensively cited throughout this chapter. Indeed, a full the acceleration of gravity at sea level is essentially
course of study of biomechanics is far beyond a simple 9.8 m/s2 , and that weight is a force, the weight of a
CLINICAL BIOMECHANICS AND PATHOMECHANICS OF THE LUMBAR SPINE 337
A person of 70-kg mass would be 70 kg × 9.8 m/s2 =

686 N.
Newton’s second law includes the concept of di-
rection as well as magnitude, whereas Equation 18.1
is simply a scalar quantity (i.e., a magnitude with-
out direction). More formally, Newton’s second law is
– represented by a vector equation:
F
F̄ = mā
where the bars over F and a (i.e., F̄ and ā ) indicate

that they are vector quantities.
The benefit of using vector quantities becomes
clearer if we attempt to understand the loading (a
term not yet defined) on our antalgic patient’s lumbar
spine. More specifically, if we take an anteroposterior
(AP) lumbar radiograph, we may note that our pa-
tient’s L5 vertebra is rotated relative to the sacral base
(Fig. 18–2B). The load of her upper body, being trans-
mitted mostly through her L5 vertebra, can be repre-
sented by a single force vector (Fig. 18–3). However,
compared to the patient’s normal erect posture, with
all lumbar vertebra stacked symmetrically on top of
one another, this force vector is at an angle (θ) relative
to the sacrum. What we wish to determine is how that
force vector is being applied to the L5-S1 disc.
B By defining a coordinate system (see Fig. 18–3), it
is possible to decompose the single force vector F̄ into
two components that lie parallel to the two coordinate
axes (i.e., the x and y axes, for this two-dimensional
example). The magnitudes of each of these two com-
ponents are found by employing trigonometry. The
FX
X
Θ
FY
F
FIGURE 18–3. Decomposition of force vector F̄ into compo-

nents F X and FY that lie parallel to the x and y axes, respec-
FIGURE 18–2. A. Two-dimensional schematic of lumbar spine tively. The lengths of the lines represent the respective magni-
of an antalgic patient. Force vector F̄ representing the load of tudes of F̄ , F X , and FY . The magnitude of F X is equal to the
the upper body passing through the L5 vertebra. B. Antero- sine of the angle times the magnitude of F̄ . The magnitude
posterior (AP) radiograph of patient with mild antalgia demon- of FY is equal to the cosine of the angle times the magnitude
strating altered loading of the L5 vertebra. of F̄ .
vertical component of F̄ , FY , is equal to the magni- By convention, compressive forces are designated as
tude of F̄ multiplied by the cosine of angle θ , and the negative (e.g., – FY ), and tensile force as positive (e.g.,
+
horizontal component of F̄ , F X , is equal to the magni- FY ). Pure compression or pure tension deforms ob-
tude of F̄ multiplied by the sine of angle θ : jects and causes change in their volume; but pure shear
causes deformation of objects without change in their
FY = F cos θ (18.2)
volume. In real materials, and especially biological tis-
F X = F sin θ (18.3) sues, undergoing loading, there is almost always a
combination of shear with either compression and/or
Hence, as angle θ grows larger, the vertical compo- tension.
nent of the force F̄ (i.e., FY ) becomes smaller, while
the horizontal component (i.e., F X ) becomes larger, Torque (Moment)
and these changes occur not linearly, but as sinusoidal In the example of the antalgic patient, a decision was
functions. It is important to restate that the decomposi- made to adjust a specific vertebra in an attempt to
tion is dependent on the choice of coordinate systems, change the biomechanics of the vertebra. A force was
and varying the coordinate system will vary whether applied to the transverse process of the vertebrae
the cosine or the sine of the angle is proportional to to first achieve a preload; subsequently, a greater-
the vertical or horizontal component. magnitude force was applied at high velocity to per-
Real patients, of course, exist in three dimensions form the adjustment. What is needed is a system to
rather than just two dimensions. To account for this describe the resultant loading and displacements.
third dimension requires making additional measure- In this example, because of the applied force, the
ments of the direction of F̄ (i.e., full three-dimensional vertebra will undergo a rotation (Fig. 18–4). A loading
characterization), but which can then be straightfor- applied to an object (e.g., a vertebra) that causes it to
wardly described using trigonometry and results in rotate about an axis is called a torque. This is subtly dif-
the third force component, F Z . The three real compo- ferent from loading that causes bending (which is dif-
nents of the force vector (i.e., F X , FY , and F Z ) at the ferent from compression, tension, or shear) in objects,
L5 vertebra imply that the vertebra can also move (or and is discussed in the section Bending Moments, later
translate) along all of the three cartesian axes (i.e., x, y, in this chapter. The magnitude of the torque is defined
and z). The ability to move along all three axes defines as the product of the force and the perpendicular dis-
three of the six degrees of freedom for all vertebrae. The tance to the axis of rotation (T = F × D). In SI units, it
other three degrees of freedom are described in the is given as newton-meters (Nm). In some systems, it
subsection titled Torque, later in this chapter. is appropriate to consider some objects being loaded
In the example of the antalgic patient, one impli- as undergoing rigid body rotations (i.e., the real defor-
cation that becomes apparent by examining the force mations of the object are sufficiently small and/or of
vectors is that, when compared to normal, the antalgic insufficient interest and can be ignored). Using this
position actually reduces the compressive force on the assumption, a simple example may illustrate the ide-
L5-S1 disc (i.e., the magnitude of FY decreases), but alized torque developed during the preload phase of a
increases the shearing force on the disc (i.e., the magni- high-velocity low-amplitude chiropractic adjustment.
tude of F X increases). Using vectors is essential to not In Figure 18–4, assume that the vertebra will undergo
only quantify the forces, but to describe their lines of rigid body rotation, and a force F of 25 N is applied to
action. Thus, one aspect of loading can be defined by the transverse process of a vertebra at a perpendicular
quantifying the forces along the three cartesian axes. distance D of 3 cm (0.03 m) from the axis of rotation
F
A B C
F F
FZ
_
Yrotation X X
D D −FX
X
FIGURE 18–4. Torque loading of a single vertebra. A. Force F is applied to the transverse process of a lumbar vertebrae inducing
a rotation about the y axis. B. Assuming rigid body rotation, the magnitude of the torque T is equal to magnitude of force F times
the perpendicular distance to the center of rotation, D. C. Applying the force at an angle creates a smaller force (i.e., F Z ), which
is used to create the torque, and a lateral force (–F X ) tending to displace the vertebra along the x axis.
for the vertebra. The magnitude of the torque during Loading

the preload is: In biomechanics, loading is a term that simply refers
the sum of all the forces and torques (moments) that
T = F × D = 25 N × 0.03 m = 0.75 Nm are applied to a system (e.g., a vertebra in the spine).
In other words, if all the forces and moments that are
If the same force F were applied at an angle that was applied to a system are known, then the loading on
no longer perpendicular, then the magnitude of the that system is known. This is one of the more power-
torque would be less. Why? Well, intuitively, some of ful analytical tools available to understand the influ-
the force would still be causing the vertebra to rotate, ence and distribution of forces in biomechanical sys-
but depending on the angle, some of the force would tems and enables the prediction of the biomechanical
now be either compressing or tensioning the verte- state of tissues and joints as a consequence of normal
bra in some fashion. For example, using the same as- and abnormal loading and physiology. For systems in
sumptions as before (i.e., rigid body rotation), let the equilibrium, this means that the sums of all the forces
force F be applied at an angle of 60 degrees instead of and moments are equal to zero. For three-dimensional
90 degrees (see Fig. 18–4). The magnitude of the ide- problems in biomechanics this means that
alized torque during the preload now would be:
F̄ = 0 and T̄ = 0
◦
T = (F × sin 60 ) × D = (25 N × 0.866) × 0.03 m
which means that, for the six degrees of freedom avail-
= 0.65 Nm able for all human joints,
This is approximately a 13% reduction in torque mag-

FX = 0 TX = 0
nitude simply as a result of the change in the angle of
the applied force (or the “line of drive” of the adjust- FY = 0 TY = 0
ment). In addition, a lateral force would be developed
of magnitude equal to: FZ = 0 TZ = 0
Flateral = F × cos 60 degrees = 25 N × 0.5 = 12.5 N Conceptually, the simultaneous solving of these equa-
tions allows for determining unknown variables of in-
terest. What complicates this neat picture is that it is
Maintaining the assumption of rigid body motion unfortunately often the case that either there are too
for the vertebra and ignoring the influence of the many equations relative to the unknown variables or
articulating facet joints, then this idealized lateral too many variables relative to the known equations.
force would tend to displace the vertebra laterally and These types of problems are known as statically in-
induce shearing in the cephalad and caudal interver- determinate, because engineering statics considers all
tebral discs. structures as nondeformable (i.e., rigid bodies). How-
Rotations about the three cartesian axes are the ever, all real structures always deform in response to
other three of the six degrees of freedom that exist for any loading, and using analytical tools developed in
objects in general, and for the lumbar vertebrae specif- mechanics of materials enables solutions to some of
ically. In other words, the motion (or kinematics) of a these biomechanics problems.
vertebra that results from any arbitrary loading of the
spine can be completely described using the rotations Bending Moments
about and translations along the three cartesian axes.
Because forces are intrinsically vectors, it should not During the preload phase of a vertebral adjustment,
be a surprise that torques (and moments) are also in- the force on the transverse process (or spinous or
trinsically vector quantities, as follows: mammillary processes) increases until an equilibrium
is reached. Usually, this is held for a relatively short
time and then the actual thrust is administered, typ-
T̄ = F̄ × D ically as an impulse load (i.e., a load applied over a
very short duration). During this equilibrium phase,
where D is the shortest distance between the line of the force applied to the transverse process will cause
action of force F and the axis of rotation. it to bend (Fig. 18–5). Intuitively, it is obvious that
In biomechanics, it is common that the word mo- the greatest anterior displacement will occur toward
ment is used synonymously with torque. As is de- the lateral aspect of the transverse process and the
scribed later, they have the same units, but have subtly amount of displacement (or bending) will diminish
different meanings. towards the lamina–pedicle junction. This is directly
F describes the internal loading that develops when an

F
A B object is undergoing a bending deformation. Often,
applying a torque to any tissue that articulates (e.g.,
vertebrae) will also result in bending moments.
X Stiffness
Stiffness is a property of a system that describes how
Z
Moment (Nm)
much force must be applied to achieve a given dis-
placement (stiffness = F/D) and has SI units of new-
tons per meter (N/m). Its inverse is called compliance
or how much displacement must be applied to achieve
a given force (compliance = D/F [m/N]). Chiroprac-
FIGURE 18–5. Bending moment in the transverse process tors use this property intrinsically during palpation
of a vertebra during preload of an adjustment. A. The solid of the spine to determine how freely a vertebral mo-
line with angled lines underneath symbolizes that the body of tion segment moves relative to others. In particular,
the vertebra has been locked in position. B. The transverse the technique of motion palpation is based on this
process (TP) has been magnified and the dotted outline ideal- concept.5–8
izes how it deforms as a result of the force F. The graph un- The stiffness of a vertebral motion segment is
derneath depicts that the bending moment is smallest at the
dependent upon all the components that make
location of the application of the force and increases towards
up the segment including the articulating joints,
the lamina–pedicle junction. The nonlinear relationship between
the moment and distance is caused by a number of factors
intervertebral discs, joint capsule, intervertebral liga-
of the transverse process, including its nonlinear geometry, ments, and muscles. The relative symmetry of motion
inhomogeneity, and anisotropy. segment geometry can affect stiffness, and if trophism
of the facets is present, then the stiffness will not
be symmetrical (e.g., the stiffness would be different
analogous to what happens when somebody stands when actuated from left to right versus right to left).9
on the end of a diving board in preparation for jump- Linear stiffness is defined by a relationship be-
ing into a swimming pool. As the person walks toward tween force and displacement that can be graphically
the end of the board, the board bends, and the greatest represented by a straight line. Common mechanical
amount of bending occurs when the person stands on systems that exhibit linear stiffness are springs. In
the very end of the board. this case, the slope of the line is equal to the stiff-
In biomechanics, this type of loading is said to pro- ness of the system (Fig. 18–6A). Human biomechani-
duce a bending moment that is directly proportional cal systems like the spine, however, exhibit nonlinear
to the product of the force and the perpendicular dis- stiffness (Fig. 18–6B) because of the complex geom-
tance, and has SI units of Nm. Hence, the bending etry of the joints and the intrinsic properties of the
moment is zero at the point of application of the load tissues themselves, which are nonlinear, inhomoge-
and increases with distance away from it. Torque and neous, and anisotropic.10
moment have the same units (i.e., Nm), but they are There exists an extensive literature extending al-
subtly different. Torque is used to describe the load- most two decades on the reliability of static and
ing that causes an object to rotate, whereas moment motion palpation for assessing the presence of the
A B
FIGURE 18–6. Idealized stiffness of
a system. A. Linear stiffness can be
depicted by a straight line that de-
scribes the relationship between force
and displacement. The slope of the
Force (N)
Force (N)
line (a scalar value) is equal to the

stiffness. B. Almost all biological sys-
tems (e.g., spine) exhibit nonlinear
stiffness, which is most commonly de-
picted by a sigmoidal curve. The stiff-
Slope = Stiffness ness becomes greater with increasing
displacement, but the rate of increase
of stiffness tends to fall just before the
Displacement (m) Displacement (m) system fails.
“manipulable lesion” (i.e., subluxation).11–17 From a jured, but it did not fail). Conceptually, strain is the ra-
biomechanical point of view, all of these studies were tio of the change in deformation of an object (e.g., the
essentially measuring the ability of examiners to as- intervertebral disc) to its original volume. A simplistic
sess the in vivo stiffness of vertebral motion segments. illustration in one dimension would be to take a rub-
Interexaminer reliability varied greatly between stud- ber band, measure its initial length (L 0 ), stretch it and
ies, whereas intraexaminer reliability was consistently measure the new length (L 1 ), and calculate the ratio
better. The use of instruments designed to quantify between the change in length ( L = L 1 – L 0 ) to the
stiffness does not appear to substantially improve the original length ( L/L0 ). For example, say the rubber
interexaminer reliability.18 This illustrates the com- band was initially 1.0 cm and that after stretching it
plexity of spine biomechanics and the difficulty in ap- was 1.3 cm. Then, the uniaxial tensile strain would be
plying these principles to the clinical setting.
L L1 − L0 1.3 cm − 1.0 cm 0.3 cm
Elasticity ε= = = =
L0 L0 1.0 cm 1.0 cm
Elasticity is an important concept in biomechanics; it
provides a theoretical foundation for the discipline.1 = 0.3, or 30% strain
However, at best, elasticity is only approximated in
human biomechanics, for reasons that will become This example, while not accurate for real three-
apparent. Conceptually, there are two properties that dimensional tissues, describes two important aspects
characterize tissue (or more generally, system) elas- of strain. First, it is a dimensionless number because
ticity: time invariance and complete recovery of ge- the units (in this case, centimeters) literally cancel each
ometry following removal of load. The first property, other out in the process of the division. Second, it is
time invariance, means that the relationship between equally appropriate to express it explicitly as a di-
load and displacement is independent of how fast or mensionless number (e.g., 0.3) or as a percentage (e.g.,
how slow the system is actuated. The second property 30%). By convention, tensile strains are defined as pos-
means that once a load is removed, the tissue (or sys- itive (e.g., +0.3) and compressive strains as negative
tem) is immediately restored to exactly the way it was (e.g., –0.3). Consider the compression of the L5-S1 in-
before the load was applied. In humans, there are no tervertebral disc during simple standing (Fig. 18–7). It
biomechanical systems that are truly elastic, although is loaded with a force that is a proportional to the mass
there is a common extracellular matrix (ECM) protein, of a person’s upper body times the acceleration caused
elastin, that closely approximates elasticity.19–21 This by gravity. Because of this loading, it undergoes a
protein is found in most connective tissues, includ- compressive strain (εY ) along the vertical axis, but
ing skin, muscle, tendon, ligaments, joint capsule, and it expands along the horizontal plane (ε X and ε Z ).
vessels. However, it is almost always found in associa- The ratios of these strains are called Poisson’s ratios
tion with other ECM proteins, especially collagen,22–24 (νYX = −ε X /εY and νYZ = −ε Z /εY ). For incompress-
which are viscoelastic; hence, most intact tissues and ible isotropic materials (solids), it can easily be shown
systems made of them are viscoelastic rather than that this value in theory is equal to 0.5.25 For example,
elastic. natural rubber, which is homogeneous and isotropic
and almost linearly elastic, has a Poisson’s ratio ex-
Strain In biomechanics, any tissue undergoing any ceeding 0.49.26
loading exhibits strain. This is in direct contrast with From the example above, it should be evident that
the common clinical usage of the word to imply non- because strains are associated with directions, they are
catastrophic injury to a tissue (i.e., the tissue was informally vector quantities (i.e., having both magnitude
A B
X
Z
FIGURE 18–7. Poisson effect during axial loading of an intervertebral disc. A. Unloaded state. B. Applying an axial load (solid black
arrows) causes a compressive strain (εY ) along the y axis, but results in elongation or tensile strain (ε X ) along the x axis (and also,
but not depicted ε Z ). Poisson’s ratio (ν) is the ratio of the strains on the unloaded to the loaded axes. In this example, ν = ε X /εY .
A B C
Y
Θ
FIGURE 18–8. Schematic of the shearing of the intervertebral disc between two lumbar vertebrae. A. Prior to shearing. B. Loads
are applied in the directions of the arrows causing the disc to deform, but keeping its volume unchanged. C. For small shears,
the angle γ is equal to the magnitude of the shear strain. This approximation is accurate for strains less than 5%, but for strains
greater than 5%, a more robust definition of strain must be employed that uses second-order terms.
and direction). In addition to the strains that can occur Stress In biomechanics, any tissue undergoing defor-
along any of the three cartesian axes (i.e., x, y, and z) mation develops mechanical stress, which is related to
and that result in changes in volume, strains can occur force. This is in contrast to the usage of the same term
tangentially to a surface and as such are called shear in physiological sciences, where it typically refers to an
strains. By definition, pure shear strains cause defor- increased or abnormal physiological/biological chal-
mation of the object, but do not change its volume.27 lenge to a cell, tissue, or organism. Conceptually, stress
Consider the case of two lumbar vertebrae and their is directly proportional to the ratio between the mag-
intervening intervertebral disc (Fig. 18–8). If the ori- nitude of an applied force and the area over which
entation of the facet joints is in the sagittal plane and a that force is applied. In SI units, it is given as newtons
posterior-to-anterior force (F Z , Fig. 18–8B) is applied per meter squared (N/m2 ) or pascals (Pa). Because
to the spinous process of one vertebra, it will tend to force is a vector quantity, stress is also a vector quan-
develop a shear load on the intervertebral disc, result- tity. By convention, tensile stress is a positive quantity
ing in a shear strain in the zy-plane (εZY ) (Fig. 18–8C). and compressive stress is a negative quantity. Stress
Most biological tissues (e.g., an intervertebral disc) describes the internal distribution of force within an
are inhomogeneous (e.g., the intervertebral disc has a object (or tissue).
gel-like nucleus pulposus surrounded by concentric A common conservative technique for treating
collagenous layers with alternating orientations) and lumbar intervertebral disc problems uses a table that,
anisotropic (i.e., a pure load results in nonsymmetri- with the patient prone and strapped to the table, flexes
cal deformations). Hence, during an arbitrary load- the lower extremities, and so distracts and loads the
ing (in equilibrium), within the tissue the strains vary lumbar spine.28–32 The tensile force produced in this
spatially. For any given subvolume within a tissue, to technique is effectively distributed through the ver-
fully describe the three-dimensional state of strain for- tebral bodies and into the intervertebral discs (Fig.
mally requires nine terms. These strain components 18–9). For purposes of illustration, assume that the
form what is called a tensor and can be depicted in a net tensile force reaching the L4-L5 intervertebral disc
matrix as follows: at maximum distraction is 100 N and it is uniformly
distributed, and the average radius of the disc is 2 cm;
then, the average tensile stress would be
⎡ ⎤
εxx εxy εxz
F 100 N 100 N 100 N
ε = ε̂ = ⎣ ε yx ε yy ε yz ⎦ σY = = = =
εzx εzy εzz A πr 2
π (0.02 m) 2 0.00126 m2
= 79.6 kPa
In this matrix form, the terms forming the diagonal An important concept in the above example is that
are the three axial strains and all the other terms rep- 79.6 kPa (or 79,600 Pa) represents the average tensile
resent the six shear strains. It can be shown that for stress (σY ), and implies that the actual stress varies
most real materials in equilibrium, the strain tensor spatially throughout the disc. At the lateral borders
is diagonally symmetric, such that the strain compo- of the disc, the stress perpendicular to the long axis
nents mirrored about the diagonal axis are equal to one of the spine (see Fig. 18–9, the y axis) must be zero
another (i.e., εXY = εYX , εZX = εXZ , and εZY = εYZ ). (i.e., σ X = σ Z = 0). However, towards the center of
Hence, only six of the terms are independent. the disc, along the x and z axes, the stress would be
Y
A B
F F
Z
FIGURE 18–9. Tensile loading of an intervertebral disc. A. Prior to loading. B. During loading, the disc elongates along the y axis
but diminishes along the z axis. The average tensile stress is equal to the force, F, divided by the cross-sectional area, A, of the
disc: σ = F/A.
compressive, and hence negative in magnitude (i.e., Consider an idealized tissue that is linearly elastic
σ X < 0, σ Z < 0). Intuitively, this can be understood and isotropic (which means that it exhibits the same
because of the Poisson effect, which was presented properties along any arbitrary axis), and, for purposes
earlier in this section. In essence, because the disc is of simplification, is uniaxial. While no such tissue ac-
being elongated along one axis, then it must be di- tually exists, there are tissues (e.g., the distal tendon
minishing (or contracting) along the other axis. Be- of the gracilis muscle) that are long and very thin, for
cause the nucleus pulposus is a relatively homoge- which this illustration might be germane. Under ex-
neous gel,33,34 these two stresses would be expected to perimental conditions, it is possible to attach a force
be close in magnitude (i.e., σ X ≈ σ Z < 0). Because the transducer to the gracilis tendon that would measure
disc is a composite structure and anisotropic, during the force developed and there are numerous meth-
such a tensile loading it would be expected to generate ods for measuring its elongation. Using the previously
shear as well as axial stresses.35 To fully characterize discussed definitions of stress and strain, it would be
the stress at any subvolume within the disc requires possible to calculate each at various increments as
nine components. Stress, like strain, is more formally the knee was extended and the tendon stretched. If
represented by a tensor, which can be shown in matrix the stress–strain data points were fit with a straight
form as follows: line (or statistically “regressed”), then the slope of
⎡ ⎤ that line would be equal to the modulus of elasticity
σ XX σ XY σ XZ of that tendon (Fig. 18–10). Algebraically, the relation-
σ = ⎣ σY X σYY σY Z ⎦ ship would be expressed as: σ = Eε, where σ and ε
σ ZX σ ZY σ ZZ are the stress and strain, respectively, and E is the elas-
ticity modulus (also known as the Young modulus).
Similarly, as was described for the strain tensor, Thus, this single modulus (a scalar quantity, with SI
the stress components on the diagonal are the ax- units of pascals) would represent the material prop-
ial stresses, and all the other components are shear erties for this idealized tissue.
stresses. The stress tensor, like the strain tensor, is diag-
onally symmetric during equilibrium (i.e., σY X = σ XY ,
σ ZX = σ XZ , and σY Z = σ ZY ); hence only six of the stress
tensor components are independent.
Material Properties (Relationships Between Stress and

Strain) The previous discussion of stress and strain
implied that a relationship should exist between stress Slope = elastic modulus
and strain; that is, any loading applied to any tis-
Stress (Pa)
sue will develop both stresses and strains in the tis-

sue. This concept is directly analogous to the stiffness
(or its inverse, compliance) property of a system that
describes the relationship between force and displace-
ment. However, the essential difference is that the re-
lationship between stress and strain describes prop-
erties intrinsic to the material (tissue) itself, whereas
stiffness describes attributes of a system that may be
composed of different tissues and includes factors
such as geometry and how the tissues interact. Ma- Strain
terial properties, on the other hand, are defined only
for a given tissue and are independent of the geometry FIGURE 18–10. Modulus of elasticity or the Young modulus
of the tissue. for a linearly elastic, homogeneous, isotropic material (tissue).
Obviously, most biological tissues are much more

complex and exist in three dimensions. Except for rel-
atively homogeneous tissues such as the nucleus pul- Ultimate
Strength
posus, most tissues are anisotropic as a consequence of
the different material properties that collectively rep-
resent arrangements of the structural proteins (e.g.,
Stress (Pa)
collagen) that give rise to their geometry and ability
to resist loading on different axes. In general, to fully
describe the material properties of an anisotropic, yet
still linearly elastic, material requires not one, but 21
Linear region
independent moduli, as follows:
⎧ ⎫ ⎡ ⎤⎧ ⎫
⎪
⎪ σ XX ⎪
⎪ C11 C12 C13 C14 C15 C16 ⎪ ⎪ ε XX ⎪
⎪
⎪
⎪ ⎪
⎪ ⎢ ⎪
⎪ εYY ⎪
⎪
⎪ σ ⎪
YY ⎪ C22 C23 C24 C25 C26 ⎥
⎥⎪
⎪
⎪
⎨ ⎬ ⎢⎢
⎪
⎨ ⎪
⎬
σ ZZ C33 C34 C35 C36 ⎥ ε
=⎢
⎢
⎥ ZZ Strain
⎪
⎪ σ ⎪
XY ⎪ C44 C45 C46 ⎥
⎥⎪ ε XY ⎪
⎪
⎪ ⎪ ⎢ ⎪
⎪ ⎪
⎪
⎪
⎪ σ XZ ⎪
⎪
⎪
⎣ C55 C56 ⎦ ⎪
⎪
⎪ ε ⎪
XZ ⎪
⎪
⎩ ⎭ ⎩ ⎭ FIGURE 18–11. Sigmoidally shaped uniaxial stress–strain
σY Z C66 εY Z curve depicting the nonlinear elasticity more typical of real bio-
logical tissues. There is typically a portion of the curve that is
where the number subscripts for all the C terms in- relatively linear. The “ultimate strength” of the material is de-
dicate a potentially different material property. The fined as the magnitude of the stress just before the material
matrix is “diagonally symmetric,” meaning that the failed.
terms not shown are identical to those mirrored about
the matrix diagonal (e.g., C12 = C21 , C13 = C31 , etc.). in highly contrived experimental situations, it is gen-
This matrix equation is simply a shorthand way of ex- erally impossible to directly measure stress in any tis-
pressing a series of linear equations, which in this case sue. However, it is relatively easier to measure strains,
collectively describe the complex, but real, relation- and hence the importance of knowing the material
ship between stress and strain in anisotropic tissues. properties of tissues.
The value of each stress term in the vector column Most tissues in the human body are composed
on the left hand side of the equal sign is equal to the of different types of structural proteins (especially
product of the respective row in the material property collagen) that collectively exhibit nonlinear rather
matrix times the strain column. For example, the first than linear properties.19,22 During loading, the stress–
term in the stress vector is calculated as follows: strain relationship is more commonly represented by
a sigmoidal curve rather than a straight line (Fig.
σ XX = C11 ε XX + C12 εYY + C13 ε ZZ + C14 ε XY 18–11).38,41 For an idealized uniaxial tissue (e.g., gra-
cilis tendon), this relationship could be expressed
+ C15 ε XZ + C16 εY Z algebraically using a three-parameter equation for
sigmoidal curves,
A way of conceptualizing what these material prop-
erty terms (i.e., C11 , C12 , etc.) mean is to think of them a
σ = ε−ε0
as representing the “coupling” between stress on a 1 + e −( b )
given axis (in the equation above, σXX ) and the six
possible strains. For example, in the equation above, where σ and ε are the stress and strain, respectively,
C11 is the coupling between stress and strain along the and a , b, and ε 0 are parameters to be determined
x axis, C12 is the coupling between stress along the x through analytical curve fitting.
axis and strain along the y axis, C14 is the coupling Clearly, this sigmoidal equation (i.e., nonlinear re-
between stress along the x axis and shear strain in the lationship) is much more complex than the simpler lin-
xy plane, and so on. ear relationship in which the stress was proportional
The value of knowing all the material properties to the strain by a single scalar value (i.e., the Young
of a tissue is that if they are known or measurable, modulus). It should also be noted that the material
then it would be possible to calculate the stresses in properties of a tissue determined during, for exam-
the tissue by measuring the strains. While this is not ple, tension are commonly different from the properties
something that any clinician would normally ever be found during compression.42 Furthermore, when non-
expected to do, it is a procedure that scientists com- linear material properties are combined with the typ-
monly employ to discover how biological tissues (e.g., ical anisotropy of most biological tissues, this begins
the spine) respond to mechanical loading.36–40 Except to explain some of the complexity and wonderful
A B
Strain Rate
Increasing
Stress (Pa)
FIGURE 18–12. Nonlinear stress–
strain relationships. A. Elastic tissues
by definition do not have time depen-
dence. B. For viscoelastic tissues,
the relationship between stress and
strain is dependent on the rate of
loading. Strain Strain
functionality that is present in biological tissues, as vertebral column in response to the erect posture over
well as suggesting a component of why it can often be the course of a day.59–61 This is an example of com-
difficult to treat patients with musculoskeletal condi- pressive creep, in which in the presence of a constant
tions. compressive load (in this case, the weight of the upper
body), the intervertebral discs throughout the spine
Viscoelasticity nonlinearly decrease (i.e., creep) in height. The inverse
When most animals, including humans, first wake up of this situation is commonly observed during a con-
after sleeping for any length of time, one of the first stant stretch (e.g., flexion of the lumbar spine) during
things they tend to do is stretch. Most competitive ath- which the load will nonlinearly decrease (also referred
letes are taught that it is important for them to engage to as “relaxation”) (Fig. 18–13).62
in regular periodic stretching in order to perform at The time-dependent relationship between stress
their best.43 In addition to regular exercise, stretching and strain for viscoelastic tissues requires more so-
is an integral part of most preventative and therapeu- phisticated mathematics than can be expressed alge-
tic treatments for musculoskeletal disorders.44–49 It is braically. Specifically, this relationship requires the use
important to note that stretching alone is insufficient of time derivatives (i.e., an aspect of calculus). One of
to prevent musculoskeletal injuries and that there is the simpler models of viscoelasticity is called the stan-
controversy regarding the effectiveness of its use in dard solid model (although it has been used effectively
prevention.50–52 The fundamental reason why stretch- to model spine viscoelasticity),63 and requires three
ing is so crucial is that all biological tissues are inher- parameters as follows:
ently viscoelastic rather than simply elastic.
An essential feature of viscoelastic materials is E 1 (E 2 ε + ηε̇)
σ = − ησ̇
that their response to loading is dependent on time53–56 ; E1 + E2
that is, the material exhibits increasing stiffness (or a
greater elasticity modulus) for increasing rates of load- where ε̇ = dε dt
and σ̇ = dσ
dt
and σ and ε are the stress
ing (Fig. 18–12). In contrast, the stiffness (or elasticity and strain, respectively; E 1 and E 2 are elasticity pa-
modulus) of elastic materials is, by definition, indepen- rameters; and η is a viscosity parameter.
dent of time. For viscoelastic tissues, and essentially all The stress and the strain time derivatives are sim-
musculoskeletal tissues are viscoelastic, this is one of ply measures of the rates of change over time of the
the key reasons why stretching should in general be stress and strain, respectively. The values for the elas-
performed relatively slowly, at least at first. For the ticity and viscosity parameters are determined exper-
same amount of strain (stretch), a higher rate of strain imentally and do not, in general, represent anything
(i.e., stretching faster) will produce greater stress, and about the internal structure of the tissue. What should
if the stress exceeds the tissue ultimate strength, then be clear from this model is that at any given time the
the tissue will fail.57 Even if the stress does not reach stress (σ ) is a function of the strain (ε), strain rate (ε̇),
the ultimate strength, it may be high enough to initi- and stress rate (σ̇ ). That is, not only is the stress de-
ate subcatastrophic failure, wherein small tears may pendent on the current strain, it is also dependent on
develop (e.g., a clinical sprain).58 rates of change of the stress and strain. In other words,
Another essential feature of viscoelastic tissues is the current stress in the tissue is dependent on the cur-
their dynamic response to a static load. In the spine, rent strain and how the tissue was being previously
this can be observed as a decrease in height of the loaded.
A B
Creep Relaxation
Strain
Stress
FIGURE 18–13. Viscoelastic tis-
sues exhibit dynamic responses to
static loads. A. Constant stress
(tension in this example) applied to
a viscoelastic tissue results in a
Stress
Strain
nonlinear increase in tensile strain,
which is called “creep” behavior. B.
Constant strain (again, tensile in
this example) results in a nonlinear
decrease in tensile stress, which is
Time Time called stress “relaxation.”
Fatigue 360 million years ago, quadrupedal land-based ver-

Structural or material failure due to repeated load- tebrates were walking around, and by 50–60 million
ing, which is less than the ultimate strength, is called years ago, primates first appeared.68 For all these
fatigue. This concept is highly relevant to spine biome- species, the vertebrate spine has functioned to protect
chanics as cyclic loading of the spine is a normal the spinal cord,69 as well as being a fundamental com-
in vivo phenomenon. In vitro, compression of verte- ponent of locomotion.70 The more recent adaptation of
brae, at 5000 cycles can result in failure (fracture) at bipedal locomotion by humans has necessitated some
approximately half the static ultimate strength.64 The evolutionary modifications, particularly to the lumbar
process of fatigue failure is well understood in non- spine.71 In this section, the relevant anatomy and biol-
biological materials. Essentially, during cyclic load- ogy of the lumbar spine are considered from a biome-
ing, small imperfections that exist in all materials, chanics perspective.
even those created in the most carefully controlled
circumstances, will develop stress concentrations that Vertebra
exceed their local strength. Microcracks develop at There may be perhaps no better example of the re-
these imperfections, which grow larger as cyclic load- lationship between structure and function than the
ing continues, until eventually the crack propagates lumbar vertebra. That is, the basic structure of the ver-
sufficiently to cause material failure. What compli- tebra, although highly conserved over hundreds of
cates understanding of structural fatigue in biological millions of year, is precisely evolved to handle the
tissues is that the cells that create the structural pro- biomechanical functions required for the survival of
teins (e.g., collagen) that give rise to tissue strength are Homo sapiens. Collectively as a spine organ, in addition
themselves affected by cyclic loading. Hence, these to providing protection and a conduit for the spinal
cells are continually attempting to remodel the tis- cord and the distribution of all the nerve roots, the ver-
sue. If the cells are unable to remodel the tissue fast tebrae have to provide fundamental mechanical sup-
enough to keep pace with local structure changes port to all the tissues of the upper body. This includes
during cyclic loading, then the tissue will eventually static and dynamic loading (and impulse loading that
undergo fatigue failure. For tissues evolved for sus- can be many times body weight) in compression, ten-
taining substantial loads, in addition to being suscep- sion, and torque for a relatively wide range of posi-
tible to failure by fatigue, loads which are too small tions of the body (Fig. 18–14).
can result in tissue atrophy and consequent decrease Given these functional requirements, the anatom-
in strength (e.g., disuse osteopenia).65 Indeed, too litical structure of the lumbar vertebrae becomes com-
tle or too much hydrostatic pressure on intervertebral prehensible. The lumbar vertebra (like those in the
discs inhibits their cellular metabolism.66,67 thoracic and cervical spine) is composed of a roughly
cylindrical bony anterior portion (the vertebral body)
and a bony neural arch, from which seven bony pro-
LUMBAR SPINE ANATOMY AND BIOLOGY
cesses are derived and through which passes the
The vertebrate spine first appears in the fossil record spinal cord (Fig. 18–15). The vertebral body is com-
some 500 million years ago in aquatic creatures. By posed of a relatively thin cortical shell (∼2.7 mm) and
FIGURE 18–14. Lumbar spine drawing

from the left posterior oblique view depict-
ing the bony anatomy, intervertebral discs,
some of the lumbar spine ligaments, and the
facet joints.
two slightly concave endplates, enveloping spongy compressive stresses (as a consequence of physiolog-
trabecular bone. On average, the vertebral bodies are ical loading), and hence have similar FRIs (0.42).76
larger in males than in females (width: 51 mm vs. However, during aging, gender differences in changes
45 mm; height: 36 mm vs. 32 mm, respectively), and in vertebral cross-sectional areas and bone mineral
for both sexes, increase in size for more caudal verte- density result in substantial differences in the in-
bra (Fig. 18–16).72 The disc height is about one-third creases in the FRI between men and women (0.51 and
the height of the vertebral body, and, again, is slightly 0.87, respectively).76 Hence, postmenopausal females
larger in males than in females. have substantially higher incidences of vertebral frac-
During axial compression of the spine, the load tures than do their age-matched male counterparts.
is carried almost entirely by the vertebral body, with
only a small portion carried by the facet joints.73 The
cortical shell carries a large portion of the compres- Intervertebral Disc
sive load, ranging from approximately 34% close to The intervertebral disc (IVD) functions to spatially
the vertebral endplates to approximately 63% at the distribute load over the vertebral endplates, while
midline plane of the body, with the remaining load car- simultaneously allowing motion between adjacent
ried by the trabecular bone.74 While lumbar vertebra vertebrae. Temporally, because it is a poroviscoelas-
in vitro can withstand compressive forces up to about tic (rather than elastic) structure, it acts to dampen
6 kN before failure,75 it is the endplate that fails first dynamic (especially impulse) loads. To accomplish
when the compressive stress approaches 7.6 MPa (i.e., these tasks, it is structurally composed of three differ-
the mean strength of vertebral endplates is 7.6 MPa).76 ent types of tissues: the nucleus pulposus, a hydrated
However, the strength of the endplate varies spatially gel consisting of water, proteoglycans, and type II
by a factor of approximately 5 and is strongest toward collagen78,79 ; the anulus fibrosus, concentric layers of
the posterior lateral aspect.77 primarily type I collagen organized as alternating lay-
A fracture risk index (FRI) has been pro- ers at ± 60 degrees relative to the vertical axis80,81 ; and
posed, based on the compressive load and endplate fibrocartilaginous endplates.80
strength; healthy middle-age men and women have During activities of daily living, intradiscal com-
similar endplate strengths and experience similar pressive pressure (i.e., compressive stress that is the
same magnitude on any axis of observation) has
FIGURE 18–15. Drawing of a sin-

gle lumbar vertebra. Left. In this
cephalad view, the vertebral end-
plate is highly stylized to depict the
trabecular bone comprising most
of the volume of the vertebral end-
plate. Right. In this oblique view,
the articulating facets are highly
stylized to depict the cartilaginous
articulating surfaces.
60
50
Dimension (mm)
40
Width FIGURE 18–16. Average dimen-

30 Depth sions (height and width) of the
Disc Height
three lower lumbar vertebrae for fe-
20
males (F ) and males (M). (Adapted
from Zhou SH, McCarthy ID, McGregor
10 AH, et al. Geometrical dimensions of the
lower lumbar vertebrae—Analysis of data
0 from digitised CT images. Eur Spine J
F M F M F M
L3 L4 L5 2000;9:242–248.))
been measured in vivo as minimal while lying (0.1 the fibrocartilaginous endplate and into the cancellous
MPa: supine, prone, or side lying), but can increase vertebral body. For a 3-kN impulse load, varying the
more than 20 times that while lifting in a bent posi- duration of the impulse from 2.5 to 200 ms resulted in
tion (2.3 MPa for a 20-kg mass) (Fig. 18–17).82 While a relatively invariant compressive stress (0.25 MPa) in
lying, the acts of sneezing or simply rolling over the nucleus pulposus but a logarithmically increasing
can transiently increase intradiscal pressure by four compressive stress (from 0.6 to 1.4 MPa) in the cancel-
and eight times (0.38 and 0.80 MPa), respectively. lous bone (as a result of the water flow). In this same
However, intradiscal pressure varies spatially with model, mean von Mises stress (a measure of total lo-
much larger magnitudes in the center of the nucleus cal stress magnitude) in the endplates decreased from
pulposus,83,84 is relatively constant within the anulus 22 to 19 MPa for the same range of impulse loads,
fibrosus, but then increases toward the lateral aspects but maximum values approached 36 MPa. These data
of the annulus.85 suggest that the movement of water through the end-
Validated computational models (poroelastic fi- plate produces high rates of change of loading of this
nite element analysis) of impulse loading of the disc structure.
(which could happen during falls, athletic injuries, Disc degeneration is closely tied to aging.78 This
impacts, or other sudden applied loads) predict that degeneration involves a variety of biological factors,
water moves from the nucleus pulposus both radially which are dominated by a loss of proteoglycan synthe-
and axially.86 The axial flow of water passes through sis as a result of either too much (>3 MPa) or too little
FIGURE 18–17. A comparison

between the intradiscal pressure
data (normalized to standing) of
Nachemson120 and Wilke et al.82 for
70-kg individuals in common postures
and activities. In the Wilke et al. study,
lying in any position resulted in an in-
tradiscal pressure of 0.1 MPa. Lifting
weights were 10 and 20 kg, respec-
tively in the Nachemson and Wilke
et al. studies. (Reproduced with permis-
sion from Wilke HJ, Neef P, Caimi M, et al.
New in vivo measurements of pressures in
the intervertebral disc in daily life. Spine
1999;24:755–762.)
hydrostatic pressure,66,67,87 as well as genetic88,89 and especially of the lumbar spine, have an enviable
probably nutritional factors. The question has been safety record compared to other treatments for spinal
posed as to what is the dominant causative factor for pain.94,95 There appears to be little concern for ia-
most people; that is, are the biomechanical differences trogenic fractures of either the spinous or transverse
caused by the biological changes or are biochemical processes during manipulation of the lumbar spine,
changes in response to alterations in biomechanics?90 probably because of the protective properties of the
This is not just an academic question, as determining surrounding soft tissues.
causation could profoundly influence a wide range of Each lumbar vertebra has a total of four facet joints
treatments. It has previously been shown that exces- (superior and inferior; left and right). These are true
sive compressive loading of vertebrae and their discs diarthrodial joints with articulating surfaces of hya-
results in failure of the vertebral endplate and not the line cartilage and encapsulating ligaments that have
disc.75 It has also been shown that damage to the end- an inner synovial membrane.
plates resulted in abnormally high stress concentra-
tions in anulus fibrosus.91 The facet cap-
Functional Characteristics of Facet Capsule
To test whether endplate damage could, within sule obtains its mechanical strength from a network of
4 hours of testing, cause structural changes associ- collagen fibers arranged in bundles of parallel fibers
ated with disc degeneration, Adams et al.90 measured with a mean diameter of 0.4 μm.96,97 Capsule cells
intradiscal pressure in cadaveric functional lumbar are principally fibrocytes and fibroblasts in minimal
motion segments during an “overload injury” and ground substance. In human cadaver studies, the facet
during 4 hours of dynamic testing of a much-lower capsule (from vertebrae T12 through S1) has the high-
load, simulating typical in vivo activities. It was found est mean stiffness (33.9 ± 10.7 N mm–1 ) of all the in-
that damage to the endplates resulted in significant trinsic spinal ligaments.98 Additionally, it has one of
and substantial decreases in intradiscal pressure and the largest mean strain at failure values (65%) of all
increases in annular compressive pressure. The ef- the spinal ligaments. The human lumbar facet cap-
fects were more pronounced in specimens from peo- sule has dimensions of approximately 16 mm in the
ple over the age of 50. Gross histology of the discs medial-to-lateral direction and approximately 20 mm
demonstrated structural changes in the annulus in- in the caudal-to-cephalad direction,97 and an average
cluding annular buckling and fissures. These data cross-sectional area of 44 mm2 .98 Although the stiff-
strongly support the idea that endplate failure may ness of facet capsule is nonlinear over its entire range,
be a causative factor in subsequent disc degeneration there exists a substantial portion of the curve that is
with associated biochemical changes. relatively linear and has been referred to as its “phys-
iological range.”98,99
Posterior Structures
The transverse and spinous processes are bony ex- Facet Joint and Capsule Loading In humans, the erect
tensions projecting laterally and posteriorly, respec- posture alone results in lumbar facet loading.100 Con-
tively, from the bony neural arch. Biomechanically, traction of extensor back muscles to counterbalance
they function as lever arms for various muscles (e.g., an anterior eccentric load results in a substantial, lin-
multifidus muscles), enabling the muscles to generate ear increase in facet load.101 During flexion, the facets
a larger torque for a given force. They are also use- do not bear loads; however, they do bear substan-
ful for surgeons to attach various stabilizing devices, tial loads during extension, axial rotation, and lateral
and in the lumbar spine, spinous processes can, on bending.102 The largest loads are encountered during
average, withstand direct axial loads of 339 N before extension when the tip of the inferior articular facet
failing.92 Their strength is reasonably well correlated impinges upon the lamina of the caudal vertebra. Dur-
to their bone mineral density. ing lumbar extension, the facets tend to rotate dorsally
There are little to no data in the literature de- and the capsule is stretched.100 The capsule is also
scribing the biomechanics of the transverse processes, stretched during lumbar flexion when the facets do
but given their similar anatomy and geometry to not normally bear loads. In functional spinal units, the
spinous processes, their strength should be of sim- largest mean capsule strains (19.25%) occurred dur-
ilar magnitude. As lever arms, transverse processes ing axial rotation for a given moment (15 Nm).99 In
are used extensively by physicians (especially chi- a human cadaver, in situ maximum tensile deforma-
ropractors) to adjust the spine. The failure loads re- tion occurred along the cephalad aspect of the dorsal
ported by Shepherd et al.92 are in the same range of capsule during lumbar extension.103 However, sub-
peak forces measured during some lumbar manip- stantial compressive deformation occurred in some
ulations (adjustments).93 However, there are no re- capsules during some joint rotations.
ports of transverse process fracture following manip- A recent study optically measured plane strains
ulation of the lumbar spine, and spinal adjustments, (i.e., εxx , εyy , and εxy ) in facet capsules of human
lumbar specimens (n = 4) during motions within to (and hence constrain) motions outside the physi-
physiological ranges (maximum joint moment and ological range.
intervertebral angle ≤10 Nm and <15◦ , respectively)
of flexion, extension, and lateral bending.104,105 Plane Muscles
strains (referenced from the spine’s neutral vertical Muscles of the spine have two primary biomechanical
position) in all joint capsules increased monotonically functions: first, they generate force to develop global
for all motions, although intracapsular strains were spine motion (e.g., flexion, extension, rotation, and/or
inhomogeneous. On average, shear strains (i.e., εxy ) lateral bending), and, second, they stiffen the spine to
were slightly larger than axial strains (i.e., εxx or εyy ), provide stability in static and dynamic loading.106,107
with the largest strains in flexion at L4-L5 or L5-S1 It has been known for quite some time that the lig-
joint levels (εxy = 0.163) and decreasing for more amentous cadaveric spine was a relatively unstable
cephalic levels (L1-L2: εxy = 0.003). During extension, structure capable of supporting only relatively small
mean strains symmetrically mirrored those of flexion, axial loads without inducing spontaneous global mo-
negatively increasing for more caudal capsules, tion (e.g., flexion).108,109 The role of spinal muscles in
hence indicating capsule relaxation: extension (L1-L2: developing stability also gave rise to the concept of
εyy = −0.022, εxx = 0.027, εxy = −0.005; L4-L5: εyy = a “neutral zone” wherein the kinematics of the spine
−0.070, εxx = 0.089, εxy = −0.167); flexion (L1-L2 : varied with virtually no muscle contraction.110 The
εyy = −0.006, εxx = −0.0003, εxy = 0.004; L4-L5 : εyy = neutral zone has been identified in both the cervical
0.082, εxx = −0.014, εxy = 0.131). Mirror symmetry and lumbar spines.111,112
was also demonstrated in left and right bending. The primary motions created by muscle contrac-
Local intracapsular tensile strains were present even tion depend on the origins and insertions of the mus-
during relaxation of the entire capsule. cles (Figs. 18–18 and 18–19), as well as cocontrac-
tions. Broadly speaking, muscles involved with the
Longitudinal Ligaments lumbar spine can be categorized as to whether they
All longitudinal ligaments, including those in the are anterior or posterior to the vertebral body (see
lumbar spine, function to constrain motion, depend- Fig. 18–19). Anterior muscles include the rectus ab-
ing on their attachments (origins and insertions) and dominis, abdominal obliques (internus and externus),
material properties (especially moduli of elasticity). and the transverse abdominis. Posterior muscles are
There are five main longitudinal ligaments in the often further subcategorized as deep, intermediate,
lumbar spine, as follows: anterior longitudinal liga- or superficial.109 The superficial muscle group in the
ment (ALL), posterior longitudinal ligament (PLL), lumbar spine consists of the erector spinae, which in-
ligamentum flavum (LF), interspinous ligament (ISL), cludes the spinalis, longissimus, and iliocostalis. The
and supraspinous ligament (SSL). Given their orien- intermediate group in the lumbar spine involves pri-
tation with respect to the spine, their dominant con- marily the multifidus muscles, which travel from the
straints are either in flexion or extension. Ligaments spinous process of one vertebra to the transverse pro-
posterior to the axis of flexion–extension (i.e., SSL, cess of the vertebra below. The group of deepest mus-
ISL, and LF) are stretched during flexion and “re- cles are quite short and span only to the next vertebra;
laxed” during extension. This relaxation is caused these include the intertransversarii (transverse pro-
by the preload that exists on these ligaments in the cess to transverse process), the interspinales (spinous
neutral vertical position of the spine,104 and can be process to spinous process), and the rotatores (trans-
easily demonstrated by cutting the ligaments free of verse process to the lamina). Extrinsic muscles of the
their bony attachment and observing the approxi- spine include the psoas, quadratus lumborum, and
mately 10% reduction in length.99 Ligaments ante- latissimus dorsi.
rior to the axis of flexion–extension (i.e., ALL and The magnitude of the force that can be gener-
PLL) are stretched during extension and relaxed dur- ated by a muscle is largely determined by its mass,
ing flexion. For full physiological motions of flexion which, in turn, can be represented by its physiologi-
and extension, the SSL has the largest uniaxial strain cal cross-sectional area (volume/length).113 Magnetic
(32%) and the ALL the smallest (13%), with substan- resonance imaging (MRI) was used to measure phys-
tially smaller strains developed during either rota- iological cross-sectional area in healthy young men
tion or lateral bending.99 The stiffness curves for all and women, and it was found that significant gen-
these ligaments are relatively linear within the phys- der differences exist, with the physiological cross-
iological range of motions, but highly nonlinear and sectional areas of men significantly larger than those
much larger in the “trauma range,” and will gener- of women.114 For the erector spinae muscles, which
ally fail when stretch ratios extend into the 50–65% had the largest physiological cross-sectional areas of
range. Hence, these ligaments offer little resistance any of the intrinsic or extrinsic spine muscles, the male
to physiological motion, but have high resistance physiological cross-sectional areas were 40% greater
FIGURE 18–18. Lumbar spine drawing

of posterior aspect depicting deep mus-
cles, including multifidus, posterior and
anterior transverse, interspinales, and
quadratus lumborum muscles.
than the female physiological cross-sectional areas. function. While FSUs have been, and continue to be,
Furthermore, the muscle moment-arms are also larger valuable experimental models, it is important to note
for males than for females.115 However, despite these that they have limitations and that the interpretation
differences, women report incidence of low back pain of the data from them should only be extrapolated to
only slightly more frequently than men.116,117 intact spines with careful rationale and justification.
During flexion, lumbar FSUs have a mean com-
LUMBAR BIOMECHANICS bined “strength” in torque and shear force (i.e., the
loads that result in failure) of 156 Nm and 620 N,
Functional Spinal Motion Units respectively.119 At failure in flexion, the maximum
The basic biomechanical functional “unit” for a spine mean load on the posterior structures (i.e., the facet
consists of two vertebrae and their intervening lig- joints) was 2.6 kN. Panjabi and White have compiled
amentous tissues (including the disc).109,118 Func- data illustrating flexibility and stiffness of a “repre-
tional spinal units (FSUs) exhibit the fundamental sentative” lumbar FSU (Table 18–1).109 FSUs are much
biomechanical properties of the spine and the spine more flexible and much less stiff in shear (plane of
can be conceptualized to be composed of FSUs. As the disc) and in x-axis rotation (flexion and extension)
such, FSUs have been extensively used for asking ex- than in tension, compression, and z- or y-axis rotation
perimental questions regarding spine biomechanical (lateral bending or axial rotation, respectively).
FIGURE 18–19. Transverse plane through

the L1 vertebra depicting the arrangement of
various muscles effecting motion of the lumbar
spine.
Mean Flexibility and Stiffness Coefficients for a Representative

TABLE 18–1.
Lumbar FSU*
Forces
Tension Anterior Shear Posterior Shear Lateral Shear

(+FY) Compression(−FY) (+FZ) (−FZ) (FX)
Flexibility 1.30 0.50 8.30 5.90 6.90

Stiffness 770 2000 121 170 145
Moments
Flexion Lateral Bending Axial Rotation
(+MX) Extension(−MX) (MZ) (MY)
Flexibility 0.74 0.48 0.57 0.20
Stiffness 1.36 2.08 1.75 5.00
*Flexibility coefficients are mm/kN for forces and degrees/Nm for moments. Stiffness coefficients are N/mm for forces and
Nm/degrees for moments.
Adapted from Panjabi M, White AA. Physical properties and functional biomechanics of the spine. In: White AA, Panjabi M, eds.
Clinical Biomechanics of the spine. Philadelphia: Lippincott Williams and Wilkins, 1990:58–66.
In vivo, FSUs experience preload simply as a result During isolated global motions (rotations) about
of the force exerted by the weight of the upper torso, the primary cartesian axes (i.e., flexion–extension
which changes by posture.120 The effects of preload about the x axis, lateral bending about the z axis, and
on the biomechanics of the lumbar spine are highly axial rotation about the y axis), the coupled segmental
variable, ranging from essentially no effects (e.g., ax- motions are dominated by the rotation about the pri-
ial compression, extension, and posterior shear) to in- mary axis (Fig. 18–21). In addition to rotational cou-
creasing stiffness for certain types of loads to decreas- plings, primary rotations are typically coupled with
ing stiffness for others.121 Specifically, the spine be- translations about perpendicular axes.125 For exam-
comes more flexible with forces directed anteriorly or ple, forward flexion of the lumbar region induces
laterally and for torques producing lateral bending segmental rotation about the x axis and translation
and flexion, and less flexible for forces and torques along the z axis. Lateral bending induces segmen-
directed axially. tal rotation about the z and y axes and translation
along the x axis. Axial rotation induces segmental ro-
Regional Lumbar Biomechanics tation predominately about the y axis with auxiliary
During physiological motions of the spine, one of rotations about the x and y axes, depending on
the most characteristic aspects of the kinematics is vertebral levels.130 Combined global rotations (e.g.,
the coupling of motions that occur intersegmentally. flexion and lateral bending) can further alter the
These coupled motions were first reported by Henke coupling patterns, such that while laterally bent or ax-
in 1863 in the upper cervical spine,122 and have ially rotated, flexing or extending tends to straighten
been extensively documented to occur throughout the the spine. The clinical significance of coupled mo-
spine, especially in the lumbar spine, by Panjabi and tions is uncertain because there has been a lack of sig-
colleagues.123–126 The basis of the coupling is evident nificant correlation between patients with low back
in ligamentous spines during in vitro testing and oc- pain and radiographic measurements, at least, of cou-
curs in the lumbar spine as a result of the geom- pling motions,123,131–133 and even less correlation of
etry of the vertebrae (especially of the facet joints), radiographic findings from static134 or stress two-
the lordosis of the spine,127 the mechanical properties dimensional radiographs135 with low-back-pain pa-
of the intervertebral disc, and the attachments of the tients.
ligaments.128 However, in vivo testing reveals that
muscles affect the coupling patterns, tending to re-
duce the magnitudes of some of the motions, as well
LUMBAR PATHOMECHANICS
as introducing high variability.129 Dynamic measure-
ments most clearly and indisputably reveal the cou- The earlier sections of this chapter described aspects
pling (Fig. 18–20), and even with high variability in of biomechanics pertaining to the lumbar spine. The
the segmental and global ranges of motions for indi- principles of biomechanics apply to normal and ab-
viduals, average values demonstrate the phenomenon normal spines, and hence the term “pathomechanics”
(Table 18–2). needs some clarification. Indeed, it is used by various
L3/L4 Segmental Motion for Lateral Bending

Angular Displacement Linear Displacement
Segm + flexion Segm ap shear (+unit)
Linear Displacement (mm) Angular Displacement (degrees)

Segm axial rotation (+left) Segm lal shear (+left)
Segm lal beading (+left) Segm + distraction
8
6
4
2
0
-2
-4
-6
-8
12
FIGURE 18–20. Coupled motions 10
of the L3-L4 vertebral motion seg- 8
ment recorded for one subject dur- 6
ing four successive lateral bending 4
exercises. (Reproduced with permis- 2
sion from Steffen T, Rubin R, Baramki H, 0
et al. A new technique for measuring lum- -2
bar segmental motion in vivo. Method, -4
accuracy, and preliminary results. Spine 0 5 10 15 20 25
1997;22:156–166.) Time (Seconds)
authors to refer to people with back pain but without The question of whether the chiropractic
observable pathology,136 and by other authors to refer subluxation143 should be included as a path-
to people with pathology (e.g., scoliosis) but without omechanical lesion and whether it can be defined
significant pain.137 It should be clear that mechani- as a biomechanical entity has been raised.144 There
cal failure of lumbar tissues inevitably results in al- are many theories that have been developed to
tered loading of the spine, and it is known that perma- describe a biomechanical basis for the chiropractic
nently altered loading causes further changes in the subluxation,145–147 including recent energy opti-
spine.138–141 It is further debatable whether the natu- mization models.148 However, despite the plethora
ral history of the spine in populations of “developed of theories, research into the biomechanical basis
nations” (e.g., the United States) includes commonly of the chiropractic subluxation (or manipulable
observed conditions such as disc degeneration.142 lesion149 ) is only beginning and accurate and reliable
TABLE 18–2. Ranges of L3-L4 Active Segmental Motion and Coupled Segmental Motion
Mean Range n
Active Motion and Coupled Motion (Degrees) (Degrees) (Subjects)
Flexion-extension*(with knees straight) 16.9 7.1–29.9 16

Flexion-extension*(with knees bent) 17.1 9.7–27.2 12
One side lateral bending 6.3 4.3–8.8 16
Coupled one side rotation 1.8† 1.0–2.7 15
Coupled flexion-extension 2.7 1.4–5.2 11
One side axial rotation 1.1† 0.5–1-.9 16
Coupled one side lateral bending 1.8 1.0–3.6 14
Coupled flexion-extension* 1.1 0.4–3.0 11
*Flexion–extension range expressed as total amplitude.

†
Paired t test: P < 0.0001.
Reproduced with permission from Steffen T, Rubin R, Baramki H, et al. A new technique for measuring lumbar segmental motion
in vivo. Method, accuracy, and preliminary results. Spine 1997;22:156–166.
25
Flex & Ext.
Lat. Bend. FIGURE 18–21. Best estimates
Axial Rot. of average ranges of segmental
20 motions of the lumbar spine. Er-
ror bars represent limits of ranges
and the value reported is the “rep-
Rotation(Deg)
15 resentative” value. Lateral bend-

ing (Lat. Bend.) and axial rotation
(Axial Rot.) are one-sided-only mo-
10 tions, whereas flexion and exten-
sion (Flex and Ext) are for complete
motion from full flexion to full ex-
5
tension. (Adapted from White AA, Pan-
jabi M. Kinematics of the spine. In: White
AA, Panjabi M, eds. Clinical biomechan-
0
L1-2 L2-3 L3-4 L4-5 L5-S1 ics of the spine. Philadelphia: Lippincott,
Vertebral Segment Williams and Wilkins, 1990:85–127.)
clinical methods for its detection have yet to be based on Euler theory. An experimental animal model
developed.150 Two explanations for the difficulty in has been developed demonstrating that bipedalism
describing a definitive biomechanical mechanism and pinealectomy are necessary and sufficient to cause
for the subluxation are as follows: First, the intrinsic scoliosis in animals, and that either by itself is insuffi-
biomechanical variability between subjects may cient to produce scoliosis in animals.157,163
be so great that it would take much larger sample The principal orthopaedic approach of treatment
sizes than have been employed to detect significant is to hope that the curves do not progress further than
differences with existing methods. Second, existing 20 degrees, but when they do (or if they’ve already so
theories are insufficient to explain the fundamental advanced), then treatment consists of external brac-
biomechanics involved with subluxation. A newer ing or, in more advanced cases, surgical approaches
theory is proposed by Triano, based on buckling and that include internal bracing of various kinds. Chi-
stability theory, that with some experimental support ropractic has a history of anecdotal reports164 that
might eventually prove fruitful.151–154 suggest spinal manipulation in concert with conser-
vative care can be effective in slowing or stopping
Scoliosis the curve progression. However, the one prospective
Idiopathic juvenile scoliosis is a classic example of clinical trial reported in the literature found no signif-
pathomechanics that can be used to illustrate appli- icant improvement in scoliosis using spinal manip-
cations of biomechanics to understand an enigmatic ulation with heel lifts combined with postural and
condition. An excellent and comprehensive review of lifestyle counseling.164 High-velocity low-amplitude
the topic, from a biomechanical approach, is presented manipulations were the principal intervention and
in White and Panjabi,155 as well as in recent reviews were administered multiple times per week, at least
in peer-reviewed journals.156–161 The ancient Greeks biweekly, depending on the likelihood of curve pro-
recognized the condition, but its pathogenesis still regression. However, a single clinical trial, particularly
mains an enigma. one with relatively small numbers of patients (two-
Idiopathic scoliosis is characterized by deformity thirds of whom dropped out before the 1-year study
of the torso associated with lateral deviation and rota- date concluded), is not conclusive evidence for effec-
tion of the lumbar or thoracolumbar spine. It always tiveness or lack thereof. It will take a much more so-
progresses from an apparently normal straight spine phisticated trial with a large number of patients and
to the deformed stage, which includes a deformed rib acceptable follow-up to answer this question.
cage, and most typically occurs during rapid growth
in adolescence. In addition to the change in global
alignment of the spine, there are changes in the ver-
SUMMARY
tebrae themselves. These later changes appear to be
caused by remodeling of the vertebrae in response to 1. The following key concepts in biomechanics have
the altered biomechanics rather than the reverse.162 been developed:
Proposed etiologies of idiopathic scoliosis161 include • Force: a function of the mass and acceleration
heredity, neurological and neuromuscular disorders, of the object.
growth disorders as a consequence of a variety of • Force vector: a force applied in a particular di-
causes (e.g., hormonal), and mechanical buckling rection.
• Torque: a load applied to an object that causes B. Tension only.

it to rotate about an axis. C. Moment (torque) only.
• Loading: the sum of all forces and torques ap- D. Compression anteriorly and tension posteri-
plied to a system. orly, but not torque (moment).
• Bending moment: proportional to the product E. Compression posteriorly and tension anteri-
of the force and the perpendicular distance. orly, but not torque (moment).
• Stiffness: how much force must be applied to F. Compression anteriorly, tension posteriorly,
achieve a given displacement. and moment.
• Elasticity: the ability to recover its original 4. Which of the following loadings of lumbar facet
shape after applying a force. joints is correct?
• Strain: ratio of change in deformation of an ob- A. During flexion, the facet joints bear high loads.
ject to its original volume. B. During full extension, the tip of the superior
• Stress: ratio between the magnitude of an ap- facets can impinge upon the inferior laminae.
plied force and the area over which it applies. C. During flexion, the facet capsule is stretched.
• Viscoelasticity: increasing stiffness for increas- D. During left lateral bending, typical coupling of
ing rates of loading. the vertebrae induces stretch in the right facet
• Fatigue: structural or material failure as a con- capsule and “relaxation” of the left facet cap-
sequence of repeated loading. sule.
2. The specific anatomy of any tissue, which includes E. A and B.
overall geometry, types of cells, and the structural F. B and C.
proteins they produce that result in material prop- G. B, C, and D.
erties, is developed as a consequence of the biome- H. All of the above.
chanical functions it serves.
3. Load transmission and partitioning for the ante-
ANSWERS
rior body and the “weakest link” of the vertebral
endplate were reviewed. Mechanisms involved 1. Mean stress = F /A = (mass × acceleration)/
with disc degeneration were explained. The con- (π × r 2 ) = [(70 kg × 2/5) × 9.8 m/s2 ]/[3.14 ×
straining role of the facet joint and its capsule was (2 cm × 1 m/100 cm)2 ] = (274.4 N)/(0.001256
discussed, as well as the role of muscles as force m2 ) = 218.5 kN (or 218,500 N).
and torque generators. 2. Torque = F × D = [(70 kg × 2/5) × 9.8 m/s2 ] ×
4. Functional spinal units consist of two vertebrae [50 cm × 1 m/100 cm] = 274.4 N × 0.5 m = 137.2
and their intervening disc and ligaments. The role Nm.
of intact spine specimens in testing, as well as in 3. F. The only possible answer is F because A, B, and C
vivo testing, was reviewed. are not possible at all, and D and E are not possible
5. Mechanical failure of lumbar tissues inevitably re- because the combination of tension and compres-
sults in altered loading of the spine, and it is known sion in a single structure implies that it must be
that permanently altered loading causes further undergoing bending deformation.
changes in the spine. 4. G. A is incorrect because during the forward flex-
ion, the facet joints are relatively unloaded al-
though the capsule is still stretched.
QUESTIONS
1. Calculate the mean compressive stress exerted on
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C H A P T E R
19
THE THEORETICAL BASIS
FOR SPINAL MANIPULATION
John Triano
O U T L I N E
INTRODUCTION Manipulation
THEORETICAL FOUNDATIONS Treatment Control Strategies
Science versus Vitalism Mobilization and Manipulation Methods
Underlying Assumptions Continuous Passive Motion Methods
BASICS OF SPINE BIOMECHANICS Stiffness-Dependent Procedures
Kinematics Combined/Motion-Assisted Procedures
Equilibrium SAFETY
Tissue Properties Operator
SPINAL BUCKLING: A MECHANICAL MODEL Patient
OF SUBLUXATION CONCLUSION
THE MECHANICS OF MANIPULATION SUMMARY
PROCEDURES QUESTIONS
Classification of Procedures ANSWERS
Massage KEY REFERENCES
Mobilization REFERENCES
7. To review the biomechanical evidence on safety for

OBJECTIVES
these procedures.
1. To describe the current conflict between clinical ap-
proaches focusing on vitalism versus reductionism
as it relates to the practice of spinal manipulation.
INTRODUCTION
2. To present the basic concepts necessary to under-
stand the biomechanics of subluxation and manip- Manipulation/adjustment is a bimanual task requir-
ulation. ing motor/sensory coordination and skill. Directed
3. To develop the buckling model of subluxation movements are performed sequentially to achieve a
from the scientific evidence. specific clinical objective. Procedures must be flexi-
4. To develop the knowledge base of manipulation ble to accommodate use under complex, sometimes
mechanics necessary to promote skilled clinical ap- unique, clinical circumstances. The standard for a
plication. minimum clinical skill is that it can be accomplished
5. To define the concept of treatment control strate- safely. Competency assumes effectiveness with the
gies for problem solving and innovation in care ability to avoid injury and ranges from “adequate”
delivery. to “masterful.”1 Understanding how to perform these
6. To develop an understanding of differences in pa- procedures masterfully requires an understanding of
tient response to manipulation procedures based the biomechanics, not only for the methods them-
on tissue properties and objectives of treatment. selves, but also the lesion to be treated and its
361
surrounding structural and functional integrity. Ef- disorders, and improving quality of care. What fol-
fective case management involving manipulation is lows is a systematic review of manipulation theory,
more than repeating manual movements. It requires its basis, and its practical applications.
integration of sensory feedback from patient reaction
to touch and positioning along with cognitive use
of diagnostic information on tissue properties and Underlying Assumptions
local pathology while attempting to solve a clinical The fundamental concept underlying manipulation
problem. use is based on the presence of a functional lesion,
often termed a subluxation or joint dysfunction.5,6 The
lesion is essentially a mechanical event or behavior
THEORETICAL FOUNDATIONS of the joint components that has both local and re-
mote influence on health and symptoms.7 These le-
Science versus Vitalism sions are considered amenable to the application of
There is inherent, but healthy, tension between vital- loads (forces and moments) to the body, termed adjust-
ism and reductionism within the concept of health. Vi- ment or spinal manipulation, with the intent of restor-
talism suggests the wonder of life and its robust coming normal behavior and reducing unhealthy effects
plexity. It provides a metaphor for “subluxation” and of these lesions.
“adjustment” and the ability to imagine new frame- In biomechanical terms, this reduces to the prob-
works for thinking.2 Reductionist exploration pro- lem of the equilibrium and stability of multimuscle,
vides answers on how life remains so robust. It pro- biarticular structures (Fig. 19–1) under load in com-
vides the details that allow the doctor to intervene plex postural configurations and the mechanical in-
productively using a theoretical foundation for the terventions to restore and maintain both equilibrium
doctor’s discipline. and stability.
Patients are people with health predicaments. For
some that means they have failed structure or function
with symptoms that interfere with their desired qual-
ity of life. For others, they aspire to optimal physique
and performance. Each perceives his or her dilemma
and its solution differently. For those who are ill, the
first criterion is relief of symptoms and restoring func-
tion to acceptable levels. For a privileged few who are
interested and able, it is a self-actualization of per-
ceived potential. In either case, when people adopt
the patient role, they reach out to health care profes-
sionals for intervention and advice. As they do, they
encounter an array of credentials (DC, MD, DO, DN,
PA, NP, RN, PT, OT, PhD). The distinct body of knowl-
edge used by each group provides a basis for profes-
sional jurisdiction—their scope of practice. Control of
that jurisdiction is maintained through the advance-
ment of core knowledge and the demonstration of su- Erector
perior effectiveness with which members of the group Spinae
implement that knowledge.3 Abdominal
Regardless of differences in practice styles among
doctors of chiropractic, it is manipulation theory that
binds them, forming the common core on which their
professional practice is built.4 A number of ancillary Multifidus
diagnostic and treatment techniques are available and
help to differentiate intraprofessional subspecialties
(e.g., radiology, rehabilitation) and individual career
tracks (private, group, multidisciplinary practice). Re-
FIGURE 19–1. The lumbar spine is modeled as a single pivot
search accomplished over the past three decades has joint traversed by multiple muscles (represented as springs)
helped to refine the empirical chiropractic hypotheses. that bridge more than one articulation. Motion is initiated by
Modern manipulation theory embraces early vitalism. the regional muscle groups (erector spinae and abdominal),
At the same time, it thrives on scientific advances en- while local stability is controlled by the smaller intrinsic (e.g.,
hancing knowledge of spine function, spine-related multifidus) muscles.
THE THEORETICAL BASIS FOR SPINAL MANIPULATION 363
F1
BASICS OF SPINE BIOMECHANICS B
The characteristic properties of tissues are a function
of age, fitness, and the presence of disease or injury. A
F
Successful treatment outcome and prevention of ad- 2
verse reactions can be influenced by knowledge of US C
C
these factors. For example, patients with profound B
osteoporosis may benefit from care but have signif-
icant loss of bone strength and are susceptible to A
F3
fracture from loads that healthy bone would nor-
mally sustain.8 Each type of tissue plays a significant
role in structural equilibrium and stability under dif-
ferent functional circumstances. Several biomechani- FIGURE 19–2. A. Tensile load (F1 ) applied to a tissue re-
cal properties are key to the development of symp- sults in a linear stress–strain curve. B and C. Increased force
toms while others have important influence over (F2 and F3 ) begins to overload individual fibers, resulting in
subcatastrophic failures. On reaching ultimate strength (US),
the response to different manipulative procedures
catastrophic failure occurs.
(Table 19–1) and to the prevention of injury.
The biological notion of physiologic homeostasis
is mirrored in biomechanics by the concepts of equi- behavior)7,9 or it will separate (tear/fracture). When
librium and stability. Both must be maintained for failure is partial, even microscopic, versus a total fail-
healthy function under static and dynamic conditions. ure with full separation, it is termed a subcatastrophic
Static loads, both forces and moments, acting on the failure (Fig. 19–2). Conceptually, treatment of struc-
body are transmitted through and distributed among tural failure simply requires reducing the local tis-
the various tissues. Each tissue is stressed in propor- sue stress and deformation so that healing can occur.
tion to its geometrical relationship with the loads act- The extent to which the tissues are restored to nor-
ing on it. mal health and function depends on the severity of
If strains are excessive, the tissue will fail in at least residual damage or scarring.
one of two ways. Either the system will undergo a de- The practicing chiropractor uses basic knowl-
formation inconsistent with usual function (buckling edge of biomechanics, physiology, and pathology to
TABLE 19–1.Tissue Biomechanical Properties That Influence Functional Integrity

During Activities of Daily Living or Trauma and Response to Manipulative Treatments
Property Definition
Compliance Deformation of tissue for a unit of load.

Constitutive properties (static The characteristics of materials that dictate how much stress
and dynamic stability) and strain they will undergo during a load.
Creep Strain of loaded tissue over time.
Elasticity Ability of tissue to deform under load and to return to original
shape when load is removed.
Load Mechanical force/moment applied to a tissue.
Stability The tendency for a perturbed system of tissues to develop
internal loads to restore equilibrium.
Strain The percentage change of tissue dimension from loading.
Stress Force/area that resists deformation.
Stress relaxation Reduction of tissue stress over time as a result of creep
deformity.
Stiffness The ratio of load to deformation.
Ultimate strength Maximum load/area at which a tissue will fracture or tear in
catastrophic failure.
Viscoelasticity The ability of a viscous tissue to store energy of deformation and
to demonstrate slow, elastic return of shape.
Viscosity Resistance to deformation of a tissue as a result of fluid motion.
Lower body mass and inertia Upper body mass and inertia
Φ a
F M
σ [BF]
FIGURE 19–3. Diagram depicting
the loads acting on the target level
σ (L3-L4 cutting plane) during spinal
manipulation. Loads (F, M), ap-
plied from below the cutting plane,
[G] cause accelerations (a, ) of the
L3/4 cutting plane lower body. Forces pass through
the target spine segment ([BF] ref-
erence frame) to be resisted by the
upper body and support table. (([G]
Rm
reference frame.) Modified with permis-
R
f sion from Mediclip.)
convert information from the diagnostic examination relates to the spine, the most biomechanically studied
and laboratory tests to an understanding of the extent tissue is the intervertebral disc.
of failure and damage, leading to a treatment plan.
A brief description of biomechanical building blocks Equilibrium
follows. For a more technical review of mechanics fun-
When manipulation is performed, both forces and mo-
damentals as they relate to subluxation and manipu-
ments are applied as external loads. Figure 19–3 de-
lation see Triano.7
picts all of the loads acting on the spine during a treat-
ment. These are among the elements controlled by the
Kinematics operator. Control strategies that the operator adopts
Kinematics is the study of the motions of a system. in matching the procedure to the patient can have sig-
The elements include position, displacement, velocity, nificant influence on the success or failure of the pro-
and acceleration. Each can influence the likelihood of cedure.
structural failure under specific conditions. For exam- As the external loads act on the body surface, a
ple, lifting a heavy load is best accomplished with the number of things happen. First, the body segment
weight held close to the body10 and with as erect a pos- under pressure deforms. Relative movement between
ture as possible. Attempts to lift while in a flexed po- body parts (e.g., upper versus lower) occurs, often in
sition more easily result in spinal injury. Loads lifted opposite directions, and loads are transmitted to the
too quickly have a higher risk. Patients subjected to targeted joint structures and soft tissues. The most
sudden accelerations, as in falls, motor vehicle ac- interesting effects occur at the articulation. Relative
cidents, or simply a missed step off a curb, can ex- movements of the joint components result in some tis-
perience painful symptoms. In similar fashion, kine- sues undergoing increased local stress while in others
matics plays an important role in joint manipulation. it decreases. These movements may be facilitated or
Patient position varies in setup from one technique to inhibited by loads generated internally from patient
another. Speed of application can define whether the muscle action.
therapeutic effect is dominant for the soft tissues or Applied force and moment generate inertial loads
for joints.7,9,11 as can be seen in Figure 19–3. Inertia is the property
When knowledge of the loads causing motion is of matter that resists effort to change its momentum.
included, the study falls under the science of dynam- It is a property that is a function of the geometry
ics. Loads acting on body structures take two forms: and mass of the object. In contrast to mass effects, in-
forces and moments. The probability of nontraumatic ertia is not the same in all directions because of its
injury is more highly correlated with moments act- dependence on geometry. That is, the geometry and
ing across a joint structure than with forces. There mass impart an acceleration of the body part, which
are many sources of loads across specific structures, creates an effective force and moment that may add
which can be divided into two general classifications: to or subtract from the total load acting at the tar-
external and internal. Understanding their combined geted joint. Together, the applied manipulation forces
effects on a specific structure can be complex. As it and moments sum with the loads caused by body
Static Equilibrium Results When the Sum of Forces and

TABLE 19–2.
Moments Acting on the Body Cancel Each Other Out
Static Equilibrium Dynamic Equilibrium
F = ma = 0 F − ma = 0
Fx = max = 0 Fx − max = 0
Fy = may = 0 Fy − may = 0
Fz = maz = 0 Fz − maz = 0
M = I = 0 M − I = 0
Mx = Ix x = 0 Mx − Ix x = 0
My = Iy y = 0 My − Iy y = 0
Mz = Iz z = 0 Mz − Iz z = 0
Dynamic equilibrium involves acceleration of the body segment into motion, which then offsets the trig-
gering forces and moments. For the two-dimensional case, “a” is the total acceleration defined by
a = (ax2 + ay2 )1/2 and, similarly, “” is the total angular acceleration defined as = (2x + 2y )1/2 . The
subscripts (x, y) designate the components acting along the respective reference axis. General move-
ments in three directions are of the same format but the equations are much more complex in the
moments, owing to the additional geometric factors that must be added.
segment movement and muscle action to create the efficiency of transmission is dependent on the relative
net action at the targeted joint. At all times, the sys- viscoelastic and stiffness properties. Muscle is the wild
tem is in fundamental balance. Under static condi- card in this process because its stiffness can change
tions, the balance is strictly from the counteracting with activation. Existing data on muscle action during
loads. When movement occurs, the loads are offset by manipulation comes primarily from study of healthy
any motions that arise. The basic equations shown in subjects.12 Twitch responses have been observed to oc-
Table 19–2 give quantitative definition to static and cur during and following the load application. Gen-
dynamic equilibrium, showing that the balance exists erally, the amount of activity in healthy subjects is in-
in all directions. It is this fundamental fact of mechan- sufficient to generate loads that significantly alter the
ics that allows experimental study of manipulation treatment effort.13 Clinically significant muscle ten-
biomechanics. sion is observed empirically in patients, however. It
During the preparation for treatment, the patient may contribute to load transmission passively like all
is usually prepositioned and a preliminary load is other soft tissue, or it may become an independent
applied followed by a pause. This preload phase is load generator based on voluntary or reflexive con-
a static equilibrium. There is almost always some traction during preload or the manipulation itself.
slow movement as it is quite difficult for the patient– Very little is known about the distribution of trans-
doctor configuration that is being stabilized by the mitted loads among the soft tissues. What is clear is
doctor’s muscles to be truly “static.” However, from that the loads do pass through with some degree of
a biomechanical perspective, as long as the move- attenuation. The effect of the transmitted loads on
ments are slow relative to the speed of loading during the elemental tissues of the spine depends on their
the procedure, a static analysis is appropriate. These
conditions of “near” static configuration are called Transmitted moment
“quasistatic.” vector Transmitted force
vector
Once the treatment loads are implemented and the
patient’s body is in motion, the system is in dynamic
equilibrium where the body mass and inertial prop-
Intersegmental ligaments
erties, excited by the accelerations (see Fig. 19–3 and Spinal nerve
Table 19–2), create an effective force and moment that
Disc
either augment or interfere with the intended manip-
ulation effort.
Tissue Properties
FIGURE 19–4. Manipulation forces and moments acting on
Changing the frame of reference to the targeted joint the spinal tissues are the sum of the applied, inertial, and pa-
(Fig. 19–4), the perspective on loads is different. Forces tient’s muscular tension loads that cause relative movement:
and moments are transmitted from the surface and Transmitted load = Applied load + Inertial load + Muscle action. (Mod-
passively through the soft tissues to the target. The ified with permission from Mediclip.)
20 lb/sec
20 lb/sec
∇
h
∇
h1
FIGURE 19–5. Bone, like other tis-

sues, is rate-sensitive in its response
to load application. At lower rates,
it deforms more ( h) than at higher
rates ( h1).
amplitude and speed, as well as the tissue consti- deformation. Stiffness and viscoelasticity interact in
tutive properties. Constitutive properties govern the response to task demands; sometimes stiffness prop-
amount of strain that will be experienced by tissue ex- erties predominate, while under other conditions it is
posed to a given load. Figure 19–2 demonstrated the the viscoelastic response. This interaction is an impor-
relationships that lead to function or failure. The ul- tant factor that differentiates the response to mechan-
timate strength of tissues is a function of the material ical treatment methods.
and its geometry. As loads increase, nearing the limit, The difference in the rate of deformation of a tis-
a few of the fibers may break, resulting in a subcatas- sue versus its viscoelastic return to relaxed conditions
trophic failure. Other fibers take up the load and the is called hysteresis (Fig. 19–6) and plays an important
structure as a whole survives. However, some dam- role in spine biomechanics. The elastic response often
age has been done. Continued increase in loading will reconstitutes tissue to its original length after being de-
ultimately lead to complete structural separation and formed. Joint surfaces are not held tightly in relation
failure as the ultimate strength is passed. to each other. Return to the original position or
How much tissue strain occurs under a specific
load is a function of its inherent properties. Both its
material and water content, with its ability to shift
from one compartment to another, play important
roles under different conditions. The tissue substrate
provides stiffness and elasticity. Stiffer materials de- A
form less when exposed to a given force. The amount
of deformation for that force is defined as tissue com-
pliance. When an examiner palpates the tissues, it is
Load
the relative difference in compliance that assists in de-

termining if the tissue is normal. Elasticity is the prop-
erty of the tissue to immediately recover from the de-
B
formation imposed. However, living tissue tends not
to have an instantaneous, complete recovery. Rather,
the return to preload state occurs more slowly. The de-
lay arises from the viscous shift of fluids from one com-
partment to another. Fluid movement has a dampen-
ing effect, absorbing energy and tending to protect
Deformation
the underlying tissues. The image of bone, for exam-
ple, is dominated by the impression of its stiffness.
FIGURE 19–6. The solid line (A) plots the type of path for the
Yet, bone is viscoelastic and bends under physiolog- return to the undeformed state typical of an elastic tissue and
ical loads, recovering when unloaded (Fig. 19–5). If defines hysteresis. The larger the area enclosed, the greater
loads are applied rapidly, as in the sudden lifting of a the energy stored by the tissue. The dashed line (B ) represents
very heavy load, there is little time for fluid shift out a delayed or incomplete return to the original state where some
of the bone, resulting in increased stiffness and less of the original energy is lost.
P1
Flexion
I1
NZ
P2
I2
FIGURE 19–7. For the vertebra, neutral is a zone Extension

(NZ), not a position. The actual position (P1 vs.
P2) and intravertebral foramen (IVF) shape (I1 vs.
I2) will vary. (Modified with permission from Mediclip.)
orientation is not exact. For the spine, the region of “toe” region of the deformation/strain region in Fig-
unloaded positions has been described as a neutral ure 19–8 has an equally important role to play. The
zone. The representative neutral zone for each func- neutral zone, schematically depicted in Figure 19–7 as
tional spinal unit (FSU) and each spine region is quite a straight line leading up to the elastic zone, is more ac-
variable.7 It may also vary with posture.14 As depicted curately divided into two parts.14 It defines a central
in Figure 19–7, the relative bone positions at rest are region of normal rest positions from which the seg-
different after each movement. The result is a change ment can move when a load is applied. Within the neu-
in the intervertebral foramen (IVF) dimensions (see tral zone, the intrinsic resistance to movement is neg-
Fig. 19–7) and relative overlap of the facet articula- ligible. As internal disc fibers are engaged, resistance
tions. If ligament elasticity is compromised, the re- begins to rise. When the stiffness (slope of the load
gion of hysteresis can increase,14 which may result in stress–strain curve in Fig. 19–8) is approximately half
an enlargement of the neutral zone. that of the elastic zone, the lax zone has been reached.
Daily activity deforms tissue. Prolonged or re- When the stiffness becomes linear, the elastic zone
peated loading expends the elastic reserve. Tissues has been reached and the segment will increase re-
stretch by a process called creep. In the early stages, sistance to further motion as displacement increases.
the stretch is temporary and gradual recovery (hys- Increases in the neutral zone and lax zone have been
teresis) will occur when activity stops. Extreme use of
the tissues over weeks and months, however, can re-
Traumatic
sult in remodeling and a permanent change in shape. Range
Physiologic
Spine behavior, including intersegmental motion, Range
is the aggregate of biomechanical factors. Figure 19–8
defines the biomechanical and the physiological be- Voluntary
haviors of spinal units in terms of the load (stress)– Range
deformation (strain) curve. The physiologic range of

Load/Stress
Paraphysiologic
motion is divided into a voluntary and an involuntary Space
component. The paraphysiologic space represents a Failure
reserve of passive motion that can be engaged when Lax Range
external loads strain the tissues beyond voluntary lim- Zone
its without exceeding the injury threshold. Creep de-
formity of the restraining ligaments may allow the Neutral Elastic Plastic
Zone Zone Zone
joint to move into the paraphysiologic space, exhaust-
ing its reserve capacity. With additional loading, the
traumatic range is reached. Deformation / Strain
Historically, the elastic zone has been the focus
of effort to understand the biomechanics of the FSU. FIGURE 19–8. Relationship of the tissue stress–strain re-
In the 1990s, however, studies demonstrated that the sponse and clinically relevant motion ranges.
found to be a more sensitive indicator for develop- accounts more fully for both biomechanical and clin-
ing spinal instability than are measures of the elastic ical behaviors.7,9
zone or range of motion. Crawford et al.14 found that People perform their activities of daily living un-
the extremes of the neutral zone plus the lax zone for der a wide range of circumstances even if they have
flexion–extension can be as much as 75% and 70%, re- undergone previous injury. Figure 19–10 summa-
spectively, of physiologic flexion–extension axial ro- rizes the biomechanical and physiological interactions
tation motions. As restraining structures begin to fail, leading to normal or abnormal function during task
more distant structures (e.g., intrinsic–extrinsic mus- performance.7,9 If people operate under low-risk,
cle, articular facets) are engaged to resist the loads. The physiologic conditions, the injury threshold is never
neutral zone and lax zone then increase as one bone reached, and they cycle from one task to another with-
moves further with respect to its mate, because it is out any adverse response. When injury does occur, it
no longer limited by the same structures. The elastic will take the mechanical form of deformation incom-
zone may decrease or remain stable as the more distant patible with the intended function (buckling), or as an
structures ultimately restraining the motion are often excessive compression or separation within the tissues
more rigid.14 Changes in the neutral or lax zones as (tearing/fracture). Pain response develops by neuro-
a result of subluxation, theoretically, are likely. How- genic or nonneurogenic mechanisms and is consid-
ever, such studies have yet to be conducted. ered nociceptive. That is, the pain is organically based
with pending or actual tissue damage at the site of le-
sion. If unresolved and the problem becomes chronic,
SPINAL BUCKLING: A MECHANICAL MODEL
sensitization occurs that makes the patient perceive
OF SUBLUXATION
normal function as painful even when further tissue
The index for the modern era of chiropractic was the damage is not present.7
first scientific conference on spinal manipulation in In its simplest form, a motion segment buckling
1975. Since then, a healthy dialogue has begun that behavior represents a local, uncontrolled, mechanical
challenges traditional concepts of spine care, filling response to spinal loading. The relative displacements
in some of the voids in knowledge and posing new never exceed the normal range of motion within the
questions. The result is a tighter theory, able to more joint.19 However, there is a sudden shift in the loca-
completely account for clinical observations and rely- tion of the axis of rotation (Fig. 19–11), concentrat-
ing less upon empirical notions. ing stress in any of the several tissues that make up
The classical hypothesis of subluxation remained the motion segment or functional spinal unit. In vitro
largely unchanged through the majority of the twen- studies of human spine response to loads using both
tieth century. Attributed to Palmer, the historical ex- isolated FSUs20–23 and entire regions24,25 have demon-
planation assigned four attributes: vertebral misalign- strated buckling behavior in the laboratory. McGill
ment, narrowing of the intervertebral foramen, nerve and colleagues26–28 observed a buckling event in vivo
pressure, and interference with nerve function.15 As during fluoroscopic studies of weightlifters. Symp-
understanding of neuromusculoskeletal structure and toms that result from these lesions may be strictly
function advanced, modifications of the original the- local or may be remote from the spine. How they de-
ory were introduced by a number of authors.6,16–18 velop depends on which tissue or tissues reach injury
The Palmer subluxation concept (Fig. 19–9) was el- threshold.
evated to that of a complex of pathophysiologic There are three reasons why such critical spine be-
elements. More recently, the clinical model was havior has gone largely unrecognized in the broader
modified further to include scientific evidence that clinical and scientific community. First, the details of
spine biomechanics under both normal and abnor-
Subluxation Complex mal conditions have had to wait for technological ad-
vancements. Second, specific conditions are necessary
Kinesiopathology to lead to buckling behavior. At a minimum, they ap-
pear to be the presence of a critical load acting on the
FSU and the load coinciding with the FSU being at
Myopathology Neuropathology its balance point within the neutral zone. The balance
point is defined as the relative position of two ver-
Connective tissue Vascular tebrae at rest where the application of a compressive
pathology pathology load results in no movement. The exact location is id-
iosyncratic. Experimentally, it tends to be near, but not
FIGURE 19–9. The pathophysiologic complex model of sublux- at, the centroid of the cross-sectional area of the disc.
ation describes component elements without clarifying mecha- Finally, the motions associated with buckling do not
nisms. extend beyond the physiological range. Figure 19–12
Activities of Daily Living
Physiologic Prolonged Rapid dynamic Vibration

variation static posture load
Injury
Viscoelastic No
deformation Yes
Failure
Tear/Fracture
& Repair
Subluxation
(Buckling failure) Residual No residual
Neurogenic Nonneurogenic
pain pain
Neurogenic Nerve ending

Inflammation sensitization
Reduced
threshold
Spine motion
sensitization
FIGURE 19–10. Schematic cas- Central Peripheral

cade of biomechanical interactions sensitization hyperalgesia/spasm
associated with injury and local or
remote symptom production.
demonstrates the incremental displacements during loading of the spine. Sudden jarring of the spine that
biomechanical testing leading to buckling as reported increases spinal loading at a rate of 500 lb/s or more
in the original work of Wilder and colleagues.21–23 will cause buckling. An unexpected, missed-step or
What is clear is that while the buckling event is de- near-fall incidents are examples of rapid loading. Fi-
fined by a large, nonlinear displacement (e.g., 2.70) nally, buckling is facilitated by vibration, lowering the
disproportionate to the increased load, the total dis- threshold by which it occurs. Moreover, vibration also
placement is well within the normal range of motion inhibits intrinsic muscle response to stretch that might
(e.g., 4.30). This is consistent with the illustration in prevent the buckling event.
Figure 19–11, where there is a shift in the instanta- If the capsular ligament is the structure (see
neous axis of rotation between segments, resulting in Fig. 19–11) that undergoes subcatastrophic failure,
greater tissue strain than would normally occur dur- then the presenting symptoms represent a facet com-
ing the task at hand. Such behavior has been demon- plaint with capsulitis. Similarly, the disc, nerve, or any
strated with cervical spine whiplash injury19 and in other injured tissue element of the motion segment
the lumbar region during heavy weightlifting.26,28 will present appropriate symptoms. Accordingly, it is
Three kinds of mechanical overload that foster easy to see that these lesions (e.g., subluxation, func-
spinal buckling have been identified.20–25,29,30 In the tional spinal lesion, joint dysfunction) may be primary
first, the spine experiences prolonged static posture disorders or may be subcomponents of other condi-
followed by an additional small load. For example, tions, occurring alongside of pathology.31
prolonged sitting or bending followed by a reaching Treatment of patients with these lesions, then,
action or an effort to rise. An alternate cause is rapid needs to consider appropriate means of unbuckling
application of forces and moments in an effort to

C5 C5 restore normal function, alter tissue stress distribu-
Strain Strain
tion, and reduce local or remote symptoms. The clini-
C6 C6
cal conditions treated may traverse a broad spectrum
ICR of disorders ranging from isolated dysfunction or sub-
luxation to complicated cases in which reversible dys-
Normal Motion Buckled Segment
function is a comorbid component. Skilled perfor-
mance of these procedures permits patients to benefit
even in the presence of complex pathology and post-
surgical status by adapting procedures accordingly.
Table 19–3 lists a number of factors that may require
modification of treatment approach to achieve maxi-
mum clinical benefit and safety.7,31,32
Pain Classification of Procedures

generator
Various manual treatment methods are available.
Typical descriptions group them into the categories
of massage, mobilization, and manipulation.11 Sub-
FIGURE 19–11. Shifting of the instantaneous center of rota- categories exist for each that can lead to a bewil-
tion (ICR) associated with buckling. Symptoms are determined
dering set of over 200 different named systems,
by the identity of the tissue or tissues that have been strained
90 for chiropractic manipulation alone.33,34 Adjust-
beyond injury threshold. (Modified with permission from Mediclip.)
ment/manipulation techniques generally used by
chiropractors are referred to as high-velocity (speed)
the involved segments and reducing local tissue low-amplitude (displacement) procedures that target
strain. As this occurs, inflammatory changes and any specific joints. Mobilization, on the other hand, is de-
neurogenic or nonneurogenic mechanisms of sensiti- fined as a cyclic application of joint loads at lower
zation may be addressed. The extent to which normal velocity, while massage is a systematic application of
function is restored and healing occurs will depend pressures focusing on the soft tissues.
on the degree of residual capacity of the tissues. The common denominator for all of these ap-
proaches is the fact that, regardless of system or tech-
nique, there are only six means of loading the spine
THE MECHANICS OF MANIPULATION
(Fig. 19–13) and the tissues around it. It may be
PROCEDURES
pushed/pulled in the transverse (Fx), cephalocaudal
Spinal manipulation or adjusting is a form of biome- (Fy), or anteroposterior (Fz) directions. It may also
chanical problem solving. It involves the controlled be twisted by a moment (Mx, My, Mz) about each
2.5
2
Post-buckling
Pre-buckling behavior
Degrees
behavior
1.5
FIGURE 19–12. Incremental mo-

0.5
tion of a lumbar segment taken
from data reported by Wilder
0 et al.22 when loaded to the critical
Incremental Loading load at the balance point.
TABLE 19–3. Patient Factors Associated with patient and provider. Remote contacts also may be
Altered Tissue Properties That Might Require incorporated where leverage is used to affect the tar-
Modification of Treatment Options geted joint.
Considerable controversy remains among various
Factor Effects health providers who use manual treatment meth-
ods as to what characteristics differentiate between
Age and fitness Affects tissue properties, strength, categories, particularly for mobilization and manipu-
endurance, and coordination. lation. Until recently,7,9,32 efforts to distinguish tech-
Bone-weakening Alters ultimate strengths of tissues. niques have focused either on description or intent of
pathology the procedures themselves. For example, mobilization
Direction of Alters feasible modes of treatment. is a slow, oscillating motion designed to be carried out
hypermobility within the normal range of motion39 and not intended
Postoperative status Influences tissue compliance, to result in cavitation of the joint with audible release.
ultimate strengths, and Separately, manipulation has been described as a sin-
viscoelasticity. gle, rapid motion imparted to a joint and carrying
Provocative Maneuvers that inform as to loads it into the paraphysiological space with the intent to
maneuvers or directions that aggravate achieve cavitation and audible release.34,40 Unfortu-
symptoms. nately, in practice, neither definition seems to agree
Progressive neuro- Increasing loss of nerve function. with clinical observations. Joints undergoing mobi-
logic deficit lizations sometimes cavitate. Cavitation does not al-
Stature Distribution of patient body mass ways seem to require the movement of the joint into
(height and weight), which may the paraphysiological space. Rapid procedures do not
influence mode of treatment. necessarily result in cavitation. Recognizing the incon-
sistencies, certain authors have attempted to resolve
them by reclassifying mobilization and rapid, manip-
ulation procedures under one broad heading of mo-
respective axis. The loads (forces and moments) may bilization. Under this scheme, procedures are ranked
be applied to the targeted joint manually,34,35 by me- I to IV according to speed of performance and rela-
chanical instrumentation,36,37 or by mechanically as- tive displacement. Such a system fails to account for
sisted manual methods (Table 19–4).33,38 At the site the different diagnostic and technical skills required
of application, the local stresses may be concentrated in order to ensure effectiveness and safety.9,41,42
or distributed by selection of the contact interface An alternative approach that seems to avoid the
(thumb, index, pisiform, pollicis, etc.) between the pitfalls of earlier categorizations bases the differenti-
ation on biomechanical properties of the procedures
Fy in the context of the joint to be treated. Under such
My
a system, issues of intent and result become irrele-
vant and the basis for earlier inconsistencies becomes
apparent. An additional clinical advantage is the de-
velopment of a basis for understanding the effects of
each type of procedure on joint function.
The lesioned joint, and its local or remote symp-
Fz tom complex, has no awareness of the intent of the
provider (e.g., to achieve cavitation, remove nerve
Mz
interference). It is responsive, however, to the loads
Mx that are applied based on its intrinsic biomechanical
properties. Of particular interest are the viscoelastic or
Fx
damping properties and stiffness. When the speed of
the procedure (in the mathematical form of normal-
ized angular velocity) is plotted with respect to the
FIGURE 19–13. Reference frames are defined in many ways
by different authors and are meaningless unless given an
viscoelastic and damping properties of the spine (Fig.
anatomical basis. Each plane defines two cardinal force and 19–14), a pattern emerges that clearly distinguishes
one moment direction: Sagittal = P − A (+ Fz), cephalic (+ Fy), procedures. Moreover, the plot, along with Figure
and flexion (+ Mx); coronal = left (+ Fx), cephalic (+ Fy), and 19–15, is instructive in explaining the difference in
right bend (+ Mz); and transverse = P − A (+ Fz), left (+ Fx), biomechanical responses seen with these treatment
and left rotation (+ My). (Modified with permission from Mediclip.) methods as reported in the literature.
TABLE 19–4. Variability of Administration for Manual Methods
Mode of Administration
Mechanically Mechanically
Variables Manual Instrumented Assisted Manual
Preload–static/dynamic Massage S Massage — Massage S

Mobilization S Mobilization S Mobilization S
Manipulation S/D Manipulation S Manipulation S/D
Load amplitude–force/moment Massage F, M Massage — Massage F, M
Mobilization F, M Mobilization F Mobilization F, M
Manipulation F, M Manipulation F Manipulation F, M
Application speed–impulse ≥ low Massage LS, VL Massage LS, VL Massage LS, VL
Mobilization LS, VL Mobilization LS, VL Mobilization LS, VL
Manipulation I, HS Manipulation I, HS Manipulation I, HS
Application–concentrated ≥ distributed Massage C/D Massage — Massage C/D
Mobilization C/D/R Mobilization D/R Mobilization D/R
Manipulation C/D/R Manipulation C Manipulation C/D/R
/ = and/or; C = concentrated local contact; D = distributed local contact; D = dynamic preload; F = force application; HS = high speed; I = impulse;
LS = low speed; M = moment application; R = remote contact; S = static preload; VL = very low speed.
Typical treatment velocities for massage, mobiliza- and pelvis below. Figure 19–15 demonstrates how the
tion, and high-velocity low-amplitude (HVLA) proce- FSU displacements differ for mobilization and HVLA.
dures have been marked on Figure 19–14. The behav- Each spine segment, through its intrinsic muscles and
ior of the tissues is given as a function of the speed of ligaments, offers its own stiffness (k2–5 ) and viscoelas-
procedure application. At slower speeds the relative tic resistance (R2–5 ). As the initial preload is applied,
proportion of viscoelastic resistance to loads is large the tissues deform. If the treatment then applied is a
and that of stiffness is small. On the other hand, sim- slow movement, a broad deflection spreads over the
ilar to the behavior of bone, shown in Figure 19–5, entire lumbar spine (b-b) with resistance increasing
the faster a load is applied, the greater the stiffening with greater displacement. This occurs because the
reaction. As can be seen, viscoelasticity contributes loads are applied sufficiently slowly to permit the tis-
significantly less to overall load resistance across the sue fluids to shift from one region to another. Load is
range of speeds and reaches a maximum sooner than transferred along the spine and sequential displace-
does tissue stiffness. ment occurs from one vertebral segment to the next.
The lumbar spine is stabilized by the stiffness (K1 For HVLA, there is not enough time for exchange
and K2 ) and body mass of the thorax segment above of fluid to occur between tissue compartments. Tis-
sue resistance relies upon the relative stiffness of the
Resistance to load
a
ss a
e Manipulation
ti ffn b σ
S (HVLA)
b
Mobilization
K1 K2
σ
Viscoelastic damping k2 k3 k4 k5
Massage R2 R3 R4 R5
0.001 1.0 1000.0

Angular velocity FIGURE 19–15. The lumbar spine resistance to manipulation
loads is represented by spring elements (K1 , K2 , and k2–5 )
FIGURE 19–14. Manual treatment methods plotted according for stiffness properties and dash pots (R2–5 ) for viscoelastic
to speed of administration versus body resistance to load from elements. See the text for discussion of displacements (a-a,
viscoelastic or stiffness properties (idealized). b-b).
0.5 effects. Stimulation of skin and joint receptors occurs

and mechanical, reflexive, and psychological effects
0 can be expected.
Mm or Degrees
−0.5 Manipulation Manipulation with high-velocity low-

T10-11 amplitude methods targets the normalization of joint
−1 T11-12 function and related local or remote symptoms.6,7,17,48
The mechanisms of action focus on the relative stiff-
−1.5 ness properties of the constitutive joint tissues using
high-speed and impulsive loading of the tissues. De-
−2
sired biomechanical effects are the redistribution of lo-
PA Lat Axial Sagittal
cal joint stresses and maximizing normal motion. Like
FIGURE 19–16. Local displacements between T11 and T12,
other manual methods, stimulation of skin and joint
the targeted joint, are larger than for more remote segments receptors occurs. In view of the relatively short dura-
as reported in Gal et al.43 tion of contact, the mechanical and reflexive mecha-
nisms are thought to be more dominant than psycho-
logical effects, although psychological responses can
different tissues. Because bone is much more stiff
be expected.
than disc, ligament, or muscle, bone shifts within the
soft tissues locally (a-a) and less movement occurs at Treatment Control Strategies
points more distant from the point of application. In
Safe and successful treatment requires the skillful ap-
summary, then, mobilization results in broad regional
plication of loads to the targeted joint. In practice,
movements and is primarily a function of viscoelastic
patients will present with concurrent problems like
transfer of loads. HVLA creates a more local move-
osteoporosis or internal disc derangement and hy-
ment and relies more on the relative stiffness proper-
permobility, which must be considered in treatment
ties. These locally greater displacements can be seen in
planning. Generally, there are three ways that the ad-
the work of Gal and colleagues (Fig. 19–16),43,44 while
ministration of procedures can be modified to accom-
the work of Lee et al.45,46 shows sequential displace-
modate special circumstances. They are procedure se-
ment from one segment to another for mobilization
lection, factors of the initial patient configuration, and
procedures.
factors of the doctor’s application of the procedures
Manual treatments can be differentiated through
(Table 19–5).
analysis of their biomechanical characteristics. The
mechanical effects similarly are determined by the Mobilization and Manipulation Methods
properties of the tissues on which the procedures are
As treatment procedures, mobilization and manipu-
administered.
lation methods can be grouped for discussion from
the perspective of tissue properties on which they
Massage Massage generally uses the application of rely for their clinical effects (see Fig. 19–14). Table
pressure and stretch in slower movements on the sur- 19–6 is organized in this manner, with the intensity
face of the skin. Load applications are through con- of applied loads, generally, from lowest to highest.
tacts that may be distributed over wide areas or may Although typical examples of procedures are given
be concentrated focally. Its effects are primarily on for purposes of illustration, the organization relates
muscle and fascia and may include mechanical, reflex- to all systems of techniques that apply loads to the
ive, and psychological components.11 Its mechanisms spine or other joint structures. The four categories
of action are the mobilization and transfer of fluids, are unloaded joint motion, mobilization, HVLA ma-
the normalization of motion within the fascial planes, nipulation, and mechanically assisted HVLA proce-
and stimulation of the peripheral nervous system by dures. Referring back to Figures 19–14 and 19–16, it
touch, pressure, and stretch receptors. can be seen that unloaded spinal motion and mobi-
lization methods have stronger interaction with the
Mobilization Mobilization targets regional joint motion time-dependent viscoelastic tissue elements, while the
and the related soft tissues. Load application may be HVLA and mechanically assisted HVLA techniques
concentrated locally or may be remote, using leverage rely primarily on relative differences in stiffness.
to exercise joint function. Its mechanism of action fo-
cuses on the viscoelastic and stiffness characteristics Continuous Passive Motion Methods Continuous pas-
at lower speeds. Tissue compartment fluid transfer sive motion (CPM) is defined as stimulation through
(e.g., reduction of edema and hydration of cartilage47 ) the body support planes in order to provoke time-
and normalization of joint motion are the desired related tissue-pressure changes.49 CPM methods of
TABLE 19–5. Elements of Control Strategies for Manual Treatment Methods
Procedure Patient Factors Operator Factors
Massage Posture Load amplitude

Mobilization Recumbent Preload
Manipulation Prone Peak thrust
Supine Repetition
Lateral Single
Sitting Cyclic
Standing Rate (accelration and velocity/speed)
Preload state Low
Static—constant position Rapid
Dynamic—cycling Impulse
pressures/displacements Load duration
Transient
Sustained
Direction
Axial
Sagittal
Transverse
TABLE 19–6. Manual Procedures as a Function of their Effects∗
Category Procedure Definition Mechanism of Action
Unloaded joint motion Continuous passive motion Motorized cyclic motion; Viscoelastic properties
(CPM) non-weight-bearing
positions; physiologic range
of motion; 0.03–0.53 Hz
Flexion/distraction (F/D) Manual cyclic motion; Viscoelastic properties
non-weight-bearing
positions; physiologic range
of motion; 0.05–0.50 Hz
Mobilization Grade I oscillation Neutral and lax zone Viscoelastic properties
neighborhoods;
0.50–2.00 Hz
Grade II oscillation Lower half of elastic zone; Viscoelastic and
0.50–2.00 Hz lower-range stiffness
properties
Grade III oscillation Upper half of elastic zone; Viscoelastic and
0.50–2.00 Hz mid-range stiffness
properties
Grade IV oscillation Terminal portion of the Primarily, stiffness
physiologic range; properties
0.50–2.00 Hz
High-velocity Physiologic range; Primarily, stiffness
low-amplitude 32–140 msec properties
manipulation
Mechanically assisted CPM + HVLA Physiologic range; Full viscoelastic and
HVLA superposed stiffness properties
Impulse hammer HVLA Physiologic range; Primarily stiffness
<20 msec properties
∗
Most authorities agree that grade IV mobilization and HVLA procedures are biomechanically similar if not the same.
70
Axial
60
50
newtons or newton-meters
Lateral
40
30
Flexion
FIGURE 19–17. Loads transmit- 20

ted through the lumbosacral spine 10
Lat Bend
region during continuous passive Twist
motion (CPM) while a patient is 0
PA
prone with lateral bending and the
−10
table is moving in flexion. Forces
(axial, lateral, PA) are in newtons −20
(N). Moments (flexion, lateral bend,
−30
twist) are in newton-meters (Nm). Time
treatment for joint disorders have been increasingly intradiscal pressure ranging from 39 to 192 mmHg in
in use since the 1970s. Promoted initially by Salter,47 unpressurized cadaver discs was produced. When un-
they have been used primarily for peripheral joint der induced pressure from injection of water into the
(knee, shoulder, elbow) postoperative recovery for re- disc, flexion–distraction resulted in reduced pressures
lease of joint contracture and posttraumatic arthri- of 117–720 mmHg.
tis and synovitis.50,51 The biological effects include Patients suspected of having active joint or nerve
neochondrogenesis with enhanced repair to recently swelling may be primary candidates for use of these
damaged cartilage,52–54 reduction of acute periarticu- procedures.
lar edema,55 and prevention of atrophy.56
CPM induces oscillating pressures within the joint Stiffness-Dependent Procedures Procedures applied at
and stretching of the capsular ligament.55 The first higher speeds induce relative motions that are re-
systematic use of CPM in the spine was for flexion– sisted by the material substrate of the tissues. There
extension. It was introduced in 199457 as a means is insufficient time lapse for significant flow of flu-
of enhancing seated comfort. Van Duersen et al.49 ids between tissue compartments. As a result, local
evaluated seated axial rotation CPM on chronic low- displacements are controlled by the relative stiffness
back-pain patients. Very small rotations of less than between the tissues. Because bone is stiffer than disc
2.5 degrees at 0.08 Hz (12.5 seconds per cycle) relieved and other soft tissues, the targeted segment has the
symptoms. The loads induced by the motion similarly greatest movement once adequate load has been ap-
were small at 23.1 N (5 lb) per millimeter. Recum- plied. High-velocity low-amplitude adjusting tech-
bent CPM is more versatile in that it may be applied niques and instrumented procedures, such as impulse
for any of the cardinal directions of motion (flexion– hammers (typically, the Activator), apply loads at suf-
extension, lateral bending, axial rotation) or in combi- ficiently high rates to accomplish focal displacement.
nation. There is a consistent and predictable relation- The biomechanical studies on representative
ship between the amplitude of the motion applied and HVLA procedures (Fig. 19–18) were reviewed by
the motion induced at the lower lumbar spine. The Herzog12 and Triano.9 They are characterized by rapid
small relative motions between vertebrae and the low application of forces and moments at rates similar to
amplitudes of force and moment acting on the spine human reaction times with slopes ranging between
(see Table 19–6) are consistent with those reported by 519 N/s and 2907 N/s. Peak amplitudes of applied
Van Duersen et al.49 Figure 19–17 demonstrates the loads have ranged widely in the mean from 41 N
complex loading of the spine that can be achieved by to 889 N. Loads transmitted through the spinal col-
configuring patient position in lateral bending while umn and surrounding tissues from complex HVLA
undergoing flexion CPM. procedures were studied by Triano13 and by Triano
Flexion–distraction methods are another means and Schultz58 in both the cervical and lumbar regions.
of applying passive motion. Loads are applied By varying selection of the procedure, patient pos-
through manual oscillation of the treatment table ture, peak load amplitude, duration, and direction, the
in single or combined directions. Auxiliary pres- operator can control spinal loading. Skilled manipu-
sures may be applied to individual joints while mo- lators can provide symmetrical loading of the spine
tions are induced. Gudavalli and colleagues37 studied with comparable total loads from the right or left,
flexion–distraction using approximate cycling rates of as necessary. Similarly, with specific rehearsal to pro-
0.20 Hz and 4–8-degree table flexions. A decrease in vide varied amplitudes as a percentage of maximum
350
300
250
F1 F2
newtons/newton-meters
200
150
100
M1 M2
50 FIGURE 19–18. Two HVLA proce-
0 dures performed on the same sub-
ject by one operator during a test
−50 on control strategies. Note the sim-
ilarity in peak amplitudes for both
−100
the forces (F1 , F2 ) and moments
−150 (M1 , M2 ).
provider effort, on demand, skilled operators can table resists pressures applied to the patient. Once
supply a controlled load at a desired level within release threshold is reached, the cam mechanism
20%.59 Operators randomly instructed to perform pro- is tripped and the body part falls a short distance,
cedures with maximal permissible or minimally effec- accelerated by gravity and the operator’s force.
tive effort, based on clinical judgment, produced sig- The therapeutic action develops from the sudden
nificantly different manipulation loads (p<0.0294).58 deceleration when the travel of approximately one-
In the cervical spine, transmitted force means for quarter to three-eighths inch is suddenly stopped.
the various components of a single HVLA procedure No quantitative studies have been conducted to
were 34 N (axial), 43 N (sagittal), and 93 N (trans- determine the difference in loading resulting from
verse). Transmitted moment amplitude means were these techniques. Theoretically, the applied forces
32 Nm (flexion), 50 Nm (rotation), and 65 Nm (lateral and moments may be augmented a small amount in
bending). proportion to the threshold of the cam setting. The
Adapted from instruments designed to apply or- rapid deceleration likely exceeds the muscle reaction
thodontic appliances, impulse hammers deliver a uni- time. Drop-section tables are widely available that
axial load over a small area (1 cm square), effec- permit application of these loads individually to the
tively avoiding applied moments. The applied peak lumbopelvic, thorax, and cervical spine regions.
forces are small in comparison to manually applied Various segmented treatment tables have been de-
HVLA procedures. In the lumbar spine, measures signed over the years that are hinged and induce user-
have ranged from 41 N to 120 N,60,61 with an impulse controlled relative flexion–extension, lateral bending,
duration of less than 20 msec. Solinger hypothesized or axial rotation between body parts. The more ad-
that small inputs at or near critical spine frequen- vanced of these designs introduce a wide range of user
cies would result in a mechanical resonance pro- control to assist in the treatment of complex problems.
ducing greater motion than otherwise expected.62,63 Depending on the features, the versatility of the table
Keller61,64 has studied the Activator adjusting instru- may allow for varied initial postures and permit di-
ment, which delivers impulse loads in the resonant rected motion of the body segment after being accel-
spine frequencies. erated by the applied loads. Later versions automated
Another type of procedure that relies on the rela- table segment motion. Some table mechanisms at-
tive stiffness properties between soft and hard tissues tempt to produce near linear distraction/compression
has been termed “drop” techniques. (see below). motions while others incorporate bending as the pri-
mary action. By coupling initial body postures of
Combined/Motion-Assisted Procedures Bergmann and bending, lateral bending, and rotation with a cycling
Davis have compiled a comprehensive review of bending or distraction (see Fig. 19–17), complex load
mechanically assisted procedures from both a his- vectors can be produced in the spine.
torical and technical perspective.33 Early procedures When HVLA or manual pressures are applied to
used cam mechanisms that could be cocked and the patient in conjunction with motion, there is a
released based on user-controlled thresholds. These summation effect that offers biomechanical advan-
procedures are generally described as “drop” tech- tage. Figure 19–19 demonstrates the loads transmitted
niques and rely on the difference in relative stiffness through the lumbopelvic spine during a side-posture
in joint tissues to achieve the therapeutic effect as HVLA procedure while the lumbopelvic region is un-
described in the section above. The cam-supported dergoing lateral bending CPM. The peak loads that
CPM + HLVA
180
160
140
120
Newton-meters
100
80
60
FIGURE 19–19. HVLA plus CPM 40

timed to increase the peak load.
The patient was in lateral recumbent 20
posture and side-bending CPM mo-
0
tion. (Reproduced with permission from
Triano J. Biomechanics of spinal manipu- −20
lation. Spine 2001;1:121–130.) Time
can be achieved are enhanced or minimized as desired to be the wrists, shoulder, and lumbar spine. While no
by timing the HVLA thrust with the table motion. This epidemiological studies have been completed, empir-
may serve to reduce the applied load necessary to ac- ical observations show these areas as being the more
complish to reach therapeutic threshold of forces or frequent sites of complaints for injury to the operator.
moments. An application might include the treatment The two activities that seem to be most associated
of a larger patient by a smaller doctor where it is nec- with risk are the processes of patient transfer and dy-
essary to overcome the inertia of the patient’s body namic procedure application. In patient transfer, two
mass. Alternatively, the doctor may need to maintain factors conspire. First is the use of poor ergonomic
a higher load transmitted through the spine yet be principles that promote increases in tissue strain as
hindered by patient sensitivity to pressure at the ap- patients are assisted from one position to another. The
plication site. second is uncontrolled and unexpected patient move-
Similarly, it may be desirable to reduce the trans- ment. A sudden lurch of the patient during a transfer
mitted load in one or more directions where certain or one who suddenly grabs the doctor for support can
pathologies exist. Patients with extreme osteoporosis, result in accidental injury to the doctor.
clinically significant disc herniation, internal disc de- During dynamic application of treatment proce-
rangement, and instability are examples where reduc- dures, the risk factors include the use of extreme joint
tion of load in specific directions may be useful. angles, for example in wrist extension and ulnar or
radial deviation, and repeated heavy loading as in
prolonged and repetitive flexion of the lumbar spine.
SAFETY
Table 19–7 lists the ergonomic factors that promote
The ability to perform treatment procedures safely injury.
and effectively under both simple and complex cir- Triano7 has reviewed the biomechanics of patient
cumstances is the hallmark of a skilled physician. transfer methods and offered specific recommenda-
While safety for the patient is the primary concern tions to avoid injury. The primary principle is to
during administration of individual procedures, the use appropriate postures, bracing techniques, tripod
cumulative effect on the operator must also be consid- stances, and operator body weight to offset the weight
ered. Performing manipulative treatment can be phys- of the patient. Careless assistance of a patient walking,
ically demanding in terms of endurance and strength. sitting, rising, and on treatment tables often uses poor
The ergonomic toll of procedures that spare patients operator posture and requires strong muscular effort.
may result in injury to the doctor if performed care- Together, they spell the formula for a shortened pro-
lessly. fessional career.
Operator Patient
Like any other physical task, the mechanical work of In a sequence of studies, loads transmitted through the
manipulation causes structural strain. The tissues that cross-section of the patient’s body at the targeted seg-
take the most stress during delivery of treatment tend ment for HVLA procedures have been estimated.13,65
TABLE 19–7.Risk Factors That Promote Injury to the Operator During Application of
Manipulative Procedures
Ergonomic Factor Example Solution Options
Prolonged static posture Lumbar flexion for treatment procedures Variable height treatment tables
Extreme joint position Wrist deviation Wrist-strengthening exercise; use of neutral
wrist postures
Repetitive joint loading Patient volume Incorporate operator-sparing procedures
wherever possible (CPM, motion assist, etc.)
Extreme loads Large patients Routine exercise and fitness; incorporate
operator-sparing procedures wherever
possible (CPM, motion assist, etc.)
Stress concentration Hand-held assistive devices (impulse Avoid applying pressure through
hammers, T-bars, etc.), HVLA contact small-diameter instrument ends; avoid
positions extreme joint angles
The reported incidence of complications from manip- Understanding the biomechanical elements of manip-
ulation is quite small.8 The loads transmitted across ulation coupled with exposure to a broad base of pa-
the body under conditions of maximum clinical ef- tient problems is the only means to become master-
fort deemed clinically safe can be significant. For the fully skilled. The result is a well-rounded clinician
lumbar spine, the loads that are generated during a able to diagnose and treat complex problems, provid-
maximum-effort HVLA procedure are consistent with ing a value-added service to the health care delivery
common daily tasks on jobs requiring lifting and twist- system.
ing movements. They are comparable, for example, to
when an airline ticket agent performs a one-handed
lift on a 50-pound bag and twists to place it on the con-
veyer belt. The majority of the population (>83% of SUMMARY
females and >92% of males) are able to safely perform 1. The philosophical concepts of vitalism and reduc-
such tasks.65 However, submaximal manipulation ef- tionism have long been used as a means to seg-
forts that make up the great majority of HVLA manip- regate the chiropractic profession. Such divisions
ulations are easily performed by trained and skilled are artificial and irrelevant to practice. These con-
operators as circumstances require. cepts are not mutually exclusive. Rather, they form
Similar studies of common HVLA neck procedures a nested understanding of health care delivery
demonstrated that maximum moment loads acting at where vitalism/holism remains the objective and
the level of C2-C3 were well within ranges of dynamic reductionism supplies the details for improving
loading experiments tolerated well by human sub- the effectiveness and quality of health care deliv-
jects. Volunteers under simulated accident conditions ery.
reported no adverse reactions or pain.66–68 Subjects 2. Manipulation and adjustment are mechanical
undergoing spinal manipulation of the neck experi- treatment procedures that are applied for the pur-
ence similar loads. pose of solving clinical problems. Proper imple-
mentation in biomechanical problem solving re-
quires a basic understanding of tissue properties,
CONCLUSION
structural balance, and equilibrium, and of the dy-
Manipulation for musculoskeletal disorders is an an- namic interactions between the body and its envi-
cient remedy that has been in and out of favor for ronment.
centuries. Recent technological advances have permit- 3. Loading of the spine that simultaneously acts on
ted the collection of quantitative data to better un- the balance point of the intersegmental joint as it
derstand mechanisms and actions. Modern investiga- reaches critical load results in a buckling event.
tions have focused on spinal procedures. A wealth The significance of these observations is that the
of empirical knowledge previously carried from one mechanism of spinal buckling explains more of the
generation to the next by apprenticeship is yielding its clinical observations associated with subluxation
secrets. The data is diverse and rich in variability for than earlier theories. The symptomatic response
biomechanical problem solving by skilled physicians. varies according to the identity of the tissues that
are stressed past injury threshold and the severity 2. There are three conditions known to potentiate
of the injury. buckling: (a) prolonged static posture followed by
4. Understanding of the biomechanics of the tissues, an incremental load; (b) rapid loading beginning
dynamic response to loads, and the subluxation at about 500 pounds per second; and (c) vibration.
forms the building blocks for clinical judgment 3. Differentiating methods of treatment is best char-
and skill development. acterized by relating the velocity of the treatment
5. Age, stature, and pathological condition may re- to the properties of the tissues. Slow-acting (mo-
quire adaptation of treatment procedures to ac- bilization) procedures are handled by the vis-
complish effective and safe treatment. Control coelastic elements and the low end of stiffness
strategies involve administration of specific pro- characteristics. Rapid procedures (high-velocity
cedures taking advantage of the elements that can low-amplitude) saturate the viscoelastic elements
be controlled by the doctor. Variables that have quickly and rely primarily on the relative differ-
been identified include both patient- and operator- ence in stiffness properties between tissues.
based elements. With skilled implementation, pa- 4. Mechanisms of action for treatment procedures
tients with conditions ranging from the simple to rely on the dominant action through viscoelastic
complex and postsurgical may receive benefit from or stiffness properties. Unloaded joint motion, in-
treatment. cluding CPM and flexion–distraction, and grades I
6. Patient response to selected procedures may be and II mobilization rely primarily on viscoelastic
divided into categories based on whether the treat- properties. Grade III invokes midrange stiffness
ment action primarily affects viscoelastic or stiff- and viscoelastic properties. Grade IV and HVLA
ness characteristics. Viscoelastic responses gen- procedures and mechanically assisted HVLA, in-
erally result in more regional movement with cluding CPM + HVLA and use of impulse ham-
dispersion of applied loads through a broader set mers, rely primarily on stiffness properties.
of joint structures while stiffness responses tend to 5. Breaking down the phenomena of health and func-
be more focal and directed. tion into their mechanistic details enables clini-
7. Studies on safety of treatment procedures have cians to be more effective in helping their patients.
been accomplished for cervical and lumbar high-
velocity low-amplitude procedures. Performed
using the standard precautions based on diagnos- KEY REFERENCES
tic information and skillful application, the exist-
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Cholewicki J, McGill SM, Norman RW. Lumbar spine load
during the lifting of extremely heavy weights. Med Sci
QUESTIONS Sports Exer 1991;23:1179–1181.
Herzog W. The mechanical, neuromuscular and physiologic
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what are the patient and operator variables that W, ed. Clinical biomechanics of spinal manipulation. New
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O’ Driscoll SW, Giori NJ. Continuous passive motion (CPM):
lization from high-velocity low-amplitude proce-
Theory and principles of clinical application. J Rehabil
dures?
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4. Define the mechanism of action for each biome- O’ Driscoll SW, Kumar A, Salter RB. The effect of the vol-
chanical classification of treatment procedures. ume of effusion, joint position and continuous passive
5. How does a reductionist view of clinical chiroprac- motion on intraarticular pressure in the rabbit knee.
tic assist patient care? J Rheumatol 1983;10:360–363.
Ogon M, Bender BR, Hooper DM, et al. A dynamic ap-
proach to spinal instability. Part II: Hesitation and
ANSWERS giving-way during interspinal motion. Spine 1997;22:
2859–2866.
1. Patient variables include posture and initial con- Panjabi M, Yamamoto I, Oxland TR, Crisco J. How does
dition, which may be categorized as static or dy- posture affect coupling in the lumbar spine? Spine
namic. 1989;14:1002–1011.
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tion of synovial joints. The first 18 years of basic research entific basis for the chiropractic subluxation complex.
and its clinical application. Clin Orthop 1989;242:12–25. J Manipulative Physiol Ther 1985;8:163–174.
Triano J. Biomechanics of spinal manipulation. Spine 17. Lantz CA. The vertebral subluxation complex. In:
2001;1:121–130. Gatterman MI, ed. Foundations of chiropractic subluxa-
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Morganthal P, eds. The aging body. New York: McGraw- 18. Triano J. The subluxation complex: Outcome measure
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19. Yoganadan N, Cusick JS, Pintar F, Rao JK. Whiplash
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C H A P T E R
20
PATHOPHYSIOLOGY OF DISC
DEGENERATION
Michael A. Adams
O U T L I N E
INTRODUCTION EPIDEMIOLOGY OF DISC DEGENERATION
DISC STRUCTURE AND FUNCTION Genetic Risk Factors
Gross Structure Environmental Risk Factors
Composition DISC DEGENERATION AND BACK PAIN
Mechanical Function Epidemiological Evidence
DISC BIOLOGY Evidence from Pain-Provocation Studies
Metabolism Pain Sensitization
Metabolite Transport Why Some Degenerated Discs Are Not Painful
Healing NATURAL HISTORY OF DISC DEGENERATION
Normal Aging SOME MEDICOLEGAL IMPLICATIONS
DISC DEGENERATION Healthy Discs Can Prolapse if Loaded Severely
Structural Changes in Degenerated Discs All Disks Are More or Less Vulnerable to Prolapse
Circumferential Tears and Delamination Degenerative Changes Can Follow Disc Prolapse
Rim Tears Spinal Loading Mostly Comes from Back Muscles
Internal Disc Disruption SUMMARY
Radial Fissures QUESTIONS
Disc Prolapse ANSWERS
Other Features of Degenerated Discs KEY REFERENCES
Functional Changes in Degenerated Discs REFERENCES
1. To review the functional anatomy and biology of This chapter describes the features of intervertebral
the intervertebral disc. disc degeneration, explains their probable natural his-
2. To describe disc metabolism, healing, and aging. tory, and indicates their relevance to back pain. In this
context, disc “disease” and disc “degeneration” can
3. To describe pathological changes in degenerated
be taken as synonymous, both implying deleterious
discs.
changes in structure and function. Degeneration can
4. To describe the epidemiology of disc degeneration, occur at any age, but because it is much more com-
including risk factors. mon in older discs, some scientists speak of aging and
5. To describe the role of degenerated discs in back degeneration as if they were the same thing. This is un-
pain. fortunate, because distinctions can be drawn between
6. To explore related medicolegal issues, including them, and a great deal of current research is aimed
the concept of “vulnerable” discs. at making the distinctions clearer still. As is shown
383
below, it is useful to consider degeneration not as an

inevitable process, but as one that is initiated by some
mechanical or nutritional insult and superimposed on
normal aging.
This chapter draws on a more extended exposition
in Adams et al.,1 to which the reader is referred.
DISC STRUCTURE AND FUNCTION

Gross Structure
Intervertebral discs are pads of fibrocartilage, approx-
imately 10 mm thick, which join adjacent vertebral
bodies in the spine. A soft pulpy center, the nucleus
pulposus, is surrounded and restrained by a tough
fibrous ring, the anulus fibrosus. Between the disc
and the adjacent vertebral body endplates lies a thin
layer of amorphous hyaline cartilage, which proba-
bly functions as a barrier and filter between the nu-
cleus and the perforated cortical bone of the endplate
itself. The annulus consists of approximately 15–25
concentric lamellae, each being composed mainly of
large collagen fiber bundles (Fig. 20–1).2 Fibers in
one lamella all run obliquely in approximately the
same direction, and at an angle of 50–60 degrees to
the fibers in adjacent lamellae. Note that the lamellae
bulge radially outward, and that the laminate struc-
ture is far from perfect, with many discontinuities be-
ing seen in discs of all ages, especially in the posterior
annulus.2 Collagen fibers of the outer annulus are em-
bedded deep into bone, but those of the inner annu-
lus merge obliquely into the cartilage endplate so that
they surround the nucleus (Fig. 20–2). This region of
FIGURE 20–1. Top: A lumbar motion segment consists of two
inner annulus is sometimes referred to as a “transition
vertebrae and the intervening disc and ligaments. “Compres-
zone.”3 sive” forces acting perpendicular to the midplane of the disc
Blood vessels do not penetrate far into a healthy generate a hydrostatic pressure in the nucleus pulposus (np),
intervertebral disc, being confined to the outermost and tensile (“hoop”) stresses (T ) in the anulus fibrosus (af ).
few millimeters of annulus3 by the hydrostatic pres- aj = apophyseal joint; il = interspinous ligament; na = neural
sure that exists in the nucleus.4 A hydrostatic pressure arch; pll = posterior longitudinal ligament; vb = vertebral body.
has the same intensity in all directions, and would Middle and Bottom: An intervertebral disc expanded to show
act to collapse any hollow tube (such as a capillary), the concentric lamellae of the anulus fibrosus surrounding the
which lay within its influence. Nerve endings are also soft nucleus pulposus.
confined to the peripheral annulus,5 and presumably
for the same reason. The free and encapsulated nerve and enable blood vessels and nerve endings to grow
endings in the outer posterior annulus arise from the into the center of the disc.5
sinuvertebral nerve plexus lying within the posterior
longitudinal ligament (Fig. 20–3). The sinuvertebral Composition
nerve, which contains fibers from both the somatic and The main chemical constituents of the disc are wa-
sympathetic nervous systems, is believed to be capa- ter, collagen, proteoglycans, and various noncollage-
ble of signaling pain.3 The peripheral anterior and lat- nous proteins. Collagen is a fibrous protein (Fig. 20–4),
eral annulus are supplied by the gray rami communi- which provides tensile strength, whereas proteogly-
cantes of the sympathetic nervous system. A detailed cans are very large composite molecules (Fig. 20–5)
account of the nerve and blood supply to interverte- consisting of a protein core with many side chains
bral discs can be found in the recent book by Bogduk.3 of glycosaminoglycans (GAGs), which are compound
As is discussed later, degenerative changes in a disc al- sugars. GAG molecules have a high, negative, fixed-
ter the distribution of hydrostatic pressure within it,4 charge density, which means that they have exposed
PATHOPHYSIOLOGY OF DISC DEGENERATION 385
FIGURE 20–2. Lumbar interverte-

bral discs sectioned in the midsagit-
tal plane, anterior on left. A. Non-
degenerated disc, typical of ages
15–40 years. Note how the inner
lamellae encapsulate the nucleus
and merge obliquely into the hyaline
cartilage endplates. B. Nondegen-
erated disc, typical of ages 35–70
years. The nucleus appears fibrous
and there is some dark pigmentation
typical of aging. However, the disc’s
structure is intact. C. Disc show-
ing moderate degenerative changes.
Note the annulus bulging into the nu-
cleus, damage to the inferior end-
plate, and the lack of pigmentation in
some regions of the disc, which sug-
gest that it is not old. (It is, in fact,
only 31 years old.) D. Disc showing
severe degeneration. Note the dark
pigmentation, the disruption to both
endplates, and internal collapse of
annulus, with corresponding reduc-
tion in disc height. This disc also is
only 31 years old.
surface regions with a negative charge (which are bal- Chemical composition changes gradually from the
anced by less accessible positive regions so that the nucleus, which is typically 70–85% water, 10% pro-
molecule is electrically neutral overall). The negative teoglycans, and 5% collagen, to the outer annulus,
regions have a strong electrostatic attraction to the which is approximately 50% water, 5% proteoglycans,
positive (hydrogen) end of water molecules, which and 35% collagen. The proportion of collagen type I
are similarly polarized. In this manner, GAGs attract (which is usually found in tensile structures such as
water into the disc and cause it to swell, unless the ligaments) is highest in the outer annulus, and very
swelling pressure is opposed by considerable external low in the inner annulus and nucleus. Collagen type II
loading (and by tension in the collagen network). In- (which is normal in compressed tissues such as articu-
dividual proteoglycan molecules bind to hyaluronan lar cartilage) is abundant in the nucleus, less common
to form huge aggregate molecules, which are physi- in the inner annulus, and absent in the outer annulus.
cally entwined with the collagen fibers, and therefore The coarse collagen fiber bundles in the outer annulus
anchored within the tissue. display a zigzag “crimp” pattern that enables them to
FIGURE 20–4. A. Each molecule of collagen type I or II con-

sists of three polypeptide chains, twisted into a triple helix, with
a nonhelical region on each end. B. In the extracellular ma-
trix, collagen molecules “self-assemble” into microfibrils. The
“quarter-stagger” structure is stabilized by various crosslinks
FIGURE 20–3. Oblique posterior view of the lumbar spine between parallel molecules. C. Microfibrils aggregate to form
showing the sinuvertebral nerve (svn) which supplies the an- fibrils. Fibrils can be identified on electron micrographs from
ulus fibrosus (af ) of the intervertebral disc and the posterior their distinctive striations (periodicity of 67 nm), which are a
longitudinal ligament (pll ). The neural arch has been cut away result of the overlap and gap regions of the quarter-stagger
at the pedicles ( p). The sinuvertebral nerve is a mixed nerve structure. (Adapted from Adams MA, Bogduk N, Burton K, Dolan P.
containing fibers from the gray rami communicantes (gr) and The biomechanics of back pain. Edinburgh: Churchill Livingstone, 2002.)
the ventral ramus (vr) of the spinal nerve. (Adapted from Bog-
duk N. The innervation of the intervertebral discs. In: Grieve’s modern
manual therapy. Edinburgh: Churchill Livingstone, 1994.)
stretch more as the kinks straighten out, so the tissue

can be stretched by up to 10%. Physical interactions
between the straightening collagen kinks and sur-
rounding molecules can absorb a great deal of energy.
As a result, the annulus can act to a certain (limited)
extent as a shock absorber, and is extremely “tough”
in the sense that a great deal of energy is required to
damage it. Approximately 10–15% of disc collagen is
type VI, which forms a network of very fine short fib-
rils within the pericellular matrix. Small quantities of
collagen types III, V, IX, XI, and XII are also present.
Endplate cartilage contains collagen type X that is as-
sociated with hypertrophic chondrocytes involved in
calcification.
FIGURE 20–5. The proteoglycan molecule “aggrecan” has a
Mechanical Function protein core linking three globular regions (G1, G2, G3). Side
The central region of a healthy disc is sufficiently chains of chondroitin sulphate (CS) and keratin sulphate (KS)
attract water into the tissue. Many individual aggrecan units
soft and deformable that it behaves like a pressurized
can bind to a long molecule, hyaluronan, by means of their G1
fluid. Up until the age of approximately 30 years, the
domain. This attachment is stabilized by a link protein (denoted
fluid region can extend to within a few millimeters of by a dark circle). In mature tissue, many aggrecan molecules
the disc periphery,4 so the whole disc behaves essen- are cleaved by enzyme action, leaving fragments attached to
tially like a waterbed, which distributes compressive hyaluronan, or lying free in the matrix. (Adapted from Adams MA,
loading evenly on to the vertebral bodies. This has Bogduk N, Burton K, Dolan P. The biomechanics of back pain. Edinburgh:
been demonstrated on cadaveric specimens by pulling Churchill Livingstone, 2002.)
a miniature pressure transducer along the midsagit-

tal diameter of a disc while it is subjected to com-
pressive loading (Fig. 20–6). With increasing age, the
fluid-like region shrinks4 as the lamellae of the inner
annulus become thicker2 and less deformable.6 The
annulus exhibits complex mechanical behavior: It can
resist high compressive forces in its own right, but it
also acts to confine the hydrostatic pressure in the nu-
cleus, rather like the walls of a high-pressure hose. In
this way, a compressive force acting down the long axis
of the spine generates a tensile “hoop” stress within
the outer anulus fibrosus.
The disc’s main mechanical function is to permit
small bending and twisting movements between adja-
cent vertebrae. During bending movements, the outer
annulus behaves like a continuous strong ligament,
which protects the softer nucleus from excessive de-
formation. In the toe-touching posture, the posterior
annulus is stretched vertically by 50%,7 and such high
deformations probably require some reorientation of
collagen fibers within each lamella. The outer annu-
lus, which is stretched most by bending of the spine,
is stiffer and stronger than the inner annulus.6 Tor-
sional movements (as in discus throwing) are resisted
by only half of the lamellae of the annulus, because
the orientation of collagen fibers in the other lamellae
would ensure that they are actually shortened by the
movement. However, lumbar discs are well protected
by the neural arch in torsion, and also in shear.
Sustained (“creep”) loading expels 20% of the wa-
ter from the disc during the course of each day, with
most of the water loss occurring from the nucleus.8 As
a result, the pressure in the nucleus falls, and concen-
trations of compressive stress arise in the annulus.9
The disc then bulges radially, rather like a flat tire.
Creep also causes a (temporary) loss of disc height,
which allows more slack to the outer annulus and in-
tervertebral ligaments, so that the spine’s resistance to
bending is greatly reduced.1 Diurnal disc height loss
causes the neural arches to come closer together and
resist approximately 20% of the compressive force act-
ing on the spine.
DISC BIOLOGY
FIGURE 20–6. Profiles of vertical and horizontal compres-
sive “stress” obtained by pulling a miniature pressure trans- The adult disc has a very low density of cells (approx-
ducer along the sagittal midplane of cadaveric lumbar inter- imately 60,000 cells/mm3 ) to maintain and repair the
vertebral discs. A = anterior; P = posterior. Each disc was tissue. This is no doubt related to the fact that the in-
subjected to a 2-kN compressive force during the stress mea- ner regions of lumbar discs are the largest avascular
surements. Upper: Profiles for a young nondegenerated disc
structures in the body.
(“grade 1”). Middle: Profiles for a typical mature nondegener-
ated disc (“grade 2”). The extent of the hydrostatic nucleus is Metabolism
indicated by vertical dashed lines. Lower: Profiles for a mod-
erately degenerated disc (“grade 3”) showing several localized Tissue mechanical function appears to determine cell
stress concentrations (arrows). (Data from Adams MA, McNally type. The rounded cells in the nucleus are notochordal
DS, Dolan P. “Stress”distributions inside intervertebral discs. The effects during development and growth, but resemble artic-
of age and degeneration. J Bone Joint Surg Br 1996;78:965–972.) ular cartilage chondrocytes in the adult. The more
elongated cells in the outer annulus resemble fibrob- or more (both in vivo and in vitro7 ), and it remains to
lasts. Each disc cell is surrounded by a collagenous be seen what effect such large deformations have on
“basket” to form a chondron, with the matrix lying be- annulus cells.
tween the cell and basket being rich in collagen III and Disc metabolism is so slow that it is difficult to
VI.10 As far as proteoglycan synthesis is concerned, study in man or animals. Static compression of dog
the most active cells lie in the mid-annulus region, discs increases collagen I synthesis and inhibits pro-
and synthesis rates fall when the water content of the teoglycan synthesis in the nucleus. Requiring dogs to
tissue is reduced or increased substantially. run on a treadmill for up to 40 km (24.6 miles) per
Cells in the nucleus and inner annulus are sen- day for 1 year showed several conflicting changes in
sitive to changes in their mechanical environment: the composition and metabolism of the discs. Some
Very high and very low hydrostatic pressures both of these discs were found to creep more under load,
decrease proteoglycan synthesis, whereas moderate suggesting that adaptive remodeling effects were be-
loading increases it.11 Pressures in excess of 3 MPa ing countered by the accumulation of fatigue damage
(which would be equivalent to moderate manual la- during the severe exercise. That discs do strengthen in
bor) increase the synthesis of the matrix-degrading response to increased mechanical loading is suggested
enzyme MMP3 (matrix metalloprotease 3).12 This be- by a small cadaveric study which found that physi-
havior is a manifestation of adaptive remodeling, in cally active people have stronger vertebrae and discs.13
which the properties of the extracellular matrix are ad- However, failure was more likely to occur in the disc
justed to suit the mechanical demands placed upon it than the vertebrae in spines from the most physically
(Fig. 20–7). Nucleus cells respond to cyclic stretching active people, suggesting that discs adapt more slowly
by proliferating and producing more collagen, sug- to increased mechanical demands than do bones. Ex-
gesting that disc cells may be capable of behaving like periments on rats and mice show that intervertebral
the fibroblasts in tendon, or chondrocytes in articu- disc degeneration can be induced by prolonged im-
lar cartilage, depending on whether they are being mobilization and static compressive loading.14
stretched or compressed. During spinal flexion move-
ments the posterior annulus can be stretched by 50% Metabolite Transport
Low-molecular-weight metabolites such as oxygen
and glucose are transported mostly by diffusion,
whereas high-molecular-weight metabolites (which
include the proteins that control and coordinate cell
function) are transported by bulk fluid flow. Fluid
flows in response to rapidly fluctuating forces are
small and affect only the periphery of the disc, but
slow fluid exchanges resulting from changes in pos-
ture and levels of activity can be substantial, and affect
the whole of the disc.8 Diffusion and fluid flow can be
distinguished by imagining a quantity of colored dye
thrown into a slow-moving stream: The spreading of
the dye into a large cloud is caused by the random
molecular movements that underlie diffusion, and the
slow drift of the dye downstream illustrates the ef-
fects of bulk fluid flow. There are also two transport
routes: through the peripheral annulus and through
the perforated bone and hyaline cartilage of the cen-
tral regions of the endplates (Fig. 20–8). Difficulties
in metabolite transport explain the very low cell den-
sity in the nucleus, and they may underlie many of
FIGURE 20–7. Skeletal tissues adapt their mechanical prop- the processes of aging and degeneration. A recent
erties to the forces applied to them, a process sometimes experiment on nucleus pulposus cells suggests that
referred to as adaptive remodeling. If mechanical loading in-
they effectively “hibernate” when starved of oxygen
creases so that tissue deformation (strain) is unusually high,
for several days, but die when similarly deprived of
then more matrix is deposited. This causes matrix stiffness
to increase so that strain returns to the normal range. Sim-
glucose.15
ilarly, low loading produces low strain and encourages matrix
resorption until strain rises to normal levels again. (Adapted
Healing
from Adams MA, Bogduk N, Burton K, Dolan P. The biomechanics of Discs show only a limited ability to heal follow-
back pain. Edinburgh: Churchill Livingstone, 2002.) ing injury, presumably because of the difficulty in
FIGURE 20–8. Detail of a verte-

bral endplate, showing how the disc
merges into a layer of hyaline car-
tilage, which is loosely bonded to
a plate of perforated cortical bone.
There are two routes for metabo-
lite transport into the center of the
disc: through the marrow spaces
(shaded) of the endplate (shown by
curved arrows) and through the an-
nulus (straight arrow). (Based on an
original69 and adapted from Adams MA,
Bogduk N, Burton K, Dolan P. The biome-
chanics of back pain. Edinburgh: Churchill
Livingstone, 2002.)
repairing the large collagen fibers in the annulus. that occur between collagen and tissue sugars.22 These
Scalpel-induced peripheral annular tears in animal reactions are not controlled by cells, and they partic-
discs lead to collagenous scar formation and granula- ularly affect those tissues that have a low turnover
tion tissue in the outer annulus, and vascular ingrowth rate for collagen. The main effect of NEG is to inhibit
into the middle annulus.16 However, few inflamma- cell synthesis and to make the tissue more brittle and
tory cells are found in the disc, and the inner regions of vulnerable to injury.23 In the center of large avascu-
the tear do not heal—in fact, they continue to progress lar discs, these reactions may well be accelerated as
inward.16 Artificial enzymatic destruction of the a result of “oxidative stress” arising from nutritional
nucleus reduces proteoglycan synthesis, but this later compromise.24 Similar changes occur in the cartilage
recovers to a certain extent. Proteoglycan–collagen endplates, and accompanying calcification of the end-
interactions within the annulus1 may partly explain plate may compromise the nutrient supply to the ad-
why old radial fissures can “heal” in the sense that jacent nucleus. Age-related biochemical changes are
they do not readily allow nucleus pulposus material less pronounced in the annulus. Overall collagen con-
to escape, even under severe loading.17 In contrast, tent of the disc increases with age, and the collagen
herniated tissue that escapes from the pressurized molecules aggregate into increasingly thick fibrils and
confines of the disc can undergo extensive biochemi- fibers, as more and more nonreducible crosslinks are
cal changes, starting with rapid swelling, followed by formed between adjacent collagen molecules.22
shrinking as proteoglycans diffuse out of the tissue.18 These biochemical changes affect disc function.
The dehydrated nucleus becomes physically stiffer,
Normal Aging its volume decreases, and the region of inner annulus,
Age-related changes occur in all collagenous tissues of which exhibits hydrostatic pressure, is reduced.4 More
the body, starting at birth. The first changes in the disc of the disc’s compressive load bearing is taken by the
occur within the nucleus, which changes from a soft, annulus, especially the posterior annulus.4 The annu-
white, amorphous gel into a mixture of fibrous lumps lus becomes weaker with age, even though increased
with softer material adjacent to the endplates.19 Older collagen cross-linking should make it stiffer. This ap-
cells become less able to respond to mechanical stimuli parent contradiction can be explained by assuming
and appear to produce fewer proteoglycans.20 Proteo- that gross defects accumulate within the tissue with
glycan concentration within the tissue falls. Those that advancing age. It is often assumed that disc height de-
remain become smaller and less aggregated,21 pre- creases with age, but this is not generally the case, even
sumably because of mechanical and enzymic disrup- though there is an increased risk of severe disc degen-
tion. As a result of these changes, the water content of eration and its accompanying height loss.25 However,
the nucleus falls with increasing age. Brown pigmen- the shape of the disc changes as the endplates bulge
tation becomes apparent, and is probably indicative more into the vertebral bodies,25 presumably as a re-
of the slow nonenzymatic glycation (NEG) reactions sult of reduced support from the trabecular bone.
DISC DEGENERATION
Structural Changes in Degenerated Discs
Degeneration can involve all of the age-related
changes in composition described above, and so is
difficult to distinguish from accelerated and/or exag-
gerated aging. Crucially, however, degeneration also
involves gross structural changes in the annulus, nu-
cleus, or endplate.4,21,26–28 We suggest that the pres-
ence of these structural changes should be a defining
feature of disc degeneration, because they do not seem
to be an inevitable consequence of aging.
Rough grading schemes have been proposed to
characterize disc degeneration on a numerical scale,
based either on morphological features alone,29 or on
a combination of morphology and response to in-
jected fluid,19 as shown in Figure 20–9. Figure 20–2
shows photographs of typical grade 1–4 discs . These
schemes are unable to differentiate clearly between
aging and degeneration, but one of them does try to
relate “degeneration” grade to pain.19
Structural disruption tends to appear after age 20
years, and reaches a maximum in middle age rather
than old age.27 Several types of annular tears are com-
mon by middle age (Fig. 20–10). They appear to evolve
independently of age and of each other.30
Circumferential Tears and Delamination

Concentric clefts between adjacent lamellae are com-
mon, even in young discs. Often they are small, but
can extend for several centimeters. They are proba- FIGURE 20–9. A rough grading scheme for disc degenera-
bly created by interlaminar shear stresses generated tion based on morphological features and the distribution of
by loading in bending and torsion. Delamination can injected dye (shown black) during discography. Posterior is on
progress to internal disc disruption (see Internal Disc right. 1. Cottonball: no sign of degeneration; soft white amor-
Disruption below). The lamellae of the annulus can be phous nucleus. 2. Lobular: mature disc with nucleus start-
separated fairly easily, rather like peeling the layers of ing to coalesce into fibrous lumps. 3. Irregular: degenerated
disc with fissures and clefts in the nucleus and inner annulus.
an onion,2 so the radial tensile strength of the annulus
4. Fissured: degenerated disc with radial fissures leading to
is low.
the outer edge of the annulus. 5. Ruptured: disc has a com-
plete radial fissure which allows injected fluid to escape. (Can
Rim Tears be in any state of degeneration.) (Reproduced with permission from
“Rim lesions” consist of focal circumferential avul- Adams MA, Dolan P, Hutton WC. The stages of disc degeneration as re-
sions of the peripheral annulus, sometimes with scle- vealed by discograms. J Bone Joint Surg Br 1986;68:36–41.)
rosis and osteophytosis of the adjacent bone. Rim tears
are twice as common in the anterior annulus than in of cadaveric discs of all ages31 and in 33% of elderly
the posterior, and typically affect the upper anterolat- cadaveric discs.32 This type of disruption requires the
eral margin of the disc.26 Rim tears in the outer anterior lamellae to separate radially, and so it probably oc-
annulus are probably created by interlaminar shear curs after delamination as described above (see Cir-
stresses when the disc is loaded in torsion, extension, cumferential Tears and Delamination). The clinical signif-
and compression. Animal experiments show that ar- icance of internal disc disruption was first suggested
tificially created rim tears in the outer anterolateral by Crock33 and is now more widely accepted.3,34 In ca-
annulus can progress inward to the nucleus over a daveric specimens, the inner annulus can be induced
period of many months.16 to bulge inward by reducing the volume and pres-
sure of the nucleus pulposus following fracture of a
Internal Disc Disruption vertebral body endplate (Fig. 20–11).35 Presumably,
Inward buckling of the inner annulus was observed the decompressed nucleus can no longer resist the
in 33% of the anterior and 4% of the posterior annuli inward collapse of the buckling annulus. Damage to
FIGURE 20–12. There is a large posterolateral radial fissure

(arrow) in this lumbar disc, which otherwise shows little sign of
degeneration. (Reproduced from an original color print in Adams MA,
Bogduk N, Burton K, Dolan P. The biomechanics of back pain. Edinburgh:
Churchill Livingstone, 2002.)
starting from the inner annulus, and sometimes pro-

FIGURE 20–10. The three common types of annular tear: gressing right to the outer margins of the disc so that
(A) concentric clefts, (B) radial fissures, and (C) peripheral rim nucleus pulposus material can escape. They are most
lesions. Disrupted disc tissue is shown in black, and nucleus common in the posterolateral annulus27 as shown in
pulposus is shaded. Left: Discs sectioned in the transverse Fig. 20–12, but they can penetrate the anterior annu-
plane (anterior on top). Right: Discs sectioned in the sagittal lus, sometimes in an irregular fashion.19 Complete ra-
plane, anterior on left. (Reproduced from Adams MA, Bogduk N, dial fissures are not uncommon in young discs, which
Burton K, Dolan P. The biomechanics of back pain. Edinburgh: Churchill show no other signs of aging or degeneration.19 They
Livingstone, 2002.) can be created in cadaveric specimens by cyclic load-
ing in combined compression and bending17 when
the vertebral endplate (and to the trabeculae that sup- the fissure grows into the region of annulus that is
port it) is extremely common in older people,28 so this stretched most by the bending. The presence of tor-
could be a common cause of internal disc disruption sion appears to facilitate the formation of radial fis-
in life. sures during cyclic loading.1
Radial Fissures Disc Prolapse
The third type of annular tear is the radial fissure, Intervertebral disc prolapse (or “herniation”) in-
which involves radial disruption of the lamellae, volves relative displacement between nucleus and
FIGURE 20–11. Midsagittal section of a lumbar disc, anterior on left. This disc was subjected to cyclic compressive loading following
experimentally induced overload damage to the upper vertebral endplate (*). Damage to the endplate reduced the pressure in the
nucleus, which could explain why the inner annulus appears to have collapsed into it. (Digitally enhanced image from an original photograph
in Adams MA, Freeman BJ, Morrison HP, et al. Mechanical initiation of intervertebral disc degeneration. Spine 2000;25:1625–1636.)
(which may include cartilaginous endplate, especially

in older patients37 ) is expelled from the disc and is
no longer attached to it. Experiments on cadaveric
spines show that discs can be induced to prolapse in
the laboratory in response to severe loading in bend-
ing and compression7,35 where either the bending or
the compression exceeds normal physiological limits
(Fig. 20–14). The component of bending stretches and
thins the posterolateral annulus so that it becomes the
“weak link,” and fails when the compressive force in-
creases the pressure in the nucleus above a critical
level. A similar mechanism can cause disc prolapse
during cyclic loading of less severity.17 Prolapse can
also be demonstrated in vitro by applying moderate
bending and compression to cadaveric discs in which
a fissure has already been created in the posterior an-
nulus using a scalpel blade.38 Disc prolapse reduces
the volume and pressure of the nucleus, and reduces
disc height, initially by approximately 1 mm.7
Other Features of Degenerated Discs

Degeneration is associated with various changes in
the biological and chemical properties of the disc. Cell
clustering is common, the proportion of collagen types
I and VI increases, and concentric rings rich in type III
collagen can appear around some cells.10 As indicated
above, blood vessels and nerves usually grow into the
center of severely degenerated discs, along the mar-
gins of clefts and radial fissures.5,28 Matrix-degrading
enzymes (including matrix metalloproteases and ag-
grecanase) are produced in greater quantity in degen-
erated discs, both by the indigenous cells and by in-
vading cells, and enzyme levels are particularly high
in herniated discs.39 Large molecules of fibronectin,
which link cartilage cells to their matrix, become more
abundant in degenerated discs, and are increasingly
fragmented, presumably because of increased enzyme
activity.40 Some research publications appear to sug-
FIGURE 20–13. Three categories of disc prolapse (or “hernia-
tion”) are widely recognized: (A) annulus protrusion, (B) nucleus
gest that matrix enzymes (or the chemical messen-
extrusion, and (C) sequestration. Disc sections are drawn in gers [“cytokines”] that instruct the cells to produce
the transverse plane, anterior on top. The site of herniation them) actually cause disc degeneration. However, the
is usually posterior or posterolateral, but can be lateral or increased activity of these agents in degenerated discs
anterior.27 Distortion of the lamellae of the annulus is not probably represents an attempt by the tissue to adapt
always present. (Adapted from Adams MA, Bogduk N, Burton K, to deteriorating circumstances, rather than an initiat-
Dolan P. The biomechanics of back pain. Edinburgh: Churchill Living- ing event.
stone, 2002.) Disc degeneration can affect adjacent tissues. Os-
teoarthritic changes often appear in the apophyseal
annulus. Three types of posterior disc prolapse can be joints, and osteophytes (bony outgrowths) can grow
distinguished,36 as shown in Figure 20–13. In a disc around the margins of the vertebral bodies,26,28 partic-
“protrusion,” a small region of the annulus bulges ularly in the anterolateral regions, as shown in Figure
markedly outward, but does not allow contact be- 20–15. In both cases, it could be argued that changes to
tween the nucleus and the extradiscal space. Incom- adjacent bony structures represent a beneficial adap-
plete prolapse or “extrusion” occurs when the annu- tive remodeling response, rather than a degenerative
lus is completely ruptured but the expelled nucleus condition.3 For example, vertebral body osteophytes
is still attached to the rest of the disc. In a complete effectively increase the cross-sectional area of the disc
prolapse, or “sequestration,” the displaced disc tissue and so reduce the compressive stress acting on it. The
FIGURE 20–14. Cadaveric lumbar disc (male 40 years, L2-L3) sectioned in the midsagittal plane following mechanical loading
(anterior on left). The disc was compressed to failure (9.8 kN) while positioned in 6 degrees of flexion. Note the radial fissure and
the herniated nucleus pulposus trapped behind the posterior longitudinal ligament. (Reproduced from an original color print in Adams MA,
Bogduk N, Burton K, Dolan P. The biomechanics of back pain. Edinburgh: Churchill Livingstone, 2002.)
vertebral body endplates become more vascular fol- exhibit high, localized stress concentrations within
lowing experimentally induced degeneration in the the annulus (Fig. 20–16). Reduced nucleus pressure
adjacent disc.41 has been demonstrated in vivo in the degenerated
discs of patients with back pain or sciatica.42 It ap-
Functional Changes in Degenerated Discs pears that structural damage destroys the disc’s abil-
Disc function is affected more by structural degenera- ity to distribute compressive stresses evenly on the
tive changes than by the age-related changes in com- adjacent vertebrae, so that different parts of the dis-
position described earlier. Normal discs contain a soft rupted tissue resist compression in a more or less
deformable nucleus that exhibits a hydrostatic pres- haphazard way. When nucleus pulposus cells are de-
sure even when old and pigmented.4 Degenerated formed by nonhydrostatic loading, as they would be
and structurally disrupted discs, however, have either in a disrupted disc, then they respond by producing
a very small hydrostatic region, or none at all, and more collagen, which could explain why degenerated
discs have such a fibrous nucleus. Other mechani-
cal changes in degenerated discs include an increased
FIGURE 20–16. The distribution of vertically acting compres-

sive stress along the sagittal midplane of a cadaveric lumbar
FIGURE 20–15. Digitally enhanced radiograph of an old and intervertebral disc (anterior on right). Endplate (e/ p) fracture,
degenerated lumbar spine showing extremely narrowed discs, caused by overloading the motion segment in compression, re-
large marginal osteophytes, and bony sclerosis adjacent to the duces the pressure in the nucleus and generates high stress
endplates. (Anterior on left.) peaks in the annulus.
“neutral zone” (region of minimal stiffness) in bend- this degeneration was rarely painful.49 The main value
ing and torsion, combined with a reduced range of of this small study was that the subjects were between
bending.43 Age-related stiffening of collagenous tis- 9 and 21 years of age at follow-up, so there was little
sues may explain the reduced range of motion, and disc degeneration in the age-matched control group.
the increased neutral zone could indicate an instabil- Radiographically defined severe disc degeneration is
ity (or “wobble”), which may be attributable to the more common in westernized societies than in certain
loss of nucleus pressure and disc height. The range of native populations. This has been attributed to a pro-
axial rotation is increased, possibly because of loss of tective effect from the increased spinal mobility and
cartilage in the apophyseal joints. habitual flexed “squatting” postures of the latter,50 al-
though factors such as genes and diet could also play
a role. Certain vigorous sports, such as weightlifting
EPIDEMIOLOGY OF DISC DEGENERATION and gymnastics, carry an increased risk of disc degen-
Epidemiologists have found that disc degeneration, eration, some of which is symptomatic,51 but running
as revealed by x-ray and magnetic resonance images, does not.52
is not easy to define. Often, any age-related change in Disc prolapse shows little correlation with age (in
the disc (such as reduced water content of the nucleus) adults) or with other signs of spinal degeneration,53
has been included, with the result that “degeneration” suggesting that it represents something more than
is extremely common and difficult to relate to any risk just the end-point of some age-related degenerative
factor other than age. Nevertheless, several risk factors process. The greatest known risk factor for acute disc
have emerged which give insights into the causes of prolapse is the frequent lifting of heavy weights from
disc degeneration. the ground while in a twisted position.54 Car driving
also carries an increased risk of disc prolapse,55 which
could be related either to vibration or to reduced
Genetic Risk Factors
muscle protection of the spine following prolonged
Identical twins studies show that approximately 70% flexion.
of intervertebral disc degeneration is statistically asso- The importance of mechanical factors in causing
ciated with genetic inheritance, even after many en- disc degeneration is likely to be underestimated in
vironmental factors have been controlled for.44 This cross-sectional occupational studies. This is because
applies to both lumbar and cervical discs, and when discs can either strengthen in response to repetitive
degeneration is defined in a number of different loading, or else accumulate microdamage leading to
ways.44 Only a few of the genes responsible for disc fatigue failure. Essentially, repetitive loading sets up
degeneration have so far been identified, including a “race” between adaptation and damage accumu-
genes for the vitamin D receptor, for collagen type IX, lation, with the outcome depending on the age and
and for proteoglycans. Disc prolapse in the lower lum- health of the individual, as well as the rigors of the job.
bar spine has a much weaker dependence on genes Those who develop strong backs will tend to be over-
than other aspects of disc degeneration.45 Tall people represented in cross-sectional surveys because some
are at greater risk of disc prolapse,46 presumably be- of their colleagues who succumbed to fatigue failure
cause they load their backs more severely by lifting and back problems may have sought less physically
weights on longer lever arms. demanding work. Fatigue failure of poorly vascular-
ized tissues is more likely to be associated with an
Environmental Risk Factors abrupt increase in the level of physical activity, rather
The environment must still play an important role than with a consistently high level of such activity.
in disc degeneration, because defective genes can ex- There is some evidence in support of this hypothesis,56
ert their influence from the moment of conception, but longitudinal epidemiological experiments are re-
whereas degenerative changes usually appear 30–50 quired to test it properly.
years later. Generally, degeneration is more severe and Some nonmechanical environmental factors are
starts earlier at the L4 and L5 levels than at L3, and the important. Most notably, cigarette smoking accounts
L2 and L1 levels are less frequently affected.27,47 The for approximately 2% of disc degeneration57 and in-
fact that disc degeneration is more prevalent at lower creases slightly the risk of disc prolapse.55 Presum-
lumbar levels and in men47 suggests a strong mechani- ably, smoking interferes with the precarious supply
cal influence. Also, a large cadaveric study has shown of metabolites to the center of the disc. In this context,
that disc degeneration, annular ruptures, and verte- it is interesting to note that the vertebral endplates
bral osteophytes are related to a history of back injury adjacent to degenerated discs are relatively imperme-
and to heavy work.48 Previous injury to a vertebral able to the passage of small molecules,58 suggesting
body was found to lead to disc degeneration several that nutritional compromise could be a direct cause of
years later in a high proportion of subjects, although disc degeneration.
that cause morphological and functional changes in

DISC DEGENERATION AND BACK PAIN
spinal nerve roots,65 and which cause pain-related be-
In the not-too-distant past, pathological changes in in- havior in laboratory animals.66 This apparent “pain-
tervertebral discs were more or less equated with back sensitization” effect of displaced nucleus tissue can
pain and sciatica. Then, magnetic resonance imaging be modulated by inhibiting the synthesis of nitric
(MRI) studies showed age-related “degeneration” of oxide.65 It is not yet clear if nucleus pulposus migrat-
the spine to be almost universal,59 and there was a ing down a radial fissure can similarly induce pain
move to dismiss spinal pathology as clinically irrele- from the outer annulus, even when the disc is not pro-
vant, an attitude fostered by the important discovery lapsed.
that certain psychosocial factors are closely associated
with back pain.60 The truth lies somewhere in the mid- Why Some Degenerated Discs Are Not Painful
dle: A great deal of pathology is not painful, but a great It is instructive to turn around the usual question and
deal is, and psychosocial factors explain how people ask why some degenerated discs are not painful. There
respond to pain rather than how they get it in the is an obvious mechanical reason: Damaged or degen-
first place. The following sections briefly review the erated tissues are mechanically incompetent and tend
current evidence linking disc degeneration with back to be protected by adjacent healthy tissue. A narrowed
pain and sciatica. and severely degenerated intervertebral disc can be
“stress-shielded” by the neural arch to such an extent
Epidemiological Evidence that only 30% of the compressive force on the spine
If any age-related change in the disc is termed “de- actually passes through the disc.1 This logic suggests
generation,” then it is extremely common and of lit- that, under certain circumstances, moderate degener-
tle clinical relevance. However, if disc degeneration ative changes in a disc should be more painful than
is more specifically defined by the presence of disc advanced changes, because they do not relieve the disc
space narrowing, osteophytes, and sclerosis, then it is of its primary mechanical function. There is little evi-
associated with nonspecific low back pain with odds dence to support this speculation, other than the fact
ratios ranging from 1.2 to 3.3.61 MRI scans reveal disc that the prevalence of back pain is lower after middle
herniations in a sizable proportion of asymptomatic age, whereas degenerative changes in the spine get
volunteers, but a recent study showed that patients progressively worse. On the other hand, there is no
with severe back pain and sciatica are almost three reason to suppose that pain increases in proportion to
times as likely to have a disc extrusion as are subjects the severity of degeneration.
in a matched control group.59 Evidently, the MRI find- Another possible reason why disc degeneration
ing of a disc prolapse is not clinically irrelevant in a is not always painful is that severe symptoms might
statistical sense, although in particular cases it may be require biochemical changes in the vicinity of nerve
painless. endings to amplify the pain sensation. This specula-
tion is supported by pain-provocation experiments in
Evidence from Pain-Provocation Studies which a full symptomatic pain response is induced
One large-scale study has shown that in patients from patients by relatively innocuous probing of the
awaiting disc surgery for severe back pain and sciat- disc (see above). If pain sensitization is a normal fea-
ica, their characteristic symptoms can be reproduced ture of discogenic pain, then small differences in the
by mechanical stimulation of the posterior anulus length of a radial fissure, or in the mechanical and bio-
fibrosus,62 which was found to be the source of symp- chemical properties of the migrating nucleus, could
toms in more than half of the patients examined. Pain have a large influence on the resulting symptoms.
reproduction in patients has been linked to structural Other explanations can be offered,1 but are equally
and functional abnormalities in intervertebral discs34 : unproven. Evidently, the complex links between disc
Painful discs do not distribute loading evenly onto degeneration and pain require further investigation.
the vertebral bodies as normal discs do, but concen- It would be unfortunate if disc degeneration, and the
trate it in several regions of the annulus63 in a manner pathological processes that underlie it, was dismissed
that is typical of severely degenerated discs (see Fig. as clinically irrelevant simply because the association
20–16). Provocation discography shows that symp- with pain is more complicated than was originally an-
tomatic pain reproduction is most common in discs ticipated.
that have a radial fissure extending into the outer
annulus.64
NATURAL HISTORY OF DISC DEGENERATION
Pain Sensitization On the basis of the available evidence, we propose
There is increasing evidence that a displaced nucleus that intervertebral disc degeneration represents a pro-
pulposus can release chemicals such as nitric oxide gressive cell-mediated response to structural damage
to the anulus fibrosus or vertebral endplate. As dis- severe degenerative changes.7,17 On the other hand,
cussed above, damage to either structure causes the animal models show that primary structural damage
hydrostatic pressure within the nucleus to fall, and to a disc leads quickly to cell-mediated degenerative
high concentrations of compressive stress to appear changes similar to those seen in living people.16
in the inner annulus. Cells within the nucleus could
conceivably restore normal disc function by produc-
SOME MEDICOLEGAL IMPLICATIONS
ing more proteoglycans to increase nuclear volume
and pressure. However, the reduced pressure in the Disc degeneration in general, and disc prolapse in par-
nucleus provides a paradoxical stimulus to these cells, ticular, is often the subject of medicolegal disputes.
encouraging them to respond as if the overall load- One side will claim that a disc prolapse was caused
ing of the disc had been reduced, even though load- by some specific incident involving high loading of
ing of the annulus has actually increased. In this way, the spine, while the other maintains that the disc was
nucleus cells would reduce their synthesis of proteo- “diseased” and was about to prolapse anyway. The
glycans, and further reduce nucleus volume and pres- following statements, which are based on the research
sure, intensifying stress concentrations in the annu- literature reviewed in this chapter, may help resolve
lus. Cells in the annulus would respond to greatly some of these disputes. Personal dislike for (or igno-
increased mechanical stress by producing more rance of) this research should not be confused with
matrix-degrading enzymes. Hence, the original dam- scientific debate.
age to the annulus or endplate would precipitate a
progressive degenerative process in the disc, rather Healthy Discs Can Prolapse if Loaded Severely
than initiate a reversible remodeling (or repair) This has been demonstrated by cadaver experiments
process. (see above). The biological relevance of these exper-
It is not yet clear exactly how disc cells respond iments to living people has been justified at length,
to their mechanical environment, but it is apparent and the mechanisms involved have been explained
that they are most influenced by their local environ- by mathematical models.1,67
ment, and may be insensitive to events occurring just a
few millimeters away. Structural disruption has such a All Disks Are More or Less Vulnerable
harmful effect on disc metabolism precisely because it to Prolapse
uncouples the local tissue environment from the over- In the medicolegal context, it is important to consider
all loading of the disc. the nature and extent of tissue vulnerability, because
Inappropriate cell-mediated responses to limited it can impact on issues of liability. Genetic predis-
structural disruption could serve to weaken a disc and position to disc degeneration is rarely simple, and
leave it vulnerable to further mechanical damage, so rarely decisive. Usually, many genes contribute to a
that a “vicious circle” of tissue weakening and reinjury person’s predisposition to “disease,” and the environ-
occurs. ment must still play an important role. Increasing age
Structural damage could possibly lead to disc de- also contributes to vulnerability, because discs accu-
generation by other means. Endplate fracture and sub- mulate “wear-and-tear” damage, and because slow
sequent healing could reduce the number of marrow biochemical changes, such as nonenzymatic glyca-
cavities in contact with the cartilage endplate, and tion, probably make the annulus stiffer and less able to
hence reduce metabolite transport into the nucleus. absorb strain energy. However, advanced age-related
Alternatively, a fractured endplate could allow con- degenerative changes make it difficult for discs to pro-
tact between nucleus pulposus tissue and vertebral lapse, at least in the laboratory, so age-related vulner-
marrow, leading to an inflammatory or autoimmune ability probably peaks at about age 40–50 years.
response.33 It follows that an individual should not be consid-
It could be argued that disc degeneration leads ered to have a “weak” or “normal” back. Rather, each
to structural disruption, rather than the other way person lies on a continuous scale of vulnerability, de-
round. For example, inherited defects or prolonged pending on the environment in which he or she has
high loading could adversely affect cell metabolism, lived and worked, as well as on genetic inheritance.
leading to a weakened extracellular matrix, which is Cadaveric experiments demonstrate that the strength
then vulnerable to injury under normal loading. This of spinal tissues varies widely and continuously be-
is the traditional concept of “disease” leading to sub- tween individuals. The question of tissue vulnerabil-
sequent mechanical failure. However, there is com- ity is likely to be the subject of debate for some time to
paratively little evidence to suggest that degeneration come: Should a patient be held responsible for his or
does cause structural failure. Indeed, cadaveric exper- her own genes? Should his or her employer assume
iments suggest that, as far as intervertebral disc pro- responsibility for fatigue damage which started to ac-
lapse is concerned, structural failure does not follow cumulate during a previous occupation?
Degenerative Changes Can Follow Disc avulsions of the peripheral annulus, sometimes
Prolapse with sclerosis and osteophytosis of the adjacent
Animal experiments show that structural damage bone. Internal disc disruption consists of inward
to an intervertebral disc leads inexorably to cell- buckling of the inner annulus. Radial fissures in-
mediated degenerative changes over a period of sev- volve radial disruption of the lamellae, starting
eral months or years (see above). The swelling of from the inner annulus, and sometimes progress-
displaced disc tissue occurs as soon as it escapes the ing right to the outer margins of the disc so that
pressurized confines of the disc: In cadaveric speci- nucleus pulposus material can escape, resulting
mens, its weight can increase by 100–200% in just a few in disc prolapse. Disc prolapse includes protru-
hours.18 This could explain why symptoms arising sion, where a small region of the annulus bulges
from a prolapsed disc do not always appear at once. markedly outward; extrusion, where the annulus
Specific degenerative changes have been reported to is completely ruptured but the expelled nucleus is
predispose a disc to prolapse, but there is little evi- still attached to the rest of the disc; and seques-
dence to support this. Certainly, it is no longer valid tration, where the displaced disc tissue is expelled
to say that “this disc prolapsed so it must have been from the disc.
degenerated already.” 4. Disc degeneration, as revealed by x-ray and MRI
images, is not easy to define. Twins’ studies show
Spinal Loading Mostly Comes from that 70% of intervertebral disc degeneration is as-
Back Muscles sociated with genetic inheritance. Tall people are
at greater risk of disc prolapse. Disc degeneration
This statement is justified by a great deal of biome- is related to a history of back injury, heavy lifting,
chanics research that lies outside the scope of this weightlifting, gymnastics, and smoking.
chapter.1 The fact that vertebral fractures often oc- 5. Disc space narrowing, osteophytes, and sclerosis
cur during major epileptic fits68 indicates that any sit- are associated with nonspecific low back pain. Pa-
uation that calls for a person to contract their back tients with severe back pain and sciatica are al-
muscles in alarm has the potential to injure spinal most three times as likely to have a disc extrusion.
tissues. Provocative discography shows that pain repro-
duction is most common in discs that have a ra-
dial fissure extending into the outer annulus. A
SUMMARY
displaced nucleus pulposus can release chemicals
1. The intervertebral disc consists of a soft, pulpy such as nitric oxide that cause morphological and
center, the nucleus pulposus, surrounded and re- functional changes in spinal nerve roots.
strained by a tough fibrous ring, the anulus fi- 6. Healthy intervertebral discs can prolapse if they
brosus. The intervertebral disc is composed of are loaded severely. Advanced age–related degen-
water, collagen, proteoglycans, and various non- erative changes make it difficult for discs to pro-
collagenous proteins. The mechanical function of lapse, at least in the laboratory, so age-related
the intervertebral disc is to permit small bending vulnerability probably peaks at about age 40–50
and twisting movements between adjacent verte- years.
brae.
2. Disc metabolism is very slow. The most active cells
lie in the mid-annulus region, and synthesis falls
ACKNOWLEDGMENTS
when the water content of the tissue is reduced or
increased substantially. Discs show only a limited I gratefully acknowledge the contributions of my coauthors N.
ability to heal following injury. Proteoglycan con- Bogduk, K. Burton, and P. Dolan (The Biomechanics of Back
centration, and therefore water content, within the Pain1 ), and hope that they will recognize some of their own in-
tissue decreases with age. The dehydrated nucleus fluence (if not their own words!) in this chapter.
becomes physically stiffer, its volume decreases,
and the region of inner annulus that exhibits hy-
drostatic pressure is reduced.
QUESTIONS
3. Degeneration involves gross structural changes
in the annulus, nucleus, or endplate, such as 1. The annulus consists of how many concentric
circumferential tears, rim lesions, internal disc dis- lamellae?
ruption, radial fissures, and disc prolapse. Circum- A. 5–10
ferential tears are likely brought on by interlaminar B. 10–15
shear stresses generated by loading in bending and C. 15–25
torsion. Rim lesions consist of focal circumferential D. 20–30
2. How much water (%) is lost from the disc over the Osti OL, Vernon-Roberts B, Fraser RD. 1990 Volvo award in
course of a day as a consequence of creep? experimental studies. Anulus tears and intervertebral
A. 5 disc degeneration. An experimental study using an an-
B. 10 imal model. Spine 1990;15:762–767.
C. 15 Roberts S, Caterson B, Menage J, et al. Matrix metallo-
proteinases and aggrecanase: Their role in disorders
D. 20
of the human intervertebral disc. Spine 2000;25:3005–
3. Give a brief definition of the following types of disc 3013.
prolapse: protrusion, extrusion, and sequestration. Sambrook PN, MacGregor AJ, Spector TD. Genetic influ-
4. Which of the following genes has not been identi- ences on cervical and lumbar disc degeneration: A mag-
fied as contributing to disc degeneration? netic resonance imaging study in twins. Arthritis Rheum
A. Vitamin D receptor 1999;42:366–372.
B. Glucosamine sulfate
C. Collagen type IX
D. Proteoglycans
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spinal degeneration. Spine 1995;20:928–935. lumbar spine using local anesthesia. Orthop Clin North
54. Kelsey JL, Githens PB, White AA III, et al. An epidemi- Am 1991;22:181–187.
ologic study of lifting and twisting on the job and risk 63. McNally DS, Shackleford IM, Goodship AE, et al. In
for acute prolapsed lumbar intervertebral disc. J Orthop vivo stress measurement can predict pain on discogra-
Res 1984;2:61–66. phy. Spine 1996;21:2580–2587.
55. Kelsey JL, Githens PB, O’Conner T, et al. Acute 64. Moneta GB, Videman T, Kaivanto K, et al. Reported
prolapsed lumbar intervertebral disc. An epidemi- pain during lumbar discography as a function of anular
ologic study with special reference to driving au- ruptures and disc degeneration. A re-analysis of 833
tomobiles and cigarette smoking. Spine 1984;9:608– discograms. Spine 1994;19:1968–1974.
613. 65. Brisby H, Byrod G, Olmarker K, et al. Nitric oxide
56. Adams MA, Dolan P. Could sudden increases in phys- as a mediator of nucleus pulposus-induced effects on
ical activity cause degeneration of intervertebral discs? spinal nerve roots. J Orthop Res 2000;18:815–820.
Lancet 1997;350:734–735. 66. Kawakami M, Tamaki T, Hayashi N, et al. Mechani-
57. Battie MC, Videman T, Gibbons LE, et al. 1995 Volvo cal compression of the lumbar nerve root alters pain-
award in clinical sciences. Determinants of lumbar related behaviors induced by the nucleus pulposus in
disc degeneration. A study relating lifetime exposures the rat. J Orthop Res 2000;18:257–264.
and magnetic resonance imaging findings in identical 67. Adams MA. Mechanical testing of the spine. An ap-
twins. Spine 1995;20:2601–2612. praisal of methodology, results, and conclusions. Spine
58. Nachemson A, Lewin T, Maroudas A, et al. In vitro dif- 1995;20:2151–2156.
fusion of dye through the end-plates and the annulus 68. Vascancelos D. Compression fractures of the vertebra
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Orthop Scand 1970;41:589–607. 328.
59. Boos N, Rieder R, Schade V, et al. 1995 Volvo award 69. Roberts S, Menage J, Eisenstein SM. The cartilage end-
in clinical sciences. The diagnostic accuracy of mag- plate and intervertebral disc in scoliosis: Calcification
netic resonance imaging, work perception, and psy- and other sequelae. J Orthop Res 1993;11:747–757.
C H A P T E R
21
PATHOPHYSIOLOGY OF THE POSTERIOR
ZYGAPOPHYSIAL (FACET) JOINTS
Lynton G. F. Giles
O U T L I N E
INTRODUCTION Intraarticular Adhesions
ANATOMY OF THE ZYGAPOPHYSIAL JOINTS Synovial Fold Entrapment
Articular Cartilage EFFECT OF LEG-LENGTH INEQUALITY ON
Joint Capsule LUMBOSACRAL ZYGAPOPHYSIAL JOINTS
Synovial Membrane CLINICAL PRESENTATION OF ZYGAPOPHYSIAL
Innervation of Zygapophysial Joints JOINT FACET SYNDROME
PATHOLOGY OF THE ZYGAPOPHYSIAL JOINTS SUMMARY
Overview of Joint Pathophysiology QUESTIONS
Osteoarthritis ANSWERS
Synovial Cysts KEY REFERENCES
Ligamenta Flava REFERENCES
occupied by the spinal cord, meninges, and their

OBJECTIVES vessels.1 Adjacent mobile vertebrae articulate by
1. To review the anatomy of the zygapophysial joints. means of the “articular triad” (i.e., the intervertebral
2. To review the pathology of the zygapophysial joint anteriorly and the paired zygapophysial syn-
joints, including osteoarthritis, synovial cysts, liga- ovial joints posteriorly).2 Between the adjoining neu-
menta flava changes, intraarticular adhesions, and ral arches, near their junctions with vertebral bod-
synovial fold entrapment. ies, intervertebral foramina transmit mixed spinal
3. To review the effect of leg-length inequality on nerves, smaller recurrent meningeal nerves, and blood
lumbosacral zygapophysial joints. and lymphatic vessels.3 This chapter deals specifically
4. To review the clinical presentation of zyga- with the posterior zygapophysial (facet, interlaminar)
pophysial joint facet syndrome. joints. In general terms, the anatomy of all the synovial
zygapophysial joints is similar, but they vary in shape
and orientation depending on their position within
the spine.4 Figure 21–1 shows the orientation and an-
INTRODUCTION
gulation to the horizontal for typical lumbar, thoracic,
There are normally 5 lumbar, 12 thoracic, and 7 cer- and cervical vertebrae.
vical vertebrae that are unfused, as well as 5 sacral The laminae, spinous processes, and transverse
and 4 coccygeal vertebrae that are fused. Each mobile processes are connected by ligamenta flava; in-
vertebra consists of two principal parts: the anterior terspinous, supraspinous, and intertransverse liga-
vertebral body, which is composed of spongy bone ments; and the ligamentum nuchae, respectively (de-
covered by a thin layer of compact bone, and the pos- pending on the spinal level), which can all be regarded
terior vertebral (neural) arch with its lever-like pro- as accessory ligaments of these joints.3 Zygapophysial
cesses, together enclosing a vertebral foramen (canal) synovial joints are formed by the superior articular
401
FIGURE 21–1. Orientation of zy-

gapophysial joint facets. The approxi-
mate horizontal orientation (black lines)
of the zygapophysial joint facets is
shown for lumbar, thoracic, and cervi-
cal spines. The approximate inclination
of the respective facet surfaces to the
horizontal is shown in degrees. Both
the horizontal orientation and the facet
inclination vary according to the spe-
cific spinal level for a given vertebral
segment.
process of the caudad vertebra and the inferior ar- because the low back is the most frequently in-
ticular process of the adjacent cephalad vertebra; volved area of spinal pain (80–90%).8 This compares
they have a joint capsule composed of a posterolat- with 34–40% of the adult population experiencing
eral fibrous capsule and an anteromedial ligamentum neck and arm pain9 and 7–14% experiencing thoracic
flavum.5 The articular capsule of zygapophysial joints spine pain.10 The lumbar zygapophysial joints are
contains intraarticular synovial folds, which are nor- formed by the convex, laterally facing, inferior articu-
mal structures found in almost all the zygapophysial lar process of the upper vertebra, and the concave,
joints.6 The superior and inferior recesses of the joints medially facing, superior articular process of the
contain adipose or fibrous folds, lined with a syn- lower vertebra.11 These joints lie posterolateral to the
ovial membrane that also lines the inner surface of lumbar spinal canal and posterior to the intervertebral
the joint capsule but not the articular cartilage on the foramina or “canals.”12 The lumbar zygapophysial
facet surfaces.7 joints, which are originally orientated in the coro-
The zygapophysial joints have been the subject of nal plane, assume their final form and orientation in
extensive research in an attempt to understand their childhood.13 In the upper lumbar spine these joints are
function and pathology in relation to the costly and approximately sagittally orientated, but they gradu-
debilitating condition of zygapophysial “facet” joint ally become more coronally orientated as they reach
pain. These zygapophysial joints are described with the lumbosacral junction.14 They are “biplanar” joints,
regard to (a) their general anatomy, (b) their func- with both coronal and more sagittally orientated
tional and degenerative pathology and resulting pain, planes present in each joint.15 Their articular facets
and (c) the clinical presentation of zygapophysial joint have a smooth hyaline articular cartilage surface av-
“facet” syndrome. eraging 8–10 mm in adults.16
The zygapophysial joint is a true diarthrodial joint,
complete with a joint capsule and a synovial lining.17
ANATOMY OF THE ZYGAPOPHYSIAL JOINTS
The posterolateral and posteromedial parts of the
The lumbar zygapophysial synovial joints are de- capsule are fibrous and resemble the fibrous capsule
scribed in greater detail than for other spinal levels of other synovial joints. However, the medial part
PATHOPHYSIOLOGY OF THE POSTERIOR ZYGAPOPHYSIAL (FACET) JOINTS 403
FIGURE 21–2. A 100-μm-thick horizontal section of the lumbosacral zygapophysial joints at the level of the inferior joint recesses
from a 54-year-old man (the plane of the section is slightly oblique). A = arachnoid membrane; B = Batson’s venous plexus; C =
cauda equina; D = dura mater; H = hyaline articular cartilage; IVD = intervertebral disc; JC = posterolateral fibrous capsule; L =
ligamentum flavum; N = spinal ganglion; R = right side; S = sacrum; SP = base of trimmed-off spinous process. The intraarticular
synovial fold is shown by an arrow ( ). Arrow (→) shows a neurovascular bundle (Ehrlich hematoxylin stain with light green
counterstain). (Reprinted with permission from Giles LG, Taylor JR. Intra-articular synovial protrusions in the lower lumbar apophyseal joints. Bull
Hosp Jt Dis Orthop Inst 1982;42(2):248–255.)
of the capsule is formed by the ligamentum flavum Using phase-contrast illumination to microscopically
(Fig. 21–2).7 examine human adult fresh and cadaveric cartilage,
It is worth noting that the morphological config- MacConaill25 showed a thin bright line at the surface
uration of the thoracolumbar zygapophysial joints is of articular cartilage, which was not visible by ordi-
extremely variable18 ; therefore, judicious use of monary light illumination; it was so conspicuous that it
bilization procedures is particularly necessary for this merited the name of lamina splendens. However, ac-
region of the spine.19 cording to Aspden and Hukins,26 the so-called “lam-
ina splendens” described by MacConaill25 is an arti-
Articular Cartilage fact of phase-contrast microscopy caused by a Fresnel
Hyaline articular cartilage lines all sliding joint diffraction pattern on the edge of a section of car-
surfaces.20 The cartilage surface is devoid of tilage, while Sokoloff27 suggested that MacConaill’s
perichondrium,21 although some reference is made in bright line was a “halo” resulting from phase-contrast
the literature to a chondrosynovial membrane that is microscopy. However, Giles showed what appears to
only a few tenths of a micron thick, which Wolf refers be an acellular surface lamina on the opposing carti-
to as being of cartilaginous origin and which may be laginous surfaces in normal joints.5
torn off the articular surface “like a sheet of paper.”22 Hyaline articular cartilage has a special shock-
The uppermost layer of amorphous substance forms absorbing property, which may be explained by the
the actual smooth “glide” surface of articular cartilage interaction between collagen, proteoglycans, and the
and can be distinguished from the undersurface layer extracellular fluid as a response to loading.28 Nor-
of thin collagenous fibrils, which smoothly pass with mal adult hyaline articular cartilage is aneural and
their fibrillar structure into the cartilaginous tissue be- avascular,29 and is composed of approximately 75%
neath the membrane.22 A narrow surface lamina, de- water and 25% solids.30 Figure 21–3 shows its histo-
void of fibers, appearing to correspond to the lam- logical zones.
ina splendens, was described by Davies et al.,23 while Hyaline articular cartilage cell density and chemi-
Weiss et al. concluded that the lamina was fibrous.24 cal content vary in different parts of the same joint and
FIGURE 21–3. A 100-μm-thick horizon-

tal section from the left lumbosacral zy-
gapophysial joint of a 54-year-old man. A.
The articular facets of the superior artic-
ular process of the sacrum (S1) and the
inferior articular process of the fifth lum-
bar vertebra (L5) are lined with hyaline ar-
ticular cartilage. The rectangle on the L5
inferior articular process represented in B
shows the histological zones of hyaline ar-
ticular cartilage. The collagen fibers in the
deeper zones are perpendicular to the car-
tilage surface, then become parallel to the
surface in the more superficial zones. See
also the lower left schematic diagram (C).
The deeper chondrocytes are more spher-
ical and are arranged in approximately ver-
tical rows, whereas the superficial chon-
drocytes are flattened and are randomly
located. (Adapted from Junqueira LC, Carneiro
J, Long JA. Basic histology, 5th ed. CA: Lange,
1986:162; and Giles LGF, Taylor JR. Innervation of
human lumbar zygapophysial joint synovial folds.
Acta Orthop Scand. New York 1987;58:43–46.)
at different depths of the tissue.31 The cartilage has of convex surfaces.36 However, this is not usually the
a dense extracellular matrix populated by a sparse, case in lumbar zygapophysial joints, where the carti-
diffuse population of chondrocytes.32 The main com- lage may be thicker at the center of concave surfaces.37
ponents of the matrix are long fibers of collagen, which Across the center of lumbar zygapophysial joints, the
form a meshwork, and proteoglycans filling the inter- combined thickness of both hyaline articular carti-
stices of this meshwork. Benninghoff described the lages is approximately 2–2.4 mm.38
arcade arrangement of the collagen fibers, in which Hyaline articular cartilage transmits loads and al-
fibers orientated perpendicular to the subchondral lows repetitive joint motion without breakdown39 and
bone plate arch around to become tangential to the its elastic properties permit normal joint function.
articular cartilage surface (see Fig. 21–3).33 Normal The cartilage’s ability to deform under load enables
human adult hyaline articular cartilage contains only greater congruency to occur between opposing sur-
type II collagen, which (a) protects the chondrocytes, faces of the joint, thereby spreading a load over a larger
(b) provides attachment for proteoglycans, (c) anchors surface area.40
the cartilage to the subchondral bone, and (d) resists
the tensile stresses produced by compression.34 Joint Capsule
Hyaline articular cartilage thickness varies in dif- The zygapophysial joint capsule is unique in having
ferent parts of the same joint,35 but it is usually thicker two different structures forming it (i.e., the fibrous
at the periphery of concave surfaces and at the center capsule posterolaterally and posteromedially, and the
ligamentum flavum anteromedially) (see Fig. 21–2).41 fibrocytes,50 with only a few irregularly dispersed
The fibrous capsule is relatively loose above and be- blood vessels.37
low where it forms superior and inferior recesses,
which contain small synovial fat pads.42 The fibrous Synovial Membrane
capsule contains mainly fibrocytes or fibroblasts with The synovial membrane is a complex lining tissue that
little ground substance, and its fibers are mainly white is the conduit for the exchange of nutrients and waste
collagenous fibers, which are arranged in parallel products between blood and the joint tissues. The
bundles having a diameter of 0.3–0.5 μm. The rel- cells of the synovial lining membrane synthesize and
atively poor blood supply only allows slow healing secrete the proteins and proteoglycans that are neces-
once the capsule is damaged.43 In the lumbar spine, sary for normal joint lubrication.51 The synovial mem-
a tendon of the multifidus muscle is attached to the brane consists of two parts: a synovial lining layer (or
fibrous capsule as the multifidus muscle crosses the synovial intima), which is predominantly cellular, and
joint to attach to the mamillary process and the poste- a subsynovial layer (or synovial subintima), which
rior part of the joint capsule.37 is formed by loose, fibrous connective tissue, rich in
The ligamenta flava are interlaminar ligaments blood vessels, lymphatics, and adipose tissue.52
that are located within the spinal canal and cover The synovial membrane lines the inner surface of
most of the posterior bony wall of the spinal canal,44 the zygapophysial joint capsule and the fat pads in
transforming the deep aspect of the posterior wall of the joint recesses, forming synovial folds. Figure 21–4
the spinal canal into a uniformly smooth surface.45 shows an example of a lumbosacral intraarticular syn-
These ligaments consist of fibers of yellow elastic tis- ovial fold. The synovial membrane also lines the intra-
sue that extend from the articular capsule antero- capsular parts of bone that are not covered by articular
medially to the midline where the laminae fuse to cartilage,53 and it overlaps the nonarticular margins of
form the spinous process.46 The fiber direction is the cartilage where it terminates without a clear line
slightly oblique in the capsular portion and is es- of demarcation.43 Small-diameter (0.2–1.2 μm) nerve
sentially perpendicular in the medial interlaminar fibers have been found in the synovial membrane of
portion. The anteromedial border of the ligament zygapophysial joints, and it is reasonable to assume
passes around the zygapophysial joint, skirts the pos- that synovial folds in all zygapophysial joints have a
terior edge of the intervertebral canal, forming its roof similar innervation.37,54
and posterior wall, and then blends with the fibrous The synovial lining layer has a smooth, moist, and
capsule.45 glistening surface with small villi.55 The synovial lin-
The ligamentum flavum not only provides a ing layer cells (secreting fibroblasts) form a meshwork
smooth covering for the posterior part of the spinal between the joint cavity and the subsynovial tissue
canal, but also acts as (a) a capsule on the ventral part (Fig. 21–5).37 The synovial lining cells do not form a
of the zygapophysial joint, (b) an elastic band keeping continuous compact layer as with true epithelium, but
the spinal nerves free from compression when pass- form a layer that varies in depth and that can have
ing through the intervertebral canal, and (c) a check minute gaps between the synovial cells.56 The syn-
ligament to prevent hyperflexion.16 These ligaments ovial lining cells are of two types: A and B cells. The A
are generally thin, but broad and long in the neck, cells have a phagocytic function, whereas the B cells
thicker in the thoracic region, and thickest at the lum- probably represent different functional stages of the
bar levels,46 where their thickness ranges from 2 to same cell type.21
10 mm, depending on where it is measured.38 Accord- The subsynovial layer of the synovial membrane
ing to Farfan,47 the average thickness for the ligamen- can be areolar, areolar-adipose, fibrous, or fibroare-
tum flavum in the lumbar spine is 3 mm, although olar. This layer is rich in blood vessels, and it has
this may vary with the health of the adjacent joints. a plentiful supply of elastic fibers, which impart a
Giles and Taylor38 found the ligamentum flavum to function of elastic recoil during joint movement.57
be approximately 2.5–4.9 mm thick in the horizon- The zygapophysial joint intraarticular synovial folds
tal plane midway between the lamina junction and have two common types of subsynovial tissue: fibrous
the zygapophysial joint. The height of the ligamen- and adipose.55 The intraarticular synovial folds con-
tum flavum ranges from 1.0 to 2.0 cm.48 The thick- sist of various shapes and sizes and are described
ness of the ligament increases during extension of the in almost all the zygapophysial joints.19,58 Some con-
trunk and decreases during flexion and, at the L4-L5 troversy exists on the subject of zygapophysial joint
level, the range is 3.3–5.9 mm for flexion and exten- “synovial folds” and “menisci.” Some authors re-
sion, respectively.49 fer to “true” mesenchymal intraarticular menisci42 as
In the adult, the ligamenta flava consist of yellow semilunar fibrous structures that remotely resemble
elastic fibers (80%), collagen fibers (20%) interspersed menisci,59 or as “meniscoid inclusions.”60 However,
between the elastic fibers, and a few spindle-shaped according to Tondury,6 no “true” menisci are found in
FIGURE 21–4. Horizontal section

across the right lumbosacral zy-
gapophysial joint of a 54-year-old
man. IAP = inferior articular pro-
cess of L5; JC = posterolateral fi-
brous joint capsule; LF = ligamen-
tum flavum; M = multifidus mus-
cle fibers; P = periosteum; S =
sacral superior articular process.
The arrow points to an intraar-
ticular synovial fold (Ehrlich hema-
toxylin stain with light green coun-
terstain). (Adapted from Giles LGF,
Taylor JR, Cockson A. Human zy-
gapophysial joint synovial folds. Acta
Anat 1986;126:110a.)
zygapophysial joints, a finding that is confirmed by nerves ramify diffusely within the capsule and con-
this author. tain sensory fibers.65 According to Wyke and Paris,
The free irregular margins of the synovial folds a zygapophysial joint is innervated by no less than
may be quite long and thin and may project between three adjacent posterior primary rami.65,66 Most au-
the articulating surfaces where they often have fibrous thors, however, found each joint to be supplied by
tips.58 The principal functions of the intraarticular only two spinal nerves41 : one spinal nerve supplying
synovial folds are (a) to fill space between periph- the superior aspect of the zygapophysial joint capsule
eral noncongruent parts of the articular surfaces6 and one segment caudad, and the other spinal nerve sup-
(b) to secrete synovial fluid (a dialysate of plasma and plying the zygapophysial joint capsule in the region
hyaluronate protein), which acts as a lubricant and al- of the inferior recess at the same level at which the
lows nutrients to flow through it from the capillaries spinal nerve passes through the adjacent interverte-
in the synovial fold and the capillary bed surrounding bral foramen.
the joint cavity.61 Historically, the synovial folds were found to have
no innervation and, therefore, have been considered
Innervation of Zygapophysial Joints not to be involved in zygapophysial joint pain.65,67
Spinal nerves divide into anterior and posterior pri- However, histological studies by Giles and Harvey68
mary rami. The anterior primary rami form the cervi- and Gronblad et al.54 show that lumbar zygapophysial
cal, brachial, and lumbosacral plexuses, whereas in the joint synovial folds do contain both paravascular
thoracic region they remain segmental as intercostal and nonparavascular nerve fibers ranging in diam-
nerves.62 The posterior primary rami provide innerva- eter from 0.2 to 1.2 μm in the synovial lining layer
tion for the zygapophysial joints.63 Figure 21–6 shows (Fig. 21–7). Substance P antibody immunofluorescent
the distribution of the posterior primary ramus. nerves were demonstrated in the synovial folds by
Each lumbar posterior primary ramus, which has a Giles and Harvey68 and Gronblad et al.,54 and these
diameter of 2 mm or less, divides into a medial branch, were considered to have a putative function of noci-
which has a diameter of less than 1 mm, and a lateral ception, because substance P has been closely identi-
branch.64 The medial branch descends beneath the fied with nociception.69
mamilloaccessory ligament, and then gives branches The innervation of the fibrous part of the joint
to the fibrous capsule as it passes to lie directly super- capsule consists of both myelinated and unmyeli-
ficial to the communication between the fat-filled in- nated fibers, with a full triad of nerve endings, that
ferior recess of the joint and the synovial cavity.57 The is, fine free fibers, complex unencapsulated endings,
the ligamenta flava, in agreement with Ashton et al.,

who concluded that the ligamenta flava do not contain
many sensory or autonomic nerve fibers.75
PATHOLOGY OF THE ZYGAPOPHYSIAL JOINTS

Overview of Joint Pathophysiology
It is important to note that spinal pain may have a mul-
tifactorial etiology and that there may be several types
of back pain that closely mimic each other, each with
its own unique pathophysiological etiology.76 With
this in mind, the pathology of zygapophysial joints
is now considered.
The bony articular processes of the zygapophysial
joints are susceptible to all the disorders that affect
bone, the main disorders being infections, benign and
malignant tumors, endocrine disorders such as os-
teoporosis, congenital abnormalities, and fractures.
The synovial zygapophysial joints are also affected
by disorders of the large synovial joints, for example,
osteoarthritis, rheumatoid arthritis, and ankylosing
spondylitis. Apart from osteoarthritis, these patholog-
ical processes are not discussed in this chapter.
It should be emphasized that because of the artic-
ular triad, consisting of the fibrocartilaginous inter-
vertebral joint and the two synovial zygapophysial
joints,42 structural abnormalities in the interverte-
bral disk are always accompanied by osteoarthritis
FIGURE 21–5. A 30-μm-thick section showing part of a syn- changes in the zygapophysial joints.77 The spe-
ovial fold from the lumbosacral zygapophysial joint of a 45-year- cific functional and “degenerative” joint disease (os-
old woman. Note the synovial lining cells (C) in the synovial teoarthritis) conditions affecting the various compo-
lining (intimal) layer. BV = blood vessel containing blood cells; nents of a zygapophysial joint are now discussed.
E = elastic fibers; J = joint cavity; S = interlocular fibrous sep-
tum in the subsynovial (subintimal) layer. There is a rich blood
Osteoarthritis
supply (modified Schofield silver impregnation and Verhoeff
hematoxylin counterstain). (Adapted from Giles LGF. Human lum- The prevalence of facet joint osteoarthritis increases
bar zygapophysial joint inferior recess synovial folds: A light microscope with age.78 Vernon-Roberts and Pirie dissected more
examination. Anat Rec 1988;220:121.) than 100 lumbar spines and concluded that disc de-
generation was the primary event leading to osteo-
and small encapsulated endings2 ; it contains sub- phyte formation and to zygapophysial joint changes,
stance P immunoreactive nerves.68 Some of these finding that structural abnormalities in discs were
nerve endings have been classified as “pain sensitive” always accompanied by osteoarthritis in associated
on the basis of their histological appearance,70 and facet joints; osteoarthritis was absent or minimal when
electrophysiologic studies suggest the presence of no- the discs were relatively normal, or when only minor
ciceptive nerves.71 Fine free nerve fibers and endings, degenerative changes were present.78
which are considered to be nociceptive, have been de- Osteoarthritis is said to be primary when no eti-
scribed on the outermost posterior surface of the lig- ologic factors can be discerned, and secondary when
amentum flavum,2 but not in its deeper regions,41 al- an identifiable cause is found,79 such as previous in-
though Bridge72 claimed that the ligamentum flavum jury to a joint.80 According to Bland,81 there are four
contained many nerves in its deep region in tho- theories of the pathogenesis of osteoarthritis: (a) The
racolumbar specimens. Single nerve fibers, usually initial event occurs in cartilage, the result of a change
associated with blood vessels, are found in the liga- in the microenvironment of the chondrocytes (a view
mentum flavum.73 However, no immunoreactivity to held by most investigators); (b) the initial event oc-
substance P antibody was found in small pieces of curs in subchondral bone with mechanical factors be-
ligamentum flavum by Gronblad et al.,74 who con- ing the primary cause; (c) micro-osteonecrosis occurs
cluded that no nociceptive-type nerves are present in in the subchondral bone as a consequence of vascular
L3
TVP
GRC
ZJC
3
5
4 1
Sympathetic
nerve ganglion FIGURE 21–6. Part of the lower spinal innervation
(lateral view). 1 = Anterior primary ramus of the
2
spinal nerve; 2 = anterior primary ramus branch
to the intervertebral disc; 3 = posterior primary
ramus of the spinal nerve; 4 = medial branch of
the posterior primary ramus with an adjacent zy-
gapophysial joint capsule (articular) branch and a
descending branch to the zygapophysial joint cap-
sule (articular branch) one joint lower; 5 = lateral
branch of the posterior primary ramus; arrow =
mamilloaccessory ligament; GRC = gray ramus
communicans; TVP = transverse process; ZJC =
S1 zygapophysial joint capsule. (Reproduced with permis-
sion from Giles LGF. Anatomical basis of low back pain. Bal-
timore: Williams and Wilkins, 1989:60.)
FIGURE 21–7. Part of a whole mount, silver-

impregnated synovial fold from a 40-year-old man.
Note the extensive paravascular nerve plexus (NP) on
the capillary (C) and the synovial fold fat cells (FC).
A single nerve fiber (N1) with an average diameter
of 1.7μm traverses the synovial fold; it is not associ-
ated with any blood vessels. The silver-stained struc-
ture (N2) consists of one or two nerve fibers; also
note the reticular fibers (RF) adjacent to the fat cells.
(Reproduced with permission from Giles LGF, Taylor JR. In-
nervation of human lumbar zygapophysial joint synovial folds.
Acta Orthop Scand 1987;58:44–45.)
disease; and (d) a proteolytic enzyme from type A osteophytes from the zygapophysial joints, as well as
synovial cells that is normally neutralized by an in- from the von Luschka joints, may compress the ver-
hibitor from type B synovial cells digests the pro- tebral artery, interfering with brainstem and posterior
tein core of chondroitin sulfate if the inhibitor is fossa circulation.85 Although osteoarthritis occurs in
absent.82 the thoracic spine, it is almost always asymptomatic,
Whatever the mechanics, osteoarthritis of zy- which is probably a result of this area being minimally
gapophysial joints leads to bone proliferation at the mobile.85
edges of the facets with some degree of encroachment The articular surface of zygapophysial joints may
on the spinal and intervertebral canals.83 Large osteo- retain an intact covering of hyaline articular carti-
phytes can project from the margins of zygapophysial lage even when osteophytes have formed and there
joint articular surfaces anteriorly into the interver- is dense sclerosis of subchondral bone (Fig. 21–8).
tebral canal, or medially into the spinal canal.84 These joints may, however, show the classic changes
Osteophytes projecting into the intervertebral canal of severe osteoarthritis.77 Occasionally, zygapophysial
from the margins of osteoarthritic zygapophysial joints exhibit a subchondral bone cyst. The impacted
joints may cause pressure on the spinal nerve77 and, cartilage in the articular process of Figure 21–8 prob-
in a small spinal canal, osteophytes can contribute ably represents traumatic herniation of hyaline artic-
to neurological symptoms and signs83 caused by ular cartilage and an early stage of subchondral bone
spinal stenosis. Furthermore, in the cervical spine, cyst formation.
FIGURE 21–8. A 100-μm-thick horizontal section through the right L5 to S1 zygapophysial joint of a 54-year-old man. Note
the early osteophyte (O ) with subchondral sclerosis and a fibrocartilage “bumper” (F ). Some areas of the hyaline articular car-
tilage show other early osteoarthrotic changes, for example, early fibrillation and clustering of the chondrocytes; also note
the fissure (arrow; →) in the cartilage and the defect in the subchondral bone plate with hyaline articular cartilage impacted
in the articular process (tailed arrow; ). JC = posterolateral fibrous joint capsule; L = ligamentum flavum; N = neurovascular
bundle nerve.
Facet osteoarthritis affects segmental motion86 and normal-sized spinal canals.83 Thickened ligamenta
is considered to be a relatively important cause of in- flava (which have no true hypertrophy, but do have
tractable back pain in young and middle-age adults.87 thickening and fibrosis)103 can buckle inward, de-
Bearing in mind that cartilage is aneural, pain from pressed by enlarged laminae, or they can become
osteoarthritic joints derives from a number of factors, incorporated into zygapophysial joint osteophytes
the pain originating from nociceptors both within and at the site of attachment of the ligamentum flavum
surrounding the joints.88 The painful symptoms of to the zygapophysial joint capsule.16 Spurs in the
osteoarthritic zygapophysial joints are partly a re- ligamentum flavum may displace the ligament, caus-
sult of (a) joint wear (involving cartilage degeneration ing encroachment on the intervertebral canal and dis-
with loss of joint space, formation of osteophytes and tortion of the spinal nerve.104
loose bodies, and joint capsule fibrosis); (b) episodes Thickening of the ligamenta flava can, in conjunc-
of synovial fold inflammation; and (c) inflammation, tion with zygapophysial joint facet subluxation and
fraying, and degeneration of ligaments around the disk thinning, compromise the nerve root in the inter-
joints.89 Venostasis may occur in the adjacent bone vertebral canal.105 As the ligamentum flavum extends
marrow, resulting in hypertension,81 which may cause far laterally (see Fig. 21–8) to blend with the fibrous
pain as a consequence of pressure on small nerves in joint capsule on the roof of the lateral recess and inter-
the bone.90 Osteoarthritis can also lead to swelling of vertebral canal, minimal thickening may cause dorsal
the joint capsules,83 which are well innervated, and root compression.106
to periosteal elevation with accompanying marginal
bony spur formation.88 Intraarticular Adhesions
Intraarticular adhesions are perceived as forming as a
Synovial Cysts
result of zygapophysial joint trauma, inflammation, or
Synovial cysts usually originate from osteoarthritic immobilization.107 Adhesions within zygapophysial
zygapophysial joints and are frequently found in the joint capsules may occur and adhesions have been
medial margin of the L4-L5 zygapophysial joint.91 demonstrated histologically where joint capsule fi-
Lemish et al. found synovial cyst prevalence of 0.5% brous tissues have become attached to the adjacent
in 2000 lumbar spine computed tomography (CT) hyaline articular cartilage by adhesions.7
studies.92 Synovial cysts characteristically appear as
having a flat base paralleling the ligamentum flavum
Synovial Fold Entrapment
at the medial margin of the zygapophysial joint.93 Syn-
ovial cysts can affect any level of the spine,94 although The innervated synovial folds68 may interfere me-
they are rare in the cervical spinal canal95 ; myelopa- chanically with joint movement,108 causing pain and
thy is the predominant initial symptom of cervical and muscle spasm. Pain also may result from entrapment
thoracic cysts.96 Synovial cysts can cause spinal pain of the synovial folds between the facet surfaces. Two
with radiculitis,97 and impingement upon the thecal main mechanisms by which pain may arise because
sac and/or the emerging nerve root makes it difficult of synovial fold pinching are (a) traction on pain-
to distinguish the symptoms from those caused by sensitive tissues such as the synovial fold and the fi-
disc herniation or stenosis.98 Cysts of the ligamentum brous joint capsule, and (b) synovial fold traumatic
flavum may cause compression of a lumbar nerve root synovitis with associated tissue damage and cell rup-
with low back pain and sciatica, and may be mistaken ture. The latter condition can cause the release of pain-
for more common intraspinal synovial or ganglion producing substances, such as histamine, substance P,
cysts.99 According to Husson et al., an intraarticular bradykinin, and potassium ions, all of which cause no-
lipoma can also cause spinal pain with radiculitis.100 ciceptive nerve impulses, and ischemia, with resultant
ischemic pain caused by an accumulation of metabolic
Ligamenta Flava products (e.g., lactic acid).
Hypertrophy at the attachment of the ligamentum
flavum to the zygapophysial joint may cause spinal
EFFECT OF LEG-LENGTH INEQUALITY ON
stenosis,101 and Kirkaldy-Willis et al.102 found that the
LUMBOSACRAL ZYGAPOPHYSIAL JOINTS
ligamentum flavum may be 7–8 mm thick in stenosis,
as compared with the usual thickness of 2.5–4.9 mm.38 The clinical findings of Gofton indicate that there is
Swollen ligamenta flava can encroach upon the a strong correlation between leg-length inequality of
spinal canal, and may be a contributory factor in 1 cm or more and low back pain.109 Uncertainty in
spinal pain syndromes.85 Referred pain syndromes the literature relating to the possible relationship be-
can occur in the presence of swollen ligamenta flava tween leg-length inequality and low back pain110 is
in association with a small lumbar spinal canal, and partly a result of the fact that different clinicians use
may even cause sciatica in some patients who have various methods (some of questionable accuracy) to
zygapophysial joint facet angles from erect posture

oblique radiographs.119 The plumb line, between the
Bucky diaphragm and the cassette, gives a true ver-
tical reference line on the radiograph, as in the case
of anteroposterior pelvis–lumbar spine radiographs.
This line is used as a reference point to draw a horizon-
tal line at right angles to it on the radiograph. A line is
then drawn through the plane of each lumbosacral zy-
gapophysial joint to bisect the horizontal line so that
the inclination of the facet surfaces to the horizontal
can be measured using a Perspex protractor.119 It has
been shown that there is a statistically significant dif-
ference between paired left and right lumbosacral zy-
gapophysial joint facet angles with the horizontal (7.1
± 4.4 degrees) in patients with leg-length inequality
and pelvic obliquity, whereas in cases with equal leg
lengths, the left and right angles are virtually the same
(1.8 ± 1.6 degrees).119 The difference in angles asso-
ciated with leg-length inequality and pelvic obliquity
implies that asymmetrical biomechanical loads will be
borne by the paired lumbosacral zygapophysial joints
in cases where leg-length inequality of 1 cm or more
and pelvic obliquity are present.
Indeed, Giles and Taylor38 found that leg-length
inequality of 1 cm or more is associated with a
FIGURE 21–9. An erect posture radiograph, taken using the tendency toward asymmetrical changes in zygapo-
method of Giles and Taylor, of a 19-year-old woman with a left physial mid-joint cartilage thickness and subchondral
leg-length deficiency of 27 mm, pelvic obliquity, and a postural bone thickness in postural scoliosis. In cases of leg-
scoliosis of 12 degrees. The postural scoliosis was measured length inequality of 1 cm or more with pelvic obliq-
using Cobb’s method. The angle of curvature is measured by uity and postural scoliosis, the zygapophysial joint
drawing lines parallel to the superior surface of the uppermost facets are probably no longer congruous and, conse-
vertebral body of the curvature and to the inferior surface of
quently, increased friction may occur at some point
the lowest vertebra of the curvature (radiograph viewed in the
of the gliding movement.120 Abnormally shaped or
posteroanterior position).
positioned zygapophysial joint facet surfaces appear
to be a cause of osteoarthritis,121 which is not a dis-
measure absolute leg lengths,111 although it has been ease, but is an expression of the morphological con-
known for many years that radiographic methods are sequences of stresses applied to the zygapophysial
most accurate,112–114 and that tape measurement pro- joints.122 Preliminary data suggest a tendency toward
cedures are inaccurate.115 It has been found that the a larger area of bumper fibrocartilage in the lum-
zygapophysial joints carry a proportion of the incum- bosacral zygapophysial joints of cadavers with a leg-
bent body weight116 that varies from 16–40% of the length inequality of 1 cm or more and a postural
total compressive load on the spine.117 In cases where scoliosis of 4 degrees or more.37 The data indicate
a leg-length inequality of 1 cm or more is present with that, in such a postural scoliosis, there is probably a
pelvic obliquity, a marked postural scoliosis may be greater sideways “thrusting” of the lateral margins of
present (see Fig. 21–9). the facets of the zygapophysial joints against the in-
Carefully standardized erect posture radiographs nervated synovial lining layer. This condition could
can be used to measure accurately leg-length inequal- cause pain of zygapophysial joint origin, because
ity, pelvic obliquity, and the associated postural scol- the synovial lining membrane and subsynovial tissue
iosis by using a wire plumb line between the patient have small-diameter nerves that have been shown to
and the cassette as a reference line.118 Patients with have substance P antibody–positive profiles and are,
unleveling of the left and right pubic rami were ex- therefore, considered to have a putative function of
cluded from the clinical study by Giles and Taylor nociception.
because this unleveling could be a result of sacroiliac Finally, the mechanisms by which leg-length in-
joint subluxation.118 equality may produce low back pain must involve (a)
Figure 21–10 graphically illustrates a method some lumbar spine pathology, whether structural or
for measuring the left and right lumbosacral functional; (b) possible sacroiliac joint dysfunction;
FIGURE 21–10. Measurement of right and left lumbosacral zygapophysial joint ‘facet angle’ in a patient with a left-leg length
deficiency of 12 mm.
(c) possible pelvic–lumbar muscle dysfunction; or give rise to pain at any place that shares a common
(d) a combination of these factors. nerve supply with the affected joint.128 The injection
of normal zygapophysial joints with contrast mate-
rial (Conray 60) followed by 1–3 mL of 5% hypertonic
CLINICAL PRESENTATION OF ZYGAPOPHYSIAL saline, under fluoroscopic control, caused a pain re-
JOINT FACET SYNDROME ferral pattern in the typical locations of “lumbago and
The zygapophysial facet joint is considered to be sciatica.”129 Furthermore, it caused marked myoelec-
an important source of low back pain123 and the tric activity in the hamstring muscles of two patients
“facet syndrome” is common, but because it is usually with chronic low back pain and sciatica, and straight-
not demonstrable radiographically, it is frequently leg raising was diminished to 70 degrees in these pa-
overlooked.124 It is known that in this syndrome lum- tients. In three patients in whom depressed tendon
bar zygapophysial joints may produce referred pain reflexes were present, facet block injection (2–5 mL of
in the legs,125 and that the course of this referred pain 1% Xylocaine) obliterated the referred pain and the
may be to the buttock, over the greater trochanter, clinical signs of diminished straight-leg raising and
down the back of the thigh to the knee, and some- depressed tendon reflexes within 5 minutes.
times down the posterior or outer calf to the ankle,
but rarely to the foot or toes.126 Patients with radicu-
SUMMARY
lar pain because of osteoarthritic zygapophysial joints
causing stenosis of the intervertebral or spinal canals 1. Zygapophysial synovial joints are formed by the
will, on occasion, report pain of a “claudicant” charac- superior articular process of the caudad vertebra
ter that is precipitated, aggravated, and progressively and the inferior articular process of the adjacent
intensified by walking. This pain differs, however, cephalad vertebra; they have a joint capsule com-
from the claudicant calf pain of peripheral vascular posed of a posterolateral fibrous capsule and an an-
insufficiency in that the pain is experienced first, and teromedial ligamentum flavum. The articular cap-
most severely, proximally in the limb, and the pa- sule of zygapophysial joints contains intraarticular
tient typically has to sit or lie down to get relief.127 synovial folds, which are normal structures found
Thus, zygapophysial joint dysfunction does not nec- in almost all the zygapophysial joints. The superior
essarily give rise to pain locally in the joint; it may and inferior recesses of the joints contain adipose
or fibrous folds, lined with a synovial membrane 4. From where do synovial cysts usually originate?
that also lines the inner surface of the joint cap- 5. What is one important source of low back pain?
sule but not the articular cartilage on the facet
surfaces.
2. The bony articular processes of the zygapophysial ANSWERS
joints are susceptible to all the disorders that af-
1. The medial branch of the posterior primary ramus
fect bone, the main disorders being infections,
from the spinal nerve leaving the adjacent inter-
benign and malignant tumors, endocrine disor-
vertebral foramen and from the spinal nerve leav-
ders such as osteoporosis, congenital abnormali-
ing the intervertebral foramen one level above (see
ties, and fractures. Osteoarthritis of zygapophysial
Fig. 21–6).
joints leads to bone proliferation at the edges
2. The joint capsule is unusual because it is made
of the facets with some degree of encroachment
up of two histologically different tissues—a pos-
on the spinal and intervertebral canals. Synovial
terolateral and posteromedial fibrous capsule, and
cysts usually originate from osteoarthrotic zy-
an anteromedial highly elastic ligamentum flavum
gapophysial joints and are frequently found in the
(see Fig. 21–2).
medial margin of the L4-L5 zygapophysial joint.
3. Small-diameter free-ending nerve fibers unrelated
Hypertrophy at the attachment of the ligamen-
to blood vessels, and paravascular small-diameter
tum flavum to the zygapophysial joint may cause
free-ending nerve fibers. Function: paravascular
spinal stenosis. Intraarticular adhesions within zy-
fibers—vasoregulation; nonparavascular fibers—
gapophysial joint capsules may occur and have
putative function of nociception (see Fig. 21–7).
been demonstrated histologically where joint cap-
4. From osteoarthritic zygapophysial joints.
sule fibrous tissues have become attached to the
5. The zygapophysial joint, causing the “facet syn-
adjacent hyaline articular cartilage. Pain also may
drome.”
result from entrapment of the synovial folds be-
tween the facet surfaces.
3. There is a strong correlation between leg-length in-
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C H A P T E R
22
THE INFLUENCE OF MUSCLES
IN SPINAL PAIN SYNDROMES
Mark T. Finneran
O U T L I N E
INTRODUCTION NEUROANATOMY
MUSCULAR ANATOMY INTEGRATION
Spinal Muscles SUMMARY
Erector Muscle Group QUESTIONS
Transversospinalis Muscle Group ANSWERS
Interspinal Intertransverse Group KEY REFERENCES
Extraspinal Muscles REFERENCES
PHYSIOLOGY AND ELECTROPHYSIOLOGY
tion, has been implicated. The paraspinal anatomy is

OBJECTIVES wonderfully complex, and in health the paraspinal
1. To review the muscular anatomy of the spine, in- musculature functions as a highly integrated pseu-
cluding the anatomical origin, insertion, and func- doautonomous system. With injury or disease, the
tion of the muscles of the spine. harmony of that system is disrupted. Understand-
2. To review the physiology of the paraspinal mus- ing the muscular response to pain of different eti-
cles, including the known physiological principles ologies can guide the physician in identifying the
of the paraspinal muscles. potential cause of the patient’s condition. Con-
3. To review the innervation of the paraspinal sequently, physicians must be familiar with the
musculature, including the neuroanatomy of the anatomy, physiology, and neurophysiology of the
paraspinal muscles. muscles to appreciate their interaction with the skele-
4. To discuss clinical methods of evaluating muscle tal support system before effective treatment may
pain such as palpation. take place. This chapter reviews the basic anatomy
5. To understand the role of different tests used to of spinal and paraspinal musculature, as well as
study the paraspinal muscles: x-ray, computed muscle physiology, neuroanatomy, and methods of
tomography (CT), magnetic resonance imaging detecting muscular pathology through diagnostic
(MRI), needle electromyelography (EMG), surface testing.
EMG, and computerized electrophysiological re-
construction of spinal regions (CERSR) physiolog-
ical imaging. MUSCULAR ANATOMY
Several muscle groups act upon the spine. Many clas-
sification systems exist for these groups, typically
INTRODUCTION
based on location (i.e., superficial to deep, cephalad
The etiology of spinal pain is often unclear. Pathol- to caudad, medial to lateral, etc.). Muscles here are
ogy of the intervertebral discs, facet joints, tendons, presented according to two broad groups: spinal and
ligaments, nerves, or muscles, singly or in combina- extraspinal.
419
FIGURE 22–1. The osseous anatomy of the human spine.

FIGURE 22–2. The erector spinae muscle group, consisting
of iliocostalis (lateral), longissimus (intermediate), and spinalis
Spinal Muscles (medial) muscles.
The spinal muscle system is composed of 96 erector
and intrinsic muscles that originate from and insert two thoracic vertebrae, as well as their supraspinal lig-
onto the spine, which is schematically illustrated in aments. The muscles also come from the dorsal aspect
Figure 22–1. These muscles span the entire length of of the iliac cress and the lateral crests of the sacrum,
the spine, and form several layers that overlap each where they blend into the sacral tuberous and pos-
other in various parts of the spine. Components of terior sacroiliac ligaments. Some fibers are contigu-
the spinal muscle system include the erector group, ous with the muscle fibers of the gluteus maximus. In
the transversospinalis group, and the interspinal in- the upper lumbar region, the erector spinae muscles
tertransversarii group. divide three columns: lateral/iliocostalis, intermedi-
ate/longissimus, and medial/spinalis.
Erector Muscle Group The erector spinae are a “great The lateral column, composed of the iliocostalis
mass of muscle” that stretches from the sacrum to the muscle, is further divided into the iliocostalis
skull. This group constitutes the first level of erector lumborum and the iliocostalis thoracis. The ilio-
muscles in the spine (Fig. 22–2). The erector spinae costalis lumborum splits from the erector spinae mass
arise from the anterior surface of a broad, thick ten- at the upper lumbar level, and ascends to insert on
don, which is attached to the median sacral crest and the inferior borders of the last six to seven ribs. The
to the spinous processes of the five lumbar and lower iliocostalis thoracis arises from the upper borders of
THE INFLUENCE OF MUSCLES IN SPINAL PAIN SYNDROMES 421
the angles of the lower six ribs, medial to the tendons

of the iliocostalis lumborum. These muscles insert on
the upper borders of the angles of the first six ribs, and
insert into the dorsum of the transverse processes of
the seventh cervical vertebrae. The action of the ilio-
costalis muscles is extension of the vertebral column.
They also provide lateral flexion, and assist in rotation.
These muscles may also depress the ribs. The primary
dorsal divisions of the spinal nerve roots innervate
these muscles.
The intermediate column, composed of the longis-
simus muscle, has three divisions: longissimus tho-
racis, longissimus cervicis, and longissimus capitis.
The longissimus thoracis separates from the ilio-
costalis lumborum (lateral) and spinalis thoracis (me-
dial) in the upper lumbar region. Below this level the
three muscles are united. This muscle inserts onto the
tips of the transverse processes of all thoracic verte-
brae, as well as the posterior surfaces of the transverse
processes, and the accessory processes of the lumbar
vertebrae. The function of the longissimus thoracis
muscle is extension and lateral flexion of the vertebral
column. The longissimus thoracis is also able to de-
press the ribs. The dorsal primary ramus of the spinal
nerves innervates the longissimus thoracis muscle.
The medial column, composed of the spinalis mus-
cle, likewise has three divisions: spinalis thoracis,
spinalis cervicis, and spinalis capitis. This column of
muscles is the smallest of the three divisions, and is
closest to the vertebral column. The spinalis thoracis
is the continuation of the erector spinae, medial to the
longissimus thoracis. It arises from three or four ten-
dons of the spinous processes of the first two lumbar
and the last two thoracic vertebrae. These join to form
a long, slender muscle that inserts onto the spinous
processes of the upper thoracic vertebrae. The inser-
tions can, depending on anatomical variation, be on
as few as four, or as many as eight, thoracic vertebral FIGURE 22–3. The multifidus muscles traverse several motion
spinous processes. segments to produce lateral flexion and rotation when acting
unilaterally, and extension when activated bilaterally.
Transversospinalis Muscle Group The transversospinalis
muscle group is deep to the erector spinae group, last two cervical vertebrae. The semispinalis are found
and fills the concave region between the spinous pro- only in the thoracic and cervical regions. They under-
cesses and the transverse processes of each vertebra. lie the spinalis (medial) and longissimus (intermedi-
The muscle fascicles course obliquely upward and me- ate) columns of the erector spinae group. The function
dial from the transverse process of the vertebrae be- of the semispinalis muscles is to extend the paraverte-
low to the next higher spinous process. The transver- bral column and to rotate it toward the opposite side.
sospinalis group is further divided into three groups: The multifidus fills the groove on both sides of the
semispinalis, multifidus, and rotatores. spinous processes of all vertebrae from the sacrum to
The semispinalis muscle group includes the semi- the second cervical vertebra (Fig. 22–3). These mus-
spinalis thoracis, the semispinalis cervicis, and the cles lie deep to the erector spinae muscles in the lum-
semispinalis capitis. The semispinalis thoracis is a bar region, and deep to the semispinalis thoracis and
thin, narrow strip of muscle between very long ten- semispinalis cervicis muscles. The origin of the mul-
dons. It arises from the transverse processes of the tifidus muscle is the back of the sacrum, as low as the
sixth to the tenth thoracic vertebrae and inserts on fourth sacral foramen, the aponeurosis of the origin of
the spinous processes of the first four thoracic and the erector spinae, the medial surface of the posterior
The rotatores are the deepest muscles in the

transversospinalis group. The rotatores longi (Fig.
22–4) cross one vertebral level in their oblique course
from the transverse process below to the base of the
spinous process of the vertebra one level above. The
rotatores brevi (Fig. 22–5) travel almost horizontally
from the transverse process of one vertebra to the base
of the spinous process of the vertebra directly above.
The rotatores muscles are divided into rotatores tho-
racis and rotatores lumborum. The rotatores thoracis
muscles are narrow and rectangular. They form the
deepest layer in the groove beside the spinous and
transverse processes of the thoracic vertebrae. They
arise from the transverse process of one vertebra and
insert into the base of the spinous process of the tho-
racic vertebra immediately above or one level above
that. They are deep to the multifidus and are dif-
ficult to distinguish from the deepest fibers of the
FIGURE 22–4. The rotatores longus (right), interspinalis (cen-

ter), and intertransverse (left) muscle groups.
superior iliac spine, and the posterior sacroiliac lig-

aments. In the lumbar region, the multifidus arises
from all of the mammillary processes. In the thoracic
region, it arises from all of the transverse processes.
Each muscular fasciculus ascends obliquely, crossing
over two to four vertebrae, toward the midline. At the
midline, the multifidus inserts on the spinous process
of a higher (two to four levels) vertebra. The multi-
fidus inserts onto the spinous processes of all verte-
brae from L5 to C2. The longest and most superficial
fascicle traverses five vertebrae from origin to inser-
tion. The deepest and shortest interconnect two ver-
tebrae. The multifidus muscle alone, ipsilaterally, lat-
erally flexes, and rotates the vertebral column. When
working in unison, they extend the vertebral column.
The medial division of the posterior primary ramus
innervates the multifidus. FIGURE 22–5. The rotatores brevi group.
multifidus. In the lumbar region, the rotatores lum- rami of lumbar nerves innervate the interspinal–
borum are less well defined and are more variable. intertransversarii muscles.
They attach to the mammillary process below and to
the inferior margin of the lamina above. The function Extraspinal Muscles
of the rotatores muscles is to extend and rotate the ver- Many muscles that do not attach directly to the spine
tebral column. These muscles are also innervated by or that are not typically described as spinal mus-
the medial division of the posterior primary ramus. cles nevertheless exert an influence on spinal function
(Fig. 22–6).
Interspinal Intertransverse Group This group of mus- The iliopsoas group of muscles is usually clas-
cles constitutes the third layer of spinal muscles, and sified with the lower limb muscles. Because spasm
passes segmentally from one vertebra to the next. As in these muscles may produce characteristic findings
its name suggests, this group is composed of the inter- in patients with low back pain, they are included
spinalis and intertransversarii muscle groups. The in- here as part of the thoracolumbosacral region. This
terspinalis muscle group is further divided into the in- group constitutes the fourth, and deepest, layer of
terspinalis lumborum and interspinalis thoracis. The muscles in the spine. The iliopsoas muscle group con-
interspinalis lumborum muscles are short, paired, and tains psoas major, psoas minor, iliacus, and quadratus
placed between the spinous processes of contiguous lumborum.
vertebrae. There is one muscle on each side of the in-
terspinal ligaments (see Fig. 22–4). In the lumbar re-
gion, there are four pairs of interspinalis lumborum
muscles. They are in the spaces between the five lum-
bar vertebral spinous processes. There is occasionally
one pair between the last thoracic and the first lum-
bar, as well as between the fifth lumbar and the first
sacral vertebra. In the thoracic region, the interspinalis
thoracis muscles are found between the eleventh
and twelfth vertebrae. They are underdeveloped in
the remainder of the thoracic spine. The function of
the interspinalis muscles is to extend the vertebral
column.
The intertransversarii muscle group (see Fig. 22–4)
is further divided into intertransversarii thoracis,
intertransversarii mediales lumborum, and inter-
transversarii laterales lumborum. In the thoracic re-
gion, the intertransversarii thoracis muscles consist
of single muscular slips on either side of the verte-
brae. They are present between the transverse pro-
cesses of the last three thoracic vertebrae, and between
the transverse processes of the last thoracic and the
first lumbar vertebrae. The intertransversarii mediales
lumborum muscles are also arranged in pairs on ei-
ther side of the vertebral column. One muscle of each
pair, the medial intertransverse muscle, passes from
the accessory process of one vertebra to the mammil-
lary process of the vertebra below. The medial division
of the dorsal primary ramus of each of the lumbar
nerves supplies these intrinsic, deep back muscles.
The intertransversarii laterales lumborum muscles are
also paired, and occupy the entire interspace between
the transverse processes of contiguous vertebrae in
the lumbar spine. The lateral lumbar intertransver-
sarii muscles are separated into anterior and posterior
groups. The action of the intertransversarii muscles
is to flex the vertebral column laterally when acting
unilaterally, and to extend the vertebral column when FIGURE 22–6. The important superficial and deep paraspinal
acting bilaterally. Branches of the anterior primary muscles.
eminence, and the lateral iliac fascia. The psoas mi-

nor is a weak flexor of the trunk and lumbar spine.
Fifty percent of patients do not have a psoas minor
muscle. The iliacus is a flat triangular muscle that fills
the iliac fossa (see Fig. 22–7). It inserts on the lesser
trochanter of the femur with the psoas major muscle.
The iliacus, along with the psoas major, is a power-
ful hip flexor. The iliacus is innervated by L2 and L3.
The quadratus lumborum is an irregular, broad mus-
cle that arises from the aponeurosis of the iliolumbar
ligament and the iliac crest (Fig. 22–8). It inserts on
the medial aspect of the inferior border of the last rib,
and onto the transverse processes of L1, L2, L3, and
L4. The quadratus lumborum laterally flexes the lum-
bar spine to the same side, when acting unilaterally.
Working bilaterally, this muscle extends the vertebral
column.
FIGURE 22–7. The iliopsoas group.
The psoas major muscle is a long, fusiform muscle

that lies lateral to the lumbar vertebrae (Fig. 22–7).
It arises from the anterior surfaces and lower bor-
ders of the transverse processes, the sides of the verte-
bral bodies and the intervertebral discs, the tendinous
arches that span the constricted portion of each lum-
bar vertebral body, and the last thoracic vertebra. The
muscle descends, past the brim of the lesser pelvis, be-
neath the inguinal ligament, and inserts, with nearly
all of the fibers of the iliacus muscle, onto the lesser
trochanter of the femur. The psoas major muscle is a
powerful hip flexor, and trunk flexor. Other functions
are unclear. The psoas major muscle is innervated by
L2, L3, and L4.
The psoas minor muscle is a long, thin muscle that
lies anterior to the psoas major. It arises from the bod-
ies of T12 and L1, as well as the disc space between
them. It inserts onto the pectineal line, the iliopectineal FIGURE 22–8. The quadratus lumborum muscle.
It curves upward, around the base of the pedicle,

PHYSIOLOGY AND ELECTROPHYSIOLOGY
and progresses to the midline of the posterior lon-
The physiology of paraspinal muscles is unique. gitudinal ligament. It divides into ascending, trans-
Skeletal muscles, including the paraspinal muscles, verse, and descending branches that then anastomose
are classically divided into three subtypes: slow with branches from adjacent (superior, inferior, and
twitch, resistant to fatigue; fast twitch, resistant to fa- contralateral) sinuvertebral nerves. The sinuvertebral
tigue; and fast twitch, fatigable. The muscles of the nerve innervates the posterior longitudinal ligament,
spine contain a high proportion of skeletal muscle that the superficial layers of the annulus fibrosus, the ante-
is slow-twitch resistant to fatigue.1,2 rior dura mater and the dural sleeve surrounding the
The function of all skeletal muscle is fundamen- spinal nerve root. It also supplies the blood vessels of
tally the same. When the muscle contracts, the skele- the epidural space and the posterior vertebral perios-
tal structure to which it is attached moves. The mi- teum. The posterior dura is devoid of nerve endings.
crostructure of skeletal muscle is the foundation of The anterior primary division of the spinal nerve
this action. A muscle is a group of muscle cells held may proceed around the body wall as, for example,
together by connective tissue. A single muscle cell is the intercostal nerves, or join other anterior divisions
a multinucleated, fibrous structure surrounded by a to form large nerve trunks, such as the sciatic nerve.
membrane, the sarcolemma. The cell is cylindrical, The posterior division, or posterior primary ramus,
measuring 10–100 μm in diameter, and may be up divides into a medial division and a lateral division
to 30 cm in length. Within the muscle cell are myas it progresses posteriorly.
ofibrils, cylindrical elements each measuring 1–2 μm The medial division of the posterior primary ra-
in diameter. There may be hundreds to thousands of mus descends posteriorly at the level of the trans-
myofibrils in a single muscle cell. The myofibrils take verse and superior articular processes to supply sen-
up 80% of the available space in a muscle cell. Each sory fibers to two facet joint levels. It innervates the
myofibril consists of smaller filaments, arranged in inferior portion of the facet joint capsule above and
repeating units, called sarcomeres. The sarcomere is the superior portion of the facet joint capsule below.
the functional contractile unit in a skeletal muscle. A Thus, two nerve root segments innervate each facet
sarcomere has two kinds of filaments: thick myosin joint. The medial division of the posterior primary ra-
and thin actin. It is the interaction between myosin mus continues caudally to innervate the musculature
and actin, in the presence of adenosine triphosphate most closely adjacent to the vertebrae, the multifidus,
(ATP), an energy source, that causes a muscle to con- intertransversarii, and interspinalis, as well as the fas-
tract. cia, the interspinous ligaments, and the blood vessels.
Muscle contraction is controlled by signals from Finally, it anastomoses with posterior primary rami
nerves. Nerves transmit an electrical signal to the mo- from levels above and levels below.
tor endplate, releasing, most commonly, the neuro- The lateral division of the posterior primary ra-
transmitter acetylcholine. Acetylcholine causes a de- mus, as its name suggests, innervates the more lateral
polarization of the adjacent muscle cell membrane, muscle groups of the spine. It is easiest to assume that
initiating an impulse that is propagated down the sar- structures lateral to the facets are innervated by the
colemma. The sarcolemma, a lipid bilayer with trans- lateral division of the posterior primary ramus, while
membrane proteins, allows select ions to pass through structures medial to and including the facets are inner-
the membrane, thus altering its resting membrane po- vated by the medial division of the posterior primary
tential. The resting membrane potential of a muscle is ramus.
–90 mV, relative to the extracellular space. During de-
polarization and contraction, the potential changes to
INTEGRATION
+50 mV. Skeletal muscle therefore constitutes a vol-
ume conductor. The function of paraspinal tissues and muscles is com-
plex, and in its complexity the healthy spine functions
beautifully. When injury or disease occurs, the normal
NEUROANATOMY
harmony of the system is disrupted. It is the disrup-
The innervation of the paraspinal musculature is tion that can cause a patient to experience spinal pain.
unique in that it is polysegmental. Upon exiting the The physician’s challenge is to diagnose and treat the
neural foramen, the spinal nerve branches into two patient and to return the patient to normal function.
primary divisions: anterior and posterior. Immedi- The diagnosis of the etiology of spinal pain always
ately after this division occurs, the sinuvertebral nerve requires a complete history and a physical examina-
arises. The sinuvertebral nerve is joined by sympa- tion. This is be followed by a thoughtful considera-
thetic branches of the ramus communicans and reen- tion of the anatomical and physiological substrates
ters the spinal canal through the neural foramen. that could be producing the painful condition. Serious
spinal conditions that could be life-threatening—for

example, tumors, infections, and fractures—are very
rare and are well described elsewhere.3 When seri-
ous spinal conditions have been ruled out, attention is
paid to anatomical pathology, for example, disc herni-
ation, arthritis, and spondylolisthesis. The literature,
however, suggests that only 15–20% of patients com-
plaining of spinal pain have detectable anatomical
pathology that is producing the spinal pain.3 The re-
maining patients, by definition, must then have an un-
derlying pathophysiological or psychological process,
or both, behind their complaints. Pain from muscles is
commonly excluded from the definition of pathology
but is potentially of great importance. Injury to the
spine can occur through disease or, more commonly,
by sudden or forceful physical events. This can cause
a disruption of the normal anatomy and may gen-
erate a muscular response. Evaluation of this mus-
cular response is accomplished in several different
ways.
The most frequent method of evaluating the mus- FIGURE 22–9. CERSR array of 63 surface electrodes.
cular response to spinal pain is palpation. The physical
examination of the paraspinal muscles is performed pathology of the disc and facets and often assumed
differently among different disciplines.4−6 Common to be a consequence of disuse. There has, however,
physical findings include spasm, hypertonicity, nor- been some exciting progress made in the area of func-
mal tone, atrophy, and hypotonicity. Despite short- tional MRI.14 This technique provides physiological
comings in our understanding of the specificity of images of the muscular anatomy, and gives the physi-
these techniques, physical examination and palpation cian some insight into its function. It is, however, a
remain the clinical standards in assessing the involve-
ment of muscles in spinal pain.
Radiographic imaging is sometimes used to
describe muscular pathophysiology but often is
inadequate.7−10 Plain x-rays may show skeletal re-
sponses to altered muscular function in the form of
scoliosis or alterations in alignment, but it is not pos-
sible to extrapolate muscular function from x-ray find-
ings.
Computed tomography (CT) has been used to
evaluate the spine, but because of the roentgeno-
graphic nature of the technique, more attention has
been paid to the skeletal structure because bony
anatomy is best seen with CT.11 With the advent of
magnetic resonance imaging (MRI), the physician is
provided a vastly improved view of the muscular
anatomy, but radiologists rarely comment on the mus-
culature unless there is an obviously serious condi-
tion such as tumor or infection.12,13 Ligamentous lax-
ity and muscular atrophy can be seen on both CT and
MRI if resolution is adequate, but the exact relation-
ship between these findings and spinal pain is not
known.
None of the common radiographic imaging
modalities provide direct insight into the physiologi-
cal function of the paraspinal musculature, although
CT and MRI may reveal atrophy and fibrosis of the FIGURE 22–10. A monofocal pattern of muscle contraction
muscles that have been associated with degenerative recorded by CERSR in an asymptomatic subject.
spinal pain and is evolving, but it is a technically chal-

lenging, as well as painful, procedure.
It is the pain associated with needle EMG that
led to the investigation of surface electromyography
(sEMG) for the evaluation of the spinal muscles. Bas-
majian was the first investigator to seriously explore
sEMG in the early 1970s.20,21 Because muscles are
volume conductors, and because other disciplines,
most notably cardiology with ECG and neurology
with electroencephalography (EEG), have success-
fully captured useful electrophysiological data from
surface leads, electrodiagnosticians have attempted to
apply similar principles to the paraspinal region.
Basic research using sEMG has revealed some
fundamental principles concerning paraspinal mus-
cle function.22−32 When muscle contracts, it emits a
bioelectric signal that propagates through space and
may be collected and displayed using surface leads.
This bioelectric signal has two fundamental character-
istics: frequency and amplitude. Both frequency and
amplitude vary with the intensity of the muscular con-
traction, and the location of the muscle in space.
A typical sEMG study involves the placement of
A two surface leads over a region of interest. Data is
collected by these leads and is displayed either on
a video screen or by printout. Raw data consists of
FIGURE 22–11A. CERSR images from patients with low back
pain of disc origin.
a time domain waveform, in other words a record-
ing of the raw signal over a period of time. This raw
data may be subjected to fast Fourier transform (FFT),
complex and expensive method of diagnosis, and it is median frequency analysis, root-mean-square (RMS),
too early to determine its application in the evaluation frequency banding, and various other mathematical
of benign spinal pain. manipulations.
Electrodiagnostic methods are the primary me-
thod used to evaluate the physiology of paraspinal
musculature, and these techniques have a long clin-
ical history.15−17 More than 200 years ago, Volta de-
scribed “animal electricity” by using a frog’s leg mus-
cle. This phenomenon of animal electricity has been
exploited for more than 80 years, primarily in the area
of electromyography (EMG) and electrocardiography
(ECG). Electromyography literally means “drawing
the electrical signal of muscles.”
Traditionally, electromyographers insert needles
into the muscles to capture and then display the myo-
electric signal. Each penetration through the skin typ-
ically includes 10–20 needle insertions into the muscle
tissue. Needle EMG is used in the evaluation of radicu-
lopathy associated with spinal pain, but because of the
large number of muscles, their anatomic location, and
their polysegmental innervation, routine paraspinal
needle EMG does not provide significantly useful data
in the evaluation of nonradicular spinal pain.
A simplified method of paraspinal mapping has B
been developed that reduces the number of needle in-
sertions to approximately 45.18,19 The technique has FIGURE 22–11B. CERSR images from patients with low back
been shown to be of some use in the evaluation of pain of facet origin.
are displayed in 0.8 seconds. Normative studies using

CERSR demonstrate that the healthy asymptomatic
spine functions symmetrically.57 The majority of sub-
jects demonstrate a monofocal pattern of muscular
contraction (Fig. 22–10).
Ongoing work suggests that different etiologies
of pain—disc pathology, facet joint pathology, and
muscle pathology—may produce characteristic elec-
trophysiological images58 (Fig. 22–11 A, B, C). As with
functional MRI, it is too early to determine this tech-
nology’s clinical application, but the data is promis-
ing. Additionally, in contrast to functional MRI, this
physiological imaging examination is substantially
less expensive to perform.
SUMMARY
1. The paraspinal region is anatomically complex
and physiologically unique. The muscle of the
spine can be separated into two groups: the
spinal and extraspinal muscles. The spinal mus-
cles include the erector group, the transver-
sospinalis group, and the interspinal intertransver-
sarii group. Although the extraspinal muscles do
C
not attach directly to the spine and are not typically
described as spinal muscles, they nevertheless
FIGURE 22–11C. CERSR images from patients with low back
exert an influence on spinal function. Extraspinal
pain of muscular origin.
muscles include the iliopsoas and gluteal muscles.
2. The physiology of paraspinal muscles is unique.
Investigators have used sEMG data to describe Skeletal muscles, including the paraspinal mus-
some fundamental functional characteristics of cles, are classically divided into three subtypes:
the paraspinal muscles,33−47 including identifying slow twitch, resistant to fatigue; fast twitch, re-
changes that occur in different pathophysiological sistant to fatigue; and fast twitch, fatigable. The
situations.48−53 However, the technique has several muscles of the spine contain a high proportion of
limitations.54 skeletal muscle that is slow twitch and resistant to
sEMG is not a standardized procedure, al- fatigue.1,2
though some have sought to create standardized 3. The innervation of the paraspinal musculature is
protocols.36−38 The data from sEMG is complex. unique in that it is polysegmental. The medial
Coming from multiple muscle groups, it contains a division of the posterior primary ramus contin-
large amount of crosstalk. It is difficult to interpret ues caudally to innervate the musculature most
sEMG data from the patient who primarily has spinal closely adjacent to the vertebrae, the multifidus,
pain.48,55,56 Practicing physicians frequently observe intertransversarii, and interspinalis. The lateral di-
that the data collected via sEMG from the patient with vision of the posterior primary ramus innervates
spinal pain has normal characteristics. the more lateral muscle groups of the spine.
Computerized electrophysiological reconstruc- 4. The most widely used clinical method for evalu-
tion of spinal regions (CERSR) is a recently developed ating muscle pain is palpation during the physical
electrodiagnostic method. In this technique, data is examination. Palpatory findings on physical ex-
collected from the paraspinal region with a fixed array amination include spasm, hypertonicity, atrophy,
of 63 surface leads (Fig. 22–9). Positioning the array hypotonicity, or normal tone. Palpatory examina-
on the patient’s spine using three skeletal landmarks tion requires careful attention to symmetry and
standardizes its placement, and triangulation allows coverage of all major muscle regions.
the software to scale the display to correspond to 5. Traditional radiographic imaging assists diagno-
the patient’s skeletal anatomy. A standardized three- sis of pathoanatomical disorders, but provides lit-
position protocol is used to collect the electrophys- tle direct insight into pathophysiological function.
iological data from the patient. Approximately 2000 Needle electrodiagnostic studies have been used
data points are collected over 1 second and results historically to localize radiculopathy but can be
painful. Surface electromyography is noninvasive, Johnson EW, Pease WS. Practical electromyography, 3d ed.
but shares the same problem of focal anatomical Baltimore: Williams and Wilkins, 1997.
coverage, compounded by nonstandardized pro- Suarez-Almazor ME, et al. Use of lumbar radiographs for the
tocols and nonnormalized data. CERSR technol- early diagnosis of low back pain. Proposed guidelines
ogy is an evolving physiological imaging tech- would increase utilization. JAMA 1997;27(22):1782–
1786.
nique that holds promise for the future evaluation
Taylor JAM, Clopton P, Bosch E, Miller KA, Marcelis S. Inter-
of patients with spinal pain. pretation of abnormal lumbosacral spine radiographs.
A test comparing students, clinicians, radiology resi-
dents, and radiologists in medicine and chiropractic.
QUESTIONS Spine 1995;20(10):1147–1154.
1. Name the three divisions of the erector spinae. Van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM.
Spinal radiographic findings and nonspecific low back
2. What is the innervation of the multifidus?
pain. A systematic review of observational studies. Spine
3. Why are muscles considered volume conductors? 1997;22(4):427–434.
4. What is the clinical standard for evaluating the in-
volvement of muscles in spinal pain?
5. Name four methods of evaluating the physiologi-
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C H A P T E R
23
BIOMECHANICS AND
PATHOPHYSIOLOGY OF THE
SACROILIAC JOINT
Dale Mierau
O U T L I N E
INTRODUCTION PATHOPHYSIOLOGY
MACROSCOPIC AND MICROSCOPIC ANATOMY Injury
OF THE HUMAN SACROILIAC JOINT Failure of the Self-Locking Mechanism
DEVELOPMENT AND MORPHOLOGY Subluxation
Fetal Osteoarthrosis
Infant Joint Dysfunction
Child SUMMARY
Adolescent QUESTIONS
Adult ANSWERS
Past Middle Age KEY REFERENCES
BIOMECHANICS REFERENCES
area. Some believe that the sacroiliac joint can be

OBJECTIVES the source of low back pain without evidence of lo-
1. To describe the macroscopic and microscopic cal pathology. For lack of a better term, nonspecific
anatomy of the human sacroiliac joints. sacroiliac joint pain has been called the “sacroiliac
2. To review the development and morphology of the syndrome.” This chapter describes the unique devel-
sacroiliac joints. opment, anatomy, biomechanics, and pathophysiol-
3. To describe the biomechanics of the sacroiliac ogy of the human sacroiliac joint, and presents five
joints. theories about the possible etiology of the sacroiliac
4. To review the pathophysiology of injury, fail- syndrome.
ure of the self-locking mechanism, subluxation,
osteoarthrosis, and joint dysfunction.
MACROSCOPIC AND MICROSCOPIC ANATOMY
OF THE HUMAN SACROILIAC JOINT
The sacroiliac (SI) joints are weight-bearing joints be-
INTRODUCTION
tween the sacrum and the ilia of the pelvis. The sur-
Although the embryologic development, anatomy, face bony landmarks of the SI joint are the posterolat-
and biomechanics of the sacroiliac joint are well un- eral border of the sacrum and the posterior–superior
derstood, its role in low back pain is difficult to de- and posterior–inferior iliac spines of the ilium. The
fine. There is no clinical test available to confirm or synovial part of the SI joint occupies the caudal por-
rule out the sacroiliac joint as the source of the pain tion of the joint when viewed on a plain film radio-
in a patient who presents with symptoms in that graph of the pelvis. The adult SI joint is auricular or
433
“C-shaped,” with the convex contour of the joint fac-

ing anteriorly. The adult joint usually has a longer
caudal arm that faces posterolaterally, and a shorter
cephalad arm that faces posteriorly. There is much
variation of the size, shape, contour, and relative
lengths of the arms, even between sides of the same
individual (Figs. 23–1 to 23–4).
Strong ligaments support the SI joint. The anterior
joint capsule is well developed with an outer fibrous
layer. The middle portion of the anterior joint cap-
sule is thickened and forms the anterior sacroiliac lig-
ament. The anterior sacroiliac ligament is close to the
anterior fibers of the iliolumbar ligament. The poste- A
rior joint capsule is much less well developed and can
be absent. The interosseous ligament, the strongest lig-
ament in the body, can form the posterior border of the
joint if the posterior joint capsule is absent.1 The thin
posterior sacroiliac ligament is separated from the in-
terosseous ligament by the dorsal rami of the sacral
nerves and blood vessels. The iliolumbar, sacrotuber-
ous, and sacrospinalis ligaments provide additional
support to the SI joint (Figs. 23–5 and 23–6).
The sacroiliac joint capsule has a dense plexus
of unmyelinated nerve fibers that carry nociceptive
signals.2 Segmental innervation of the SI joint is highly
variable and can range from L2 to S4.3 The L4-L5 roots B
innervate the anterior components of the joint. Lat-
eral branches of the primary rami of the S1 and S2 FIGURE 23–1. Location and bony landmarks of the sacroiliac
roots innervate the posterior parts of the joint includ- iliac joint. A. Posterior view. B. Anterior view.
ing the interosseous ligament and the rudimentary
joint capsule.1 Even within the same individual the short arm is fibrous. The synovial portion is located
innervation of the sacroiliac joint may not be symmet- at approximately the level of S2 and occupies the
rical between the right and left sides. long arm and the caudal portion of the short arm of
The posterior-inferior two-thirds of the SI joint is the joint.1 The synovial portion has some character-
synovial in nature, and the cephalad portion of the istics that are typical of a synovial joint while some
FIGURE 23–2. Location and bony

landmarks of the posterior sacroil-
iac ligament.
BIOMECHANICS AND PATHOPHYSIOLOGY OF THE SACROILIAC JOINT 435
FIGURE 23–5. A horizontal section to illustrate the intrinsic

ligaments of the SI joint. A = The anterior SI ligament; I = the
interosseous ligament; P = the posterior sacroiliac ligament.
(1-mm) layer that looks like fibrocartilage.4 This

unique anatomical feature of the SI joint has clini-
cal importance. Macroscopic and microscopic changes
consistent with osteoarthrosis begin on the iliac
side of the joint by the end of the third decade.4 These
joint osteoarthrotic changes on the iliac side of the
joint are detectable by plain radiograph early in life
(Fig. 23–7).5
In summary, the anatomy of the sacroiliac joint is
unique. There is much variation in joint size, shape,
and contour among individuals and from side to
side within the same individual. The innervation of
FIGURE 23–3. Location of the synovial portion of the SI joint
on a plain radiograph of the pelvis.
the sacroiliac joint is wide (L4-S2), is highly variable
among individuals, and can vary between sides in the
same individual. The cartilage that covers the sacral
characteristics are atypical or unique (Table 23–1). The and iliac surfaces appears different: The sacral sur-
atypical or unique features are that the sacral joint surface is covered with a thick layer of hyaline cartilage,
face is covered with a thick (3-mm) layer of hyaline whereas the layer of cartilage of the iliac side of the
cartilage and the iliac surface is covered with thinner joint is thinner and looks more like fibrocartilage. The
joint surface on the iliac side is prone to the early
changes of osteoarthrosis.
FIGURE 23–6. Strong posterior ligaments that support the SI

FIGURE 23–4. The auricular-shaped adult sacroiliac joint. joint.
TABLE 23–1. Synovial Joint Characteristics

of the SI Joint
A joint cavity containing synovial fluid

Cartilage-covered contiguous joint surfaces that are not
attached to one another
A joint capsule with an outer fibrous layer and an inner
synovial lining
Strong ligamentous connections between the bones
Articular connections that allow movement between the joint
surfaces
DEVELOPMENT AND MORPHOLOGY

Fetal
The human sacroiliac joint forms at about the tenth
to twelfth week of gestation.6 The joint surfaces are
smooth and flat. This configuration allows the joint
to be manipulated in a gliding fashion in all direc-
tions. From the time the joint space develops, the sacral
and the iliac sides of the joint develop differently.4 Af-
ter endochondral ossification of the sacrum, a cover
of smooth, clear hyaline cartilage remains on the
sacral side of the joint. A thin layer of mesenchymal
cells covers the joint surface on the already ossified
ilium. The covering of the iliac side of the joint ap-
pears dull and striated, and the bone beneath shows FIGURE 23–8. A fetal SI joint demonstrating the appearance
of the sacral and iliac surfaces.
through, giving a blue luster to the joint surface

(Fig. 23–8).
Infant
After birth, the joint retains its planar configuration. A
glistening layer of hyaline cartilage covers the sacral
surface. On the iliac side, columns of cartilage cells
develop beneath the thin layer of mesenchymal cells.
These columns of cells eventually expand and replace
the mesenchymal cells to become the cartilage cover
for the iliac side of the joint. The cartilage cover on
the iliac side of the joint appears to be a thin layer
of fibrocartilage.4 However, biochemical analysis has
identified type II collagen on both the sacral and iliac
sides of the SI joint.7 Type I collagen, typical of fibro-
cartilage, is not present even though the joint surface
looks like fibrocartilage. The cartilage on the iliac side
of the joint is more friable, like fibrocartilage, and the
blue color of the trabecular bone beneath continues to
show through (Fig. 23–9).
Child
FIGURE 23–7. A section through an SI joint to show the The shape and topography of the SI joints begin to
thicker layer of cartilage on the sacral side and the thinner change as the child begins to walk. The overall sur-
layer of cartilage on the iliac side. face shape of the joint changes from planar (flat) to a
FIGURE 23–9. The sacral and iliac surfaces of the SI joint of

a 10-year-old male.
complex form of angles that resemble the blade of a

propeller.8
Adolescent
The rate of change of SI joint topography accelerates
FIGURE 23–11. In the adult, each SI joint goes on to develop
during the rapid weight gain of puberty. A central,
unique surface changes, extraarticular osseous interdigitation,
crescent-shaped ridge forms along the entire length of and a thicker joint capsule to enhance joint stability.
the iliac surface. A corresponding depression devel-
ops in the hyaline cartilage layer on the sacral surface.4
This configuration resembles a tram rail and guides and the sacrum. The surface irregularities of the SI
movement. The ridge-and-groove topography limits joint become more prominent with age.4 By mid-
movement to a posterosuperior–anteroinferior nod- dle age, the size and number of elevations and de-
ding along the crest of the interdigitation with a center pressions continue to develop and each joint is left
of rotation posterior to S2 (Fig. 23–10). with a unique surface topography. The topography
of the adult sacroiliac joint is highly variable among
Adult individuals and from left to right sides within the
By the third decade, the tram-rail configuration be- same individual.9 Usually, by the third decade, the
tween the sacral and iliac joint surfaces and a thicken- SI joints demonstrate changes consistent with os-
ing joint capsule restrict movement to a subtle for- teoarthrosis on the iliac side of the joint.4 Rough spots
ward and backward “nodding” between the ilium and fibrous plaques develop on the iliac surface of
the joint while the sacral surface remains smooth
(Fig. 23–11).
Later the cartilage cover on the iliac side becomes
thinner, with areas of erosion and sclerosis of the un-
derlying bone.4 Arthrosis on the iliac side of the SI joint
is common by the age of 40 years. Early changes asso-
ciated with osteoarthrosis usually aren’t seen on the
sacral side of the joint until the fourth or fifth decade.4
The surface irregularities that occur on the sacral joint
surface are less marked than on the iliac side, the
cartilage remains thick, and the subchondral bone re-
tains its normal appearance (Fig. 23–12).
Past Middle Age

Fibrous adhesions within the SI joint can occur in the
young, become common in middle age, and are even
FIGURE 23–10. The sacroiliac joint of an adolescent male more common among the elderly. In the elderly, in-
showing the concave sacral surface and convex iliac surface traarticular fibrous adhesions, joint space narrowing,
(tram-rail configuration). and periarticular osteophyte interdigitations restrict
FIGURE 23–13. The sacral and iliac surfaces of the SI joint of

an elderly woman are bound together by intraarticular fibrous
adhesions.
BIOMECHANICS
It is known that movement occurs in the sacroiliac
joints.11 The shape of the SI joint, the irregular inter-
locking surface topography, and the strong dense lig-
aments render the SI joint stable and capable of very
little movement. The SI joints and symphysis pubis
function as a “shock absorber” to transmit and dis-
sipate loads and forces between the lower limbs and
the trunk. The term “friction joint” has been used to
describe the function of the SI joint.8
The nature and amount of the movement at the
B
SI joint are highly variable, even among the SI joints
in the same person. There is a small amount of “nod-
FIGURE 23–12. A. An electron micrograph of the sacral and ding” motion between the sacrum and the ilium, lim-
iliac surface of an SI joint in a young adult. The sacral surface ited to less than 4 degrees of x-axis rotation and 1.6 mm
of the joint is smooth. B. An electron micrograph of the sacral of z-axis translation, which occurs about a center of ro-
and iliac surfaces of an SI joint in a young adult. The surface on tation posterior to the joint roughly at the level of S2,
the iliac side of the same joint demonstrates cartilage fibrilla-
but this is also highly variable.12,13 The forward “nod-
tion, crevices, and debris—the hallmarks of early degenerative
ding” motion of the sacrum on the ilium is called nu-
change.
tation (Fig. 23–14). Backward nodding of the sacrum
on the ilium is called counternutation. The forces of
joint movement even more.10 Joint surface erosions, standing upright tend to increase sacral nutation on
often down to the surface of the subchondral bone the ilium (and tend to increase the lumbar lordosis),
with sclerosis of subchondral bone, are common on while counternutation occurs in unloaded conditions,
the iliac side of the joint. However, true bony ankylo- such as lying down, when the lumbar lordosis “flat-
sis is rare in the absence of joint disease such as anky- tens.” Flexion of the hips in the supine position also
losing spondylitis (Fig. 23–13).4 tends to reduce the counternutation force (Table 23–2).
Developmental Adaptations
TABLE 23–3.
of the Human SI Joint
The development of a wedge and propeller-like form to the

joint
A tram-rail configuration of the joint surfaces
Complementary ridges and grooves
Roughened articular surfaces, especially on the
fibrocartilage-like iliac side∗
∗
This adaptation occurs when the child begins to walk and accelerates
during the rapid increase in body weight at puberty.
The term “form closure” is used to describe the

FIGURE 23–14. Motion at the sacroiliac joint is guided by specific anatomical features that develop to resist rota-
its surface topography. A. The iliac surface demonstrating the tion and shear at the SI joint and provide intrinsic joint
prominent ridge. The black dot represents the typical axis of stability. The complementary compression forces pro-
motion. B. Posterior superior motion of the sacroiliac joint vided by the strong ligaments and powerful muscles
(counternutation). C. Anteroinferior motion of the sacroiliac that surround the SI joint contribute to “force closure.”
joint (nutation). These forces accommodate for and adapt to specific
loading requirements and provide more resistance to
rotation and shear. This combination of form and force
The SI joint begins its development as a flat or pla- closure facilitates SI joint stability and contributes to
nar joint with parallel joint surfaces. Flat joints are the “self-locking” mechanism of the SI joint while un-
well suited to the task of transfer of large bending der load.8
forces.14 An alternative to this configuration can be Nutation at the SI joint is important for the “self-
seen in birds. Birds have fixed connections between locking” mechanism. Nutation winds up most of the
the sacrum and ilia.14 This configuration is thought SI ligaments, including the very strong interosseous
to be less adaptive for humans because the human SI ligament, to increase the compression forces (force
articulations improve shock absorption and the econ- closure) at the joint and facilitate joint stability. The
omy of gait, and allow for the birth of relatively large contraction of the erector spinae, gluteus maximus,
babies.8 The SI joint adapts with age to the loads and latissimus dorsi, and biceps femoris muscles also con-
forces of upright weight bearing. These adaptations tributes to force closure. For example, the sacral at-
increase joint friction and reduce the force require- tachment of the erector spinae pulls the sacrum for-
ments for ligament and muscle to resist the shear and ward, contributing to nutation force, which loads the
translation forces of upright posture (Table 23–3). interosseous and sacrotuberous ligaments. Contrac-
tion of the gluteus maximus provides direct compres-
sion force to the SI joint. Compression forces on the
TABLE 23–2. Summary of the Biomechanical SI joint during rotational activities, such as those of
Studies of the SI Joints ambulation and the swinging of objects like a bat or
club, are enhanced by the coupled action of the gluteus
• Mobility is greater in women and during pregnancy, but maximus and the contralateral lumbodorsal fascia.
decreases with age in both men and women In summary, except for the temporary increase
• There is 5–6 mm of ventral sacral movement between during pregnancy, SI joint motion tends to decrease
standing and lying and 5-mm movement with flexion when with age in both males and females. Periarticular os-
standing teophytes develop as early as the third decade of life to
• Two degrees of x-axis rotation of the sacrum in various enhance joint stability. These bony projections tend to
positions restrict the already small amount of “nodding” at the
• SI joint rotation is coupled with separation and translation joint. Intraarticular fibrous adhesions occur in middle
• 1–16 mm of motion is present between the two ilia age and tend to restrict sacroiliac motion to an even
• 10–12 degrees of x-axis rotation coupled with 6-mm z-axis greater degree in the elderly (65 years and older). The
translation changes of the sacroiliac joint that occur with normal
• 1.6 degrees of x-axis rotation of ilium about the sacrum development and aging suggest that kinetic testing of
• Mean axis of rotation of 2.5 degrees with a 0.7-mm the sacroiliac joints of the elderly is likely to reveal
translation false results (i.e., lack of sacroiliac joint motion) when
used to identify the SI joint as a pain generator.
Failure of the Self-Locking Mechanism

PATHOPHYSIOLOGY
The mechanisms that contribute actively to SI joint
One should consider infection, arthritis, and syn- stability (force closure) can become less effective af-
dromes that refer pain to the SI joint before one settles ter injury to related ligament or muscle; a decline of
on a mechanical condition as the cause of symptoms. muscle force or coordination that comes with a seden-
It is difficult to confirm that the SI joint is the pain tary lifestyle; deconditioning; or a decrease in the sta-
generator in nonspecific low back pain without evi- bility provided by ligaments (as during pregnancy).
dence of local pathology. A valid and reliable clinical One treatment, to address symptoms presumed to be
test or imaging procedure has yet to be found. The a result of “pelvic instability,” is the application of a
range and the asymmetrical supply of nerve root in- trochanteric belt. A side locking force, similar to that
nervation to the SI joint can result in large variations applied by the laces of a shoe, is sufficient to gener-
in pain referral patterns between sides and among pa- ate a self-locking effect to the SI joints, even under a
tients. Furthermore, structures of the lumbar spine, heavy load. Application of a nonelastic belt across the
including the nerve roots, disc, posterior joints, and plane of the SI joints (positioned just cephalad to the
the hip, are known to refer pain and tenderness to the greater trochanter) with a compression force of only
SI joint.15–17 There is more than one theory to support 50 N can decrease nutation of the sacrum by about
the pathophysiology of idiopathic sacroiliac joint pain 20%.14 However, a support belt may not improve
(sacroiliac syndrome). What follows is a description of the mechanics of walking for patients with SI joint
five such theories. pain.19
Injury Subluxation
The SI joint can be injured by force sufficient to dis- The subluxation theory of SI joint pain is popular
rupt the pelvic ring, such as a fall from a height or a among those who provide manipulation treatment.
high-speed motor vehicle accident. Diagnosis of these The painful SI joint is thought to have subluxed (a
injuries is made from radiographs of the pelvis, which small displacement of joint surface position) and is
demonstrate obvious disruption of the SI joint and therefore painful. They postulate that an SI joint ma-
at least one other structure in the pelvic ring. Some nipulation can reduce a joint subluxation or put the
dispute claims that the very stable SI joint can be in- joint “back into place.”20,21 There is little good evi-
jured without sufficient force to disrupt the pelvic dence, radiographic or otherwise, to support the idea
ring. However, a proposed mechanism for injury to that the SI joint is subject to small displacements
the SI joint is a combination of axial compression and (subluxation) that can be reduced by manual ther-
torsion. Biomechanical studies demonstrate that the apy. However, trauma to the pelvis, sufficient to dis-
lumbar spine can withstand 20 times the axial com- rupt the pelvic ring, can damage the supporting liga-
pression force and twice as much axial torsion as the ments of the SI joint and result in displacement of the
SI joint. This biomechanical comparison of relative re- joint.
sistance to injury provides some credence to the no- Sacroiliac joint manipulation/adjustment may re-
tion that the SI joint is vulnerable to injury from these lieve some of the chronic SI joint pain following such
forces (Fig. 23–15).18 an incident, but the treatment is not likely to re-
duce permanent displacement of the joint, which has
been fortified by the process of healing and the ten-
dency for surrounding structures to stabilize the joint
(Fig. 23–16).22
Osteoarthrosis
Changes consistent with osteoarthrosis occur at the SI
joint at a young age. These changes were documented
by macroscopic and microscopic inspection of cadav-
eric samples.4,10 The changes first occur by the third
decade on the iliac side of the joint, which is covered by
a thin layer of fibrocartilage.4 However, the mere pres-
ence of osteoarthrosis does not necessarily mean that
a joint is painful. There is a poor association between
pain and osteoarthrosis in other areas of the spine.23
FIGURE 23–15. A plain film radiograph of the pelvis demon- Moreover, some of the changes, once perceived to be
strating traumatic disruption of the sacroiliac joint. those of osteoarthrosis, such as the interdigitation of
FIGURE 23–16. After healing and improvement of symptoms,

the joint remains displaced and there are signs of joint stabi-
lization and scarring. A
osteophytes, are consistent with the normal process

of the adaptive developmental change that enhances
joint stability as supporting ligaments age and become
less effective at supporting the SI joint.
Joint Dysfunction
Sacroiliac joint dysfunction, an alteration in normal
motion or mechanics, has been documented as a cause
of SI joint pain.15 The term has been used to describe
either too much motion (hypermobility) or not enough
motion (hypomobility/fixation). However, normal SI
joint mechanics are poorly understood. The move-
ment of the SI joint is so slight that it is difficult to
detect, let alone measure. Furthermore, SI joint motion
is known to be highly variable so side-to-side compar-
ison is difficult and may not be reliable.
Some clinicians believe that after acute or repeated
injury, or during pregnancy, the SI joint becomes hy-
permobile. In the chronic state of dysfunction, the joint B
may become stiff, or fixed, by scar tissue. Those who
favor a diagnosis of hypermobility suggest treatment FIGURE 23–17. A. The motion of the ilium on the sacrum dur-
with external or internal joint stabilization.24 There is ing the step test. B. The bony landmarks and proposed mech-
evidence that a trochanteric belt relieves the SI pain anism to detect motion at the sacroiliac joint by using the step
for some pregnant women.25 However, a stereopho- test.
togrammetric study failed to show any difference in
mobility between painful and nonpainful SI joints.26 However, the clinical usefulness of the step test
Some have documented that surgical arthrodesis can for SI dysfunction is questionable for several reasons.
relieve SI joint pain in a very small group of pa- The step test lacks reliability.27 The motion measured
tients who had acceptable relief of SI joint pain fol- by the test is very small in the adult. Marked vari-
lowing diagnostic injection of local anesthetic under ability of SI joint topography and motion is the norm
fluoroscopic control into the joint. The only clinical between sides even without pain or dysfunction. The
sign that was consistently positive for these patients application of an external force to the SI joint us-
was tenderness over the posterior sacroiliac ligament. ing manipulation of the lumbar spine and SI joints
Those who suggest that the alteration of joint me- can improve the biomechanics of gait.28 There is evi-
chanics is one of hypomobility may use the step test dence that manipulation of the SI joint(s) can reduce
to compare joint mobility from one side to the other chronic low back pain and disability.29 An associa-
(Fig. 23–17).15 tion between unilateral sacroiliac pain and increased
uptake of the radionuclide isotope technetium-99m

(Tc-99m) methylene diphosphonate (MDP) was docu-
mented in a study using quantitative sacroiliac scintig-
raphy (QSS).30 The SIJ/S (sacroiliac joint to sacrum) ra-
tio of radionuclide was slightly greater on the painful
side than on the nonpainful side. This difference
in SIJ/S uptake ratio between the painful and non-
painful sides disappeared in patients who had a sig-
nificant decline in pain and self-rated disability after a
course of manipulative therapy to the painful SI joint
(Fig 23–18).31
Others have documented a decline in the SIJ/S ra-
tio with an improvement in low back symptoms.32–34
However, the mechanism underlying this relationship
is not clear. The documented causes of an increase in
radionuclide uptake at the SI joint are varied and can
reflect one of many conditions. A simple relationship
between increased uptake of radionuclide isotope and
mechanical stressors or irritation is unlikely.30 Quan-
titative sacroiliac scintigraphy is a useful tool for
identifying SI joint pathology, but its use cannot ex-
tend to confirming or ruling out sacroiliac syndrome
(Table 23–4).30
A positive clinical sign, Gaenslen’s test for sacroil-
iac pain, was a statistically significant predictor of
the association between SI joint pain and asymmet-
rical SIJ/S ratios.30 This finding contradicted the com- FIGURE 23–18. A bone scan to demonstrate increased up-
monly held belief that the sacroiliac stress tests do not take of radionuclide in the region of the SI joint in a patient
believed to have nonspecific SI joint pain or “SI syndrome.”
discriminate between painful and nonpainful joints,
even in those known to have SI pain associated with
an arthritide.35,36 A valid and reliable clinical test for into the SI joint is the best way to confirm or rule
SI syndrome remains to be found (Fig. 23–19). out the SI joint as the cause of a painful low back.37
Some believe that injection, under fluoroscopic However, the procedure still requires input from the
control, of local anesthetic and/or contrast material patient to confirm or deny the provocation of “usual
TABLE 23–4. The Many and Varied Causes of an Elevated SIJ/S Ratio (Positive Bone Scan—QSS)
Neoplastic Infection Metabolic Arthritis Injury
Local tumor SI joint infection40 Metabolic bone Osteoarthrosis of the SI Injury to the SI joint47
metastasis disease41,42 joint45 Nonspecific/mechanical
Hodgkin disease33 Renal osteodystrophy43 Acute sacroiliac joint activity-related
Inflammatory bowel disease46 strain33,34
disease32 associated Subacute sacroiliac joint Altered gait33
with other disease32 Mechanical distrubance
musculoskeletal Rheumatoid arthritis41 of SI joint function30,48
conditions associated
with hip disease43
Herniated nucleus
pulposus lumbar
spine43
Degenerative
disease—lumbar
spine44
SUMMARY
1. Human sacroiliac joints are large weight-bearing
joints, shaped like the letter “C” facing backward,
between the sacrum and ilia of the pelvis. There is
much variation in size, shape, and topography of
the joint between individuals and between sides
in the same individual. The inferior part of the
joint is a synovial type of joint, while the supe-
rior portion resembles a fibrous joint. The sacral
surface of the synovial part of the joint is cov-
ered by hyaline cartilage, while the iliac surface
has a cover that resembles fibrocartilage. Strong
ligaments stabilize the joint. With time, intraar-
FIGURE 23–19. The Gaenslen test for SI pain. A positive test ticular grooves and valleys develop to stabilize
is report of pain at the SI joint when the joint is stressed in the joint. Branches from nerve roots L4 to S2 in-
nutation and counternutation. nervate the sacroiliac joint. This innervation is
highly variable, even between sides in the same
individual.
pain.” Furthermore, it is not easy to get a needle into an 2. The sacroiliac joints begin as planar joints but un-
adult SI joint.38 Satisfactory relief from pain was doc- dergo extensive change in shape and topography
umented in 81% of patients with chronic SI pain fol- in response to weight bearing to resemble the blade
lowing injection of corticosteroid under fluoroscopic of a propeller. A central ridge forms along the
control.39 This result supports the theory that some length of the iliac joint surface with a correspond-
patients with chronic, nonspecific SI pain may suf- ing depression on the sacral surface. The ridge and
fer from local reactive inflammation as the result of a groove topography limits joint movement to a for-
chronic mechanical strain. ward and backward nodding. Additional bumps
In summary, many clinicians believe that the SI and depressions develop in early adulthood to re-
joint can become painful without a measurable dis- strict joint motion even more. With age, intraar-
turbance of joint motion (either too little or too much) ticular fibrous adhesions develop along with pe-
or meaningful clinical or imaging evidence of local riarticular osteophytes. The changes that occur in
arthritis, infection, or neoplasm. The identification of and around the SI joint begin early in life and con-
the SI joint as the pain generator in a case of low back tinue throughout life to promote stability of the
pain cannot be made on the basis of pain and tender- joint.
ness alone.30 The location and innervation of the joint 3. The sacroiliac joint is capable of less and less
make it a site for referral of pain and tenderness from movement with the changes associated with
other structures of the lumbar spine and hip. weight bearing. The movement that remains is
There is still no reliable way to confirm that the described as a forward and backward “nod-
SI joint is the pain generator for a patient whose only ding” (nutation-counternutation). This movement
clinical finding is pain and tenderness in the region of is highly variable, even between sides of the same
the SI joint. The combined results of several studies, individual. The joint functions as a shock absorber
particularly those that used QSS and those that used between the lower limbs and the spine. Some de-
injection of local anesthetic and corticosteroid, suggest scribe the sacroiliac joint as a friction joint. The
that some cases of low back pain can be caused by forces through the sacroiliac joint, associated with
low-grade local irritation/inflammation of the SI joint. weight bearing and the stresses placed on lig-
The causes of this local disturbance may be many and aments and muscles that attach to surrounding
varied. structures, tend to force the joint closed. Thus,
Interest in the sacroiliac joint has led to improve- the sacroiliac joint is stabilized by form closure
ment in knowledge about the joint and its role in non- (grooves, depressions, and later interdigitating os-
specific low back pain. There is still no valid or reliable teophytes) and force closure (the “winding-up”
clinical test that can confirm or rule out the SI joint as of ligaments and muscles) that increases the fric-
the principal pain generator in nonspecific low back tion between the joint surfaces when the forces of
pain. Perhaps the greatest role played by the SI joint weight bearing are added.
in chronic low back pain is not that of a pain generator 4. There is debate about whether or not the sacroiliac
but rather as a bridge between the many disciplines joint can be a source of pain without local pathol-
that grapple with spinal pain. ogy or significant injury (such as disruption). Some
possible causes for this type of sacroiliac pain in- 3. The planar joint surfaces evolve into a complex
clude: set of angles that resemble a propeller. Develop-
A. Injury—Disruption or fracture of the pelvic ment of tram-rail configuration of the sacral and
ring can be associated with disruption of the iliac joint surfaces restricts movement to the x axis.
sacroiliac joint. Sacroiliac sprain in the absence Roughening of the iliac surface occurs early (sec-
of radiographic evidence of disruption is more ond decade of life), which increases joint friction.
difficult to diagnose. Development of interdigitating periarticular os-
B. Failure of self-locking mechanism—Weakening of teophytes occurs in the fourth and fifth decades.
the elements that contribute to force closure Intraarticular adhesions develop in the seventh
(i.e., muscles and ligaments) can lead to a and eighth decades.
condition/syndrome sometimes referred to as 4. Wide range of nerve root innervation (L2-S2); dif-
“pelvic instability.” ficult to isolate the SI joint as the pain generator.
C. Subluxation—There is little evidence for the 5. Injury: In favor: Force analysis studies suggest that
condition of sacroiliac subluxation other than the SI joint can be injured with less compression
the quick relief of symptoms after sacroiliac and torsion than those required to injure the lum-
joint manipulation. bar spine. Does not favor: The hallmark of the adult
D. Osteoarthrosis—There is good evidence that the SI joint is ligamentous and bony stability. There is
changes associated with osteoarthrosis begin no good test to identify the SI joint as the pain
early in the sacroiliac joint, especially on the generator in the absence of obvious abnormality
iliac side. The association between sacroiliac of medical imaging.
joint arthrosis and pain is not known. Failure of the self-locking mechanism: In favor: The
E. Joint dysfunction—Alteration of sacroiliac joint SI joint relies heavily on its ligaments for stabil-
biomechanics is difficult to test. The case for ity. Injury or metabolic disruption of ligamentous
joint dysfunction as a cause of sacroiliac pain stability predisposes the joint to dysfunction and
is supported by the favorable response of the pain. Does not favor: No good way to measure
painful syndrome to sacroiliac joint manipula- joint stability or instability.
tion. Subluxation: In favor: Relief from symptoms
with manipulation in some cases. Does not favor:
No evidence that the SI joint undergoes subluxa-
QUESTIONS tion.
Osteoarthrosis: In favor: Good evidence of early
1. Describe three adaptive functions of the human
degenerative change on the iliac side of the joint.
sacroiliac joint.
Does not favor: Degenerative change and pain are
2. Name two characteristics of the sacroiliac joint that
not well associated in the spine.
are typical of a synovial joint and two characteris-
Joint dysfunction: In favor: Resolution of symp-
tics unique to this joint.
toms with manipulation, injection, or stabilization.
3. Describe five developmental events of the sacroil-
Does not favor: No good way to measure SI joint
iac joint from infancy to the eighth decade.
function, dysfunction, or movement.
4. Explain the wide variation of pain patterns seen in
patients thought to have SI syndrome.
5. Name five theories of nonspecific sacroiliac joint
pain. Be sure to include at least one pro and one KEY REFERENCES
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608. integrated function of the lumbar spine and sacroiliac joint.
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887. tion palpation procedures to detect sacroiliac fixations.
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C H A P T E R
24
HEADACHES OF SPINAL ORIGIN
Simon Dagenais and Scott Haldeman
O U T L I N E
INTRODUCTION TREATMENT
HISTORICAL NOTES SUMMARY
THEORETICAL BASIS QUESTIONS
EPIDEMIOLOGY ANSWERS
DIAGNOSIS KEY REFERENCES
DIFFERENTIAL DIAGNOSIS REFERENCES
it is essential that chiropractors recognize cervicogenic

OBJECTIVES headaches, understand the mechanisms through
1. To review the historical development of the con- which these headaches can originate in the neck, and
cept of the cervicogenic headache and important understand how treatment through manual therapy,
contributions from researchers in this field. especially chiropractic adjustments, may be of benefit
2. To explain the proposed pathophysiology, sources to these patients.
of pain, and possible causes of cervicogenic The role of the cervical spine in headaches re-
headaches. mains poorly understood, with a great many con-
3. To estimate the prevalence rate of cervicogenic flicting opinions and theories in the literature. Un-
headaches in different populations, and to de- til recently, there was no diagnostic category for
scribe the typical sufferer. headaches suspected to stem from the neck. In fact,
4. To review criteria necessary to establish a diagno- this category was only added to the classification of
sis of cervicogenic headache according to different headaches established by the International Headache
expert groups. Society (IHS) in 1988.3 For most of the twentieth cen-
5. To review diagnostic criteria for common migraine tury, clinicians faced with patients presenting with
headache and tension-type headache and learn to headaches that appeared to be associated with neck
differentiate them from cervicogenic headache. pain were left without an appropriate diagnosis, and
6. To review evidence for manipulation and physical these patients were often misdiagnosed as suffering
treatment of cervicogenic headache. from either tension-type headache or common mi-
7. To make recommendations for clinicians to follow graine headache. This landscape changed in 1983,
when dealing with cervicogenic headache. when Ottar Sjaastad, a Norwegian neurologist and
researcher specializing in headaches, reported on a
group of patients with a particular type of headache
that could not properly be classified according to the
INTRODUCTION
criteria of the IHS.4 Sjaastad described the headaches
Epidemiological studies show that up to 22.5% of these patients presented with as a persistent, unilat-
chiropractic patients may suffer from cervicogenic eral, dull, achy pain in the occipital region, with ac-
headaches.1 Headaches in general are the third companying neck or upper shoulder pain. Episodes
most common reason that patients seek chiroprac- of pain could be brought on by injury to the neck
tic care after low back and neck pain.2 Consequently, or awkward head positions. Because Sjaastad felt the
447
cervical spine was significantly involved, and, in fact, TABLE 24–1.Terms Describing Conditions Similar
responsible for these headaches, he coined the term to Cervicogenic Headache
“cervicogenic” headache. This 1983 study renewed
research efforts into investigating the relationship be- Cervical headache
tween the spine and headaches. Interest in this topic Cervical migraine
has grown steadily, and there are now scientific so- Cervical spine syndrome
cieties devoted solely to furthering the knowledge of Cervicogenic cephalalgia
cervicogenic headaches. Cervicogenic syndrome
This chapter describes the history and evolution of Great occipital–trigeminus syndrome
the concept of cervicogenic headaches and presents Greater occipital neuralgia
current pathophysiological theories used to explain Mechanical headache
these headaches. This chapter also reviews the epi- Occipital headache
demiological studies on cervicogenic headache, dis- Occipital myalgia–neuralgia syndrome
cusses the diagnostic criteria for these headaches, Rheumatic headache
and describes the thought process when attempting Spondylogenic headache
to differentiate patients with cervicogenic headache Spondylotic headache
from patients suffering from other common types of Third-nerve occipital headache
headache. The evidence in support of different forms Vertebragenous headache
of treatment for cervicogenic headache, with empha- Vertebrogenic headache
sis on spinal manipulation, is also summarized.
The contribution of spinal pathology or dysfunc-

HISTORICAL NOTES
tion in the etiology of headaches was investigated fur-
The coining of the term cervicogenic headache in ther when clinicians began noting that certain patients
1983 was a breakthrough in our understanding of with headaches saw reduction in their symptoms fol-
headaches originating from the cervical spine, and lowing treatment aimed at the neck. Raney and Raney
served to stimulate interest in this topic. Prior to claimed some success in treating headaches of cervi-
1983, research on the role of the spine in produc- cal origin by surgery of the intervertebral discs.8 Later,
ing headaches was erratic and confusing because re- Nikolai Bogduk, from Australia, began considering
searchers in different fields would each describe a con- surgical ablation of the third occipital nerve to relieve
dition marked by similar symptoms but would use these headaches.9 More conservative approaches, in-
different terms to explain their observations. These cluding manual therapy, were advocated by other
terms were generally invented by naming either the medical physicians. Janet Travell and David Simons
symptoms or the perceived cause of these headaches. felt that myofascial trigger points in the neck could re-
Table 24–1 presents some of the terms attributed to fer pain to the head, and recommended treatment by
headaches of spinal origin prior to 1983, many of trigger point therapy.10 The French physiatrist Robert
which are still used. Maigne, who practiced and taught spinal manipu-
The notion that headaches could originate from the lation to medical physicians, was quite adamant in
neck first appeared in the literature in the nineteenth his recommendation of cervical manipulation to treat
century. Table 24–2 summarizes a few of the advances headaches in patients who had “blockage” of the
made in the investigation of cervicogenic headaches. cervical vertebrae.11
One of the earliest references to this concept can be The group most devoted to manual therapy for
found in a series of lectures given by a British physi- headaches was, of course, the chiropractic profession.
cian, John Hilton, during the period 1860–1862.5 He Chiropractors have claimed to treat headaches and
theorized that pain radiating to the frontal or lateral related symptoms with manipulation since the foun-
part of the head could be caused by insult to the greater dation of the profession by D. D. Palmer in the late
or lesser occipital nerves as a result of disease between 1890s. Most of the early chiropractic claims, however,
the first and second vertebrae. The French neurolo- did not attempt to identify specific headache types
gist Jean Alexander Barré furthered this concept by most likely to respond to spinal adjustments. The as-
postulating that there was a link between the cervical sumption was that the discovery of a subluxation in
spine and not only headache, but also vertigo.6 One a patient was sufficient to consider treatment of any
of Barré’s collaborators, the neurologist Yong-Choen patient with headache. However, it soon became ev-
Lieou, expanded this hypothesis by considering that ident that not all patients with headaches responded
cervical spine arthritis could be the explanation for equally well to chiropractic treatment. In 1961, Grillo,
headaches and vertigo originating in the neck.7 a Swiss chiropractor, coined the term “vertebragenous
HEADACHES OF SPINAL ORIGIN 449
TABLE 24–2. Contributions to Cervicogenic Headache by Various Researchers
Year Event
1860 Hilton gives lectures in which he proposes that pain felt in the anterior or lateral part of the head
may originate from disease of the first and second cervical vertebrae
1926 Barré proposes that the cervical spine may produce neurological symptoms such as headache
and vertigo
1928 Lieou writes that arthritis in the cervical spine can lead to headache and vertigo
1948 Raney and Raney report a case series of patients with cervical disc lesions causing headache
1955 Kovaks theorizes that motion restriction in the cervical spine may lead to muscle spasm, causing
constriction of the vertebral artery and nerves and leading to headaches
1973 Bogduk operates on patients with what he terms “third occipital (nerve) headache”
1981 Maigne reports using cervical manipulation to treat headaches
1983 Sjaastad describes patients with a type of headache he terms “cervicogenic”
1987 Fredriksen provides a detailed description of another group of patients with cervicogenic
headache
1988 The International Headaches Society adds “headaches associated with disorders of the neck” to
its diagnostic criteria
1990 Sjaastad writes specific diagnostic criteria for cervicogenic headache
1994 The World Cervicogenic Headache Society is founded
1995 Nilsson publishes the first randomized controlled trial of spinal manipulation for cervicogenic
headache
headache” to differentiate the headaches likely to re- studying cervicogenic headaches, including the World
spond to chiropractic adjustments.12 Many of the char- Cervicogenic Headache Society and the Cervicogenic
acteristics of the headaches described by Grillo are Headache International Study Group, has ensured
similar to current criteria used to diagnose cervico- that research on this condition will continue and ex-
genic headache. In the 1990s, this topic was the target pand on current knowledge.
of a much more intense investigation by Niels Nilsson
in Denmark, who completed his PhD thesis on the
THEORETICAL BASIS
subject. He performed the first randomized controlled
trial on the treatment of patients with cervicogenic Current theories used to explain cervicogenic head-
headache, comparing the effectiveness of cervical ma- ache depend, for the most part, on an understand-
nipulation versus massage for cervicogenic headache, ing of the neurophysiology of pain perception in the
and noted a significant improvement in symptoms. head, face, and neck. The sensory innervation of the
Although many clinicians and researchers have face and head is provided by the three divisions of
long been interested in spinal headaches, previously the trigeminal nerve, as well as by branches from the
their work was not systematically correlated and gen- upper cervical spinal nerves. The ophthalmic division
erally did not draw on knowledge from different dis- of the trigeminal nerve provides sensory innervation
ciplines. This helps to explain why it took so long to the skin of the upper aspect of the nose, eyelids, eye-
for the concept of cervicogenic headache to be dis- brow, forehead, and top of the head. The maxillary di-
cussed openly in the mainstream scientific literature. vision supplies the skin of the lateral and lower nose,
Discoveries categorized under one term used to ex- lower eyelid, upper lip, and cheeks. The mandibular
plain headaches associated with clinical findings in division supplies sensory innervation to the skin of the
the neck were not applied to the same condition lower lip, chin, jaw, and temporal regions. The greater
named differently. The term cervicogenic headache and lesser occipital nerves (from C2 and C3) provide
has since been adopted by most researchers, greatly sensory innervation to the vertex and upper occipital
simplifying the task of consolidating the literature. areas of the scalp, while the third occipital nerve (from
The number of articles on the topic has grown steadily, C3) supplies the lower occipital area of the scalp. The
and there are now available a number of review ar- upper cervical spinal nerves (C1-C3) also innervate a
ticles that have summarized the knowledge gleaned number of anatomic structures in the neck, including
from both basic and clinical research.13–15 The creation muscles, joints, connective tissue, and dura mater, as
of multidisciplinary expert groups devoted solely to summarized in Figure 24–1.
Ophthalmic branch (V1)
To thalamus
Semilunar ganglion
Lateral
Maxillary branch (V2) Spinal tract spinothalamic
of trigeminal tract
nerve
Spinal nerve
root
Dorsal root Substantia

ganglion gelatinosa
Mandibular branch (V3)
Nociceptive input
Structures innervated by C1- C3 spinal nerves

Joints Muscles Other
C0- C1 (all) Longissimus capitis Rectus capitis posterior major Alar ligaments
C1- C2 (all) Longus capitis Rectus capitis posterior minor Transverse ligaments
C2- C3 (facets) Longus cervicis Semispinalis capitis C2-C3 disc
C3- C4 (facets) Multifidus Semispinalis cervicis Dura mater
Obliquus capitis inferior Splenius capitis Vertebral artery
Obliquus capitis superior Sternocleidomastoid
Rectus capitis anterior Trapezius
Rectus capitis lateralis
Adapted from Bogduk, 1992.
FIGURE 24–1. Diagram showing convergence of nociceptive inputs from upper cervical nerves and trigeminal nerve.
When free nerve endings in any of the structures neurons located in the substantia gelatinosa of the
in Figure 24–1 are subjected to noxious stimuli, the no- dorsal horn. From the substantia gelatinosa, the axons
ciceptive impulses travel through afferent A-δ (sharp, of these neurons decussate before entering the lateral
fast, acute pain) or C (burning, slow, chronic pain) spinothalamic tract and synapsing with third-order
nerve fibers with cell bodies located in the dorsal root neurons in the thalamus.
ganglia of the first three cervical nerves. These im- Nociceptive impulses from structures innervated
pulses pass through the dorsal root and into the spinal by the trigeminal nerve travel through their respec-
cord, where they can travel up or down a few spinal tive nerve branches to the semilunar ganglion where
levels before entering the dorsal horn. The primary the cell bodies of these nerves are located. From the
sensory neurons then synapse with second-order semilunar ganglion, the axons enter the nucleus of the
spinal tract of the trigeminal nerve. Unlike other nuclei ligamentum nuchae to the dura mater, and proposed
from cranial nerves, the spinal tract of the trigeminal that injury to this ligament could cause traction or
nerve is continuous with the substantia gelatinosa of irritation of the dura with a similar outcome.17 It has
the first three upper cervical spinal cord levels. Be- also been proposed that a ponticulus posterior or bony
cause of this arrangement, nociceptive impulses from bridging at the lateral mass of the atlas over the verte-
the upper cervical spinal nerves form synaptic con- bral artery may represent an anomaly that could cause
nections with neurons in the substantia gelatinosa that compression of the vertebral artery and/or tension on
originate from the trigeminal nerve. This convergence the dura. The observation that vertebral artery dissec-
of nociceptive neurons from upper spinal nerves and tion can be very painful has led to speculation that ir-
the trigeminal nerve provides a plausible explana- ritation of this artery by local inflammation, traction,
tion through which pain from the cervical spine could or an anomalous ponticulus posterior could result in
actually be felt in the face and head. Figure 24–1 more benign forms of cervicogenic headache. Again,
is a representation of this convergence phenomenon however, there remains no serious evidence that such
between upper spinal nerves and the trigeminal irritation is a significant cause of these headaches. The
nerve. finding that vasoactive medication produces no relief
Theories of cervicogenic headache based on this of cervicogenic headache symptoms argues against a
convergence have a number of shortcomings that vascular involvement. On the other hand, because the
have yet to be resolved. Because it is possible to suf- dura is a pain-sensitive structure that can potentially
fer from neck pain without accompanying cervico- trigger headaches if stimulated, these authors have
genic headache, nociceptive stimulation of structures proposed that it is through one or more of the above
in the neck does not explain why neck pain causes mechanisms that cervicogenic headache can occur.
headaches in some individuals but not in others. Sim- Unfortunately, it is not possible to validate such hy-
ilarly, convergence does not help to identify what potheses solely on the basis of anatomical dissections;
pathology or structure in the neck is most likely to it may well be that these findings and/or anoma-
result in cervicogenic headache. Table 24–3 lists the lies are no more than incidental observations. Con-
structures proposed as potential sources of cervico- sequently, theories of headache causation based on
genic headache and the mechanisms through which irritation of the dura mater require considerably more
these structures can be irritated. research before they can be considered viable.
Careful anatomical dissection of suboccipital Much evidence points to the primary upper cervi-
structures has led to the discovery that certain struc- cal structures (i.e., muscles, posterior facet joints, and
tures are directly attached to the dura mater at the intervertebral discs) as being responsible for headache
cervical–cranial junction. Hack noted that there can be of cervical origin. Theories about the role of particu-
a small attachment or filament from the rectus capi- lar structures in causing headache can be supported
tis posterior minor to the dura (Fig. 24–2).16 He pro- in three ways: Direct irritation of these structures
posed that tension in this muscle could cause traction through the injection of noxious substances causes
on the dura resulting in headaches. Mitchell et al., on headache; injection of local anesthetics or steroids
the other hand, were able to isolate attachments of the brings relief of symptoms; and other treatments
TABLE 24–3. Theories of Pathogenesis for Cervicogenic Headache
Cause Mechanism
Myofascial trigger points39 May cause referred pain to the head and face; may also lead to
restricted joint motion or dysfunction
Rectus capitis posterior minor16,56 Muscle tension may pull directly on the dura
C2-C3 facet joints57 Irritation stimulates the C1-C3 nerves and refers pain to the occiput
Trapezius40 Increased involuntary tension may indicate a response to stress from
headache
Ponticus posterior1 This bony abnormality of the atlas may increase tension on the dura or
cause compression of the vertebral artery
Ligamentum nuchae17 Injury may pull directly on the dura
Intervertebral disc22,58 Trauma or displacement stimulates nociceptors in annulus fibrosus
Nerve roots12 Local irritation causes nociceptive discharge
Vertebral artery59 Arthritic changes (i.e., exostoses) may impact blood flow
Basilar portion
of occiput
Rectus capitis posterior
minor (RCPM)
Connective tissue
C1 Dura from RCPM
2
C2 Ligamentum nuchae
C3
FIGURE 24–2. Diagram of recent

discoveries showing attachment of
the rectus capitis posterior minor
1. Attachment of RCPM to dura
and ligamentum nuchae to the up-
2. Attachment of ligamentum nuchae to dura per cervical dura.
aimed at these structures reduce symptoms. A cur- but these studies have failed to identify any findings
rent theory with strong support suggests that any that could be considered unique or diagnostic for this
structure innervated by the upper cervical nerve condition (Table 24–5). One interesting observation
roots can be a source of cervicogenic headache is that patients with cervicogenic headache have de-
through either direct stimulation of suboccipital no- creased mobility from the occiput to C5 as measured
ciceptors resulting in local pain or, in the case by flexion–extension studies.19 This study did not,
of referred pain, through convergence within the however, determine whether this finding was simply
spinal cord between these fibers and the descending the result of arthritic changes or because of hypomo-
nucleus of the trigeminal nerve. This is consistent with bility as a result of joint dysfunction.
the observation that injury to many of the cervical Myofascial trigger points have been reported to
structures can cause both neck pain and cervicogenic cause pain that can be felt in areas distant to the mus-
headache with what appears to be a single pathologi- cle in which they are located. In certain muscles, direct
cal process. irritation of trigger points by means of palpation or in-
An important cause of insult to many of the jection produces defined patterns of referred pain in
structures capable of causing cervicogenic headache the head and face. These muscles include the frontalis,
is acceleration–deceleration injury, or whiplash, re- temporalis, masseter, trapezius, sternocleidomastoid
sulting primarily from motor vehicle accidents. (SCM), and rectus capitis posterior minor.10 Although
Headaches have been reported to be present in up to the exact mechanism through which trigger points
80% of patients within 2 months following a whiplash are formed is not fully understood, it is thought that
injury to the neck.18 A number of other studies have factors such as muscle injury or overuse, stress, poor
reported a similarly high prevalence of cervicogenic posture, and anxiety may predispose an area to their
headache in patients with whiplash (Table 24–4). The formation.
presence of cervicogenic headache in whiplash pa- Intervertebral discs can also be injured through
tients does not, however, point to a specific struc- extreme movements such as falls, accidents, or ex-
ture or pathology responsible for this condition, but cessive repetitive use. Injury to the annulus fibro-
only to the observation that mechanical injury to sus or compression of surrounding tissues by disc
cervical structures can result in headaches. Studies protrusions or fragments can be painful, probably
that have examined findings from diagnostic imaging through the release of inflammatory agents from the
in patients with cervicogenic headache have shown disc.
that many of these patients do have degenerative or As mentioned earlier, injury to any of the struc-
arthritic changes in the discs and posterior facets, tures listed in Figure 24–1 is a potential cause of
TABLE 24–4. Prevalence Estimates for Cervicogenic Headache
Population Criteria Prevalence (%)
General population28 IHS 0.4

Sjaastad (6 of 6) 1.0
Sjaastad (5 of 6) 4.6
General population48 IHS 2.5
Chiropractic patients25 Not specified 3.33
Chiropractic patients1 IHS 22.5
Chiropractic patients47 Not specified 13.3
(ages 12–24 years)
Headache center patients46 Not specified 13.8
Headache center patients28 Not specified 15
Headache center patients63 Not specified 15.8
Headache center patients45 Own criteria 36.2
Headache center patients27 Not specified 80
Whiplash patients28 Not specified 8% after 8 weeks
5% after 6 months
3% after 1 year
Whiplash patients29 Sjaastad 54.3
cervicogenic headache. Studies by Martelletti et al. the area of complaint. On the other hand, the fail-
indicate that an inflammatory mechanism may be ure of antiinflammatory medications to relieve symp-
at play in cervicogenic headache. They reported toms of cervicogenic headache has cast doubt on this
increased levels of the proinflammatory cytokines theory.
interleukin-1β (IL-1β) and tumor necrosis factor-α An important trait of cervicogenic headache is the
(TNF-α) in the blood serum during induced attacks of presence of symptoms indicative of autonomic ner-
cervicogenic headache.20 They also reported that lev- vous system involvement, such as nausea, vomiting,
els of both markers were significantly higher than in photophobia, and phonophobia. Sjaastad compared
migraine headache patients, and suggested that this the frequency of these symptoms in cervicogenic and
might be the response of an immune system signal migraine headaches and reported that 55% of cer-
to activate pain-producing agents such as substance vicogenic headache patients complained of nausea
P and calcitonin gene-related peptide. According to and/or vomiting, as compared with 70–85% for mi-
this theory, the exact structure causing the initial pain graine headache patients.21 Forty-five percent of cer-
is less important and cervicogenic headache is sim- vicogenic headache patients reported photophobia, as
ply the end result of an inflammatory response in compared with 88% of migraine headache patients.
which biochemical markers of pain accumulate in However, little is understood about the cause of these
TABLE 24–5.Findings from Cervical Spine Diagnostic Imaging on Patients with

Cervicogenic Headache
Evaluation Abnormalities
Plain-film radiography53 Arthritic changes (retrospondylosis, osteochondrosis)

Plain-film radiography60 Arthritic changes (uncovertebral arthrosis, osteophytic protrusion)
Flexion–extension radiography19 Decreased C0-C5 mobility; increased C6-C7 mobility
Myelography60 Disc protrusion; uncovertebral spondylosis
Computed tomography (CT)60 Reduced spinal cord diameter
Magnetic resonance imaging (MRI)61 Retrospondylosis; disc protrusion; ventral dura compression; narrowed
subarachnoid space
MRI62 Spondylosis
symptoms in cervicogenic headache. What may be As a point of reference, the prevalence rates for
happening is that nociceptors from the upper cervical tension-type and migraine headaches in the general
spine converging within the trigeminal spinal tract adult population are approximately 69% and 16%,
might affect the autonomic component of the trigem- respectively.24
inal nerve, possibly triggering these symptoms or The prevalence rate for cervicogenic headache
somehow lowering the threshold necessary to pro- among chiropractic patients is estimated to be some-
duce these symptoms. where between 3.3% and 22.5%.1,25 This finding
Partly because so many structures and causes should not be surprising, because a survey of alter-
could be responsible for cervicogenic headache, objec- native medicine users revealed that severe headaches
tions have been raised as to the credibility of cervico- were the second most common condition (after mus-
genic headache as a diagnosis. Some authors suggest cle sprains and strains) for which chiropractic care was
that cervicogenic headache is not a clear diagnostic sought.26 A recent study examined the nature of pre-
entity, but rather a pain syndrome.22 Another pos- senting complaints for 7527 patients reporting to 161
sible explanation, however, is that the constant pain chiropractors in 32 states and 2 Canadian provinces.2
signals from the cervical spine, whether from, for ex- Results indicated that almost 5% of visits were for
ample, whiplash, arthritis, or trigger points, may in headache, making headache the fourth most common
time overwhelm the nociceptors and mechanorecep- complaint after low back pain, neck pain, and shoul-
tors and make them hyperirritable. Once this state der pain. Because patients were only asked for their
of central nociceptive sensitization is reached, seem- primary complaint, it is probable that patients seek-
ingly innocent events such as touching the neck ing care for low back or neck pain may also have re-
or maintaining an awkward posture too long may ported headaches as a secondary complaint. Rothbart
cause nociceptors that are normally silent to send sig- reported the highest prevalence rate for cervicogenic
nals suggesting injury, thereby triggering a headache headache, which he estimated was present in 80%
episode.23 of the patients presenting to his headache clinic in
Toronto, Canada.27 This estimate may simply reflect
this clinician’s awareness of the condition because he
EPIDEMIOLOGY
is the founder and president of the World Cervico-
The prevalence (number of people in a given popu- genic Headache Society. It is also likely that many
lation with a certain disease at a specific time) of cer- patients are referred to his clinic for the evaluation
vicogenic headache has only recently been the topic of suspected cervicogenic headache. Other studies on
of epidemiological research and, as such, remains the prevalence of cervicogenic headache in patients in
controversial. Table 24–4 summarizes the prevalence headache centers report estimates of 13.8–36.2%. Pa-
estimates that have been published for different popu- tients with whiplash have a reported prevalence rate
lation groups. The results of these studies are difficult of cervicogenic headache of 8% to as high as 54.3%,
to synthesize because each study has looked at dif- depending on the criteria used to define cervicogenic
ferent populations, used different diagnostic criteria, headache.28
and often incorporated different study designs. This Epidemiological studies also help us define the
has resulted in prevalence estimates that vary consid- typical sufferer of a given condition. Cervicogenic
erably from study to study. Closer comparison of these headache is reported to be much more prevalent in
studies, however, does allow for some conclusions. women and those older than age 40 years. Data from
One would generally expect a lower prevalence rate various studies indicate that 79.1% of cervicogenic
for a specific type of headache in a broad sample, such headache patients are female and that the mean age
as the general adult population, than in a preselected of sufferers is 42.9 years. This condition also tends to
sample, such as patients seeking treatment in a spe- be chronic, with patients reporting a mean duration
cialized headache center or patients with whiplash. of symptoms of 6.8 years. Additional data on cervico-
This assumption has generally held true. Nilsson genic headache sufferers have been provided by Shah
et al. reported a prevalence rate of 2.5% in the general and Nafee in an epidemiological study in India. They
adult population aged 20–59 years, whereas Sjaastad reported that 43% of cervicogenic headache patients
reported three different estimates (0.4%, 1.0%, and lived in urban areas, whereas 57% lived in rural ar-
4.6%) for the general population. Using criteria spec- eas. Shah also reported that among those patients who
ified by the IHS, only 0.4% of the general population were employed, the majority (55.7%) worked in hand-
was diagnosed with cervicogenic headache. When us- icraft occupations, 28.3% worked as laborers, 10.0% as
ing all six of the major criteria suggested by Sjaastad, clerks, 4.9% as business executives, and 1.6% as doc-
the prevalence increased to 1.0% of the general pop- tors. The mean age of onset of cervicogenic headache
ulation. Reducing the number of major criteria re- symptoms was 62.5 years, considerably older than re-
quired to five of six increased this estimate to 4.6%. ported in most other studies. Perhaps the repetitive
and physical nature of handicraft work and manual TABLE 24–6.Major Symptoms and Signs of
labor, together with high incidences of injury, account Cervicogenic Headache
for the higher prevalence in these groups. This propo-
sition is supported by Bono et al., who reported a I. Unilaterality without sideshift
prevalence rate for cervicogenic headache of 39.1% II. Symptoms and signs of neck involvement
among patients with degenerative disease of the A. Provocation of attacks
cervical spine.29 1. Pain triggered by neck movement and/or sustained
awkward head position
2. Pain elicited by applying pressure to the ipsilateral
DIAGNOSIS
upper, posterior neck region, or occipital region
When Sjaastad first introduced the term cervicogenic B. Ipsilateral neck, shoulder, and arm pain of a vague,
headache, he was attempting to describe a group of nonradicular nature
patients with a headache not classifiable by IHS cri- C. Reduced cervical spine range of motion
teria at that time. Although diagnostic criteria were
not specified in his 1983 article, characteristics of cer- Reproduced with permission from Sjaastad O, Fredriksen TA, Pfaf-
fenrath V. Cervicogenic headache: Diagnostic criteria. Headache
vicogenic headache patients were given. This lead 1990;30(11):725–726.
Fredriksen to provide a detailed description of pa-
tients he had diagnosed with cervicogenic headache
This test involves grasping a skin fold in the anterior
based on the characteristics observed by Sjaastad.30
neck and gently squeezing and rolling it between the
This discussion of cervicogenic headache may have
thumb and index finger. Pain produced by this proce-
spurred the IHS into amending its diagnostic classi-
dure can be perceived as a sign of hyperesthesia in the
fication system—which it did in 1988—to include a
C2 and C3 dermatomes, indicating possible irritation
category for “headaches associated with disorders of
of these nerves and their involvement in cervicogenic
the neck.”3 By using the IHS criteria, it has been es-
headache. Bansevicius et al. used a similar skin-rolling
timated that 15–20% of patients with recurrent, be-
test to study patients with cervicogenic, tension-type,
nign headaches may be suffering from cervicogenic
and migraine headaches.34 Fourteen of 15 (93.3%) cer-
headache.31 Sjaastad eventually published his own
vicogenic headache patients reported tenderness with
diagnostic criteria for cervicogenic headache in 1990,
the skin-roll test in the upper trapezius, as compared
and these were quickly adopted by a number of au-
with 8 of 15 (53.3%) tension-type headache patients
thors on the topic.32 Although he revised these crite-
and 8 of 43 (18.6%) migraine headache patients. When
ria in 1998, the original criteria seem to have gained
comparing tenderness in the upper trapezius bilater-
the most recognition and are still widely used by re-
ally, 67% of cervicogenic headache patients had sig-
searchers. Other groups that have proposed diagnos-
nificantly more pain on the side of head pain, as com-
tic criteria or definitions for cervicogenic headache in-
pared with only 20% of tension-type headache and
clude the International Association for the Study of
0% of migraine headache patients. The authors con-
Pain (IASP), and the Quebec Headache Study Group
cluded that such asymmetrical tenderness to skin-roll
in 1993.11,33 Tables 24–6 to 24–8 demonstrate that there
are more similarities than differences among these dif-
ferent diagnostic criteria. TABLE 24–7. Cervicogenic Headache Description
The common features from the foregoing defini-
tions and diagnostic criteria are (a) the pain typically Pain is:
starts in the upper neck or occiput after a nonspecific 1. Moderately severe
injury to the neck; (b) the pain is often, but not neces- 2. Unilateral without change in sides
sarily, unilateral and usually remains on the same side; 3. In the whole hemicranium
(c) the pain is dull, achy, nonthrobbing, and of moder- 4. First in the neck or occipital area
ate intensity; (d) the pain can persist for hours, days, or 5. Eventually in the forehead and temporal areas, where pain
even weeks; (e) the pain may radiate to the face, upper can be most severe
shoulder, or arm; (f) the pain may be accompanied by 6. Of varying duration, usually becoming more frequent and
photophobia, phonophobia, dizziness, or nausea; and continuous
(g) palpation of the neck typically reveals tenderness 7. Precipitated mechanically
and can even precipitate a headache. This last point 8. Confirmed by anesthetic blockade of the GON, LON, or
is of special significance to chiropractors and other cervical nerve roots
clinicians who commonly use findings from a manual
examination of the cervical spine to aid in their diag- Key: GON = greater occipital nerve; LON = lesser occipital nerve.
Reproduced with permission from Merskey HB, ed. Classification of
nosis. Maigne recommends that the skin rolling test be chronic pain. Descriptions of chronic pain syndromes and definitions
used as a diagnostic tool for cervicogenic headache.11 of pain terms. In: Cervicogenic headache, 2nd ed. Seattle: IASP, 1994.
TABLE 24–8.Diagnostic Criteria for Headaches TABLE 24–9.Diagnostic Criteria for Common
Associated with Disorders of the Neck Migraine Headache (without Aura)
A. Pain localized to neck and occipital region. May also project A. At least five episodes fulfilling B to D
to forehead, orbital region, temples, vertex, or ears B. Headaches last 4–72 hours untreated
B. Pain precipitated or aggravated by special neck movements C. Pain is at least two of the following:
or sustained neck posture • Unilateral
C. At least one of the following: • Throbbing
• Resistance to or limitation of passive neck movements • Moderate to severe
• Changes in neck muscles’ contour, texture, tone, or • Worse with physical exertion
response to active and passive stretching and D. At least one of:
contraction • Phonophobia and photophobia
• Abnormal tenderness of neck muscles • Nausea and/or vomiting
D. Radiological examination reveals at least one of the E. At least one of the following:
following: • History and examination do not suggest other types of
• Movement abnormalities in flexion–extension headaches
• Abnormal posture • History and examination did suggest other types of
• Fractures, congenital abnormalities, bone tumors, headaches which were ruled out by diagnostic testing
rheumatoid arthritis, or other distinct pathology (not • Another type of headache does exist, but without
spondylosis or osteochondrosis) temporal relation to the migraines
Adapted from HIS–Headache Classification Committee of the Inter- Adapted from IHS–Headache Classification Committee of the Inter-
national Headache Society. Classification and diagnostic criteria for national Headache Society. Classification and diagnostic criteria for
headache disorders, cranial neuralgias, and facial pain. Cephalalgia headache disorders, cranial neuralgias, and facial pain. Cephalalgia
1988;8(Suppl 7):1–96. 1988;8(Suppl 7):1–96.
testing of the upper trapezius could help to rule in cer- or temporal areas, whereas pain in cervicogenic
vicogenic headache and rule out migraine headache headache tends to be located in the occipital area.
for cases of unilateral headache. Another study using This was reported in a study by D’Amico, which com-
a pressure algometer found significantly lower cer- pared the pain patterns of cervicogenic, migraine, and
vical paraspinal pain thresholds in patients with a tension-type headaches.36 One hundred percent of
diagnosis of cervicogenic headache than in patients cervicogenic headache patients reported pain in the
suffering from tension-type or migraine headaches
and in healthy control subjects.35 The lowest TABLE 24–10. Diagnostic Criteria for
pressure-pain thresholds were found in the occipi- Tension-Type Headaches
tal area in cervicogenic headache, indicating possi-
ble involvement of the greater and lesser occipital
A. At least 10 episodes fulfilling B to D
nerves.
B. Headache lasts 30 minutes to 7 days
C. At least two of the following:
• Nonthrobbing, tightening pain
DIFFERENTIAL DIAGNOSIS
• Mild to moderate
The main challenge in making a diagnosis of cervico- • Bilateral
genic headache—after excluding headaches from tu- • Not aggravated by physical exertion
mors, infections, neoplasms, fractures, metabolic and D. Neither nausea nor vomiting are present; photophobia or
bleeding disorders, and other causes—is to differenti- photophobia may appear singly
ate it from other common types of chronic headache, E. At least one of the following:
mainly tension-type and migraine headache. Tables • History and examination do not suggest other types of
24–9 and 24–10 list the diagnostic criteria for these headaches
other two types of headache. Migraine headache • History and examination did suggest other types of
may be confused with cervicogenic headache because headaches which were ruled out by diagnostic testing
both tend to present with unilateral pain and may • Another type of headache does exist, but without
also involve photophobia, phonophobia, and nau- temporal relation to the tension-type headaches
sea/vomiting. However, these similarities are over-
shadowed by the differences in pain presentation. Adapted from IHS–Headache Classification Committee of the Inter-
national Headache Society. Classification and diagnostic criteria for
Although both may have unilateral pain, pain in headache disorders, cranial neuralgias, and facial pain. Cephalalgia
migraine headache tends to migrate to the frontal 1988;8(Suppl 7):1–96.
occipitonuchal region, as compared with only 12.5% Another distinguishing characteristic useful in dif-
for migraine headache and 20.0% for tension-type ferentiating between types of headache is the nature
headache. The initial location of pain also differed. or quality of pain reported. In cervicogenic headache,
None of their cervicogenic headache patients re- the pain is usually dull and aching. Certain diagnos-
ported the initial pain in a nonoccipital area, whereas tic criteria even specify that the pain must be of a
76.6% of migraine headache and 30.0% of tension-type nonthrobbing or nonlancinating nature, presumably
headache patients described the initial pain as being to exclude migraine headache or its variants. Factors
outside of the occipital part of the head. Consequently, that may trigger a headache episode may also dif-
it is important to ask the patient where the pain be- fer between cervicogenic, migraine, and tension-type
gan, because pain patterns can shift throughout a headache. Migraine headache may be brought on by
prolonged headache episode. It is also worth inquir- physical exertion, certain foods, or hormonal factors,
ing as to whether a particular headache presentation whereas cervicogenic headache tends to be triggered
is “typical” or “nontypical” for a patient. A study by awkward neck movements, posture, or strong neck
by Sjaastad reported that while only 16% of typical palpation.
migraine headache attacks were unilateral without A number of diagnostic tests have been used in an
side shift (the common presentation for cervicogenic attempt to objectively diagnose patients with cer-
headache), 75% of patients reported an occasional vicogenic headache. Table 24–11 presents the results
nontypical episode of migraine headache where pain reported in various studies. Although certain of
presented in a fashion more suggestive of cervicogenic these diagnostic tests are reported to be abnormal
headache. One must therefore clarify in the history in cervicogenic headache patients, the importance of
taking that answers should apply mostly to the typi- these findings remains unclear. Until a better un-
cal pattern of headache experienced by a patient.37 derstanding of the etiology and pathophysiology
Differentiating cervicogenic headache from of cervicogenic headache is obtained, many of the
tension-type headache can be challenging, although physiological tests, such as sweating patterns19 and
this differentiation can usually be accomplished with electronystagmography,38 are of questionable rele-
a thorough history. The pain pattern in tension-type vance to clinical practice. Other tests, such as those
headache tends to include a band-like distribution used to examine muscle function, may turn out to
around the entire head, and is therefore bilateral. The be of importance in defining the source of pain and be
nature of the pain, however, is mostly dull and achy, helpful in directing treatment efforts but will have to
similar to cervicogenic headache. An important factor be reproduced by other authors. Certain of these ob-
in diagnosing tension-type headache is to monitor servations may in the future serve to support the
the patient’s stress and anxiety levels, because these different theories of the pathogenesis of cervicogenic
tend to rise throughout the day and many episodes headache. For example, many cervicogenic headache
of tension-type headache will begin in the late after- patients were found to have multiple myofascial trig-
noon. Cervicogenic headache patients, on the other ger points in the cervical spine, with significantly
hand, can often awaken with a headache after sleep- more trigger points on the symptomatic side than
ing fitfully or in an unusual location or position (e.g., the asymptomatic side.39 Patients with cervicogenic
couch, hotel bed, car, plane). headache were also found to have increased motor
TABLE 24–11. Results from Various Diagnostic and Other Studies on Patients with Cervicogenic
Headache
Test Results
Muscle dysfunction64 Significant ↑ upper trapezius passive stretching response vs. controls
Myofascial trigger points39 Significantly more on symptomatic vs. asymptomatic side
C2-C4 instantaneous axis of rotation65 No relation between abnormality and headache
Response of shoulder, neck, and facial Significantly ↓ shoulder MCV in CGH
muscles to mental stress40 Significantly ↑ pretest activity in frontalis on symptomatic side
Significantly ↑ EMG response in trapezius on symptomatic side
Head posture ↑ Forward carriage vs. controls
Cervical flexor endurance ↓ Endurance vs. controls
Cervical flexor strength66 ↓ Strength vs. controls
Key: CGH = cervicogenic headache; EMG = electromyography; MCV = motor nerve conduction velocity.
activity in certain muscle groups in response to mental migraine and tension-type headache, there is a fair
stress,40 and an increased response to passive stretch- degree of overlap in the presentation of patients
ing of the trapezius. These findings support the theory with these three diagnoses. A study by Bono re-
that increased muscle tension in the neck and shoul- ported that 75% of patients fulfilling IHS criteria
ders is the primary cause of cervicogenic headache. for migraine headache could also meet most of the
While this blurs somewhat the distinction between criteria for cervicogenic headache.43 The reverse is
cervicogenic and tension-type headaches, it could also not necessarily true, however, because a study by
indicate that some of the stress-reduction techniques Sjaastad reported that cervicogenic headache patients
used for tension-type headache may be helpful in cer- could only fulfill, on average, 3.79 of 7 IHS crite-
vicogenic headache. Other investigations of the cervi- ria for migraine headache, an insufficient number
cal musculature reported decreased strength and en- to establish a diagnosis.37 Most patients with mi-
durance of these muscles. This could lower a patient’s graine headache did not fulfill what is arguably the
ability to sustain a stationary posture for prolonged most important criterion for cervicogenic headache:
periods and could thereby trigger a headache.41 An- precipitation of headaches with neck movements
other way to distinguish cervicogenic headache from and/or external pressure on the neck. One study re-
other common headaches is by monitoring the reported that patients with cervicogenic headache typ-
sponse of patients to various medications. Studies re- ically fulfill 10.51 of Sjaastad’s 18 major and minor
port that cervicogenic headache patients typically do criteria for cervicogenic headache, as compared with
not respond to the vasoactive medications used in only 3.85 for migraine headache patients and 4.89
treating migraine headache,42 nor do they respond to for tension-type headache patients.44 Patients with
oxygen therapy as prescribed for cluster headaches. true migraine and tension-type headache should not,
Although most clinical studies have attempted to therefore, be mistakenly classified as having cervico-
differentiate cervicogenic headache from other types genic headache. They also reported that 33.3% of pa-
of headache, it does not appear that any specific test or tients with cervicogenic headache could have been
clinical finding can consistently and reliably be used classified with migraine headache according to IHS
to confirm a diagnosis of cervicogenic headache. Most criteria, and 3.3% could have been classified as hav-
of the distinguishing characteristics must be gathered ing tension-type headache. The remaining majority
by obtaining a detailed clinical history. Table 24–12 (63.6%) of patients with cervicogenic headache, how-
lists the questions that are most relevant to a diagno- ever, could not properly be diagnosed with either mi-
sis of cervicogenic headache, along with typical an- graine or tension-type headache, demonstrating the
swers from patients with cervicogenic, migraine, and importance of considering the cervicogenic headache
tension-type headache. diagnosis.
Although this information can assist a clinician An additional confounder in the diagnosis of cer-
in making a diagnosis of cervicogenic headache, vicogenic headache must also be mentioned. Cer-
and in distinguishing cervicogenic headache from vicogenic headache also appears to frequently coexist
TABLE 24–12. Questions to Ask in Obtaining a Clinical Headache History
Cervicogenic Headache Migraine Headache Tension-Type Headache
Where did the pain start? Neck or occipital region Frontal or temporal region Temporal region
What triggered this Sleeping wrong, reading for Foods (cheese, wine, coffee, Stress, anxiety
headache? a long time, jerking head alcohol), menstruation,
movements physical exertion
What type of pain do you Dull, achy Throbbing, pulsating Tight, squeezing
feel?
How severe is the pain? Moderate Moderate to severe Mild to moderate
Do you have pain anywhere In the neck and upper No No
else? shoulders
Do you have nausea and/or Sometimes Almost always No
vomiting?
What type of treatment has Analgesics, ice, neck Migraine-specific medication Analgesic and anxiolytic
been helpful? massage medication, head
massage, relaxation
with other primary headache disorders such as mi- the results of studies on manipulation for cervico-
graine and tension-type headache. One study of pa- genic headache. The two randomized controlled tri-
tients at a headache center reported that while only als by Nilsson, in 1995 and 1997, have been the most
16.1% of patients were diagnosed with cervicogenic rigorous.48,49 The first demonstrated that both spinal
headache alone, an additional 20.1% were diagnosed manipulation and massage were successful in reduc-
with both migraine and cervicogenic headache, for ing the frequency and severity of headaches and the
a total prevalence of 36.2%.45 A similar study of pa- amount of analgesic use by patients. Although results
tients with whiplash reported that 34.3% had cervico- from manipulation were better than those for mas-
genic headache alone, while an additional 11.4% had sage, there was no statistical difference between the
both cervicogenic and migraine headache, and a fur- two groups. This may indicate that massage in and
ther 8.6% had cervicogenic headache in combination of itself may be a valid treatment for a headache of
with headaches associated with the neck, for a total muscular origin. There were also probably insufficient
prevalence of 54.3% (the reason for the latter distinc- numbers of patients to reach significance in the first
tion was unclear, but may be a result of the terminol- trial. When additional patients were recruited for the
ogy used in different diagnostic criteria, as mentioned second study, manipulation was shown to be statisti-
earlier).29 Another study reported that the majority cally superior to massage in the treatment of cervico-
(56.4%) of patients with cervicogenic headache also genic headache. A study by Bitterli also reported that
have other headaches, commonly migraine, tension- results from cervical manipulation were superior to
type, and drug-induced headaches.46 A case series by mobilization and no-treatment controls after 3 weeks
Sjaastad reported on four patients with both migraine of treatment; these differences again, however, did not
and cervicogenic headache.21 These patients were cog- reach statistical significance.50 Another study report-
nizant of the particular episode of headache they were ing a positive effect for manipulation was that con-
experiencing at any given time, even reporting im- ducted by Howe, demonstrating that manipulation
provement of migraine headache but not cervicogenic and nonsteroidal antiinflammatory drugs (NSAIDs)
headache with sumatriptan and ergotamine (com- were superior to NSAIDs alone in relieving cervico-
mon vasoactive migraine medications), and relief of genic headache pain; this difference did not achieve
cervicogenic headache but not migraine headache statistical significance 3 weeks after the treatment.51
with greater occipital nerve anesthetic blockade. Clin- The thesis by Bronfort reviewed the evidence for
icians must therefore be aware that patients with a all randomized controlled trials on manipulation
confusing headache presentation may be suffering for headaches, and found moderate evidence to sup-
from coexistent cervicogenic, migraine, or tension- port its use for both cervicogenic and tension-type
type headaches. headache.50
Another therapy that chiropractors may elect to
use for cervicogenic headache is transcutaneous elec-
TREATMENT
trical nerve stimulation (TENS). Studies on TENS
As mentioned earlier, the reported prevalence of cer- show that it is helpful in bringing temporary re-
vicogenic headache in chiropractic patients ranges lief of symptoms. A case series of 60 patients with
from 3.3% to 22.5%.1,25,47 While we do not know how cervicogenic headaches treated with TENS reported
many of these chiropractic patients with cervicogenic that after 2 months, 80% of patients had experienced
headache receive chiropractic care specifically for at least a 60% improvement in their symptoms; the
their headaches, studies report that headaches are other 20% had experienced a 40–60% improvement in
commonly treated by chiropractors.2 Because cervico- symptoms.52 A second study by Tarhan and Inan on
genic headache appears at this point to be related to the use of TENS for cervicogenic headache reported
insult or injury to the joints and supporting tissues significant improvement compared with a placebo.14
of the upper cervical spine leading to inflammation, Other treatments for headache, including biofeed-
one would anticipate abnormal cervical biomechanics back, exercise, and nutrition, have not been investi-
to be associated with the pain. It would therefore be gated for their efficacy in patients with cervicogenic
reasonable to consider a mechanical form of therapy. headache.
The use of manual therapy, including manipulation, Results obtained with surgical treatment of cer-
mobilization, and soft-tissue techniques, to treat cervicogenic headache are mixed. Given the uncertainty
vicogenic headache is supported by a small number as to the exact structure causing the pain, and the need
of research studies that are by no means conclusive. for surgical intervention to be directed at a particu-
There are, however, more randomized controlled tri- lar structure, this may not be surprising. A multitude
als for manual therapy than for any other treatment of approaches have been attempted from radiofre-
approach (i.e., medication, injections, and surgery) quency neurotomy of various nerves, to ventral and
to cervicogenic headache. Table 24–13 summarizes dorsal decompression at multiple spinal levels, and
TABLE 24–13. Manipulation for Cervicogenic Headache
Treatment Study Type Control Results
Manipulation67 RCT Massage; laser light Both groups had a decrease in headache
hours/day, VAS, NSAIDs/day; no significant
differences were found between the
treatment and control group
Manipulation49 RCT Massage; laser light Significant difference in headache hours/day in
favor of manipulation; significant difference in
↓ VAS in favor of group 1; no significant
difference for analgesics/day between two
groups
Manipulation50 RCT Mobilization; no Manipulation was more effective than
treatment mobilization and wait list, but without
statistical significance between groups
Manipulation and RCT NSAIDs A single manipulation added to NSAIDs was
NSAIDs51 superior to NSAIDs only immediately after
treatment, but not at 3 weeks; not
statistically significant
Manipulation68 Case series — Decrease in headache severity, frequency, and
duration
Manipulation69 Case series — Decrease in drug consumption index and total
pain index
Manipulation25 Case series — 80% had a > 75% reduction in symptoms
10% had a 50–75% reduction in symptoms
3% had a 50% reduction in symptoms
2% had no change
5% had aggravation in symptoms
Key: NSAIDs = nonsteroidal antiinflammatory drugs; RCT = randomized controlled trial; VAS = visual analog scale.
disc fusion.15 None of the surgical studies are random- of botulinum toxin injected in the upper trapezius
ized or controlled, and consist mainly of case series muscle and reported significant improvement in pain
with follow-up of only a few months. and neck range of motion compared to placebo.55
Referral to a medical physician (i.e. neurologist, However, these results have not been reproduced by
anesthesiologist, or physiatrist) for injections may, others. By working closely with the medical physi-
under certain circumstances, be helpful in treating cian performing the injections, a chiropractor may, by
patients with cervicogenic headache. The injection means of palpatory skills and other diagnostic tools,
of local anesthetics to the upper cervical spine, and help to choose specific structures to be injected. For
more specifically to the greater or lesser occipital example, manipulation or injection of a C1-C2 zy-
nerves, may help to confirm a diagnosis of cervico- gapophyseal joint may be considered if joint palpa-
genic headache if the patient reports relief of pain fol- tion indicates restricted motion or tenderness in that
lowing the injection. Research to date, however, sug- area. This multidisciplinary approach may help to
gests that injections may be more useful as a diagnostic determine the treatment most likely to be beneficial
aid than as a treatment modality since pain relief tends and focus the treatment efforts to a specific region or
to be brief, lasting only a few hours to a few days.53 structure.
The use of longer-lasting steroids may prolong this
pain relief, but has a greater complication rate. The
SUMMARY
placebo effect of the injection is not likely to play a
role in patients reporting immediate pain relief, be- 1. The concept that headache may originate from the
cause a study examining sterile water and saline in- spine has been discussed in the literature for al-
jections reported no effect in cervicogenic headaches most 150 years. Researchers who made important
patients.54 An interesting study examined the use contributions to this field include Barré, Lieou,
Raney and Raney, Bogduk, Maigne, Sjaastad, and 3. How can pain from a structure in the neck be per-
Nilsson. ceived in the face or head? Which nerves are in-
2. Many structures in the upper cervical spine, involved in this process?
cluding muscles, joints, blood vessels, dura, and 4. What are the main clinical criteria necessary to di-
connective tissue, may produce a pain signal that agnose cervicogenic headache?
is felt as a headache. Pain from the upper cervi- 5. How is cervicogenic headache different from com-
cal spine can present as a headache because of the mon migraine and tension-type headache?
convergence within the spinal tract of the trigem-
inal nerve.
3. Various epidemiological studies show a preva- ANSWERS
lence rate of 0.4–4.6% among the general popula-
tion, 3.3–22% among chiropractic patients, 8–54% 1. The term was introduced in 1983 by Sjaastad to de-
among patients with whiplash, and 14–80% of pa- scribe a group of patients with a type of headache
tients in headache centers. Cervicogenic headache not classifiable according to current IHS criteria.
patients tend to be female (79.1%), middle-aged 2. A. 0.4–4.6% of the general population.
(42.9 years old), and have chronic symptoms B. 3.3–22.5% of chiropractic patients.
(mean duration of 6.8 years). C. 8–54% of whiplash patients.
4. Many diagnostic criteria for cervicogenic D. 14–80% of patients in headache centers.
headache exist, and have in common the following 3. Through convergence of nociceptive inputs within
features: The pain starts in the neck or occipital the spinal nucleus of the trigeminal nerve. The
area, and the headache is usually felt unilaterally nerves involved include the three divisions of the
and does not change sides. It is dull, achy, and trigeminal nerve, and sensory nerve branches from
moderately severe. It is often precipitated by neck cervical nerve roots C1-C3 (greater and lesser oc-
movement or posture and may be accompanied cipital nerves, third occipital nerve).
by upper shoulder, neck, and arm pain. It can last 4. Cervicogenic headache pain (a) usually begins in
several hours to days. the neck after trauma, awkward posture, or dur-
5. The differential diagnosis for cervicogenic heading firm palpation of neck structures; (b) the pain
aches includes tension-type headache and com- presents unilaterally on the same side; (c) the
mon migraine headache. Pain patterns obtained pain is dull and nonthrobbing in nature; (d) the
from a thorough clinical history are the best way to pain eventually reaches the frontal or temporal ar-
differentiate among these three common headache eas; (e) the pain lasts several hours to days; and
types. (f) the pain can be accompanied by nonradicular
6. Treatment of cervicogenic headaches through shoulder or arm pain.
manual therapy, including manipulation, has been 5. Pain in common migraine headache usually starts
shown to have positive effects in randomized con- in the frontal or temporal areas, is throbbing in
trolled trials and case series. TENS and massage nature, is moderate to severe, is accompanied
may also be helpful. by nausea and/or vomiting, and can frequently
7. Clinicians who suspect cervicogenic headache change sides. Pain in tension-type headache is of-
should obtain a headache history and perform ten bilateral, is not accompanied by neck pain,
a manual palpation examination of the upper is brought on by stress or anxiety rather than
cervical spine to reach a diagnosis of cervicogenic neck movements, and usually lasts only a few
headache. hours.
QUESTIONS KEY REFERENCES
1. When and why was the term cervicogenic head- Alix ME, Bates DK. A proposed etiology of cervicogenic
ache introduced in the literature? headache: The neurophysiologic basis and anatomic re-
lationship between the dura mater and the rectus pos-
2. What is the estimated prevalence rate of cervico-
terior capitis minor muscle. J Manipulative Physiol Ther
genic headache
1999;22(8):534–539.
A. In the general population? Bogduk N. The anatomical basis for cervicogenic headache.
B. Among chiropractic patients? J Manipulative Physiol Ther 1992;15(1):67–70.
C. Among patients with whiplash? Coulter I, et al. The appropriateness of manipulation and mo-
D. Among patients presenting to headache cen- bilization of the cervical spine. Santa Monica, CA: RAND,
ters? 1996.
Haldeman S, Dagenais S. Cervicogenic headaches: A critical 10. Simons DG, Travell JG, Simons LS. Myofascial pain
review. Spine 2001;1(1):16–31. and dysfunction—The trigger point manual. Philadelphia:
Nilsson N, Christensen HW, Hartvigsen J. The effect of Lippincott Williams and Wilkins, 1998.
spinal manipulation in the treatment of cervicogenic 11. Meloche J, et al. Painful intervertebral dysfunction:
headache. J Manipulative Physiol Ther 1997;20(5):326– Robert Maigne’s original contribution to headache of
330. cervical origin. The Quebec Headache Study Group.
Pollmann W, Keidel M, Pfaffenrath V. Headache and the Headache 1993;33(6):328–334.
cervical spine: A critical review. Cephalalgia 1997;17(8): 12. Grillo F. The differential diagnosis and therapy of
801–816. headache. Swiss Ann Chiropr 1961;II:121–166.
Sjaastad O, et al. “Cervicogenic” headache. An hypothesis. 13. Pollmann W, Keidel M, Pfaffenrath V. Headache
Cephalalgia 1983;3(4):249. and the cervical spine: A critical review. Cephalalgia
Sjaastad O, Bovim G, Stovner LJ. Common migraine (“mi- 1997;17(8):801–816.
graine without aura”): Localization of the initial pain of 14. Sjaastad O, Fredriksen TA, Stolt-Nielsen A, et al.
attack. Funct Neurol 1993;8(1):27–32. Cervicogenic headache: A clinical review with spe-
Sjaastad O, Fredriksen TA, Sand T. The localization of cial emphasis on therapy. Funct Neurol 1997;12(6):
the initial pain of attack. A comparison between clas- 305–317.
sic migraine and cervicogenic headache. Funct Neurol 15. Haldeman S, Dagenais S. Cervicogenic headaches: A
1989;4(1):73–78. critical review. Spine J 2001;1(1):16–31.
Vernon HT. Spinal manipulation and headaches of cervical 16. Hack G. Cervicogenic headache: New anatomical
origin. J Manipulative Physiol Ther 1989;12(6):455–468. discovery provides the missing link. Chiropr Rep
Vincent MB, et al. Greater occipital nerve blockade in cer- 1998;12(3):1–3.
vicogenic headache. Arq Neuropsiquiatr 1998;56(4):720– 17. Mitchell BS, Humphreys BK, O’Sullivan E. Attach-
725. ments of the ligamentum nuchae to cervical posterior
World Cervicogenic Headache Society. Taxonomical spinal dura and the lateral part of the occipital bone.
definition of cervicogenic headache, 1994. www. J Manipulative Physiol Ther 1998;21(3):145–148.
cervicogenic.com/definit1.htm. 18. Maimaris C, Barnes M, Allen M. “Whiplash in-
juries” of the neck: A retrospective study. Injury 1988;
19(6):393–396.
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computer-based measurements of cervical spine mo-
1. Wight S, Osborne N, Breen AC. Incidence of pontic- bility in 15 patients. Cephalalgia 1988;8(1):45–48.
ulus posterior of the atlas in migraine and cervico- 20. Marteletti P, et al. Proinflammatory cytokines in
genic headache. J Manipulative Physiol Ther 1999;22(1): cervicogenic headache. Funct Neurol 1999;14(3):159–
15–20. 162.
2. Hawk C, Long CR, Boulanger KT. Prevalence of 21. Sjaastad O, Bovim G. Cervicogenic headache. The dif-
nonmusculoskeletal complaints in chiropractic prac- ferentiation from common migraine. An overview.
tice: Report from a practice-based research pro- Funct Neurol 1991;6(2):93–100.
gram. J Manipulative Physiol Ther 2001;24(3):157– 22. Bogduk N. The anatomical basis for cervicogenic
169. headache. J Manipulative Physiol Ther 1992;15(1): 67–
3. IHS–Headache Classification Committee of the Inter- 70.
national Headache Society. Classification and diagnos- 23. Seaman DR, Winterstein JF. Dysafferentation: A novel
tic criteria for headache disorders, cranial neuralgias, term to describe the neuropathophysiological effects
and facial pain. Cephalalgia 1988;8(Suppl 7):1–96. of joint complex dysfunction. A look at likely mech-
4. Sjaastad O, et al. “Cervicogenic” headache. An hypoth- anisms of symptom generation. J Manipulative Physiol
esis. Cephalalgia 1983;3(4):249–256. Ther 1998;21(4):267–280.
5. Pearce JM, Cervicogenic headache: An early descrip- 24. Goadsby PJ, Olesen J. Fortnightly review: Diagno-
tion. J Neurol Neurosurg Psychiatry 1995;58(6):698. sis and management of migraine. BMJ 1996;312:1279–
6. Barré JA. Sur un syndrome sympathique cervical pos- 1283.
terieur et sa cause frequente: L’arthrite cervicale. Rev 25. Droz J, Crot F. Occipital headaches. Swiss Ann Chiropr
Neurol (Paris) 1926;33:1246–1248. 1985;VIII.
7. Lieou YC. Syndrome sympathétique cervical post- 26. Astin JA. Why patients use alternative medicine. JAMA
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8. Raney A, Raney R. Headache: A common symp- 28. Sjaastad O, Fredriksen SA. Cervicogenic headache:
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1948;59:603–621. Rheumatol 2000;18(2 Suppl 19):S3–S6.
9. Bogduk N, Marsland A. On the concept of third 29. Bono G, et al. Whiplash injuries: Clinical picture
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30. Fredriksen TA, Hovdal H, Sjaastad O. “Cervico- vicogenic headache. J Manipulative Physiol Ther 1995;
genic headache”: Clinical manifestation. Cephalalgia 18(7):435–440.
1987;7(2):147–160. 49. Nilsson N, Christensen HW, Hartvigsen J. The ef-
31. Olesen J, ed. Classification and diagnostic criteria for fect of spinal manipulation in the treatment of
headache disorders, cranial neuralgias and facial pain, 1st cervicogenic headache. J Manipulative Physiol Ther
ed. Copenhagen: International Headache Society, 1990. 1997;20(5):326–330.
32. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervico- 50. Bronfort G. Efficacy of manual therapies of the spine.
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33. Merskey HB. Classification of chronic pain. Descrip- cervical spine—A pilot study. J R Coll Gen Pract 1983;
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34. Bansevicius D, Pareja JA. The “skin roll” test: A di- neous electrical nerve stimulation. Headache 1986;26(8):
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1998;13(2):125–133. 53. Jansen J, Vadokas V, Vogelsang JP. Cervical peridural
35. Bovim G. Cervicogenic headache, migraine, and anaesthesia: An essential aid for the indication of sur-
tension-type headache. Pressure-pain threshold mea- gical treatment of cervicogenic headache triggered by
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36. D’Amico D, Leone M, Bussone G. Side-locked unilat- rol 1998;13(1):79–81.
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Migraine, tension-type headache, and cervicogenic ile water injections do not relieve pain in cervico-
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37. Sjaastad O, Bovim G, Stovner LJ. Laterality of pain 528.
and other migraine criteria in common migraine. A 55. Freund BJ, Schwartz M. Treatment of chronic cervical-
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38. Dieterich M, Pollmann W, Pfaffenrath V. Cervicogenic 56. Alix ME, Bates DK. A proposed etiology of cer-
headache: Electronystagmography. Perception of ver- vicogenic headache: The neurophysiologic basis and
ticality and posturography in patients before and after anatomic relationship between the dura mater and the
C2-blockade. Cephalalgia 1993;13(4):285–288. rectus posterior capitis minor muscle. J Manipulative
39. Jaeger B. Are “cervicogenic” headaches due to myofas- Physiol Ther 1999;22(8):534–539.
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The influence of mental load on pain level and 58. Jansen J, et al. Cervicogenic, hemicranial attacks associ-
EMG of shoulder-neck and facial muscles. Headache ated with vascular irritation or compression of the cer-
1996;36(6):372–378. vical nerve root C2. Clinical manifestations and mor-
41. Treleaven J, Jull G, Atkinson L. Cervical musculoskele- phological findings. Pain 1989;39(2):203–212.
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diagnostic criteria. Funct Neurol 1998;13(1):75–77. anism of CeH. Funct Neurol 1999;14(3):163–165.
44. Vincent MB, Luna RA. Cervicogenic headache: A com- 62. Shah PA, Nafee A. Clinical profile of headache
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response to local steroid therapy. Clin Exp Rheumatol headache. Annual postgraduate course of the association of
2000;18(2 Suppl 19):S59–S64. Swiss chiropractors. Vol. 13. Interlaken, Switzerland: As-
46. Pfaffenrath V, Kaube H. Diagnostics of cervicogenic sociation of Swiss Chiropractors, 1993.
headache. Funct Neurol 1990;5(2):159–164. 64. Jull G, et al. Further clinical clarification of the
47. Ebrall P. A description of 320 chiropractic consultations muscle dysfunction in cervical headache. Cephalalgia
by Australian adolescents. Chiropr J Aust 1994;24(1): 1999;19(3):179–185.
4–8. 65. Hinderaker J, et al. Diagnostic value of C2-3 instan-
48. Nilsson N. A randomized controlled trial of the ef- taneous axes of rotation in patients with headache of
fect of spinal manipulation in the treatment of cer- cervical origin. Cephalalgia 1995;15(5):391–395.
66. Watson D, Trott P. Cervical headache: An investigation tion, cervical radiculopathy, and associated cervico-
of natural head posture and upper cervical flexor mus- genic headache syndrome. J Manipulative Physiol Ther
cle performance. Cephalalgia 1993;13:272–274. 1999;22(3):166–170.
67. Nilsson N. The prevalence of cervicogenic headache in 69. Whittingham W, Ellis WB, Molyneux TP. The effect
a random population sample of 20–59 year olds. Spine of manipulation (toggle recoil technique) for head-
1995;20(17):1884–1888. aches with upper cervical joint dysfunction: A pilot
68. Herzog J. Use of cervical spine manipulation under study. J Manipulative Physiol Ther 1994;17(6):369–
anesthesia for management of cervical disk hernia- 375.
C H A P T E R
25
RISK FACTORS FOR LOW BACK
AND NECK PAIN: AN INTRODUCTION
TO CLINICAL EPIDEMIOLOGY AND
REVIEW OF COMMONLY SUSPECTED
RISK FACTORS
Jan Hartvigsen
O U T L I N E
INTRODUCTION Sitting
TYPES OF EPIDEMIOLOGIC STUDIES Whole-Body Vibration
Common Issues Heavy Physical Work
Definition of Low Back and Neck Pain Psychosocial Factors in the Workplace
Definitions of Risk Factors Social Support at Work
Epidemiological Study Designs Mental Stress at Work
Observational versus Experimental Studies Job Satisfaction
Measures of Disease in Populations Individual Factors
Genetic Epidemiological Study Designs Age
ASSOCIATION AND CAUSALITY Body Height
Strength RISK FACTORS FOR NECK PAIN
Consistency Social Factors
Temporality Lifestyle-Related Factors
Dose–Response Smoking
Plausibility Sports and Exercise
RISK FACTORS FOR LOW BACK PAIN Traffic Collisions (Whiplash)
Social Factors Driving a Vehicle
Family Relations Psychosocial Factors in Private Life
Social Group Physical Exposures
Compensation and Litigation Neck Posture
Smoking Arm Force and Arm Posture
Obesity Duration of Fixed Sedentary Work Postures
Alcohol Workplace Design
Physical Fitness Hand/Arm Vibration
Psychosocial Factors in Private Life Twisting and Bending of the Trunk
Work-Related Factors Psychosocial Factors in the Workplace
Lifting Quantitative Job Demands/Job Control
Bending and Twisting Social Support
Standing or Walking Job Satisfaction
465
GENETIC FACTORS IN LOW BACK PAIN QUESTIONS

AND NECK PAIN ANSWERS
CHALLENGES TO CLINICIANS AND RESEARCHERS KEY REFERENCES
SUMMARY REFERENCES
OBJECTIVES LBP and neck pain are huge. In the United Kingdom
alone, the combined direct and indirect costs are es-
1. To introduce the reader to concepts and study de-
timated to be more than £12 billion ($21.3 billion)
signs in clinical and genetic epidemiology.
annually.13 This is more than the estimated annual
2. To address the issues of association and causality.
costs of lower respiratory tract infections, Alzheimer
3. To review suspected risk factors for low back and
disease, stroke, diabetes mellitus, multiple sclerosis,
neck pain and to describe the evidence for possible
and epilepsy combined.13
causal relationships.
It is estimated that 30% of individuals will expe-
4. To suggest how clinicians might communicate in-
rience neck pain in a 1-year period,14 although re-
formation about possible risk factors to their pa-
sults vary somewhat between studies. The cumula-
tients and to briefly describe future challenges in
tive lifetime prevalence of neck pain ranges between
this field.
65 and 72%,14,15 and neck pain is consistently re-
ported as a common cause of long-term sick leave
and work-related disability compensation.15,16 Fur-
thermore, neck pain following motor vehicle accidents
INTRODUCTION
is extremely common.17,18 Consequently, as with low
Chiropractic practice includes the diagnosis, treat- back pain, billions of dollars are spent annually on
ment, rehabilitation, and prevention of, primarily, treatment, lost wages, and compensation related to
musculoskeletal disorders. Low back pain (LBP) and neck pain conditions.19
neck pain are by far the most common conditions Considering the magnitude of these health prob-
treated by chiropractors worldwide.1–4 Knowledge of lems, it is truly remarkable that so little precise knowl-
the etiology of a condition is essential when advising edge exists about exact risk factors. Compared to
patients regarding prevention and treatment options, other areas in health care, there is comparatively lit-
which justifies a special focus on the etiologies of LBP tle research, and no commonly accepted definitions
and neck pain in a chiropractic textbook. or “gold-standard” definitions of LBP and neck pain
The novice reader of scientific literature on risk exist. Accordingly, in systematic reviews of the litera-
factors for LBP and neck pain will soon discover that ture, comparison of study results has proven difficult
the literature is vast, confusing, and often even con- because definitions of LBP and neck pain vary be-
tradictory. In fact, the true causes of these conditions tween studies.20–23 For example, in some studies, LBP
are largely unknown and strategies for effective pre- has been defined as self-reported pain,24–26 whereas
vention have yet to be developed. This is, indeed, un- in others outcome measures such as care seeking,27
fortunate because LBP and neck pain are enormous sick leave,28 or pension29 have been used. To compli-
public health problems in industrialized countries. cate matters even more, the same outcome variable,
Approximately 50% of individuals will experience for example, pain, is often measured using different
LBP over a 1-year period and between 70 and 80% methods and instruments that might not be directly
will experience LBP in their lifetime.5,6 LBP can start comparable. Also, definitions and measurements of
early in life and by the age of 18 years approximately the suspected risk factors often suffer from similar
half of the population have experienced at least one diversity. Finally, epidemiological studies are some-
episode of LBP.7 Whether LBP continues to be a com- times quite complex, and clinicians, politicians, jour-
mon problem in older age is, however, not known with nalists, and lay people find them difficult to under-
certainty.8 Roughly one-third of LBP sufferers seek stand. This is often because they lack the necessary
care or treatment each year,9 although this figure tends knowledge of epidemiological methodology to prop-
to vary among geographic regions.10,11 Recently, the erly interpret these types of studies. Consequently, re-
negative impact of spinal problems on physical func- sults from epidemiological studies are frequently mis-
tioning has been shown to be similar in magnitude to understood, and the importance of single studies may
that of other health conditions such as hip and knee be overestimated.
osteoarthritis requiring arthroplasty and congestive This chapter reviews the most commonly used
heart failure.12 Consequently, the costs associated with study designs in modern epidemiology, as well as
RISK FACTORS FOR LOW BACK AND NECK PAIN 467
their strengths and weaknesses. Furthermore, basic

Pain
concepts of association and causal relationships are
reviewed. Finally, these concepts are related to what Change activities
is currently known about risk factors for LBP and neck
pain. Seek treatment
Sick leave
TYPES OF EPIDEMIOLOGIC STUDIES
Compen-
Common Issues sation
Definition of Low Back and Neck Pain To the novice, the
terms low back pain and neck pain might seem straight-
forward from a conceptual point of view. However,
when reading epidemiological literature, it soon be-
comes evident that this is not the case. Frank et al.
stated that “there are two problems with LBP [and
neck pain]: How to define it and how to measure it.”30
At present there is no gold-standard definition of LBP
and neck pain, and no objective measurement can reli-
ably determine whether LBP or neck pain is present in FIGURE 25–1. The “onion” definition of LBP. The rings each
an individual or not.31,32 As a consequence, a uniform represent a different aspect or consequence of LBP. When
definition of these conditions among different stud- reading epidemiologic studies it is important to note exactly
ies is lacking, and the terms low back pain and neck which aspects of the “onion” the study is dealing with.
pain probably cover heterogeneous groups of disor-
ders all related to the neck and lower back. Thus, these
terms do not necessarily imply a well-defined disease embedded in the term low back pain.39 These may be
or injury, but rather any symptom of pain, discomfort, more or less distinct or overlapping, and may have dif-
stiffness, or other trouble in the neck and low back ferent causal mechanisms (Fig. 25–2). This model pro-
area. Given that pain, as a symptom, is a subjective vides a good framework for clinical reasoning, when
sensation, prone to affecting the individual in highly dealing with patients in daily practice, as well as un-
variable ways, interpretation of epidemiological liter- derstanding the diversity in conclusions among epi-
ature may be quite difficult. The same degree of pain or demiological studies.
discomfort might, depending on the individual’s abil-
ity to cope with pain and other external circumstances,
C7
lead to different consequences. For example, neck pain
in one office worker may cause that person to seek
treatment or change jobs, whereas the coworker also C1 LBP7
experiencing neck pain and performing identical tasks C6
LBP1
is able to ignore the pain, not have treatment, and
LBP6
stay on the job. Awareness of how LBP and neck pain
are defined in different studies is therefore important. C2
LBP2
In some studies, for instance, LBP is defined as self-
reported pain based on a survey questionnaire33 ; in
others as notes in medical records34 ; and in still oth- LBP3 LBP5
ers as taking time off work35 or retiring from work
due to LBP.36 Finally, some authors do not provide C3
any definition of LBP in their papers at all.37,38 Conse- LBP4 C5
quently, results from studies often cannot be directly
compared because they use different definitions of the
outcome under investigation, namely LBP and neck
pain. In actuality, all of these definitions are probably C4
interrelated and there is some sort of logical sequence
of events, albeit often unknown, leading from one to FIGURE 25–2. Nonspecific low back pain (large circle) may
another (Fig. 25–1). consist of a number of largely unidentified subentities (smaller
Recently, Leboeuf-Yde and Manniche proposed circles: LBP1, LBP2, etc.), each having its own set of causal
that there are probably a number of subentities mechanisms (C1, C2, etc.).
as heavy lifting or repetitive office work. This same

risk factor might, however, be different from other
factors affecting the person’s behavior once pain has
occurred (e.g., low job satisfaction causing neck pain
patients to take time off from work once pain has
occurred, or favorable disability payments influenc-
ing patients’ decisions to retire instead of returning to
work after a period of absence). It is also important
to notice how information on exposure to the various
risk factors was obtained. For instance, self-reported
workload may be influenced by factors not directly re-
lated to the workload itself. For example, persons with
pain may perceive their job as more strenuous than
persons without pain.41 Therefore, detailed and spe-
cific information on exposure pertaining to the specific
person or occupation is desirable. However, identical
FIGURE 25–3. The most common definition of low back pain work tasks are performed in varying ways by differ-
and neck pain in epidemiologic literature according to the stan- ent workers,42 and such specific information requires
dardized Nordic questionnaire is “any trouble (pain, ache, dis- many resources and may not be financially and prac-
comfort) in the neck/low back.” tically feasible, particularly in large studies.43 If little
is known about disease etiology, which, frankly, is the
The most commonly used definitions of LBP and case for LBP and neck pain, larger population-based
neck pain in epidemiological research are derived studies with general measures of possible risk factors
from the standardized Nordic questionnaire.40 Here can help to clarify the picture, form new and believ-
LBP and neck pain are defined as “any trouble (ache, able hypotheses, and thus form the basis for future,
pain, discomfort) in the neck/low back.” This compo- more detailed studies.44
nent of the questionnaire is accompanied by a drawing Finally, while some diseases may have only one
with the area in question clearly shaded (Fig. 25–3). or very few causes, both LBP and neck pain are con-
sidered true biopsychosocial conditions.45 Thus, the
It is equally important to con-
Definitions of Risk Factors idea of a single causal mechanism in the majority of
sider the definitions of various risk factors (Fig. 25–4). LBP and neck pain cases is not appropriate based on
One risk factor might lead to the debut of pain, such current knowledge.
Epidemiological Study Designs

Pain Observational versus Experimental Studies Clinical epi-
demiological studies can be divided into two main
Change activities
groups, namely observational (or nonexperimental)
Seek treatment RF I and experimental studies. In observational studies the
Sick leave
researchers do not influence any parameters relevant
RF II to the study. They do not assign any exposure or treat-
Compen- ment to the study subjects. Instead, they study the
sation “natural” events that occur when environmental, so-
RF III
cial, genetic, and other factors influence each other
and the individual. The purpose of most observational
studies is to investigate whether possible risk factors
are associated with disease and to render probable
whether such associations might be causal. Observa-
tional designs are now being used more frequently
RF V in clinical research through the establishment of large
clinical databases, and in practice-based research in
RF IV primary care.46
In experimental studies, a number of test persons
FIGURE 25–4. Risk factors for pain initiation (RF I) might be are exposed to one or more external agents, such as
different from risk factors influencing a person’s decision to an experimental treatment. The most common ex-
take time off work because of pain (RF III) or to retire after perimental design is the randomized clinical trial. In
taking a period of sick leave (RF IV). epidemiological research, experimental designs are
TABLE 25–1. The Three Most Common Epidemiologic Study Designs
Time Adresses
Type of Study Purpose Perspective Causality
Cross-sectional To collect information about the Retrospective No

prevalence of diseases and
exposures in a population
Case-control To describe the differences in exposure in Retrospective No
a diseased and nondiseased population
Cohort To measure the increase of a given Prospective Yes
condition or disease in a population, as
well as to study the influence of positive
and negative risk factors over time
exceedingly rare, primarily for practical and ethical fundamental criterion of temporal relationship—that
reasons. is, the exposure has to precede the disease—cannot
be assessed by using this design simply because the
Measures of Disease in Populations A central task in epi- study subjects are not followed over a period of time
demiological research is to quantify the occurrence (see Association and Causality below).
of disease in populations. This is primarily done via Cross-sectional studies are very common in epi-
two measures: incidence and prevalence. Incidence demiological research within the fields of LBP and
is defined as the occurrence of new cases of a dis- neck pain, probably because they are relatively easy
ease in a given population over a given period of to perform and comparatively inexpensive. Cross-
time. Incidence frequencies might thus be expressed sectional studies are often used as supportive evi-
as, for example, “4 new cases of cervical cancer per dence for causal relationships. However, such argu-
100,000 women per year” or “30 new acute LBP cases ments can lead to serious erroneous conclusions.33
per year per 100 inhabitants.” Cross-sectional studies cannot, for practical purposes,
Prevalence measures the proportion of people who stand alone as evidence of a causal link between an ex-
have disease at a specific point in time, a measure of posure and a disease.
disease status. Prevalence is thus dependent on the Case-control studies are used to describe differences
rate of incidence and the duration of disease. Preva- in exposure between diseased and nondiseased popu-
lence might, for instance, be expressed as the point lations. Consequently, participants are selected based
prevalence (roughly 15% of the population have LBP on their disease status: Cases have the disease under
at any point in time), the 1-year prevalence (30% of investigation; controls do not have the disease. The in-
the population experience neck pain every year), or terplay between the exposure and the disease has, in
the lifetime prevalence (70–80% of the population ex- other words, already taken place and the researcher
perience LBP in their lifetime). compares past and present behaviors and exposure
Cross-sectional studies (see Table 25–1) are used to among cases and controls. Cases might be recruited
collect information about the occurrence (prevalence) via surveys or from registries, hospital records, or clin-
of diseases and the presence of one or more expo- ician’s offices. Controls are selected so that they re-
sures in a chosen population, such as the general semble the cases as much as possible with respect to
population or a group of workers. Usually, the expo- a number of predetermined parameters such as age,
sure information is collected simultaneously with the sex, social class, and marital status, but, of course, not
disease information in order to compare different ex- with respect to disease status. This is called matching.
posure subpopulations with respect to disease preva- Because a case-control study is by nature a retro-
lence. Questions such as “Are there more asthmatics spective design, the basic standard of temporal rela-
among smokers than among nonsmokers?” or “Do tionship between an exposure and a disease is again
more office workers than farmers have neck/shoulder not fulfilled, and definite conclusions about causal re-
problems?” can be answered through cross-sectional lationships cannot be derived from this type of study.
studies. On the other hand, questions such as “Does Also, bias in the form of differences in recollection be-
smoking cause asthma?” or “Does office work cause tween cases and controls is a common problem. Gen-
neck/shoulder problems?” cannot be answered us- erally speaking, cases have a better memory of poten-
ing cross-sectional studies. This is because of the tial risky behaviors than controls, probably because
diseased people tend to think more about reasons for

their misfortune than well people who are busy en-
joying life.
In spite of these limitations, case-control studies Environment Genes
are very useful for preliminary investigations and can
contribute valuable information before embarking on
larger and more expensive prospective studies.
Cohort studies are used to measure the increase of
a given condition or disease in a population, as well
as studying the influence of positive and negative risk
factors over time. A cohort is a group of people at risk
of being affected by a given condition. Cohorts might Disease
be composed of extracts of the general population or
other samples, such as back pain patients, vegetari-
ans, or different working populations. Participants in
a cohort study are thus followed over a period of time
and the cumulative effect of various exposures on the FIGURE 25–6. Model for genetic epidemiologic research.
participants’ health can be studied.
Assumptions about causal relationships can be cal research methods, it is now possible to estimate
made based on cohort studies. This is because the genetic contributions to diseases, as well as to ad-
temporal sequence of events (i.e., exposure occurring dress the interplay and interaction between genes and
before or after the onset of disease) can be mapped. environment,48 thus taking into account possible ge-
Keep in mind that sometimes exposures occurring to netic confounding (Fig. 25–6).
subjects before initiating the study can influence the Family studies are used to examine whether there
health of participants during the study period and is evidence of aggregation of a certain disease or con-
consequently lead to erroneous conclusions. There- dition within families. Sometimes, in hereditary dis-
fore, inferences about causal connections are usually eases, family studies provide information regarding
not made until results of several cohort studies point the mode of inheritance.49 However, in conditions
in the same direction. with what are probably complex etiologies, such as
Potential sources of bias in this type of study in- LBP and neck pain, family studies cannot be used
clude selection bias (not forming a cohort represen- to determine whether an observed familial clustering
tative of the target population), information bias (not is a result of shared environment or shared genetic
collecting information in an objective and systematic predisposition.49
way), and bias as a consequence of dropout (ending up Twin studies are used to provide evidence for both
with an incomplete cohort because subjects may not genetic and environmental contributions to disease
return or complete all questionnaires or fail to show development. Twin studies provide a number of spe-
up for examinations). cial research methodologies that may be used in
assessing the relative contributions of genetic and en-
Epidemiologists
Genetic Epidemiological Study Designs
vironmental factors to diseases.48 Twin study method-
commonly investigate the relationship between en- ology is based on the fact that monozygotic (MZ)
vironmental factors and disease outcomes (Fig. 25–5). twin pairs are genetically identical, whereas dizy-
For more than 100 years, however, possible genetic gotic (DZ) twin pairs, like ordinary siblings, share
contributions to disease etiology have been investi- roughly 50% of their genes. Furthermore, twins are
gated through the use of family and twin studies.47 matched for a large number of known and unknown
With recent developments in genetic epidemiologi- environmental factors. They share prenatal environ-
ment and often early and later life environments such
as geographic location, socioeconomic background,
nutrition, leisure-time activities, and possible toxic
exposures.
Based on the assumption that the intrapair dif-
Environment Disease ference in environment is the same for MZ and DZ
twins, a higher degree of similarity with respect to the
presence of a disease among MZ pairs than among DZ
pairs can be taken as evidence of a genetic contribu-
tion to the etiology of the disease under study. Simi-
FIGURE 25–5. Model of traditional epidemiologic research. larly, so-called concordance rates (statistical measures
of similarity) in MZ and DZ twin pairs may indicate circumstances, making findings in epidemiological
that the disease or condition is mainly a result of en- studies appear inconsistent. However, when all causal
vironmental factors. mechanisms of a disease or condition are understood
With the formation of large population-based twin (which, unfortunately, is rarely the case), consistency
registries in several countries,50,51 and the advance of becomes apparent and evident.
methods in molecular biology, knowledge of the role
of genetic factors in a number of diseases, including Temporality
musculoskeletal conditions, will be greatly enhanced A risk factor must precede the effect or disease in time
in the future. to be causal, just as any treatment rendered for a given
disease must precede the cure in order to be labeled
successful. In fact, if the putative cause does not pre-
ASSOCIATION AND CAUSALITY
cede the disease or condition in question, this can be
Before embarking on a detailed description of vari- taken as evidence that the observed association is not
ous risk factors in relation to LBP and neck pain, it is causal under the given circumstances.
worth asking how it is possible to distinguish causal A particular form of bias arising from studies not
from noncausal associations. This is relevant because addressing temporality is the “healthy worker” effect.
factors occurring together, even on a fairly consistent This is defined as a self-selection process that allows
basis, are not necessarily causally related. Think, for relatively healthy people to remain in certain jobs or
instance, about back pain and shoe size: More adults daily functions, whereas those who change jobs are
than children have back pain and they also consis- as a group less healthy.54 In relation to LBP, it was
tently have larger feet. In spite of this, nobody (hope- recently shown that even using the same cohort in a
fully) in their right mind would conclude that larger cross-sectional and 5-year prospective study, results
feet cause back pain. were radically different between the two because of
In clinical medicine, randomized clinical trials are migration between exposure groups over time.33
normally used to provide evidence for causal rela-
tionships between diagnostic procedures, preventa- Dose–Response
tive measures, or treatments and specific outcomes. Dose–response refers to the presence of a monotonic
Randomized clinical trials are, however, rarely fea- biologic gradient; that is, larger exposures to a cause
sible when studying causes of disease. Instead, ob- are associated with higher rates or more severe dis-
servational studies (i.e., studies without any direct or ease. Such a dose–response relationship is clearly seen
indirect interference from the researchers) are used. in, for instance, smoking in relation to lung cancer.
Consequently, in questions relating to disease etiol- However, the presence of a monotonic dose–response
ogy, it is not possible to prove causal relationships relationship does not exclude the possibility of bias,
with the same degree of certainty.52 Therefore, sev- and many times the relationship between a risk factor
eral studies must be done to build up evidence for and a condition might resemble more of a J-shaped
or against a cause, and even then definite conclusions curve, or even exhibit only a single jump (threshold),
might prove elusive.52 rather than a monotonic trend.
A commonly used set of criteria to distinguish
causal from noncausal associations was proposed by Plausibility
Hill in 1965,53 and even today these criteria form the This criterion refers to the biologic plausibility of a
practical basis for such inferences.52 The most weighty hypothesis and thus relates to knowledge of human
of these criteria are strength, consistency, temporality, biology. While biologic plausibility is certainly an im-
dose–response, and plausibility. portant concern, it is not necessarily objective and
rests entirely on established beliefs, and should thus
Strength be used with caution.
Strong associations are more likely to be causal than
weak ones, whereas weak associations are more likely
RISK FACTORS FOR LOW BACK PAIN
to be explained by undetected biases. However, the
fact that an association is weak does not entirely rule In 1987, Hildebrandt reviewed the epidemiological
out a causal connection. literature and was able to identify 73 individual
and 24 work-related risk factors for LBP.55 However,
Consistency 10 years later Leboeuf-Yde et al. proposed that the
Consistency refers to the repeated observation of an causes of LBP were still largely undetermined!56 Much
association in different populations and under dif- of the confusion in this area is probably a result of the
ferent circumstances. Bear in mind that some effects aforementioned heterogeneity in LBP definitions and
might be produced only under specific or unusual other variation in quality of scientific studies.21,57,58
The following sections review the evidence for the osteoporosis and microfractures of the trabeculae of
most commonly suspected risk factors and discuss the vertebral bodies,65 and reduced blood flow to
whether the associations are merely associations, or the vertebral bodies in smokers leading to altered
whether there is evidence for a causal link. metabolic activity in the vertebral endplates affecting
the nutrition of the intervertebral discs.66
Social Factors Two major systematic reviews dealing specifi-
Family RelationsBoth Turk et al. and Payne et al. found cally with smoking in relation to LBP were recently
that family relations influenced the prevalence, per- published.23,63 Leboeuf-Yde, after reviewing results
sistence, and activity limitation in chronic pain syn- from 47 epidemiologic studies published between
dromes, including LBP.59,60 1974 and 1996, concluded that although the majority
of studies supported an association between smok-
Social Group Social group is probably an imprecise ing and LBP, the association was generally weak, and
division containing a large number of social, edu- because no true incidence data were found in the
cational, financial, lifestyle-related, and psychosocial larger prospective studies, it was not possible to study
factors. According to Waddell et al., the scientific lit- whether smoking preceded the onset of LBP.67 Nev-
erature is contradictory with respect to the influence ertheless, in the study with the largest sample size
of social group on the occurrence of LBP.61 (>38,000), a significant monotonic dose–response re-
lationship was found.45 Leboeuf-Yde concluded that
smoking should be considered a weak risk indicator
Compensation and Litigation The majority of studies
and not a definite cause of LBP.23 Goldberg et al., af-
dealing with the influence of compensation and lit-
ter reviewing 38 studies published between 1976 and
igation originate in the United States and Canada,
1997, concluded that smoking is fairly consistently
and these factors undoubtedly influence the behav-
associated with nonspecific LBP, and that a number
iors of people with LBP. Nevertheless, Waddell et al.
of plausible biological mechanisms exist that could
conclude that there is no convincing evidence that
potentially explain these associations.63 However, be-
pending litigation and compensation directly affect
cause patterns of smoking and LBP had only been ad-
spinal conditions or increase LBP.61 Furthermore,
dressed in very few high-quality longitudinal studies,
Mendelson, after reviewing a large number of studies,
no definite conclusions regarding causality could be
concluded that settlement of litigation and compen-
made.63
sation does not result in substantial changes in symp-
toms and limitation of activities in LBP patients.62
Obesity Excessive body weight has been suspected of
Smoking Cigarette smoking is a major cause of ill increasing mechanical demands on the lumbar spine,
health worldwide, and smoking has been associated which, in turn, might lead to LBP.68 Indeed, in a large
with some aspect of LBP (see Table 25–2) in at least number of epidemiological studies on risk factors for
40 epidemiological studies.63 A number of plausi- LBP, body weight has been included in the statistical
ble biological mechanisms have been suggested to analysis as a covariant. In 2000, Leboeuf-Yde system-
explain this association, including increased cough- atically and critically reviewed 65 studies investigat-
ing activity leading to increased abdominal pressure, ing this question.69 She found that a positive associ-
which, in turn, increases intradiscal pressure,64 diation was reported in only one-third of the studies,
minished bone-mineral content in smokers leading to that the association between obesity and LBP in large
TABLE 25–2. Summary of the Evidence for or Against a Causal

Relationship Between Lifestyle-related Exposures and Low Back Pain
Psychosocial
Physical Factors in
Smoking Obesity Alcohol Fitness Private Life
Strength No No No No No
Consistency Yes No No No No
Temporality No No No No Yes
Dose–response Yes/No No/Yes No No No
Biologic plausibility Yes Yes Yes Yes Yes
Evidence for causality No No No No No
population-based studies is weak and inconsistent, specific sports, or other physical activities during
and that none of the larger studies contained infor- leisure time.”74 On the other hand, Hildebrandt et
mation on temporality.69 Hence, she concluded that, al., after reviewing 39 studies published from 1975
in spite of a very large number of studies, there is onward, concluded that “stimulation of leisure time
insufficient evidence to determine whether there is a physical activity may constitute one of the means of
true causal relationship between obesity and LBP.69 reducing musculoskeletal morbidity [including LBP]
in the working population, in particular in sedentary
Alcohol Consumption of alcohol might lead to un- workers.”75
coordinated movements rendering the lumbar spine Both groups of authors agreed that the scientific
vulnerable to injury. Furthermore, excessive drinking literature on this subject showed inconsistent results,
is associated with social and psychological problems and that better longitudinal studies were needed to
that might influence illness behaviors. Additionally, adequately address the issue of poor physical fitness
consumption of alcohol often goes hand in hand with as a predictor for LBP.
smoking, which is fairly consistently associated with
LBP. Not many studies have dealt with the question Psychosocial Factors in Private Life According to
of excessive alcohol consumption in relation to LBP. A Hoogendoorn et al., only three studies have dealt
systematic, critical review published in 2000 included with the issue of psychosocial factors in private life
only nine studies published between 1992 and 1998.70 in relation to LBP, and only one of these studies
None of the nine studies showed a significant posi- was prospective.22 Muramatsu et al. found that in a
tive association between excessive drinking of alcohol group of elderly Japanese subjects, high emotional
and LBP.70 However, the author concluded that large, support had a significant positive effect in chronic
carefully designed, prospective studies were needed LBP.76 Whether these findings can be generalized to
to properly address this question.70 other populations in different settings is currently
unknown.
Physical FitnessOver the past decades a dramatic shift
has occurred in the treatment of LBP patients. The use Work-Related Factors
of largely passive treatments and bed rest has been re- According to recently published guidelines from the
placed by the promotion of physical activity. It is there- British Faculty of Occupational Medicine, there is
fore tempting to speculate that persons with a low strong epidemiological evidence that physical de-
level of physical activity at leisure time might have mands at work (manual materials handling, lifting,
a higher risk of developing LBP, and that staying in bending, twisting, and whole-body vibration) can be
good physical shape can prevent LBP. Indeed, subjects associated with increased reports of back symptoms,
with healthy low backs have significantly higher val- aggravation of symptoms, and “injuries.”77
ues in isometric and isokinetic trunk extension tests
and longer muscle holding times than subjects with Lifting Manual materials and patient handling (e.g.,
either intermittent or chronic LBP.71 However, it is working as a manual construction worker or nurse’s
unknown whether these weaker muscles precede the aid) in relation to LBP (see Table 25–3) have been
onset of LBP or might be a result of the pain. Other investigated in a large number of studies, several
studies show that persons with LBP might not be of which are acceptable in terms of methodological
deconditioned, when compared with persons with- quality.74 According to a recent systematic review,
out LBP. Recently, for instance, Wittink et al. showed there is strong evidence for manual materials han-
that levels of aerobic fitness in patients with chronic dling and moderate evidence for patient handling as
LBP were comparable to those in healthy subjects.72 risk factors for LBP.74
Burdorf and Sorock, in a review of 35 epidemiological
studies published between 1980 and 1996, concluded Bending and Twisting Punnett et al. found that persons
that leisure-time exercise was not consistently associ- exposed to frequent bending and twisting of the lum-
ated with either negative or positive effects in working bar spine were more than eight times as likely to expe-
populations.73 rience LBP than persons who did not twist and bend
Two recent major reviews dealt with the issue on the job.78 Based on this and other findings, both
of leisure-time physical activities in relation to LBP. Hoogendoorn et al. and Burdorf et al. concluded that
Hoogendoorn et al. reviewed 28 cohort and 3 case- there is strong evidence for a positive effect of frequent
control studies published between 1966 and 1997.74 bending and twisting in relation to LBP.73,74
They concluded that “there appeared to be no evi-
dence for an effect of sports, due to inconsistent find- Standing or Walking The extensive literature shows in-
ings” and that “no evidence was found for an effect consistent results and thus there is no evidence for an
of total physical activity during leisure time, various effect of prolonged standing or walking.74
TABLE 25–3.Summary of the Evidence for or Against a Causal Relationship Between Physical and
Psychosocial Exposures in the Workplace and Low Back Pain
Materials Bending Standing Heavy Social Mental

and Patient and or Whole-Body Physical Support Stress at Job
Handling Twisting Walking Sitting Vibration Work at Work Work Satisfaction
Strength No Yes No No No No No No No
Consistency Yes Yes No Yes No No No No Yes
(negative)
Temporality Yes Yes Yes/No No Yes Yes/No No No Yes
Dose–response Yes/No Yes/No No No Yes/No Yes/No No No No
Biologic plausibility Yes Yes Yes Yes Yes Yes No No Yes
Evidence for causality Likely Likely No No No No No No Likely
Sitting Hartvigsen et al. systematically and critically in only one study. Unfortunately, many of these stud-
reviewed 35 epidemiological studies published be- ies are of questionable scientific quality,81 and as a
tween 1985 and 1997 that specifically dealt with sit- consequence the effect of the majority of psychoso-
ting while at work in relation to LBP.21 They found cial variables on LBP cannot be properly assessed.
that studies concurrently, and irrespective of quality, Some variables have, however, been studied more ex-
failed to show a significant positive association be- tensively, including social support at work, mental
tween sitting at work and LBP. On the contrary, studies stress at work, and low job satisfaction. The combined
of better quality tended to show a negative association effect of various psychosocial factors has also been
between the two (i.e., persons sitting down for longer shown to influence care seeking for LBP,82 and Linton
periods of time experienced less LBP than persons sit- concluded that psychosocial variables generally have
ting down only a little or not at all).21 more impact than biomedical or biomechanical fac-
tors on back pain disability.83 Waddell and Burton
Whole-Body Vibration Lings and Leboeuf-Yde reviewed concluded that “there is strong evidence that low job
the epidemiological literature dealing with whole- satisfaction and unsatisfactory psychosocial aspects
body vibration and LBP.79 They concluded that al- of work are risk factors for reported LBP, health care
though the quality of the reviewed articles was gen- use, and work loss, but the size of the association is
erally low and evidence for a causal link was lacking, modest.”77 Recently, however, the conclusions of the
there are sufficient reasons for the reduction of whole- Boeing study have been challenged,84 and the picture
body vibration exposure to the lowest possible level.79 at present is far from clear.
Heavy Physical Work In many studies, the nonspecific Social Support at Work This variable includes aspects
exposure described as “heavy physical work” is stud- of social support from colleagues, superiors, and the
ied as a general measure of physical activity in the employer. In some studies, a significant positive as-
workplace. Included in this group are workers who sociation between social support and LBP has been
were likely exposed to some of the more specific reported,80,85 while in other studies no association was
risk factors mentioned previously (e.g., lifting, bend- found.86,87 Hoogendoorn et al., after systematically
ing). Results are inconsistent, although the majority of reviewing 11 cohort and 2 case-control studies, con-
high-quality studies tend to associate heavy physical cluded that there was evidence for reduced social sup-
work with LBP.33,73,74 port in the workplace as a risk factor for LBP. However,
the effect was low and small changes in the sensitivity
Psychosocial Factors in the Workplace analysis caused this effect to disappear.22
Since the landmark Boeing study, which concluded
that job satisfaction was the single most important Mental Stress at Work This variable includes aspects
factor responsible for the reporting of LBP in aircraft of peer and time pressure, along with difficulties in
factory employees,80 a wealth of work-related psy- coping with work demands. Increased mental stress
chosocial factors have been investigated in relation has been related to back complaints among construc-
to different aspects of LBP. In 37 studies published tion workers,88 and to medically diagnosed back pain
between 1990 and 1998, 46 different variables were in the Finnish work force.89 However, in a number of
investigated, with more than half being investigated studies this association was not found.90–92 Thus, at
present, there is insufficient evidence of an effect of the incidence and improve the prognosis of whiplash
mental stress in relation to LBP.22 injury in the Saskatchewan population.95
Job Satisfaction “Job satisfaction,” much like “heavy Lifestyle-Related Factors

physical work,” is an unspecific measure of a self- Smoking Cigarette smoking is clearly associated with
perceived exposure. Job satisfaction has been inves- LBP (see Table 25–4), even though evidence for a
tigated fairly extensively in relation to LBP. In two causal link between the two is lacking.23,63 Côté et
recent reviews and a PhD thesis,22,73,81 low job satis- al., on the other hand, did not find such an associa-
faction was found to be associated with aspects of LBP tion between either mild or severe neck pain in the
(e.g., care seeking and time off work), particularly in Saskatchewan population.18
studies of better quality.
Sports and Exercise Several studies have dealt with the
Individual Factors relationship between neck pain and participation in
Age Population-based studies mostly show an in- sports and exercise. Mundt et al., for instance, inves-
crease in the prevalence of LBP up to about age 40– tigated participation in baseball, golf, bowling, swim-
50 years, leveling off in the older age groups,88,93,94 ming, diving, jogging, aerobics, racket sports, and lift-
although the exact prevalence of LBP in the older age ing of weights, and found borderline or neutral effects
groups is not known with certainty.8 for all of these in relation to neck pain.96 In an extensive
review of physical risk factors for neck pain, Ariëns
et al. stated that there was inconclusive evidence for
Body Height According to the review by Burdorf and
a relationship between sports and exercise and neck
Sorock, the effect of body height on LBP cannot be
pain.20
determined based on the current literature.73
Traffic Collisions (Whiplash) The impact of whiplash-

RISK FACTORS FOR NECK PAIN associated disorders on both individuals and society
at large has been extensively documented in the litera-
The list of suspected etiological factors for neck pain is ture. However, the persistence of symptoms is related
also long and extensive. Again, comparison of studies to factors not directly influenced by the injury itself,95
is often difficult because of heterogeneity in neck pain making this a difficult area to study. Côté et al. found
definitions and other variations in study quality. In the a significant association between a history of rear-end
following sections, evidence for the most commonly traffic collision and mild, moderate, and severe neck
suspected risk factors for neck pain are reviewed, and pain and headaches that moderately to severely im-
whether the associations are merely associations or pact the person’s life.15,18 However, because this was
whether there is evidence for a causal link is discussed. a cross-sectional study, these results cannot be used
to infer a causal relationship between whiplash and
Social Factors chronic neck pain and headaches.17 Berglund et al.,
Very few studies deal with the issues of family influ- in a Swedish cohort study, investigated the differ-
ence, social group, and compensation and litigation ences in risk of experiencing neck pain 7 years after a
in relation to neck pain.61 The elimination of compen- motor vehicle accident in drivers reporting whiplash
sation for pain and suffering did, however, decrease compared to those not exposed to whiplash.97 In
TABLE 25–4. Summary of the Evidence for or Against a Causal

Relationship Between Lifestyle-Related Exposures and Neck Pain
Psychosocial
Driving Factors in
Smoking Exercise Whiplash Vehicle Private Life
Strength No No Yes/No No No
Consistency Yes No No No No
Temporality No No Yes Yes Yes
Dose–response No No No No No
Biologic plausibility Yes Yes Yes Yes Yes
Evidence for causality No No Likely No No
TABLE 25–5.Summary of the Evidence for or Against a Causal Relationship Between Physical and
Psychosocial Exposures in the Workplace and Neck Pain
Fixed Twisting
Arm Force Sedentary and Job
Neck and Work Workplace Hand/arm Bending Demands/ Social Job
Posture Posture Posture Design Vibration of Trunk Control Support Satisfaction
Strength No No No No No No No No No
Consistency No Yes/No Yes/No No Yes Yes Yes/No Yes/No Yes
Temporality Yes No Yes No No Yes No No Yes
Dose–response No No No No No No No No No
Biologic plausibility Yes Yes Yes Yes Yes Yes Yes Yes Yes
Evidence for causality No No Likely No No Likely No No Likely
drivers with reported whiplash injury, the risk of neck Physical Exposures
and shoulder pain 7 years after the collision was in- Neck Posture Many neck pain patients claim that their
creased nearly threefold when compared to unex- pain is aggravated by different neck postures. How-
posed subjects.97 The authors also found increased ever, that does not necessarily mean that these pos-
prevalences of various other health complaints among tures are also risk factors for neck pain (see Table 25–5).
the subjects exposed to whiplash, including headache, According to Ariëns et al., all four studies investigat-
thoracic and low back pain, fatigue, sleep disturbance, ing neck flexion in relation to neck pain found an
and general ill health.97 In spite of these findings, how- association.20 However, all four studies were cross-
ever, neck pain and headache after a whiplash injury sectional and of low methodological quality, and the
are generally considered to have a good prognosis for evidence was judged to be inconclusive.20 In only
recovery after a few months,98 and still more research one cross-sectional study has neck extension been in-
is needed before the exact role of rear-end traffic col- vestigated in relation to neck pain.103 This study in-
lisions in the genesis of neck pain is known.99 dicated a correlation; however, with only one low-
quality cross-sectional study available, the evidence is
Driving a VehicleAccording to Ariëns et al., driving a inconclusive.20 Ariëns et al. found two studies dealing
vehicle was assessed in relation to neck pain in only with neck rotation in relation to neck pain.20 Unfortu-
two studies.20 Skov et al. found increased risk for neck nately, the authors reached opposing conclusions, and
pain with greater distances driven,100 whereas Viikari- thus the evidence is, again, inconclusive.
Juntura et al. found no relationship between annual
car driving distance and neck pain.101 Thus, there is Arm Force and Arm Posture Ariëns et al. found 12 stud-
inconclusive evidence for a relationship between driv- ies dealing with arm force—that is, the force exerted
ing a vehicle and neck pain. by the arm in order to complete a work task—and pos-
ture in relation to neck pain.20 The majority of stud-
Psychosocial Factors in Private Life ies pointed in the same direction, namely, supporting
Linton, after systematically reviewing 37 studies pub- such an association. However, there were major dif-
lished between 1985 and 1998, concluded that psy- ferences between the studies regarding definitions of
chosocial variables were linked to the transition from neck pain and definitions and measurements of arm
acute to chronic neck pain, as well as neck pain– force and posture.20 Hence, it was concluded that the
related disability.83 Furthermore, psychosocial fac- current evidence was inconclusive.20
tors were associated with increased reporting of neck
pain.36 Bernard et al. reported a nonsignificant rela- Duration of Fixed Sedentary Work Postures In studies
tionship between neck pain and lack of social support dealing with sedentary work postures in relation to
from friends and family,102 and Dartiques et al. re- neck pain, quite diverse methods of measuring the
ported a significant relationship between neck pain sitting postures of workers have been used. For ex-
and conflicts with friends and family.103 Most studies, ample, Bernard et al. measured “the time spent on the
however, have dealt with psychosocial factors in the telephone,”102 whereas Kamwendo et al. studied “the
workplace and the literature is not conclusive regard- time spent working with office machines.”25 Never-
ing the influence of these factors on neck pain outside theless, Ariëns et al. found that the majority of studies,
the work environment. particularly the studies of better quality, supported an
association between fixed, sedentary work postures between quantitative job demands/job control and
and neck pain.20 neck pain.108 Also, a very recent prospective study
showed that quantitative job demand was an indepen-
Workplace Design Workplace design, that is, adjustable dent risk factor for neck pain.109 On the other hand,
chairs and tables, correct height of keyboard and com- studies dealing with opportunities to take rest breaks
puter screens, and so on, receive much attention in when needed did not find that having such opportu-
today’s office environment. The connection between nities decreased the prevalence of neck pain.102,108
“incorrect” workplace design and neck pain, however,
is not entirely clear. Schibye et al. found that there was Social Support Social support in the workplace can
no significant relationship between lack of individ- be divided into support from superiors or supervi-
ual adjustment for tables and chairs and self-reported sors and support from coworkers. Ariëns et al. found
neck pain.104 On the other hand, other studies sup- and reviewed five cross-sectional studies dealing with
port such an association.105,106 Ariëns et al., in their low supervisor support in relation to neck pain, and
extensive review, concluded that there was insuffi- concluded that there was insufficient evidence for an
cient evidence for a causal relationship between poor effect.108 Three studies dealing with low coworker
workplace design and neck pain, mainly as a result of support in relation to neck pain were found and re-
methodological problems in the reviewed studies.20 viewed and even though the estimates were found to
be low, the better-quality studies tended to support
Hand/Arm Vibration Bovenzi et al. found a significant, the existence of such an association.108 Furthermore,
positive relationship between hand/arm vibration one newer prospective study associated low coworker
and self-reported neck pain,107 and Ariëns et al. con- support with self-reported neck pain.109
cluded that there were consistent findings of positive
relationships between the two.20 They also concluded Job Satisfaction In the only cohort study dealing with
that there were major methodological problems in all psychosocial factors at work in relation to neck pain,
of the studies reviewed.20 Viikari-Juntura et al. found a significant positive rela-
tionship between low job satisfaction and the transi-
Twisting and Bending of the Trunk Viikari-Juntura et al. tion from no neck pain to severe neck pain.101 Because
conducted a prospective cohort study and found a this finding was supported by two cross-sectional
significant, positive association between both bending studies, Ariëns et al. concluded that there is some evi-
and twisting of the trunk and neck pain.101 Ariëns et al. dence for a positive relationship between low job sat-
included an additional three cross-sectional studies isfaction and neck pain.108
in their review, all pointing in the same direction.20
Thus, there is some evidence for a positive relationship
GENETIC FACTORS IN LOW BACK PAIN
between bending and twisting of the trunk and neck
AND NECK PAIN
pain.
The contribution of genetic factors to various traits or
Psychosocial Factors in the Workplace diseases can be estimated via familial studies, in stud-
As with LBP, a wealth of work-related psychosocial ies using twin samples, and via linkage analysis in
factors have been investigated in relation to neck molecular biology studies. All of these methods have
pain. In a recent systematic review, again by Ariëns been used in relation to spinal problems. In particular,
et al., covering studies published between 1966 and lumbar, and to a lesser extent cervical, disc degenera-
1997, these variables were grouped under more or tion and herniation have been focuses of interest. Both
less homogenous headings.108 Unfortunately, only 1 of Richardson et al. and Matsui et al. found an increased
29 of the reviewed studies was prospective;101 conse- risk for lumbar disc degeneration and discogenic LBP
quently, inferences regarding causal relationships are in adult relatives of patients with surgically treated
difficult to make. lumbar disc herniations.110,111 Concurrently, Varlotta
et al. found a relative risk of developing a herniated
Quantitative Job Demands/Job Control Ariëns et al. lumbar disc in juveniles to be approximately five times
found 22 studies dealing with quantitative job de- greater in patients with a family history of lumbar disc
mands, that is, the amount of work to perform in a disease.112
given time period, or job control, in relation to neck Twin samples were used by Battie and
pain.108 Even though much variation between stud- Sambrook.113–115 Battie et al., in a study using only
ies was found and even though none of the studies MZ twins, concluded that a strong influence of genetic
were longitudinal, the majority indicated a positive re- factors should be suspected in degenerative changes
lationship. Accordingly, Ariëns et al. concluded that as seen on magnetic resonance imaging (MRI),66,114
there was some evidence for a positive relationship whereas Sambrook et al., in a study comparing
findings in MZ and DZ twins, concluded that al- sense and feasibility in each situation. Firm conclu-
though an important genetic influence on the vari- sions and strong general recommendations cannot
ation in intervertebral disc degeneration had been currently be justified based on the available literature.
found, variations in disc signal both in the lum- Perhaps the greatest challenge to clinicians is to
bar and cervical spine were largely influenced by keep up with the extensive and growing body of scien-
environmental factors shared by twins.115 tific literature and to familiarize themselves with cri-
Annunen et al. found evidence for an allelic as- teria for evaluating research papers, that is, be able to
sociation in patients with lumbar disc disease when distinguish good from bad research. Changing prac-
they identified a putative disease-causing sequence tice behaviors as new and better information emerges
variation that converted a codon for glutamine to one is essential in an evidence-based health care environ-
for tryptophan in 6 of 157 cases, but in none of the ment.
controls.116 To researchers, the challenge is to provide mean-
Heikkilä et al. investigated the genetic contribu- ingful, manageable, and clinically relevant defini-
tion to sciatica in a classic twin study.117 They found tions of LBP and neck pain in their various presen-
that environmental factors accounted for more than tations, so that real subgroups of patients, risk factors,
80% of the etiology of sciatica in ambulatory patients and predictors of chronicity in these groups can be
and in more than 90% in hospitalized patients.117 identified.19 Much effort has already been used trying
Bengtsson et al. found that the influence of heavy to identify general predictors and risk factors. How-
physical workloads on self-reported LBP was greater ever, little is known about the interplay between phys-
for MZ than for DZ twins.118 However, their results ical exposures both at work and during leisure time,
are difficult to interpret, partially because they did not and between different psychosocial variables. Well-
use a classic twin-control approach in the statistical designed, large, longitudinal studies dealing with the
analysis. long-term effects of both specific physical and psy-
In summation, there is some evidence for a genetic chosocial exposures at home and in the workplace
component in both lumbar and cervical disc degenerin an integrated analysis can contribute knowledge
ation, whereas the genetic contribution to LBP and about true causal connections for the various types
neck pain per se is largely undetermined. of LBP and neck pain. Additionally, studies based on
large twin samples can help identify groups of indi-
viduals who might be genetically predisposed to—or
CHALLENGES TO CLINICIANS
protected from—disease if exposed to certain environ-
AND RESEARCHERS
mental factors.
Effective prevention for low back and neck pain is
currently an illusion as evidenced by the extremely
SUMMARY
high 1-year and lifetime prevalence rates. Informing
the population and patients about risk factors and pre- Today, no “gold-standard definitions” of LBP and
vention is therefore not easy for the clinician. Unfortu- neck pain exist, and many different definitions are
nately, little is known with certainty, and health care used in epidemiological studies. Furthermore, vari-
providers need to be very conscious not to provide ous suspected risk factors are defined and measured
information on the basis of old myths and personal in a variety of ways. This makes comparison of re-
beliefs. The truth is that much more is unknown than sults from different studies difficult. In epidemiolog-
known regarding risk factors for LBP and neck pain, ical research, the vast majority of studies are of an
and providing opinionated and unsubstantiated in- observational design; that is, researchers observe and
formation can have serious health and financial conse- measure a number of predetermined parameters in
quences for both individuals and society at large. For a defined study population without influencing any
example, billions of dollars have been spent world- parameters relevant to the study. The most common
wide on ergonomic improvements in the office envi- research designs in epidemiology are cross-sectional
ronment in order to prevent LBP, among other rea- studies, case-control studies, and cohort studies. Fam-
sons, and now recent reviews conclude that, at least ily and twin studies are genetic epidemiological study
on a large scale, sitting on the job should not even designs that can be used to describe and determine the
be considered a risk indicator for LBP.21,74 Obviously, genetic effects on disease occurrence as well as possi-
much more research is needed in this field before the ble interactions between genes and environment.
true causes of LBP and neck pain are known. The hon- Even factors occurring together on a fairly con-
est, informed clinician should convey this informa- sistent basis might not be causally related. Therefore,
tion to patients and, in an open dialogue, analyze the several studies must be carried out to build up ev-
patient’s situation and base individual recommenda- idence for or against causes of disease. Commonly
tions on what little is known combined with common used criteria for determining causal relationships
include strength, consistency, temporality, dose– Case-control studies. Individuals with a given
response, and plausibility. disease or condition (cases) are compared to mat-
A large number of lifestyle and work-related fac- ched individuals without the disease or condi-
tors have been studied in relation to low back and tion (controls) for a range of exposures. By def-
neck pain, including physical, psychological, and psy- inition case-control studies are retrospective and
chosocial factors. However, for the vast majority of pa- cannot be used as definite evidence for causal
tients a true causal connection has not been proven. relationships.
Both LBP and neck pain are true biopsychosocial con- Cohort studies. Prospective studies used to
ditions and probably not any one causal mechanism measure an increase in a given condition or dis-
is responsible for all cases. The genetic contribution in ease in a well-defined population, as well as to
the genesis of low back and neck pain is also largely study the influence of positive and negative risk
undetermined. factors over time. Cohort studies are often used as
It is important that clinicians be aware of the ex- evidence of causal relationships.
panding scientific literature in this field and advise 3. Traditional epidemiologic studies address the rela-
patients according to the newest knowledge. tionship between the environment (broadly speak-
ing) and the health in populations. In genetic epi-
demiologic studies genetic contributions to health,
as well as the interplay between genes and envi-
ACKNOWLEDGMENTS
ronment, can be addressed.
Roni Evans, DC, MSc, is gratefully acknowledged for reading 4. Today no “gold standard” and commonly ac-
through the manuscript and contributing valuable suggestions. cepted definitions of back and neck pain exist. The
same is true for a range of the factors suspected of
causing back and neck pain. Furthermore, the ma-
jority of epidemiologic studies dealing with back
QUESTIONS and neck pain are retrospective (see above) and
cannot be used to address causality.
1. List four important criteria for distinguishing 5. It is important that clinicians do not give pa-
causal from noncausal associations. tients opinionated and unsubstantiated informa-
2. List the three most common types of epidemiolog- tion about causes of back and neck pain. The
ical study design and their characteristics. true causes of back and neck pain are not known,
3. How does genetic epidemiology differ from tradi- and clinicians should convey this information to
tional epidemiology? their patients, analyze the patients’ situation, and
4. Explain why definite conclusions about causes for base individual recommendations on what little is
neck pain and LBP cannot be made at this time? known combined with common sense and feasi-
5. How might clinicians advise patients regarding bility in each situation.
prevention of neck and low back pain?
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81. Hartvigsen, J. Occupational factors and low back pain future neck or shoulder pain: A cohort study. J Clin
[PhD thesis]. University of Southern Denmark, 2001. Epidemiol 2000;53:1089–1094.
82. Vingard E, Alfredsson L, Hagberg M, et al. To what 98. Kasch H, Stengaard-Pedersen K, Arendt-Nielsen L,
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S E C T I O N
INTRODUCTION TO THE
III
CLINICAL EXAMINATION
The clinical examination section in this textbook de- say that laboratory tests and imaging studies are not
scribes current methods of assessing a patient prior important. However, they only should be used following
to beginning treatment. It includes chapters that out- a thorough case history and physical examination once
line, in some detail, the major components of the exit is fairly clear what is wrong and the problem has been
amination of a patient, starting with the case history narrowed to a short list of differential diagnoses. A clin-
and ending with advanced laboratory and imaging pro- ician may then elect to do a high-tech study to confirm
cedures. As licensed clinicians, chiropractors have the the diagnosis, obtain objective evidence of the condition,
privilege and obligation to formulate a diagnosis for each or quantify an expected pathology.
of their patients, that is, put into words what is wrong Consequently, this section begins with a discussion
with the patient using commonly accepted, descriptive of the case history by Palle Pedersen who, with great
terminology. This makes communication with fellow clin- insight, outlines the steps necessary to paint a com-
icians fast and effective, and it standardizes records for plete picture of the patient, both past and present. In
easy review. addition, Dr. Pedersen touches on a number of related
Chiropractors faced with a new patient have, as issues, such as doctor–patient relationship, patient han-
their first task, the job of performing those procedures dling, and other issues, which are increasingly being rec-
necessary to decide what is causing the presenting ognized as an important component of the treatment
symptoms. If, for example, an 18-year-old male comes encounter.
in with a cervical torticollis, a primary contact clinician The case history is usually followed by examination of
would have to consider whether this is a result of a frac- the patient. Kim Humphreys and Lisa Caputo describe
ture, dystonia, subluxation, or some other mechanical the most important components of the general physi-
lesion, or whether this is, perhaps, a result of psycho- cal examination. After discussing the principles of the
logical factors. Clinicians have a number of tools avail- physical examination, these authors review the physical
able to help them arrive at a diagnosis. Indeed, the num- examination of most regions, listing both normal and
ber of diagnostic procedures has increased dramatically abnormal findings. Along the way, examples of clinical
in the last 30 years, whereby computed tomography conditions are given in order to demonstrate how the
(CT) scans, magnetic resonance imaging (MRI) scans, examination findings should be interpreted.
bone densitometry, and other advanced laboratory tests Disorders of the nervous system can be the most dif-
are now routine and present new opportunities to im- ficult for a chiropractor to detect and differentiate from
prove diagnostic accuracy. However, clinicians must re- more routine complaints. Rand Swenson describes the
member that the most important diagnostic tools are classical procedures for examining various components
their two hands, two ears, and whatever is between the of the nervous system, including the neurologic case
latter! history, examination of motor and sensory systems, and
Several studies have examined the source of es- assessment of higher mental functions.
sential information leading to the correct diagnosis in Edward Rothman and Haymo Thiel follow the neuro-
the majority of patients, and concluded that 75% came logic examination with a chapter covering the physical
from the case history, a further 20% came from the examination of the musculoskeletal system. This chap-
manual physical examination, and only 5% came from ter is of particular importance to chiropractors, who ap-
laboratory and other high-tech studies. This is not to ply most of their treatment approaches to this system.
485
486 THE CLINICAL EXAMINATION
For each body region, Drs. Rothman and Thiel describe Dennis Skogsbergh then follows with a presenta-
the essential elements of observation, palpation, move- tion of advanced imaging studies, such as CT, MRI, nu-
ment, and provocative testing that have become the clear imaging, and bone densitometry. These studies,
hallmark of the examination of the muscles and joints although not routine in most chiropractic offices, must
of the body. nevertheless be understood because they may be im-
The manual evaluation of the patient and particularly portant in the diagnosis of selected patients and are of-
the spine is then described by Don Murphy and Craig ten contained in records from outside sources. Conse-
Morris. After covering the identification of primary pain quently, chiropractors must understand the indications
generators, the authors move on to the evaluation of for these tests, as well as be capable of interpreting the
faulty movement patterns through a number of specific meaning of the more common findings.
tests. Some of these tests have yet to be firmly estab- Robert Ward covers laboratory testing, including
lished in the medical and chiropractic literature but hold how, when, and where to use laboratory tests, and
promise in providing information concerning the evalua- also how to interpret the most commonly ordered tests.
tion of spinal biomechanics. This chapter also includes an important section on the
Keith Wells then describes some of the more com- concepts of accuracy, precision, sensitivity, and speci-
mon diagnostic instruments, including their appropriate ficity that are essential knowledge for interpreting these
use, practical application, and interpretation of findings. tests.
He has deliberately focused on low-tech tools common The final chapter in this section focuses on the fact
to daily clinical practice. that a clinician’s memory is not perfect, and that ac-
Chris Colloca, Tony Keller, Gregory Lehman, and curate record keeping is important in clinical practice.
Donald Harrison then review the more advanced diag- Louis Sportelli and Gary Tarola cover the principles of
nostic instruments with a presentation of the important record keeping and documentation. Many aspects of
factors that must be considered when assessing the record keeping included in this chapter are required by
value of any test. They then review various, often contro- law and for payment of fees by insurance companies. Al-
versial, testing procedures available for the assessment though this chapter is based on reporting requirements
of spinal disorders, including those that measure pain, in North America and may not apply to all countries,
spinal biomechanics, spinal stiffness, muscle strength, good record keeping is essential for any clinician any-
and neurophysiology. Although many of these proce- where in the world.
dures have yet to be accepted by large numbers of All of these chapters have been written by dedicated
clinicians, they remain of interest and hold promise for and knowledgeable authors, and offer important infor-
the assessment of spinal pain and biomechanics. mation for both undergraduate students and seasoned
Chiropractors have been reported to be the first clinicians. The testing discussed in these chapters ex-
profession to use x-rays in the diagnosis of spinal dis- ceeds that which is possible in any reasonable practice
orders and have continued to apply a functional inter- and attempting to perform all of these tests on any sin-
pretation to traditional static x-rays. The chapter by gle patient would take all day. The ability to focus on
Cynthia Peterson and Bill Hsu focuses on the use of the history, examination, and testing procedures neces-
traditional x-rays, and provides evidence-based guide- sary to reach a diagnosis in the shortest period of time
lines for radiological examination, as well as an overview distinguishes the experienced from the inexperienced
of the radiological presentations of various disease clinician.
categories. Niels Grunnet-Nilsson
C H A P T E R
26
THE CLINICAL HISTORY
Palle Pedersen
O U T L I N E
INTRODUCTION Cardiovascular System Including Extremity
GENERAL CONCEPTS AND TERMINOLOGY Peripheral Circulation
DISEASE: CAUSE AND EFFECT Respiratory System
DISEASE HISTORY, SIGNS, SYMPTOMS, Endocrine and Metabolic Systems
AND TIME FACTORS Gastrointestinal System
CLINICAL IMPRESSION, FUNCTIONAL DIAGNOSIS, Genitourinary and Reproductive Systems
MANAGEMENT, AND PROGNOSIS Urinary Tract: Urethra, Bladder, and Kidneys
PURPOSE OF CLINICAL HISTORY Genitals and Sexual History
CLINICAL ENCOUNTER Potential Questions to Ask
SYSTEMATIC APPROACH TO OBTAINING Obstetrical and Gynecological History:
THE CLINICAL HISTORY Menstruation
SPOT DIAGNOSES Breasts
OBTAINING THE CLINICAL HISTORY Hematological/Hematopoietic System
General Perspectives Musculoskeletal System
Structured History Nervous System
Chief Complaint General Questions
History of the Condition Sensory System
Pain Motor System
Associated Symptoms Coordination of Movement
Aggravating Factors Psychological (Emotional, Behavioral), Psychiatric,
Relieving Factors and Mental Health
Previous Episodes and Treatment Potential Questions to Ask
Leisure Activities Skin Conditions and Allergies
Occupational History Integument (Skin, Hair, Nails)
Geographical History Additional Information
Summary of the Information Obtained Summary of Your Understanding of the Patient’s
Review of Systems Complaints and Concerns
What to Ask the Patient and Why? SUMMARY
GENERAL HEALTH STATUS QUESTIONS
Constitutional Signs, Vital Signs, and Nutritional Status ANSWERS
Potential Questions to Ask KEY REFERENCES
Alimentary System: Ears, Eyes, Nose, and REFERENCES
Throat (EENT)
487
is a practical approach to a practical subject. It is also a

OBJECTIVES
recognition that past teaching methods in chiroprac-
1. To review general and specific aspects of the case tic colleges and medical schools, with heavy emphasis
history. on class contact hours and coverage of the typical pre-
2. To review the concept of the biopsychosocial sentation of diseases from A to Z, is no longer viable.
model of disease. Patients tend to present with signs and symptoms for
3. To review the difference between a diagnosis and which frequently more than one condition may be re-
a clinical impression. sponsible, and thus the clinician has to work back-
4. To emphasize practical approaches to obtaining wards toward a possible cause through a process of
a good case history in the context of chiropractic gradual elimination, likelihood, and probabilities.1–7
practice. Various approaches to hypotheticodeductive and in-
ductive reasoning, as well as other methods used
in the diagnostic process, are comprehensively dealt
INTRODUCTION
with in other texts.2,4,8,9,10,11
Based on knowledge and understanding of basic sci- Chiropractors, who deal for the most part with
ence subjects such as anatomy, physiology, patho- spinal pain syndromes, have historically taken a more
physiology, biochemistry, and biomechanics, this humanistic and holistic approach to patient manage-
chapter looks at various aspects of the clinical history ment. This is reflected in their history taking, which
and how these may be developed as part of a diagnos- tends to favor more open-ended questions than the
tic decision-making process with particular reference traditional medical barrage of closed-ended questions
to neuromusculoskeletal disorders. The emphasis is with simple yes/no answers. This method of taking a
on selected aspects of the clinical history because there clinical history lends itself well to the biopsychosocial
are many ways of developing one’s clinical thinking model described by Engel,12 which is a framework on
skills. which to establish a system of simple to increasingly
A thorough knowledge of the basic science sub- complex systems (biological, social, psychological) in
jects and the application of first principles, together the evaluation of patients with spinal pain.13 Used to-
with an understanding of the natural history of var- gether with a conceptual model of patient outcomes,14
ious clinical conditions (and access to a comprehen- one can attempt to demonstrate the patient’s experi-
sive medical dictionary), is a good starting point for ence as a series of interdependent health and qual-
developing one’s skills. It is, even with a limited ity of life–related variables as noted in the following
scope of practice, impossible to predict which condi- sequence:
tions or circumstances the patient may be experienc-
ing and, hence, to have a tailor-made approach to the Physical impairment → Symptoms →
management of all possible conditions. Adaptation
Functional status → Social roles →
to individual circumstances and taking into account
confounding factors (physical, behavioral, psychoso- Quality of life
cial, iatrogenic) are absolute necessities in chiropractic
practice. Patient presentation can be affected by individual
Furthermore, students and clinicians are often characteristics, psychological/emotional status, cop-
overwhelmed with the amount of information avail- ing mechanisms, and occupational, social, physical,
able and presented in most traditional teaching curric- and other factors. Some of these components have for
ula. Self-directed study is the most important method a long time been considered “soft data,” but recent
of learning while in practice and should be devel- studies suggest that they are usually better predictors
oped before graduation. This chapter will, with the of treatment outcomes than the biological measure-
inevitable but integrated overlap with the chapter on ments characteristic of the old diagnostic model of
the physical examination, review some of the usual disease. Thus management becomes patient-centered
and unusual presentations of common conditions, as and despite some physical impairment or pain, pa-
well as the presentation of some uncommon condi- tients may still enjoy a certain measure of quality of
tions. It should be kept in mind that common conditions life that can be assessed, for example, through the use
are common, and rare conditions are rare. Hence there is of satisfaction questionnaires.
a need for a qualification of the findings in the clin- It is not possible in one chapter to address the
ical history and examination when a priority list of learning approach used from the novice all the way
diagnoses and differential diagnoses is attempted. up to the consultant with many years of experience.
This chapter is not meant to be an in-depth review This chapter mainly addresses the basic approach to
of all the theories and research behind learning, case history taking that can be used as a starting point for
history taking, and clinical decision making; rather, it all students and practitioners. This approach works
THE CLINICAL HISTORY 489
very well with open-ended questions. The patient is with these findings,16 and may be illustrated as fol-
encouraged to give an account of his or her problems, lows, by using a model modified from MacFarlane
rather than just answering yes/no questions. When et al17 :
properly developed, this skill can obtain substantially
more useful information from the patient, often in less Disease → Pathological changes → Intervention
time. This approach is particularly important when
dealing with chronic pain patients where disabling The cause(s) of the disease may stem from the envi-
psychosocial factors rather than pathology may dom- ronment, such as exposure to physical or chemical in-
inate the picture.13,15 jury; or infection, nutrition deficiency, or immune de-
The only way for the novice to develop the skills ficiency; or psychological or genetic conditions. Some
required for clinical practice and for the experienced to of these factors may be direct causes of a disease,
further improve interpersonal communication skills is while others are merely predisposing factors weaken-
through repetition. The best results are obtained with ing the body sufficiently to succumb to another cause.
constructive feedback from colleagues or fellow stu- The cause of the disease is called its etiological agent.
dents commenting on interviewing style, jargon, body When the etiology is unknown, the disease or condi-
language, and the like. Video and audio recordings are tion is said to be idiopathic or unknown. This is often
excellent in enhancing this experience. The key refer- the case with low back pain where, in the absence
ences at the end of this chapter contain some excellent other signs and symptoms, a nonspecific diagnosis,
texts for improving case history taking and patient such as mechanical low back pain, may be inferred.11
communication skills. Generally, one can divide etiology into three broad
categories: genetic, congenital, and acquired.16 The
first follows a structural or functional defect in an in-
GENERAL CONCEPTS AND TERMINOLOGY dividual’s genes that may be traced in the family’s
bloodline (except where mutations occur). It is im-
Throughout its history, the chiropractic profession de-
portant to ask about certain aspects of the patient’s
veloped a plethora of terminologies, many of which
(biological) family history. A congenital disease may
relate to specific treatment systems. This has often re-
be a result of circumstances relating to the intrauter-
sulted in confusion and lack of consensus. This chap-
ine environment, where an individual has been born
ter presents more traditional terminology for use in
with a normal genetic makeup but defects occur dur-
the clinical history. It is generally based on commonly
ing prenatal development because of such factors as
accepted terms used by most health professionals.
prenatal medicine or excessive alcohol intake. This can
Before starting on the clinical history, the chapter
be seen in disorders such as thalidomide deformity or
looks at some concepts and definitions that should
fetal alcohol syndrome. The largest category of dis-
take us through the transition from the basic sciences
eases likely to be encountered in clinical practice re-
toward the clinical sciences. It may be useful to re-
lates to the acquired diseases, where the genes and
view these definitions from time to time when going
development are normal but environmental factors,
through the subsequent parts of this chapter. It is im-
such as infection or trauma, are experienced. These
portant to remember that some information obtained
factors may cause complications that become perma-
from the patient may be very subjective and it may be
nent, such as a shorter leg following a femoral fracture
necessary to assess how reliable and how important it
or earlier arthritis secondary to a joint infection.
is, as well as consider how this information could be
Epidemiological principles are useful in the un-
confirmed (e.g., from medical or other records).
derstanding of factors that may be involved in a dis-
ease process. There may be more than one cause and
there may be interactions between different potential
DISEASE: CAUSE AND EFFECT
causes. In the clinical diagnostic thinking process, it is
Generally, when working toward a diagnosis, it is useful to keep the following in mind (modified from
helpful to think of the manifestations of disease as Lillienfeld and Stolley6,18 ):
a process during which progression, signs, and symp-
toms are observed and investigations are undertaken 1. What is a necessary cause?
in order to determine the underlying cause(s) and 2. What is a sufficient cause?
mechanism(s). This is the primary link between the ba- 3. What is a contributory cause?
sic science and clinical practice. Disease occurs when
the body is no longer able to cope and the normal body The best example of this thought process deals
functions are interrupted. This occurs, for example, with infection. In many infections, it is necessary to
when laboratory values are outside their normal range be exposed and succumb to organism X in order to
and signs and symptoms are present that correlate get the clinical presentation of disease X. No other
organism is capable of producing the same clinical manner in an athlete or in a person who is older or
picture (the necessary cause). If the body is weakened younger than the typical patient. One should be alert
(e.g., immunosuppressed), it may be that an organism to the fact that there may be uncommon presentations
that does not normally cause problems (insufficient of otherwise common conditions.
cause) now results in the clinical condition as a conse- The symptoms are the patient’s subjective experi-
quence of the patient’s lowered resistance to infection ences of a potential change in the body’s physiology,
(contributory cause). which may manifest as, for example, pain, tingling,
With respect to neuromusculoskeletal conditions, coughing, or abdominal pain, depending on the un-
there is often a presumed mechanical component to derlying cause(s). These symptoms often result in the
the process that may manifest itself in a defined clin- patient seeking help from a health care professional.
ical pattern. However, it may not be easy to elicit the Pain is not an indication of the severity of the under-
primary mechanical abnormalities, especially if they lying pathological condition, and the total absence of
cannot be measured in an objective way. Adapting pain does not mean that an underlying condition is
certain strategies in the history taking and examina- not present or serious. Some patients, because pain
tion can often steer the clinician in the right direction is such a subjective and often distressing experience,
through a process of elimination. For example, it is only seek help when in pain. Other indications of dis-
often useful to ask the patient to describe in detail or ease, such as significant weight loss, may go unnoticed
demonstrate (e.g., lifting technique) what he or she and result in a delayed diagnosis.
was doing at the time of injury or when the pain de- Signs are usually measurable (e.g., body tempera-
veloped. From a detailed description of the activity ture, respiration rate, pulse rate) and can be detected
it may be possible to estimate one or more of the by the clinician upon examination. Other parts of the
above causal factors (e.g., forces applied to the spine investigation may include laboratory tests, x-rays, and
when lifting and twisting in a certain position carry- specialized imaging. All these findings are used in
ing weight), their relative contributions, and, together an attempt to determine the cause of the disease or
with the signs and symptoms, any potential tissue symptom. Different diseases and different conditions
damage that may have been sustained during the ac- may require different types of investigations, depend-
tivity. Knowledge of the general movement patterns ing on the signs and symptoms at presentation. Other
required in a particular sport can also help with the chapters in this textbook go into more detail regarding
diagnosis and thinking necessary to develop a strat- these investigations.
egy for rehabilitation and prevention (e.g., repetitive A collection of signs and symptoms describing a
overhead movements). typical presentation of a disease or condition is of-
ten called a syndrome, whether or not the etiology is
known. As stated earlier, it must be kept in mind that
DISEASE HISTORY, SIGNS, SYMPTOMS,
some signs and symptoms are typical of more than
AND TIME FACTORS
one disorder, hence the need for the development of
During the course of a disease, assuming it is al- a prioritized list of differential diagnoses.
lowed to take its natural course without too much A condition that appears suddenly is termed acute,
interference, a progression of events may take place, while those that are present for prolonged periods or
depending on the pathophysiological and patholog- that develop slowly over a period of time are termed
ical changes.16 This progression may be measured chronic. There are no fixed time frames for these terms.
through, for example, blood tests or radiographic Some medical diseases are termed acute even if they
imaging, as well as clinical signs and symptoms. The have been present for 1 or 2 months, while others are
changes will often, but not always, take place in a par- termed acute only if they have occurred within the
ticular order or show classic signs and symptoms. This past 24 hours. The classification of patients with spinal
makes it important to integrate all the findings in the symptoms has been the subject of debate with no
clinical history, examination, and other investigations universally accepted terminology.13,15,19–21 The terms
in order to make a diagnosis. Chiropractors are in an subacute or recurrent are frequently used, again with-
excellent position to deliver continuity of care because out consensus on the exact time frames.22–24 To avoid
it is usually the same person who interviews, exam- such problems and yet have a fairly accurate record
ines, evaluates imaging and laboratory results, and of the time frame, it is preferable to record when the
treats the patient. current episode started (e.g., 9 weeks ago; if possible,
Frequently, the description of a classic presentation obtain the exact date) and when the very first episode
of certain conditions, such as a lumbar disc prolapse of low back pain was experienced (e.g., 12 years ago).
or acute myocardial infarction, is obtained from a typ- Noting the number of recurrent episodes experienced
ical patient likely to suffer from the condition. These since the very first episode as well as within the past
conditions, however, may present in a very different 12 months (within the past month if very frequent) is
also useful. Recurrent bouts of back pain with rela- giving sufficient pain relief and controlling side effects
tively normal physiological loads may indicate struc- of medication.
tural problems, such as lumbosacral anomalies, in- When it comes to the diagnosis of neuromuscu-
stability (with or without osteoarthritic changes), or loskeletal problems, it is usually rarely this simple.
recreational/occupational risk factors (sports, hob- Ascribing a diagnosis to a neuromusculoskeletal prob-
bies, repetitive movements at work, excessive twist- lem is often difficult because most of the time the eti-
ing, etc.). ology is unknown. There are many factors that may
Some authors suggest that the pattern of back pain influence the patient’s signs and symptoms such as
over long periods of time is important, but there are physical activity, personality, work environment, and
various problems measuring this because patients can nutritional status, just to mention a few.7 In consider-
move in and out of different classifications.21 When a ing the diagnosis of spinal pain, it is necessary to get
condition develops gradually without a sudden onset an overall clinical impression of how the problems
it may be called insidious and, if the signs and symp- developed and work with multiple diagnostic con-
toms are very mild, they may go undetected initially cepts in parallel, including a pathological diagnosis, a
but gradually develop and become symptomatic over biomechanical diagnosis, and a functional diagnosis.
a period of time. The presentation may be localized This section introduces a number of concepts
or diffuse. There may also be systemic effects such as as practical approaches to managing neuromuscu-
bilateral leg swelling, rashes, or joint pain affecting loskeletal conditions. The classification and etiology
several joints (e.g., rheumatoid arthritis). of these conditions have not been fully studied but
have been accepted by mean of a consensus process
or guidelines for chiropractic quality assurance and
CLINICAL IMPRESSION, FUNCTIONAL
practice parameters.25 In these guidelines, diagnosis
DIAGNOSIS, MANAGEMENT, AND PROGNOSIS
and clinical impression are defined as follows25 :
The traditional method for reaching a diagnosis (in-
ductive method of problem solving) consists of taking Diagnosis: “A decision regarding the nature of the pa-
a full clinical history, performing the physical ex- tient’s complaint; the art or act of identifying a dis-
amination, ordering or performing special investiga- ease or condition from its signs and symptoms.”
tions if required, and, finally, integrating the findings Clinical impression: “A working hypothesis formulated
into a conclusion (diagnosis), which describes what from significant items in the history and physi-
is wrong with the patient. If the latter is not entirely cal findings; a tentative diagnosis; or a working
clear, then a list of potential conclusions that may ex- diagnosis.”
plain a patient’s condition (differential diagnoses) or- A more useful definition of the clinical impression
dered from most to least likely diagnosis should be may be “a qualifying statement made by a health pro-
developed. The clinical picture presented by a patient fessional which supports and gives rationale to a writ-
may frequently resemble that of more than one con- ten diagnosis.”26 It should not merely be a repeat or
dition. In this situation, the clinical thought process summary of findings in the case history, but the clini-
should be both wide, to encompass all possibilities, as cian’s own view and justification for his or her diagno-
well as focused on the most likely of these possibili- sis. For example, “a 36-year-old healthy and fit male
ties. The clinician should then follow up all signs and with an unremarkable past medical history complain-
symptoms that may be present (hypotheticodeductive ing of right-sided low back pain,” is not a clinical im-
method of problem solving) and explore various pos- pression but a statement of fact. Even an unqualified
sibilities simultaneously. person could obtain this information from reading the
A traditional diagnosis is where the clinician has file. A clinical impression requires a measure of clin-
found out what is wrong with the patient, that is, ical judgment. The clinical impression is often stated
identified a specific disease or organism causing the immediately before or after the diagnosis in the case
disease. If the organism is known, then the correct file and helps to define the thought of the clinician
treatment, for example, antibiotics, may be given, or and the security of the diagnosis. The following is an
surgery performed. The outcome of the treatment may example of a diagnosis and clinical impression:
be to completely cure the disease, in which case the
prognosis is excellent. If the prognosis is poor, that is, Diagnosis: Chronic, posttraumatic lumbar facet irrita-
it may not be possible to cure the disease or life ex- tion at L4-L5.
pectancy is limited, the management of the condition Clinical impression: The current presentation seems to
may simply be supportive care, which does not alter be related to the industrial accident suffered by
the natural course of the disease. However, this treat- the patient 5 years ago, although it may have been
ment approach may provide some measure of quality exacerbated in recent years by a lack of mobility,
of life for the terminally ill patient (palliative care) by poor posture, and clinical depression.
There is often the need for a qualifying statement and body language may also help facilitate or block
in relation to the diagnosis, because individual fac- answers if not considered carefully. The use of silence
tors, such as exercises, ergonomic advice, and perhaps often is a valuable means of facilitating voluntary in-
counseling from another professional, may flow from formation or to allow for short periods of patient re-
this discussion.15 The diagnosis labels the patient with flection. Silence can be a powerful clinical tool if used
a disease or condition but is not a good indicator of sensitively.
how the patient manages on a daily basis. It is possi- Obtaining a clinical history cannot be conducted
ble to have no documentable pathology and yet be to- in a cookbook fashion using the same approach with
tally disabled, which occasionally occurs with chronic every patient. The most important component of ob-
low back pain.13 This is one reason why, when dealing taining the history is the clinical encounter, that is,
with neuromusculoskeletal problems, it is important the sum of the clinician’s interaction with the patient,
to consider including a clinical impression as well as a and the communication (verbal, nonverbal, written)
diagnosis. The initial diagnosis may be no more than that allows the clinical history to be obtained. It is
a (preliminary) working diagnosis because a condi- useful to start the process of obtaining a history with
tion may change with, for example, time, treatment, a well-defined template, but common sense and per-
work positions, or exercise. It is therefore necessary to sonal judgment must always be used when determin-
maintain flexibility and be able to reevaluate a patient ing the relevance of information obtained in the clini-
on a regular basis. cal history.
A functional diagnosis attempts to explain the ar-
eas of lost function that the clinician and the patient
are interested in restoring through shared responsi- CLINICAL ENCOUNTER
bility for the management of the condition. There are
Pendleton et al.,28 Myerscough,29 and Ford30 give use-
a plethora of time- and cost-effective valid and reli-
ful overviews of the sociological aspects of the clinical
able questionnaires available to the clinician that as-
encounter and how social and psychological factors
sess the patient’s satisfaction and functional and psy-
may influence the patient’s attitude. A patient’s beliefs
chosocial status, and may highlight poor prognostic
and norms of behavior, as well as his or her percep-
indicators, such as catastrophizing and poor coping
tion of when to seek help, may be important. When
mechanisms.7,10,27 The use of these measures gives
dealing with patients with chronic low back pain, psy-
early warning signs of poor prognostic indicators that
chosocial factors may greatly influence the outcome of
may not be found on the examination, and can save
the clinical encounter and overall management of the
unnecessary and expensive investigations in the long
patient. The anthropological approach looks at vari-
term.
ous models of illness in society and the implications
for patients and health care professionals. Factors af-
PURPOSE OF CLINICAL HISTORY fecting patient compliance, including willingness to
follow health care advice such as taking prescribed
The purpose of the clinical history is to systematically
medication or doing exercises, can be very important.
acquire enough information about the patient and the
presenting complaint(s) to guide the clinician to per-
form relevant examination and investigative proce-
SYSTEMATIC APPROACH TO OBTAINING
dures and reach a clinical impression and diagnosis.
THE CLINICAL HISTORY
This may require emphasis on specific aspects of the
history, such as family history for genetic disease or Without a framework or a systematic approach to ob-
occupational history for exposure to certain working taining information from the patient it is very easy to
environments. This is a skill that can only be perfected miss important information or innocuous clues and
through extensive practice using the knowledge ac- forget to ask relevant follow-up questions. It is also
quired from basic science and clinical courses. sometimes necessary to take an approach (hypotheti-
Some questions are specific and others are gen- codeductive method) that starts with the signs and
eral screening questions. It must be absolutely clear symptoms and then work backwards toward a poten-
in your mind not only why you ask certain questions, tial diagnosis, although following up with relevant
but also how and when to ask. There is a fine line be- questions. A combination of both methods applies in
tween justifiable clinical inquiry and what is regarded clinical practice, but it is far safer to start with a system-
as general (personal) curiosity. It is advisable to be atic approach to the clinical history. Before approach-
culturally sensitive and explain first why certain areas ing the subject of obtaining the clinical history of the
of questioning may be important. Open-ended ques- main complaint(s) and reviewing the body systems
tions usually yield more information than closed ques- in the context of chiropractic practice, we will take a
tions (i.e., questions with yes/no answers). Intonation quick look at “spot diagnoses.”
the complaints most commonly seen in chiropractic

SPOT DIAGNOSES
practice as follows:
Spot diagnoses are conditions, signs, or symptoms
that should instantly suggest a diagnosis because • Chief complaint
the presentation is unique to this condition or dis- • History of the condition
ease. Some signs and symptoms are noticeable during • Pain
walking or standing, or apparent in the face or on the • Associated symptoms
hands, and hence easy to identify.1,31,32 • Aggravating factors
Greeting the patient at the door with a genuine, • Relieving factors
warm smile is courteous, and gives the impression • Previous episodes and treatment
that the patient is dealing with an empathetic pro- • Leisure activities
fessional willing to listen. It is also very useful in as- • Occupational history
sessing gait (walking toward/away from you, abil- • Geographical history
ity to sit/get up from a chair, use of a walking stick, • Systems review
etc.), handshake (e.g., strong, weak, sweaty palms, • Summary of the information obtained
warm/cold, contractures, atrophy, deformities), facial
expression (smiling, depressed, shy, facial paralysis, Chief Complaint In chiropractic practice the chief com-
other facial features), and overall body posture. The plaint most commonly relates to the low back, fol-
clues obtained within the first 30 seconds or so will of- lowed by neck and head, thoracic, and extremity
ten be very useful in guiding the clinician as to which complaints.36 Most patients do not present with more
(follow-up) questions to ask the patient. than two or three complaints. A small percentage
The prevalence of different conditions varies de- of patients, however, will present with a nonmuscu-
pending on the region or part of the world where loskeletal complaint such as irritable bowel syndrome,
the clinician practices, and may be affected by indigestion, or symptoms from a condition that is al-
the patient’s lifestyle, occupation, or environmental ready being managed by a medical physician. A clini-
exposure.33 Table 26–1 lists some selected common cal impression and diagnosis should be attempted for
and a few uncommon spot diagnoses and important each of the complaints.
signs that may present in chiropractic practice. The patient’s own words for each complaint
should be in the file. For a variety of reasons, wor-
ried patients may exaggerate the symptoms and cause
OBTAINING THE CLINICAL HISTORY confusion when the clinician tries to establish an ac-
General Perspectives curate clinical history. Following the patient’s state-
ment of the problem, it is essential to ask the pa-
Typically, the flow of the consultation is start with the tient to point to the most painful area of the com-
history, proceed with an examination, and develop plaint. Patients with considerable psychological com-
likely or possible diagnoses. If necessary, further in- ponents to their symptoms will often be inconsistent
vestigations, such as laboratory tests or radiographic and repeatedly point to different anatomical struc-
imaging, may be ordered to confirm the diagnosis and tures, which are not individually or collectively able
commence treatment.1,34,35 to produce the apparent clinical presentation.37 Some
clinicians prefer patients to complete a pain diagram
Clinical history → Physical examination → and subsequently mark their own findings, for exam-
Clinical problems → Differential diagnosis → ple, on a dermatome. This allows for a comparison
of consistency of findings and complaints and, when
Investigations → Confirmation of diagnosis → grossly inconsistent, often indicates that there may be
Treatment plan some psychological overlay in the clinical presenta-
tion, termed a yellow flag.
This is the ideal situation in a classic presentation History of the Condition The history of the complaint
of well-defined signs and symptoms, but often the re- should relate to the current episode. Often patients
ality is a bit more complicated. Frequently there are claim to have had low back pain for decades, but
many confounding factors and a wide range of nor- the current episode for which they are in consider-
mal variations, which may be confusing. able pain, has only lasted a few days after gardening.
Always obtain the date (or number of days in pain or
Structured History discomfort) of the start of the current episode. If not
In this section, a structured approach is used to obtain the first time, also obtain the month or year when they
the clinical history and other relevant information for had their very first episode, and approximately how
TABLE 26–1.Examples of Spot Diagnoses and Possible Signs Indicating Specific Disease as They May
Be Seen in Chiropractic Practice (not in Priority Order of Prevalence)
Spot Diagnoses Possible Sign
• Hemiplegia, cerebellar signs, tabetic gait

Gait, general movement,
• Paget disease of the bone (leg bowing), antalgia, ankylosing spondylitis
and body posture
• Limping (polio, short leg, coxarthrosis, drop foot, rectus femoris weakness)
• Paget disease (skull), acromegaly
Head
• Ears—hearing aid, gouty tophi, eczema, Ramsay Hunt syndrome
• Temporal arteritis, spider nevi, telangiectasia
• Titubation, tremor (Parkinson disease)
• Cushing syndrome, acromegaly, Parkinson disease, hypothyroidism, Down syndrome, myas-

Face
thenic syndromes, dystrophia myotonica
• Heart—cyanosis of lips, dyspnea, pallor, malar flush
• Lungs—cyanosis of lips, dyspnea, lip pursing, use of accessory muscles
• Eyes—glasses/contact lenses, jaundice, xanthelasma, strabismus, nystagmus, exophthal-
mos, ptosis, arcus senilis, Horner syndrome, other pupil reactions
• Neurological—hemiparesis, Bell palsy, facial movements (tardive dyskinesia), shingles,
orofacial dyspraxia
• Scleroderma, systemic lupus erythematosus, rosacea
• Nephrotic syndrome, angioneurotic edema (Quincke edema)
• Skin—psoriasis, shingles, tuberous sclerosis, neurofibromatosis, Sturge-Weber syndrome,
spider nevi, facial skin cancers, vitiligo, facial hair distribution (alopecia, fungal infection, hir-
sutism), eyebrows (hypothyroid), perioral scars (Crohn disease)
• Thyroid problems (thyroidectomy scar, hyperthyroid, hypothyroidism)

Neck
• Neck swellings—Hodgkin disease, cystic hygroma, goiter
• Torticollis, spasmodic torticollis
• Turner syndrome, Klippel-Feil syndrome
• Heart—finger clubbing (may also be congenital), splinter hemorrhages

Hands
• Lungs—finger clubbing (may also be congenital) and nicotine staining—think possibly lung can-
cer
• Liver—palmar erythema, leuconychia, flapping tremor, jaundice, spider nevi, finger clubbing,
Dupuytren contracture
• Tremor—Parkinson disease, choreathetosis, coordination,
• Muscle wasting, fasciculation, syringomyelia, motor neuron disease, carpal tunnel syndrome,
ulnar nerve palsy (claw hand), radial nerve palsy (wrist drop), dystrophia myotonica
• Skin—tattoos (recent ones may be infected), scabies, tobacco staining, vitiligo, peripheral
cyanosis (Raynaud phenomenon), scratch marks, eczema, psoriasis
• Nails—pitting, psoriasis, splinter hemorrhages
many times they get similar problems per month or Pain Many patients complain of pain and hence get
year.21 It may transpire that the problems always oc- concerned and seek help. Some patients have no pain
cur with certain types of activity, for example, twisting but may seek a consultation because of stiffness or
or when fatigued. How has the complaint progressed difficulty carrying out certain tasks at work or dur-
since this episode started? Is it about the same, bet- ing leisure activities. Thus, they may attend the clinic
ter, or worse? Have other signs or symptoms, such as more out of frustration or dissatisfaction with poor
leg weakness, or bladder or bowel problems (inconti- performance rather than discomfort. Pain, or lack
nence, retention) started emerging? It is necessary for thereof, is not an indication of severity. Some condi-
the clinician to make a judgment on the report from tions, such as disc prolapse or facet pain, may be very
the patient and assess the information for its (clinical painful but do not immediately pose a significant risk
or, to the patient, emotional) significance. to the patient’s physical health. Other conditions, such
as developing a drop foot or urinary incontinence over trauma, it may indicate potential fracture, whether or
a short period, may be the only indication of rapid not recent x-ray studies were negative. In this case,
deterioration. The clinician must be alert to such pre- the patient should not be asked to demonstrate any
sentations at all times during interaction with patients activity, especially not if this relates to the neck.
and instruct them on the appropriate action in case of Headaches, which occur early in the morning
an emergency. The professional (and moral) respon- and may wake up the patient, are always to be taken
sibility for the management of the patient usually ex- seriously, because this is an indication of raised
tends beyond the limited time period when they are intracranial pressure that may need further investiga-
in the clinic for treatment. tion. Additionally, headaches in persons not normally
With the use of a dermatome chart the clinician suffering from similar symptoms, especially if the
may record pain location, type of pain (e.g., sharp, pain recently changed character, is occipital, and/or
burning, boring), frequency (with movement in cer- presents suddenly as “the worst-ever headache,”
tain directions, at night or early in the morning— may need urgent referral to rule out cerebrovascular
possibly cancer pain), duration, radicular presenta- complications.
tion, referred pain, and other features described by the Remember that patients often take painkillers that
patient. The same recording applies to areas of weak- may mask their symptoms on the day of presentation
ness, and altered, increased, or decreased sensation, at the clinic. Ideally, they should not have taken sig-
and is followed up with testing in the neurological nificant amounts of painkillers on this day, and fortu-
examination. nately this is possible to accomplish in the vast major-
Some clinicians use various questionnaires to es- ity of patients presenting in chiropractic practice. For
tablish pain scores and disability, psychological, and those so acute that they cannot make it to the clinic,
other profiles. They are usually valid and reliable only it may, depending on the clinical practice and legal
for certain patient populations and should be used ju- context, be possible to see them in their own home, or
diciously rather than as general screening tools.10,27 ask for their family physician to visit them.
In the author’s experience, a thorough clinical history
and physical examination will usually suffice in most Relieving Factors Relieving factors may, for example,
cases and limit the need for additional paperwork to be movement to ease the pain, assuming certain body
those few patients when it really is appropriate, such positions (standing, sitting, lying down), or using hot
as some with chronic pain. or cold packs, gel, or painkillers, while sometimes
there are no significant relieving (or aggravating) fac-
Associated Symptoms There may be other (associated) tors. The clinician must explore relevant avenues of
symptoms, which the patient perceives as separate inquiry to elicit such information, depending on the
problems, whether or not they relate to any of the clinician’s impression from the first few minutes of
main complaints. It is the clinician’s duty to make meeting the patient, and the information obtained
a clinical judgment whether this is part of the main thus far.
problem, a separate underlying condition, or perhaps
an additional (purely psychological) worry that the Previous Episodes and Treatment Previous episodes,
patient has. Such worries, if ignored or not addressed treatments (when, what kind, how many treatments,
properly, may negatively influence the outcome of the by self or health care professional), and outcomes
patient management.7,10,13 (full recovery, no change, worse, level of satisfac-
tion) are important to establish. Patients who do not
Aggravating Factors Aggravating factors are not in- obtain relief may start to “shop around” for other
frequently associated with certain weight-bearing or kinds of treatment. A common reason for this is
twisting movements. The patient should be asked to that the first clinician (or any of the others) con-
describe or, even better, demonstrate which move- sulted did not take the time to adequately explain in
ments are painful and when during a particular range a language comprehensible to the patient just what
of movement the pain or problem occurs. If this is not is wrong, what needs to be done, and what to ex-
possible, then the clinician could try to physically re- pect. Sometimes, even with the best clinical history,
produce the movement and receive verbal feedback examination, and treatment, things just take a bit
from the patient. longer to resolve and everyone reacts differently to
Constant pain without movement (whether treatment.
weight-bearing or not) or pain in all directions of Furthermore, never proceed to treatment based on
movement, especially pain at night or early morning, the patient’s assertion that his or her condition is “the
may be an indication of more serious problems, such same as last time, so just manipulate my spine.” Al-
as cancer or infection. If there is a history of recent ways take a few minutes to ask relevant questions
and perform a brief examination to confirm the pa- anything in terms of risk factors. An individual may
tient’s diagnosis. The signs or symptoms might have have trained (schooling, managerial) for one thing, but
changed slightly since last time (this may happen even the actual job function (supervisor in factory) may in-
within a few hours), but the patient still perceives it volve greater risk than the title reveals. Furthermore,
as the same problem. there may be added stress and frustrations from being
With respect to prescription or other medications, trained to do one thing but being employed to do a
patients are often notoriously inaccurate in their re- less fulfilling job. The clinician must always consider
port of what they take and why. Always ask the pa- the physical, psychological, and social aspects (“triple
tient to bring in the actual bottles and packaging of diagnosis”) of the patient’s life and their potential con-
the current medication for proper recording. Patients tributions to or effects on the current problems.4
often do not consider the contraceptive pill as “being The past occupational history may be relevant
on medication” and hence may not mention it unless in terms of previous exposure and later develop-
specifically asked. Some alternative remedies are also ment of disease (e.g., mining, asbestosis), or frequent
known to cause side effects whether on their own or job changes, for example, might be an early indi-
in combination (perhaps unknown to or information cation of behavioral or other mental health prob-
withheld from the medical doctor/pharmacist) with lems. Again, it must be an overall assessment and
prescription medication. Ask the patient to bring it all no judgment should be passed on individuals based
in so that you can look up any potential side effects on single events for which there may have been per-
and assess whether or not this might be associated fectly acceptable, but so far unknown, mitigating
with the current clinical presentation. If in doubt, li- circumstances.
aise with a colleague or get the patient’s consent to
contact the patient’s family physician. Geographical History The geographical history refers
to the patient’s travel activities. In most parts of
Leisure Activities People spend approximately one- the world, people travel extensively, whether locally,
third of their life at work, at leisure, and asleep, respec- nationally, or internationally. Unfortunately, many
tively, so it could be argued that one or more of these chiropractic clinicians neglect to ask a few simple
components could have relevance to their problems. questions in this respect, which could avoid a lot of
Additionally, it may be necessary for the clinician to potential diagnostic problems with very experienced
do a brief risk analysis of the activities performed in at travelers.
least two of these three. Certain occupational activities It is essential to ask whether the patient has ever
involve heavy lifting, static postures, repetitive move- traveled, lived, or worked abroad for any length of
ments, bending, twisting, psychological distress, and time, and if so, where (countries), when, and for how
exposure to fumes, dust, and chemicals. Leisure and long? Exposure, especially when traveling in the trop-
family activities may be very physical, such as in con- ics, even for short periods of time, to unfamiliar envi-
tact sports and family activities/plays, or quite seden- ronments may carry a small, medium, or significant
tary but not necessarily less problematic in relation risk of becoming ill, for example through contact with
to the patient’s complaint. Also record a history of polluted environments (air, water, poor food hygiene,
smoking and alcohol consumption. It may also be rel- altitude), diseased individuals (coughing, sneezing,
evant to inquire about any use of recreational or per- sexual contact), animals, insects, or plants.
formance (sports)-enhancing drugs. Sleeping patterns
and positions, the nature of the bed or mattress, and Summary of the Information Obtained After having
various other bedroom activities may also be of rele- greeted, interviewed, clarified, and listened to the pa-
vance in the overall evaluation of relieving, aggravat- tient in an empathic and attentive way, it is good prac-
ing, and other risk factors. tice to sum up for the patient your understanding of
why the patient came to see you and what expecta-
Occupational History As highlighted above, the occupations and concerns the patient has.3,30,33,38,39,40 This
tional history, past and present, may be a very impor- allows the patient to correct and/or clarify any mis-
tant part of patient management because work is often conceptions that may have arisen, and avoids the clini-
perceived as aggravating the current symptoms. This cian going down the wrong track after the physical ex-
has for many years been considered from a physical amination and further investigations, reaching a diag-
perspective (i.e., physical job demands), but psycho- nosis, and commencing a plan of management. Some
logical distress, work relations, increased workload, clinicians may prefer to do the summing up after hav-
time pressure, and the like are also thought to occa- ing completed the systems review, but because both
sionally manifest as physical illness. Recording the pa- only take a few minutes there is no problem doing it
tient’s occupation/job title does not necessarily reveal again later for the systems review, if so desired.
Review of Systems chapters on neurological and general physical exam-

When all relevant aspects of the patient’s main com- ination.
plaint(s) have been thoroughly investigated through The review of systems listed below could be di-
careful interviewing, it is necessary to ask further vided into many subcategories but is kept fairly short
about the patient’s general health status.35,38,41–43 here, because it should be memorized by the clini-
Some patients, especially when they are in a lot of cian. Few people carry their clinic forms with them
pain, consider this irrelevant and a waste of time, so it and generally, with experience, the clinician should
is important to briefly explain to them that this part of not need any preprinted forms to be able to obtain a
the consultation is necessary for a number of reasons, thorough case history. However, it is important that
including the following: the language used when interviewing is simple and
jargon-free, and that examples of conditions are given
for the patient to consider. For example, the patient
• Assessing the patient’s overall health status. may not know whether shortness of breath relates to
• Following up with relevant examination if neces- a heart or lung condition, or both. In this part of the
sary. case history, there is an unavoidable overlap with the
• Referring to an appropriate clinician if found to be areas covered in the physical examination, such as ab-
outside your scope of practice. domen, cardiovascular, and respiratory systems, but
• Enabling you to establish (and therefore not miss in terms of the overall evaluation they complement
the obvious) the correct diagnosis and commence each other well.
the appropriate treatment. For positive responses (e.g., a history of previous
• Enabling you to better assess the long-term prog- disease or syndrome that may now have reoccurred)
nosis and any follow-up treatment required, such relating to any of the systems reviewed it is impor-
as a rehabilitation program or occupational modi- tant to find out whether it relates to past or present
fications. problems, which clinician (if any) was seen, what the
patient was told or did about the condition, which
In the majority of cases, there are usually few com- treatment (if any) was given, what the result was, and
pliance problems once the patient understands the sig- so forth. Negative information and negative results of
nificance of the systems review, except perhaps where a study (e.g., blood tests, MRI) are also important to
litigation (depending on the legal context), life insur- consider because they may be used to rule out certain
ance applications, or certain medical conditions (e.g., conditions and to avoid a repeat of unnecessary tests.
HIV/AIDS) are involved. In the following section, commonly asked or ap-
The order in which the systems review is con- propriate questions are listed for each system with
ducted varies depending on the clinician’s prefer- the potential condition or reason for asking written
ences. Some clinicians prefer to use questionnaires for in square brackets. It is essential that the clinician ap-
the patient to complete prior to the consultation, and ply common sense and show good judgment, empa-
then follow up positive responses with relevant ad- thy, understanding, and cultural sensitivity at all times
ditional questions. The problem with this approach is during the interview. A few of the questions asked in
that many clinicians design their own questionnaires the following section might cause problems in some
in the belief that the questions are clear and unam- cultures, but not in other cultures. At first sight, this
biguous, and hence elicit the information that they may look like a rather extensive list with a lot of ques-
are supposed to elicit. In reality, this is often not the tions to memorize. However, with practice, this part
case, and it will be necessary to ask further clarify- of the clinical history will normally only take perhaps
ing questions. The patient’s literacy, language skills, 5–10 minutes, unless, of course, the patient presents
and eyesight (cataract, print too small) may also be with an extensive past history of a variety of illnesses
obstacles to the application of such forms. Further- and can remember all aspects of them. Incidentally, at
more, the use of drawings to be marked by the patient least in a relatively young and healthy individual, this
may not reflect an accurate anatomical location of the might also be an early indication of a significant psy-
complaint, but can alert the clinician to, for example, chological overlay, especially if the signs and symp-
complaints that may have a significant psychological toms don’t “add up.” In this case, there are a number
component.37 Additionally, in the neurological exam- of valid and reliable questionnaires on pain, coping
ination, a dermatome chart to fairly accurately depict mechanisms, psychological distress, activities of daily
sensory changes, an abdominal chart to highlight an living, and the like available to the clinician, or referral
area of tenderness, mass, or swelling, and charts with might be considered.
orthopedic tests are commonly used. The application If there is no significant past medical history or
of some of these is described in more detail in the recent illness, and time is short, then the rest of the
interview may be completed on the following visit. affected, for example, in the case of an infection caus-
Always use common sense and good judgment, es- ing raised temperature and the feeling of being un-
pecially if the patient is in a lot of pain, and focus well. The vital signs refer to pulse, respiration rate,
on the main complaint(s) first (that’s the main reason temperature, and blood pressure. Most of these would
why the patient consults you). Leave less important be checked immediately if, for example, a person was
things, such as certain screening questions and proce- found semiconscious or comatose. A poor nutritional
dures, until later. Systems review in the clinical history status may also give rise to systemic [vitamin C de-
includes the following: ficiency, bruising or bleeding] or neurological prob-
lems [vitamin B12 or folate deficiency, alcohol abuse],
• General health status or weight loss [intentional weight reduction, unex-
• Alimentary system: head and neck (EENT [ears, plained weight loss in cancer].
eyes, nose, and throat])
• Cardiovascular system, including extremity pe- Potential Questions to Ask
ripheral circulation • Are you generally in good health?
• Respiratory system • Have you lost any weight recently (past few
• Endocrine and metabolic systems months) or noticed that clothes are looser? [inten-
• Gastrointestinal system tional: weight loss; unintentional: cancer, hyper-
• Genitourinary and reproductive systems thyroidism, ill-fitting dentures in the elderly]
• Hematological/hematopoietic system • Have you recently (past few months) noticed any
• Musculoskeletal system change in your usual strength and energy? [vari-
• Nervous system ous, e.g., cancer, worries, depression]
• Psychological/psychiatric/mental health • How would you describe your normal diet (poor,
• Skin conditions and allergies varied, good, vegetarian) and give examples from
• Any other problems or information the past few days? [how many meals per day;
amount per meal; assess contribution of diet to cur-
What to Ask the Patient and Why? There are many ways rent complaint, and general health status]
to obtain information related to the systems review
and the following highlights just one approach. The Alimentary System: Ears, Eyes, Nose, and
questions asked are used to screen for general, but Throat (EENT)
potentially relevant and/or important, information,
• Do you have any problems with your hearing?
but should also reflect the clinician’s line of thinking
[hearing aid, Meniere disease, last hearing test,
with follow-up questions depending on the patient’s
occupational noise exposure, recurrent ear infec-
answers. The only way to become skilled in this is
tions, children: recurrent ear or sinus problems,
through extensive practice.
otitis media]
The text in the square brackets illustrates some of
• Have you had recurrent episodes of “dizziness”?
the considerations the clinician should have in mind,
[giddiness: slight unsteadiness, e.g., getting up
but the prevalence of diseases in the geographical area
from a chair; dizziness/very unsteady: labyrinthi-
of practice and the particular population encountered
tis; vertigo: room spins around, e.g., when supine;
must be considered. Thus, the examples given are se-
vertebrobasilar artery atherosclerosis/transient is-
lected and do not represent a complete list of all the
chemic attack/subclavian steal syndrome, espe-
potential questions and conditions to consider. Re-
cially when combined with anemia in the elderly]
member that a good starting point is that common
• Do you have any problems with your vision?
diseases are common, and rare diseases are rare, but
[spectacles/contact lenses/glass eye, short-
you may also encounter common presentations of rare
sighted, long-sighted, blurred vision, double
conditions and rare presentations of common condi-
vision, photophobia; last eye check: unchanged/
tions. Therefore, always have an appropriate differen-
worse]
tial diagnosis in mind whenever you obtain informa-
• Do you have any pain in the eyes? [pain on eye
tion from the patient.
movement or pressure on eye balls; double vision:
multiple sclerosis; eye infections: rubbing dry eyes,
GENERAL HEALTH STATUS rheumatological, e.g., ankylosing spondylitis]
• Do you have any problems with your nose, throat;
Constitutional Signs, Vital Signs, and or sinuses? [bleeding, runny nose, stuffiness; chil-
Nutritional Status dren: foreign bodies, sinus headaches, recurrent
Constitutional signs and symptoms usually refer sinus problems and ear aches, otitis media; va-
to the patient’s general well-being and would be somotor rhinitis; recent upper respiratory tract
infections—in children associated with Grisel tor- • Have you noticed any recent swelling in the arms
ticollis (C1 dislocation caused by laxity of the trans- or legs? [unilateral presentation may be asso-
verse ligament of the atlas vertebra)] ciated with venous obstruction (thrombosis) or
• Do you have any recurrent episodes of nosebleed? lymphatic obstruction after mastectomy, radiation
[hereditary epistaxis, previous operation for nasal therapy, other surgery or trauma, localized infec-
polyps; undetected nasopharyngeal bleeding from tion (tuberculosis), mass (metastasis), or infiltra-
polyps in the elderly may lead to anemia] tion (tropics)]
• Do you have any recurrent throat problems?
[hoarseness, infection, papilloma of vocal cord, Respiratory System
cranial nerve lesion, pain on swallowing • Have you ever had any problems with your lungs?
(odynophagia), difficulty in swallowing (dyspha- [shortness of breath (dyspnea, orthopnea), tight-
gia: liquids [neurological], solid food [cervical ness in the chest, wheezing in asthma: in children,
osteophytes, esophageal cancer])] commonly also present with fatigue, headaches,
• Do you have any (recurrent) problems with your and allergies; bronchitis, recurrent infections: dust,
teeth? [dentures: upper/lower, proper fit, last occupational, pets, e.g., birds; pleural effusion as-
dental checkup, ulcers, caries, bad breath] sociated with various malignant lung diseases,
• Do you suffer from recurrent ulcers in or rheumatoid arthritis, or systemic lupus erythe-
around the mouth? [mouth/tongue ulcers, viral/ matosus; recent bacterial pneumonia associated
bacterial/fungal infections; lips: cancer, shingles; with back pain]
buccal cavity: also color changes in shingles, • Do you currently smoke? [cigarettes, cigars, pipe—
malignant melanoma, Kaposi sarcoma, Addison ever smoked, how many per day, for how long;
disease)] recreational drugs]
• Have you noticed any swellings or lumps in the • Do you suffer from any (recurrent) coughs? [how
neck? [thyroid, cystic hygroma, lipoma, lymph often, when during the day (at work, home, cer-
nodes, e.g., Hodgkin lymphoma, tuberculosis] tain environments), productive/nonproductive
cough: amount, color (clear/white, brown, blood,
green, yellow)]
Cardiovascular System Including Extremity
• Have you ever had any chest x-rays taken? [how
Peripheral Circulation
long ago, why (occupational health check, signs
• Do you have or have you ever had any problems and symptoms at the time), treatment if any, lived
with your heart? [congenital, acquired, previous or worked abroad—special health risks, e.g., the
investigations (electrocardiogram), medication or tropics]
surgery, current medication; systolic murmur
(usually benign/physiological, e.g., in pregnancy Endocrine and Metabolic Systems
or anemia) or diastolic murmur (always consid-
ered pathological)] • Have you ever had any glandular or hormonal
• Do you suffer from any (recurrent) chest pain, problems? [weight changes, appetite, muscle pain,
fatigue, ankle swelling, palpitations, or fainting? fatigue, bruising, thyroid, thyroidectomy, exoph-
[palpitations: “Are you aware of your heartbeat?,” thalmus, parathyroid, pancreas (diabetes), adrenal
hyperthyroidism, extra systole, panic attacks; an- (Cushing syndrome, Addison disease, pheochro-
kle swelling associated with the heart (lungs mocytoma), osteoporosis (Cushing syndrome,
and kidneys) occurs bilaterally; pain: Tietze syn- diabetes, certain medicines), acromegaly, brain (pi-
drome, pectoral muscle trigger points; fainting: tuitary) tumors; give the patient examples and
anemia, transient ischemic attacks, vasovagal or follow up with specific questions relating to hor-
micturition syncope, Shy-Drager syndrome with monal or metabolic conditions]
Parkinson disease] • Have you ever been investigated for osteoporosis?
• Do you suffer (recurrently) from cold hands [mainly postmenopausal (may receive hormone
and/or feet? [cold hands and/or feet are a very replacement therapy), hysterectomy, diabetics,
common complaint in the absence of any disease; long-term steroids: Cushing syndrome, asthmat-
question further regarding trigger factors such ics, other hormonal or metabolic disease, side
gravitational dependency (upper and lower ex- effects of certain other drugs]
tremity), and those in the upper extremity asso-
ciated with Raynaud phenomenon, e.g., in con- Gastrointestinal System
nective tissue disorders, hypothyroidism, thoracic • Do you suffer from indigestion? [changes in bowel
outlet syndrome, drug intoxication, or occupa- habits, e.g., frequency, looseness, constipation,
tional factors (vibration white finger)] vomiting; dyspepsia: epigastric discomfort after
eating, fullness, heartburn, bloating, abdominal with trauma. A common cause of low back pain
pain, and/or nausea; timing after eating: gastric without functional loss or positive spinal palpa-
vs. duodenal ulcer; heartburn/retrosternal pain tory findings in the elderly female is urinary tract
with positioning: hiatus hernia; gall bladder dis- infection, often predisposed by diabetes]
ease: fatty foods; food intolerance (gluten); chronic
appendicitis; stress; alcohol; constipation: espe- Genitals and Sexual History Questions relating to this
cially elderly on certain drugs; tarry or bloody area may be embarrassing to both the patient and
stools: upper gastrointestinal tract bleeding from the clinician, so only ask when relevant and appro-
ulcer, e.g., nonsteroidal antiinflammatory drugs, priate and inform the patient why it is important
fresh bleeding from lower gastrointestinal tract, to ask. Use good judgment and common sense. For
e.g., tumor, anal ulcers, hemorrhoids, rarely en- example, it is not likely to be relevant or appropri-
dometriosis except if related to menstrual periods; ate to ask an 80-year-old recently widowed woman
recent gastrointestinal infections (also chronic in- about her sexual history despite suspecting a urinary
flammatory bowel disease) associated with joint tract infection, but it may be highly relevant to ask a
pain/rheumatological conditions] 25-year-old woman or man questions of this nature
• Do you have any problems swallowing? [dys- (e.g., Reiter syndrome). Although human sexuality
phagia: liquids (neurological), solid food (cervical may be an important part of some patients’ clinical
spine osteophytes, esophageal cancer, dry mouth); presentation, it is an area that requires considerable
odynophagia: gastroesophageal reflux, bacterial/ tact and sensitivity. In the context of this chapter, ex-
fungal infection, tumor, achalasia, chemical irrita- cept for a superficial screen, it is considered beyond
tion, neuromuscular disorder] the scope of normal chiropractic practice and best re-
• Have you lost any weight recently (past few ferred to the appropriate medical person who may
months) or noticed if your clothes are looser? [in- undertake relevant tests and instigate treatment.
tentional: weight loss; unintentional: cancer, hy-
perthyroidism, ill-fitting dentures in the elderly] Potential Questions to Ask
• Have you noticed any discharge from or ul-

Genitourinary and Reproductive Systems cers around your genitals or anus? [discharge,
Urinary Tract: Urethra, Bladder, and Kidneys foul smell: infection; ulcers (painful or not): sex-
ually transmitted disease (especially gonorrhea,
• Do you have or have you ever had any (re- syphilis, chlamydia [repeated spontaneous abor-
current) problems with your kidneys or blad- tions, subfertility, adhesions]); various skin disor-
der? [acquired or congenital polycystic kidney ders (herpes, condylomas, itching, poor hygiene,
disease; previous surgery (adhesions), subfer- predisposition to infection in diabetics, e.g., can-
tility, infections (especially gonorrhea, syphilis, didiasis); genital skin cancer; a history of syphilis
chlamydia), previous treatment, association with may be associated with aneurysms in later life
joint pain/rheumatological conditions; high blood as a consequence of weakening of the vessel
pressure, headache, pheochromocytoma, renal wall, especially in the aortic arch and abdominal
artery aneurysm; bilateral swelling of the ankles, aorta]
facial edema] • Do you perform regular self-examination of your
• Do you have any (recurrent) problems with uri- testicles? [how often, ever checked by a medi-
nation? [avoid the meaningless term dysuria, ask cal practitioner; noticed tender or nontender hard
about pain (loin or mid-back pain with or without swellings; noticed excess fluid in scrotum (lym-
chills and fever—kidney infection; burning pain— phoedema); ever had direct trauma, e.g., a kick,
urethral/bladder infection), frequency, urgency, previous surgery (vasectomy)]
or incontinence (several times per day and/or
night—physiological load or associated with ex- Obstetrical and Gynecological History: Menstruation Chi-
cessive fluid intake—diabetes mellitus, diabetes ropractors must be aware of various factors and
insipidus, prostate hypertrophy; weak pelvic floor conditions in relation to the obstetrical and gyneco-
musculature, infection, multiple sclerosis, slow- logical history that may confuse diagnoses or affect
onset cauda equina syndrome) and stream (strong, treatment; hence a brief description of selected aspects
poor, hesitancy, increased voiding time—prostate of the obstetrical and gynecological history is neces-
hypertrophy). Also ask about color and smell of the sary. Some of these questions and examination proce-
urine but these are less useful indicators of urinary dures are part of normal chiropractic practice when
tract problems, except perhaps gross hematuria obtaining the clinical history but are here reviewed
collectively in relation to the female patient’s history. relationship to the menstrual cycle are important. The
A more detailed description can be found in a stan- degree of disability or interference with normal ac-
dard text within this field.44,45 tivities is also important to elicit. In many situations,
Complications of early pregnancy, such as abor- when all relevant information has been obtained,
tion, are often considered under the title of gynecol- assurance that there is no underlying pathology is
ogy, but more properly lie within the definition of ob- the only “treatment” required. Social history (includ-
stetrics. However, in practice gynecology now covers ing cultural and religious) is particularly important
problems of reproduction in general, many of which where the presenting difficulties relate to abortion or
do not fall within the realm of disease or disorder but sterilization.44,45
have a social content, such as therapeutic abortion, Few things are, despite individual variations, as
sterilization, and contraception.44,45 Medical special- regular as the female menstrual cycle; hence it is an ex-
ists in this area are usually trained in both obstetrics cellent tool for establishing a time-related diagnosis of
and gynecology. a few conditions that can otherwise go undiagnosed
Some chiropractors specialize in treating pregnant despite specialist attendance. In the clinical history,
females and young children using gentle techniques. it is very important to establish baseline information
In most chiropractic practices, pregnant females and regarding this cycle in the menstruating female. Cer-
young children (except when prohibited by law) contain conditions with chromosomal anomalies may go
stitute a normal, but usually limited, percentage of undetected until the late teens with absence of men-
chiropractic patients who may derive significant ben- strual periods unless specific questions are asked to
efit from care. It is the chiropractor’s duty to assess elicit the potential cause(s) of nonmenstrual periods.
them individually and determine when treatment, re- For example, the use of the contraceptive pill before
ferral, or comanagement is warranted. The obstetric establishing normal menstrual period patterns may
history as obtained in medical practice includes the mask such underlying conditions, or there may be lack
following: of conception despite several attempts.
Two common conditions seen in chiropractic prac-
• Period of amenorrhea tice are premenstrual tension and endometriosis.
• Previous obstetric history Whereas the former may respond to chiropractic man-
• Condition of previous infants at birth agement, the latter may cause significant problems if
• Previous medical history previously undiagnosed. Frequently, the condition is
• Family history already diagnosed and managed under medical care,
for example, through prescription of the contracep-
The gynecological history as obtained in medical prac- tive pill. If the signs and symptoms appear regularly
tice includes the following: and in time with the menstrual periods, always think
endometriosis first, or at least hormone related, even
• Presenting complaint if you cannot point your finger at the exact cause
• Previous gynecological history and pregnancies of the (musculoskeletal) problem. Small patches of
• Urinary symptoms endometrial tissue can sometimes be found in a va-
• Menstrual history riety of places around the body, including the rec-
• Sexual/contraceptive history tum, lungs, and respiratory tract, in muscle tissue,
• Medical history or around nerves. Thus, when swelling up and com-
• Social history pressing surrounding tissues, this can cause rectal
• Date of last cervical smear bleeding (mimic rectal bleeding from cancer, hemor-
rhoids), nose bleeding, recurrent right shoulder pain
The history should, as indicated above, be com- with diaphragmatic irritation, or cyclic sciatica when
prehensive but not intrusive in a manner that is not close to the sciatic nerve. The symptoms tend to oc-
relevant to the patient’s problem. It should also be cur regular as clockwork and always in relation to the
remembered that the presenting symptom may not menstrual periods but on examination the function of
always be related to the main anxiety of the patient the shoulder, for example, is unaffected.
and that some time and patience may be required to Other causes of pain, such as in dyspareunia, may
uncover the various problems that bring the patient be caused by trigger points in the iliopsoas muscle,
to seek advice. which is easily treated in chiropractic practice, but
General principles of case history taking relating which may lead to confusion in the diagnosis. It is vi-
to the patient’s complaint apply here. Time scaling tal that the clinician’s thinking and decision-making
of the problem, and where appropriate, the circum- process go beyond the narrow focus of purely muscu-
stances surrounding the onset of symptoms and their loskeletal problems.
Breasts and grandparents; if older patient, ask about chil-

dren and grandchildren because of risk of poor
• Do you regularly do breast self-examination? [how recollection; bleeding may also be associated with
often, when was the last examination by a medical poor diet and vitamin C deficiency, Ehlers-Danlos
doctor, routine or specific reasons] syndrome]
• Have you noticed any lumps or unusual tender- • Have you ever been anemic? [reduced production,
ness in your breasts? [recent (pregnancy) or long- increased destruction, loss, e.g., in gastrointestinal
standing, previous investigations; remember that bleeding, such as ulcer or nonsteroidal antiinflam-
because not all lumps are painful, a lump may not matory drugs, menstruation, poor diet]
cause concern or be noticed] • Have you noticed any swelling of the lymph
• Have you noticed any changes in the size or con- nodes recently [Hodgkin disease, non-Hodgkin
tour of either breast? [slow-growing tumor may lymphoma; children often have swollen lymph
just cause distortion, dimpling of the skin may be nodes in the neck as a result of recurrent upper
the first indication of malignant tumor growth] respiratory tract infections]
• Have you noticed any changes in or around either
nipple? [leaking clear fluid or milk (pituitary Musculoskeletal System
tumor in nonpregnant female or in males,
• Do you have any symptoms relating to your joints,
gynecomastia—also liver problems), nipple retrac-
bones or muscles? [joint pain, stiffness (frequency,
tion from tumor growth, Paget disease of the
duration, morning only, all day, worse/better
breast/nipple unilateral and premalignant—may
with activity), swelling (unilateral or bilateral),
be mistaken by the patient for dermatitis]
skin lesions (sites of infection, psoriasis, scle-
roderma), muscle pain, bone or joint abnor-
Chiropractors tend not to examine the female
malities/deformities (hyperparathyroidism,
breast as part of a routine screening examination, and
Paget disease of the bone, Charcot joints, Ehlers-
this will in part also be determined by the legal context
Danlos syndrome, osteoarthritis, osteoporosis,
of practice. In most cases, it is not necessary to exam-
giant cell arteritis/polymyalgia rheumatica), bone
ine the breast if a careful clinical history has been ob-
pain (especially at night and/or irrespective of
tained because there are often enough indicators from
weight bearing: cancer, osteomyelitis, previous
a report of the patient’s self-examination to warrant
bone scans or other advanced radiographic imag-
referral to the medical practitioner who will examine
ing, results, treatment, and outcome); functional
and instigate further tests if needed. Many suspected
disability: walking distance, vascular/neurogenic
breast disorders are also recognizable purely on in-
claudication]
spection and hence can be referred out for further in-
• Have you ever had any fractures, dislocations, or
vestigations without the need for the chiropractor to
bad sprains? [when, what happened, treatment
do a physical examination.
and outcome, x-rays (metal rods still present?),
Although gynecomastia (breasts in males) is usu-
surgery]
ally associated with liver disease, it may, in the absence
• Have you ever suffered any significant trauma or
of other signs and symptoms, be difficult to spot in
injury? [car crashes (details of position, impact,
the obese patient. Males may also develop breast can-
seat belt, head rest, signs and symptoms, etc.),
cer, so the above questions above are also relevant to
whiplash, sport- or occupation-related: when,
them, albeit less frequently. Differential diagnoses of
what happened, treatment and outcome, x-rays]
chest pain for both males and females include Tietze
syndrome and pectoral muscle trigger points. Females
may be worried that the pain relates to the breast (can- Most patients in chiropractic practice suffer from
cer) when on interviewing and examination it is found problems relating to the low back, head, neck, extrem-
to be associated with tenderness over the costochon- ities, and other musculoskeletal problems; hence, this
dral junction, or very commonly trigger points in the is normally covered in more detail in the clinical his-
pectoral muscles giving rise to chest pain. tory for the main complaint(s). Remember that some
systemic (rheumatic, endocrine, infections, internal
Hematological/Hematopoietic System organs) conditions also cause musculoskeletal pain,
• Are you aware of any blood disorders in your (bi- so always think of possible differential diagnoses.
ological) family? [adopted person with no knowl-
edge of biological parents, genetics: hemophilia, Nervous System
thalassemia, sickle cell anemia, connective tissue This covers a large area so it may be easier to subdi-
disorders (Ehlers-Danlos syndrome, may show vide some of the questions by function. Beware of the
many bruises); if young patient, ask about parents terminology, because some patients perceive nervous
(system) disorders as psychological/psychiatric con- disease, syphilis, alcoholism, diabetes, drop foot,
ditions. brain tumor, recurrent ankle sprains]
• Have you noticed any clumsiness of the hands or
General Questions dropped things? [cerebellar signs, tremor, lack of
• Have you ever experienced any periods of disori- fine coordination/sensation]
entation or confusion? [recent/long ago, intoxica- • Have you experienced any episodes of dizziness?
tion, brain tumor, senile dementia] [orthostatic, certain head/body positions, subcla-
• Have you ever had any episodes of loss of vian steal syndrome, transient ischemic attacks,
consciousness? [recent/long ago, with or without labyrinthitis, heart problems, alcohol related]
head trauma, stress] • Have you noticed any stiffness or shaking of your
• Have you ever had any seizures? [epilepsy, post- muscles? [recent/long ago, upper motor neurone
traumatic, cerebral infection, brain tumor] lesions, Parkinson disease, tremor: thyroid prob-
• Have you ever had any infections affecting your lems; painful muscles: metabolic problems]
nervous system? [meningitis, syphilis, other infec-
tion, peripheral neuropathies] Psychological (Emotional, Behavioral),
Psychiatric, and Mental Health
It is important to note that there is a wide variation
Sensory System
in what may be considered normal behavior. This
• Do you suffer from (recurrent) headaches? [de- may even vary considerably within the same culture,
scribe where, e.g., occipital, frontal; what brings so the clinician must be aware of the potential effect
them on, changes in character, frequency, severity, that his or her own background, attitude, and verbal
time of day (morning: potential raised intracranial and nonverbal (body language) communication may
pressure) and duration; aura, photophobia, family have on the interaction with the patient. Obtaining
history of migraine; trigger factors: alcohol, food; a working knowledge of the culture and general be-
berry aneurysm/subarachnoid hemorrhage, hy- liefs, attitudes, and behavior of the people in the area
pertension, pheochromocytoma, trigeminal neu- of practice usually avoids awkward situations, em-
ralgia, giant cell arteritis/polymyalgia rheumat- barrassment, and miscommunication.39,46,47 The ter-
ica] minology used among professionals is also subject
• Do you experience any areas of numbness, in- to different interpretations. For example, clinicians in
creased sensitivity, or unusual sensations? [radic- North America and the United Kingdom ascribe dif-
ular symptoms, peripheral neuropathy (diabetes, ferent meanings to words such as mental retardation
vitamin-deficiency disorders), fasciculations, trig- and learning disabilities.48
ger factors, altered sensation of the face, multiple In the context of chiropractic practice, it is im-
sclerosis, impending stroke] portant to realize that one is usually not expected to
• Do you have any problems with feeling or touch? reach a diagnosis in this specialized field, but must
[lack of sensitivity, peripheral neuropathies, dia- be alert to any clues that may indicate the need for
betes, syringomyelia, brain stem lesion (low pon- further psychological/psychiatric evaluation. Yellow
tine, medullary, and cervical lesions, “onion skin”): flags (e.g., signs of depressive illness, catastrophizing,
multiple sclerosis] poor coping strategies) are commonly seen in practice,
especially with chronic low back pain sufferers, and
Motor System these may have a direct influence on the outcome and
• Do you have any weakness or paralysis in the prognosis of treatment. Therefore, multidisciplinary
arms, legs, or part of your face? [history of polio, comanagement of the patient may be required.
stroke, Bell palsy, multiple sclerosis, radicular
Potential Questions to Ask
problems]
• Have you experienced any double vision? [re-
• How would you describe your general emotional
cent/long ago, multiple sclerosis, brain tumor, ex-
status? [happy, contented, stressed, frustrated
traocular muscle weakness: cranial nerve lesion]
(“hate my job”), worrier, depressed, etc., sought
• Have you had any problems with your speech?
counseling, seen medical doctor, psychotherapist]
[history of stroke, cerebral palsy, migraine]
• Are you aware of any mental/psychiatric illness
in your (biological) family? [schizophrenia, manic
Coordination of Movement depression, maladaptation, etc.: who, at what age
• Have you noticed any problems with your bal- developed, social circumstances, abuse]
ance? [recent/long ago, frequent falling, clumsi- • Do you have any other concerns in this area that
ness, cerebellar signs, multiple sclerosis, Parkinson you want to discuss with me?
Skin Conditions and Allergies including the patient’s perception and concerns.
Integument (Skin, Hair, Nails) Therefore, it is useful to encourage the patient to bring
up any other concerns that the patient may have in
the context of the patient’s current signs and symp-
• Do you have any problems with your skin, hair toms, and the clinical encounter. Sometimes worried
or nails? [psoriasis, dermatitis, side effects from patients bring up all kinds of other totally irrelevant is-
drugs, hormonal changes, fungal infections, al- sues. Do not ignore or dismiss these concerns outright,
lergy, occupational exposure] even if they seem ridiculous to you. Be sympathetic;
• Have you ever had any moles removed? [ma- show or explain that you understand and that you will
lignant melanomas may metastasize 10–15 years consider these concerns. To avoid the patient going off
later, hence it is important to ask whether any of in all kinds of directions with irrelevant information,
the previous moles were found to be benign] you should guide the patient by specifying that you
• Do you like sunbathing? [use skin protection (ap- are asking the question specifically in the context of
propriate factor used for geographical area), burn their current signs and symptoms and the clinical en-
easily (fair skinned, ginger hair), extensive sun ex- counter. This helps to focus the patient’s mind and
posure/burns as a child increases the risk of ma- usually avoids spending much time on peripheral is-
lignant melanomas later in life] sues, such as mild symptoms the patient may have
• Do you use any products on your skin on a regular had decades ago.
basis (moisturizers, skin protection)? [allergies to
any of them (including creams, lotions, shampoos,
soap, cosmetics)] Summary of Your Understanding of the
• Do you perform regular self-examination of the Patient’s Complaints and Concerns
skin? [Use mirrors, examination by partner, and As previously mentioned, some clinicians prefer to
examination by medical doctor; on examination: do the summing up of their understanding of the
always measure any suspicious looking moles in patient’s complaints and concerns after completing
two dimensions (vertically and horizontally) and the full clinical history.3,30,33,38,39,40,49 Others may do
record it with a date/year in the file; compare it after covering the main complaints, and then again
this baseline to when the patient comes in several briefly after the systems review. Either way it takes
months later, especially if changes (growth, irreg- very little time.
ular borders, color changes), or symptoms (leak-
ing fluid or blood, itching, pain) develop in or
around the skin lesion/mole (see section 3 of phys- SUMMARY
ical examination chapter on skin examination). Re- 1. The clinical history needs to include information
member that malignant melanomas are not always on the chief complaint, history of the condition,
black but may be combinations of color changes pain characteristics, associated symptoms, aggra-
ranging from black, dark brown, dark blue, to ame- vating factors, relieving factors, previous similar
lanotic/red in color. Three rare but important areas episodes and treatment, leisure activities, occupa-
to check are in the buccal cavity, under the nails, tional history, geographical history, and systems
and in the eye. In a past history of mole/skin le- review. Additional information may also be gath-
sion removal, it is important to discover if the orig- ered if indicated by the presenting complaint.
inal lesion was found to be benign or malignant. 2. The biopsychosocial model of disease was de-
Malignant melanomas may occasionally show up scribed by Engel as a framework on which to es-
10–15 years later as metastatic spread without tablish a system of simple to increasingly complex
signs of new skin lesions. If in doubt, refer to a systems (biological, social, psychological) in the
dermatologist sooner rather than later because of evaluation of patients with spinal pain. It is an at-
the aggressiveness and risk of spread of the condi- tempt to recognize that a health condition may im-
tion.] pact a patient in many different ways. Clinicians
• Do you suffer from any allergies? [seasonal varia- should be aware of this model to help interpret
tions in symptom picture, asthma, food, hay fever, information gathered from the clinical history.
pets, hypersensitivity reactions, e.g., bee stings, 3. A diagnosis is a decision regarding the nature of
ants, etc.] the patient’s complaint—the art or act of identi-
fying a disease or condition from its signs and
Additional Information Despite an extensive clinical symptoms—whereas a clinical impression is a
history, it is not possible to cover or foresee all the working hypothesis formulated from significant
different situations that may affect the clinical pre- items in the history and physical findings—a ten-
sentation, however trivial you may think they are, tative diagnosis, or a working diagnosis. Clinicians
should attempt to establish both when evaluating tive to emotional and cultural influences on the pa-
a patient. tient’s behavior, and know how to handle them in a
4. The chiropractic clinician should, based on prior totally nonjudgmental way. Poor communication
knowledge of the biomedical and clinical sciences, skills, including asking leading questions, closed-
develop a flexible, yet structured, approach to ob- ended questions, and displaying a noncaring or
taining the clinical history. A practical approach indifferent attitude through body language, are
may be to start by following the same pattern of likely to negatively influence the doctor–patient
systematic questioning with each patient to ensure relationship and do not facilitate trust in the clini-
acquisition of all pertinent information. As clinician. With miscommunication comes wrong infor-
cians develop their history-taking skills, this ap- mation, which may lead to wrong clinical impres-
proach may be tailored to each patient and situa- sions and diagnoses. Patient dissatisfaction with
tion. treatment and unprofessional or discourteous be-
havior (without apology) are common reasons for
complaints against health care personnel and may
QUESTIONS result in unnecessary lawsuits, which are both a
financial and emotional drain on both parties.
1. Why is it important to obtain a good clinical history
4. It is not really possible to totally separate the clin-
from the patient?
ical history and the physical examination as they
2. Which general and specific areas in the clinical his-
usually complement each other, and no responsi-
tory require attention and why?
ble clinician would normally undertake one with-
3. Why are the clinical encounter, courteous patient
out the other. Much of the time the physical exam-
handling, and good interpersonal communication
ination and follow-up investigations merely con-
skills so important?
firm what was suspected from the clinical his-
4. In what ways are the clinical history and the physi-
tory. However, obtaining a good clinical history
cal examination integrated, as well as complemen-
requires good interviewing and general commu-
tary?
nication skills, and especially constant alertness to
5. Why are patient-centered care and self-directed
even minor clues from the patient, whether spo-
learning so important in health care today?
ken or not. Part of this involves spot diagnoses,
that is, detecting clues that are virtually pathog-
nomonic or strong indicators of (serious) underly-
ANSWERS
ing organic disease and/or psychosocial problems
1. To assess whether or not the patient may benefit (red flags, yellow flags). It is the clinician’s duty to
from chiropractic care, it is important to establish refer out for medical care if it is suspected that
through the clinical history and physical examina- the patient’s health may be seriously at risk (red
tion whether the patient suffers from a condition flags). Other factors (yellow flags) can negatively
amenable to chiropractic care, or has an underlying influence the outcome of care and may require fur-
condition that requires medical referral or coman- ther expert evaluation and/or comanagement. By
agement. Without appropriate and relevant infor- being alert to such factors, taking appropriate ac-
mation it may not be possible to establish a clinical tion when required, and keeping proper records,
impression and diagnosis that will enable you to the clinician will ensure that he or she practices
determine a plan of management. within the legal framework and scope of practice,
2. Physical examination, especially for neuromus- and will be much less at risk of medicolegal action
culoskeletal complaints, to establish whether the from the patient or third parties.
problem is mainly physical and/or has a signif- 5. The organ-failure model of medicine has failed
icant psychological component to the symptom dismally and is now being replaced by a biopsy-
picture. Predictors of poor outcome may be deter- chosocial model that takes into account physi-
mined through the use of specific questionnaires. cal, psychological, and social issues (“triple di-
The student/clinician should always, unless ur- agnosis”) in relation to the patient’s problems—
gent circumstances dictate otherwise, address the a holistic approach to health care that should be
main complaint(s) first and then general issue and familiar to most chiropractic students and clini-
screening procedures. cians. Physical impairment is often minor, but the
3. We communicate in many ways (verbal, nonver- long-term psychological and social impact may
bal, written) when interacting with other people, propel the patient into a situation, that is totally
and in the doctor–patient relationship we also as- disabling, with chronic pain and poor psychoso-
sume certain roles and have expectations that may cial coping mechanisms. Such situations are both
or may not be realistic. The clinician must be sensi- tragic for the individual as well as costly to society.
Earlier consultation and evaluation at the pri- 2. Bickley LS, Hoekelman RA. Clinical thinking: From
mary care level and greater emphasis on patient- data to plan. In: Bickley LS, Hoekelman RA, eds. Bate’s
centered self-management, physical activity, and guide to physical examination and history taking, 7th ed.
developing coping strategies to avoid chronicity Philadelphia: Lippincott, 1999:705–717.
will help reduce the risk of developing chronic 3. Calnan J. Talking about diagnosis and prognosis. In:
Talking with patients. A good guide to practice. London:
problems and lessen dependency on the clini-
William Heinemann, 1983:81–94.
cian. To cope with increasingly complex clinical 4. Fraser RC. The diagnostic process. In: Clinical method: A
situations, many of which require expertise in general practice approach, 3rd ed. Oxford: Butterworth-
other fields, multidisciplinary approaches to pa- Heinemann, 1999:36–58.
tient management are necessary. Many clinicians 5. Nagelkerk J. Clinical decision-making in primary care.
have been brought up with the traditional lecture- In: Nagelkerk J, ed. Diagnostic reasoning: Case analy-
based teaching approach, which does not suit ev- sis in primary care practice. Philadelphia: WB Saunders,
eryone, and may not necessarily facilitate learn- 2001:3–10.
ing in all aspects of the clinical environment. They 6. Seidel HM. Taking the next steps: Critical thinking. In:
need to take personal responsibility for becoming Seidel HM, Ball JW, Dains JE, et al., eds. Mosby’s guide to
better communicators (with patients as well as col- physical examination, 4th ed. St. Louis: Mosby, 1999:835–
841.
leagues and administrators), learning more about
7. Spanswick CC, Main CJ. Clinical decision making. In:
what other disciplines may contribute, and being Main CJ, Spanswick CC, eds. Pain management: An in-
better at problem solving in the variety of different terdisciplinary approach. Edinburgh: Churchill Living-
situations—clinical or otherwise—that they will stone, 2000:233–252.
encounter in a rapidly changing society. This re- 8. Strategies and skills in the consultation. In: Pendleton
quires a major shift in thinking on part of both D, Schofield T, Tate P, et al., eds. The consultation. An
students and established clinicians. approach to learning and teaching. Oxford: Oxford Uni-
versity Press, 1984, reprinted 1996:50–60.
9. Myerscough PR, Ford M. Conducting an interview. In:
Myerscough PR, Ford M. Talking with patients: Keys to
KEY REFERENCES
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Bickley LS, Hoekelman RA. Bate’s guide to physical examina- 1996:16–41.
tion and history taking, 7th ed. Philadelphia: Lippincott, 10. Spanswick CC. General issues of assessment. In: Main
1999. CJ, Spanswick CC, eds. Pain management: An interdis-
Fraser RC. Clinical method: A general practice approach, 3rd ed. ciplinary approach. Edinburgh: Churchill Livingstone,
Oxford: Butterworth-Heinemann, 1999. 2000:117–138.
Haslett C, Chilvers ER, Hunter JAA, et al., eds. Davidson’s 11. Waddell G. Diagnostic triage. In: The back pain revolu-
principles and practice of medicine, 18th ed. Edinburgh: tion. Edinburgh: Churchill Livingstone, 1998:9–25.
Churchill Livingstone, 1999. 12. Engel G. The biopsychosocial model and medical edu-
Main CJ, Spanswick CC, eds. Pain management: An inter- cation. N Engl J Med 1982;306:802–806.
disciplinary approach. Edinburgh: Churchill Livingstone, 13. Main CJ, Spanswick CC, Watson P. The nature of
2000. disability. In: Main CJ, Spanswick CC, eds. Pain
Mootz RD, Bowers LJ, eds. Chiropractic care of special popu- management: An interdisciplinary approach. Edinburgh:
lations. Topics in clinical chiropractic series. Gaithersburg, Churchill Livingstone, 2000:89–106.
MD: Aspen, 1999. 14. Wilson I, Cleary P. Linking clinical variables with
Mootz RD, Vernon HT, eds. Best practices in clinical chiroprac- health-related quality of life. JAMA 1995;273:59–65.
tic. Topics in clinical chiropractic series. Gaithersburg, MD: 15. Waddell G. The epidemiology of low back pain. In: The
Aspen, 1999. back pain revolution. Edinburgh: Churchill Livingstone,
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communication, 3rd ed. Oxford: Oxford Medical, 1996. 16. Nowak TJ, Handford AG. Foundation concepts of
Seidel HM, Ball JW, Dains JE, et al. Mosby’s guide to physical pathophysiology—Introduction. In: Essentials of patho-
examination, 4th ed. St. Louis: Mosby, 1999. physiology. Concepts and applications for health care profes-
Souza TA. Differential diagnosis for the chiropractor. Gaithers- sionals, 2nd ed. Boston: WCB McGraw-Hill, 1999:3–5.
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agnostic examination, 7th ed. New York: McGraw-Hill, proach to the assessment and management of activity-
2000:1–12. related spinal disorders-a monograph for clinicians
report of the Quebec Task Force on Spinal Disorders. general practice approach, 3rd ed. Oxford: Butterworth-
Spine 1987;12(7S):S16–S21. Heinemann, 1999:1–24.
20. Biering-Sorensen F. A prospective study of low back 34. Putting it all together. In: Seidel HM, Ball JW, Dains JE,
pain in a general population. I: Occurrence, recur- et al., eds. Mosby’s guide to physical examination, 4th ed.
rence, and aetiology. Scand J Rehabil Med 1983;15:71– St. Louis: Mosby, 1999:805–834.
80. 35. Turner R, Blackwood R. History taking. In: Lecture
21. Croft P, Papageorgiou A, McNally R. Low back pain. In: notes on clinical skills, 3rd ed. Oxford: Blackwell Science,
Stevens A, Rafferty J, eds. Health care needs assessment, 1997:6–24.
2nd series. Oxford: Radcliffe Medical Press, 1997:129– 36. Pedersen P. A survey of chiropractic practice in Europe.
182; as quoted by Waddell G. The epidemiology of Eur J Chiropr 1994;42(1):3–28.
low back pain. In: Waddell G, The back pain revolution. 37. Kirkaldy-Willis WH. The clinical picture: Introduction.
Edinburgh: Churchill Livingstone, 1998:73. In: Kirkaldy-Willis WH, ed. Managing low back pain.
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Psychosocial factors in pain: Critical perspectives. New record. In: DeGowin’s diagnostic examination, 7th ed.
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C H A P T E R
27
THE PHYSICAL EXAMINATION
B. Kim Humphreys and Lisa Caputo
O U T L I N E
INTRODUCTION —Are the lymph nodes normal?
Role of the Physical Examination Thyroid Gland
General Considerations Inspection
Red Flags Palpation
Screening Tests Auscultation
PHYSICAL EXAMINATION OF THE SKIN AND Eye
NAILS Inspection of the External Eye
General Considerations Inspect the Conjunctivae, Cornea, and Sclera
Examination Procedure Inspect the Iris and Pupils
Observation Palpation
—Is there an increase, decrease, or loss of Ophthalmoscopic Examination
pigmentation (melanin)? Ear
—Is there redness, pallor, or cyanosis? Inspection of the External Ear
—Is there yellowness or jaundice (icterus)? Palpation of the Ear and Mastoid Processes
—Are there any primary skin lesions? Otoscopic Examination
Palpation Nose and Nasopharynx
—Temperature: Is there an increase or decrease? Is it Inspection
generalized, regional, or localized? Palpation
—Moisture: Is the skin dry, oily, or wet? Inspection of the Nasal Cavity
—Texture, mobility, and turgor: Is there a change in Maxillary and Frontal Sinuses
texture, mobility, or turgor? Mouth and Oropharynx
—Palpate observed lesions Red Flags for the Head and Neck
Red Flags Examination
Examination of Nails PHYSICAL EXAMINATION OF THE CHEST
PHYSICAL EXAMINATION OF THE HEAD (CARDIOVASCULAR SYSTEM)
AND NECK Risk Factors and Red Flags
General Considerations Physical Examination
General Head and Neck Examination Cardiovascular Screening Procedure
Inspection Cardiovascular Examination
—Is the head positioned in an upright, neutral —Take the arterial blood pressure
posture? —Auscultate the heart
—Is there symmetry of facial features and PHYSICAL EXAMINATION OF THE PERIPHERAL
movements? VASCULAR SYSTEM
—Are any abnormal skin coloring or lesions present? Peripheral Vascular Screening Procedure
Palpation Peripheral Pulses
—Is there evidence of head trauma? Observation
—What are the hair’s texture and distribution like? Temperature of the Limbs
—Are the temporal arteries palpable? Venous Filling Time
—Are the salivary glands normal? Lymphatic System
509
PHYSICAL EXAMINATION OF THE RESPIRATORY General Considerations

SYSTEM Physical Examination
Risk Factors and Red Flags for Lung Disease Inspection
Dyspnea Auscultation
Chronic Cough Percussion
Hemoptysis Auscultation
Cyanosis Special Maneuvers
Physical Examination of the Lungs Superficial Abdominal Reflexes
Screening Procedures Evaluation for Ascites
Observation of Quiet Respiration Evaluation for Peritoneal Irritation
Palpation of the Chest Wall Red Flags
Percussion of the Chest SUMMARY
Auscultation of the Chest QUESTIONS
Lung Auscultation ANSWERS
PHYSICAL EXAMINATION OF THE ABDOMEN KEY REFERENCES
Visceral Pain REFERENCES
OBJECTIVES to least probable, strongly informed by the patient’s

history.1 It should not be used as a “shotgun” ap-
1. To review the purpose of the physical examina-
proach whereby any possible test is employed in the
tion in the overall context of the clinical diagnostic
hope of finding something abnormal. The vast major-
process.
ity of patients seeking chiropractic care do so for con-
2. To identify important considerations to aid the chi-
ditions relating to musculoskeletal pain and dysfunc-
ropractic student/clinician in performing a com-
tion, such as low back and neck pain, headaches, and
petent physical examination.
shoulder, hip, and knee pain. However, it is impor-
3. To identify important clinical cues from the his-
tant for chiropractors to evaluate the general health
tory that would indicate the need for a specific and
status of patients. Chiropractors should identify both
more detailed physical examination or screening
conditions that are appropriate for chiropractor care
procedure.
and those life-threatening disorders where care is con-
4. To identify common “red flags” or signs of serious
traindicated.
pathology that would contraindicate chiropractic
care and require referral to an appropriate medical
General Considerations
practitioner.
5. To explain the essential components of the physical The physical examination is both a science and an
examination of the skin and nails, head and neck, art. The science aspect lies in the systematic elicita-
and chest and abdomen that are appropriate for tion and documentation of patients’ clinical signs and
the chiropractic practitioner. symptoms. The art lies in the skillful choice and per-
formance of specific tests or maneuvers. The physical
examination requires considerable practice and expe-
INTRODUCTION rience in order to obtain mastery and constant atten-
tion to detail so as to maintain that level of compe-
Role of the Physical Examination tence. It is important for all clinicians to remember
The general physical examination is an important part that the physical examination is only as good as the
of the overall clinical diagnostic process. For chiro- quality and skillfulness of the tests performed.
practors, the majority of presenting conditions can be Expert clinicians are skilled in the areas of observa-
diagnosed, or at least a working diagnosis established, tion and inspection, actively scanning the patient for
through a carefully elicited history and physical exam- important visual clues (observation). If a clue is found,
ination. The features identified in a patient’s history a more in-depth and careful observation of the spe-
should lead the clinician to a strong suspicion of the cific feature is undertaken (inspection). For example,
likely diagnosis, or at least a range of probable con- a patient who is experiencing pain usually provides
ditions (differential diagnosis). The role of the physi- key visual information to the clinician who is actively
cal examination should be to confirm the diagnosis or seeking it. Facial expressions such as grimaces, altered
create a hierarchical differential diagnosis from most and stiff postures, and guarded, restricted, and stiff
THE PHYSICAL EXAMINATION 511
movements are common clues that can be identified

5. Ensure that the patient is warm, comfortable, and re-
by clinicians.1,2
laxed; ensure the patient’s modesty and dignity.
Many patients are apprehensive and anxious
6. Use an efficient examination routine; minimize patient
about the physical examination. Consequently, the
movement and time.
chiropractors’ role should be to identify and be sensi-
7. Carefully observe for visual clues and investigate in
tive to patients’ concerns, as well as inform and reas-
detail any clues found.
sure them to warrant their trust. Because many chiro-
8. When palpating, ensure warm, dry, firm, yet comfort-
practors now practice in multicultural communities,
able and purposeful hands.
it is increasingly important to be aware of and re-
9. Look and act confident, organized, and professional.
spect patients’ customs, beliefs, and habits, especially
10. Strive for skillful, proficient, and consistent execution
those related to gender issues, touching, dress, and
of manual tests and maneuvers.
undress.3 To reduce anxiety and encourage trust dur-
ing the physical examination, it is recommended that
chiropractors address their patients in a calm, yet reas-
Red Flags
suring and knowledgeable manner. Explain to the pa-
tient in clear, concise, and understandable terms what A “red flag” is a general term used to identify a se-
the examination will entail and why. Ask patients if rious condition or pathology. Tumors, fractures, and
they understand the process or have any questions. infection are examples of red flags. Consequently, red
Although regulations and laws may vary from one flags contraindicate chiropractic care and may rep-
jurisdiction to another, it is advised that chiropractors resent a condition that is life-threatening to the pa-
obtain at least a verbal consent from the patient before tient. The first responsibility of the chiropractor is to
proceeding. Some jurisdictions may require written correctly identify the red flag. The second responsi-
consent. bility is ensuring continuity of care by referring the
To properly assess a body part, it needs to be clearly patient in a timely manner to the appropriate health
visualized by the chiropractor. Manual palpation of care provider along with all necessary information
the area usually follows and also requires clear vi- and documentation.1 Red flags are usually associated
sualization of the area to be inspected.1 Be mindful with characteristic features that help to identify spe-
to maintain the modesty and dignity of the patient cific conditions and help to distinguish them from
by first explaining and then asking for permission other conditions. Clinical features that are unique to
to expose those areas that are necessary for exam- a particular condition or pathology are called pathog-
ination while keeping other unrelated areas cov- nomonic. During the history and physical examination,
ered. If possible, try to keep the patient comfortable, the clinician should carefully look for clinical features
warm, and relaxed at all times. When using your that may indicate a red flag. For example, a patient that
hands, make sure they are warm, clean, and dry. It complains of deep, severe, boring pain that wakes the
is extremely important for students and novice clini- patient up from sleep may indicate a serious tumor
cians to become competent and confident palpators or infection. This chapter identifies common and im-
and to convey that confidence through firm, com- portant red-flag conditions and specific examination
fortable, and purposeful touch. The sidebar “Tips procedures to be performed.
for Conducting the Physical Examination” summa-
rizes some important tips for conducting the physical Screening Tests
examination.1,2 A screening test is a test or a combination of tests
that help to identify whether the patient has a general
problem. They do not identify specific conditions but
Tips for Conducting the Physical rather identify if a problem exists and if more specific
Examination testing is needed. Examples of screening tests would
be taking a patient’s blood pressure and radial pulse in
1. Select only those tests likely to confirm or rule out your
order to examine the cardiovascular system or auscul-
diagnosis/differential.
tation of the lungs to evaluate general lung function.
2. Explain all procedures in clear, concise, understand-
Screening tests are very useful as they can quickly alert
able terms (demonstrate if necessary).
the patient and clinician to any abnormalities. Screen-
3. Ask if the patient has any questions about the physical
ing tests do not exist for all major parts of the physical
examination and ask for consent to proceed (verbal
examination; known screening tests and their indica-
and/or written).
tions are identified in this chapter. The focus of this
4. Ensure that the patient’s body/part for inspection is
chapter is on the nonmusculoskeletal physical exami-
clearly visible under adequate light.
nation with an emphasis on vital signs, skin/head and
neck, the cardiovascular and respiratory systems, and uli. Feel for thickness, temperature, moisture, ease of
the abdomen. mobility, and elasticity of the tissues as well as other
palpatory features of the lesion. If there are nodules
or masses present, palpate for general shape (round,
PHYSICAL EXAMINATION OF THE
oval, lobulated, etc.), consistency (firm, soft, rubbery,
SKIN AND NAILS
etc.), and borders (well demarcated, circumscribed,
In the normal course of clinical practice, chiropractors indistinct, irregular, etc.). It is also important to deter-
may observe a substantial portion of the patient’s skin. mine whether the lesion is painful to both light and
Skin is the largest organ system of the body, and in- deep touch.
cludes appendages, hair, nails, and glands (sebaceous
and sweat). Unlike other organ systems such as the Examination Procedure
heart and lungs, skin and its appendages are superfi- When examining the skin, the following procedure is
cial and readily accessible to physical examination.4 A recommended.
careful examination of a patient’s skin can provide in-
dicators of their overall health status.5 Consequently, Observation
it is important for chiropractors to have a good work- Is there an increase, decrease, or loss of pigmentation
ing knowledge of common and serious skin disorders (melanin)? Is it widespread or localized? Pigmentation
in order to reassure patients concerned about a benign is increased and widespread in Addison disease; in-
mole or to provide prompt referral for a potentially creased and localized in nevi, malignant melanoma,
malignant tumor. and café-au-lait spots; decreased and widespread in
tinea versicolor; and absent and localized in vitiligo
General Considerations or scars from surgery or trauma.
A chiropractor should constantly observe the exposed
areas of skin, hair, and nails for clues of health or Redness is a result of
Is there redness, pallor, or cyanosis?
disease. To do this, these structures should be read- increased vascularity (i.e., increased oxyhemoglobin),
ily visible, preferably under good natural lighting or pallor is a result of decreased blood flow (i.e., de-
under artificial lighting that closely approximates nat- creased oxyhemoglobin), and cyanosis is a result
ural lighting.5 of decreased oxygenation of blood (i.e., increased
For skin, huge variations exist within the normal deoxyhemoglobin).5 These cues are best visualized
population in terms of appearance. Color, thickness, in fingernails, lips, and mucous membranes of the
and presence or absence of hair and moisture are mouth or palpebral conjunctiva. Table 27–1 lists some
but a few variables to consider. Skin color depends of the conditions associated with redness, pallor, and
on the pigments melanin, carotene, and hemoglobin cyanosis. Look for widespread redness (i.e., allergic re-
(oxyhemoglobin and deoxyhemoglobin). Knowledge action such as urticaria or infectious such as rubeola)
of what affects these pigments is important when ex- or localized redness (i.e., inflammation from trauma,
amining the skin. With aging, the skin becomes wrin- rheumatic disease when accompanied by swelling, or
kled, looser, and thinner. However, areas of the skin atopic dermatitis because of allergic contact). Look
exposed to the sun may be affected more than other for pallor in fingernails, lips, and mucous membranes
areas. With aging, the skin also becomes dry (asteato- (i.e., anemia or reaction to cold or stress). Look for
sis), as well as rough, flaky, and perhaps itchy. central cyanosis in the lips, mucosa of the mouth, and
When observing skin disorders, note whether the the nails (i.e., acute or chronic pulmonary disease or
lesion is widespread, regional, or localized, and ex- congenital heart disease) or peripheral cyanosis in the
amine different parts of the patient’s body in order to nails, hands, and feet (i.e., congestive heart failure, pe-
make comparisons. Carefully observe the same area ripheral vascular disease, or Raynaud disease).4,5
on both sides. For example, compare the skin on the
left forearm to the right forearm. Also observe adja- Icterus results
Is there yellowness or jaundice (icterus)?
cent tissue both superiorly and inferiorly to the area from excess bile pigments in the skin and mucous
of concern for comparison. membranes. Suspected jaundice must be visualized
Before starting to palpate, assess skin temperature under natural light and is best visualized in the sclera
using the dorsum of the fingers. Move just above the of the eyes and in mucous membranes. Jaundice is
skin in longitudinal stroking movements, making sure suggestive of liver disease or hemolytic anemia.
not to touch the skin. Compare bilaterally. When pal-
pating the skin to assess a lesion, start with adjacent, If so, visually describe
Are there any primary skin lesions?
unaffected tissues as a reference. Use gentle pressure them in terms of number (single, multiple, patch-
applied through the pads of your fingers. Avoid using like), size, border (regular, irregular), and color. Skin
the thumbs, as they are less sensitive to sensory stim- lesions are best characterized by a combination of
TABLE 27–1. Some Conditions Associated with Redness, Pallor, and Cyanosis
Observations Associated Conditions
Redness (widespread) Allergic reaction (i.e., urticaria); infectious (i.e., rubeola)

Redness (localized) Inflammation from trauma; rheumatic disease (with swelling); contact
dermatitis (allergic)
Pallor (fingernails, lips, mucous membranes) Anemia or reaction to cold or stress
Central cyanosis (lips, mucosa of mouth, and the nails) Acute or chronic pulmonary disease; congenital heart disease
Peripheral cyanosis (nails, hands, and feet) Congestive heart failure, peripheral vascular disease, or Raynaud
disease
observation and palpation. Table 27–2 provides fur- dry in hypothyroidism. Patients with acne have oily
ther information. skin, while increased moisture is found in patients
with hyperthyroidism or tumors of the adrenal glands
Palpation (pheochromocytoma), or in normal individuals dur-
Temperature: Is there an increase or decrease? Is it gener- ing stressful events.
Localized increase in tem-
alized, regional, or localized?
perature is caused by a localized increase in vascu-
Texture, mobility, and turgor: Is there a change in texture, mo-
larity (i.e., trauma, infection, or an arthritic condition
Use the pads of your fingers to assess
bility, or turgor?
if found adjacent to joints). Generalized warmth is a
for roughness or increased smoothness (i.e., general-
result of a systemic condition (i.e., fever from an infec-
ized in hypothyroidism and aging respectively). Gen-
tion or hyperthyroidism). Similarly, generalized cool-
tly move the skin about and assess for increased mo-
ness may be caused by hypothyroidism or peripheral
bility (i.e., normal aging, or Ehlers-Danlos syndrome
vascular disease if localized in the extremities. Com-
in younger individuals), or decreased mobility (i.e.,
monly, lesions with increased skin temperature have
edema or scleroderma). Examine for turgor or elastic-
secondary lesions on top of the skin such as scales,
ity by gently tugging some skin. Decreased turgor is
crusts, or lichenification, while skin that has decreased
found with aging and dehydration.
vascularity tends to be atrophic.
Use the pads of

Moisture: Is the skin dry, oily, or wet? Palpate observed lesionsHaving already observed the
your fingers and light stroking motions. Examine the skin lesion(s), gently palpate for the following:
face, palms of the hands, and other areas of skin, such
as the arms, forearms, legs, and feet. Skin becomes • Elevation: raised or flat
dry, flaky, and commonly itchy with aging. It is also • Firmness: solid, firm, rubbery, spongy, fluid-like
TABLE 27–2. Classification of Skin Lesions by Physical Examination
Name Size Border Surface Texture Example
Macule Small (<10 mm) Circumscribed Flat Not palpable Freckle

Patch Larger than macule Coalescence of Flat Not palpable Vitiligo
macules
Papule <10 mm Circumscribed Elevated and round Solid mass Nevus, malignant
melanoma
Plaque >10 mm Coalescence of Elevated but flat Firm, flat mass
papules
Nodule >5 or 10 mm Well demarcated Elevated mass Deeper, firm mass Basal cell carcinoma
Tumor Large nodule Well demarcated Elevated mass Deep, spongy to firm Lipoma, advanced
(≥20 mm) or diffuse carcinoma
Wheal Localized area Slightly irregular Slightly raised Superficial Urticaria
Adapted from Dermatologic disorders. In: Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, 17th ed. Whitehouse Station, NJ:
Merck Research Laboratories, 1999:838.
TABLE 27–3. Nail Lesions and Associated Conditions
Observed Lesion Description Associated Condition
Nail surface separation Separation of nail plate from the nail bed Hyper- or hypothyroidism, psoriasis, excessive
(onycholysis) (distal) exposure to water, soaps, chemicals, etc.
Nail surface lesions Crumbly, thickened, and discolored nails Psoriasis, dermatophyte infection
Nail surface lesion Transverse furrows (Beau lines) May follow any serious systemic illness
Nail surface lesion Atrophy of nail plate May be caused by trauma, or by vascular or
neurologic disease
Nail surface lesion Small pits on the surface of the nail plate May be early sign of psoriasis
Nail surface lesion Clubbing: nail plate is more convex Prolonged hypoxemia as a result of
cardiopulmonary disorders and cancer
Nail folds Redness, swelling, cracking of lateral Paronychia: inflammation of nail folds—prolonged
and proximal nail folds exposure to waters, chemicals, etc.
Nail bed Pigmentation: mainly whitish with a Associated with aging or chronic diseases:
brown/red distal band (Terry nails) mature onset diabetes, congestive heart
failure, cirrhosis of the liver
Nail bed Pigmentation: pigment deposits or bands May be normal in dark-skinned individuals; may
be melanoma in whites; yellow discoloration in
psoriasis or fungal infections
• Shape: round, oblong, longitudinal, arc-like, linear, • Color variation—different color than other moles
clustered, circular (ring-like), etc. (e.g., blue, blue-black)
• Borders: well demarcated, irregular, diffuse, indis- • Diameter—greater than 6 mm and rapidly grow-
tinct ing
• Temperature: increased or decreased
• Secondary lesions: atrophy, erosions, fissures,
crusts, flakes, excoriation, discharge Examination of Nails
• Vascular or pigmented: Does the lesion blanch Disorders of the nails may be a result of local, con-
on pressure (vascular) or remain the same (pig- genital, or genetic causes, or may be associated with
mented)? systemic or generalized skin diseases. Common ab-
• Painful: to gentle or firm touch normalities include changes in color, pigmentation,
or shape, and/or the presence of lesions of the nail
Red Flags bed or nail plate. Table 27–3 lists the common types of
nail lesions encountered in clinical practice. For fur-
Unfortunately, malignant lesions of the skin such as
ther information on examination of the skin and nails,
basal cell carcinoma, squamous cell carcinoma, and
see references 4–6.
malignant melanoma are common. However, if rec-
ognized early, most lesions can be successfully treated
by surgical excision. Fortunately, early lesions that are PHYSICAL EXAMINATION OF THE HEAD AND
precursors to life-threatening malignant skin disease NECK
are recognizable. It is important that chiropractors are
aware of the warning signs of malignant disease so Examination of this anatomical region is frequently re-
that patients can be referred for treatment at the ear- quired in the chiropractic office. Complaints that may
liest possible stage of the disease. Patients who are present to the chiropractor’s office that warrant a head
most at risk for skin cancer are usually fair skinned, and neck examination include the following:
have been exposed to excessive sunlight, and have a
history or family history of skin cancer. The warning • History of a recent head injury
signs of skin cancer are typically pigmented skin le- • Head pain, including headache, jaw pain, or ear
sions found on sun-exposed areas of the skin (e.g., pain
face, neck, arms) that exhibit the following “ABCD” • Eye pain or changes in visual acuity
characteristics: • Systemic symptoms such as fatigue, fever, or
weight loss or gain
• Asymmetry—skin lesion/mole is asymmetrical • Stiff neck, including swelling in the neck or diffi-
• Border irregularity culty swallowing or buttoning a shirt collar
• Inability to tolerate heat or cold, or changes in tex- TABLE 27–4. Typical Features of Abnormal Facies
ture of hair, skin, or nails
• Dizziness, vertigo, tinnitus, ear pain, or changes in Facies Description
hearing
• Dysphagia or dysphonia Myxedema Dull, puffy, yellowish skin; coarse, sparse
hair; temporal loss of eyebrows;
Several maneuvers described in this section may prominent tongue
also be dealt with in the context of a neurological Hyperthyroidism Bilateral, exophthalmos, fine moist skin,
examination, and are discussed in Chapter 28, “The fine hair, “staring” expression
Neurological Examination.” This section begins with Parkinsonism Flat affect, resting tremor
a general description of the examination of the head Systemic lupus Malar or “butterfly-shaped rash” across
and neck region, and then directly addresses the ex- erythematous bridge of nose; maculopapular lesions
amination of the thyroid, eye, ear, nose, and throat. Cushing syndrome “Moon-shaped” face, rounded with thin
erythematous skin, possibly hirsutism
Physical examination of this region involves not
only the normal steps of observation and palpation, the presence of any lesions, nodules, or swelling. The
but also use of special instrumentation such as the remainder of the face should be examined for features
ophthalmoscope, otoscope, and stethoscope. Practice of typical facies as outlined in Table 27–4. The scalp
is necessary to maintain proficiency with these in- should be inspected for lesions, such as patches of hair
struments. The patient should be in a seated posi- loss, psoriasis, scars, tenderness, or scaliness, and the
tion in a warm, well-lit room (with the exception neck should be examined for nodules or swelling.
of the ophthalmoscopic examination), with the neck
clearly exposed. As with other physical examination
Palpation
maneuvers, explain to the patient each step of the pro-
Palpate over the skull
Is there evidence of head trauma?
cedure as you progress.
for tenderness, abrasions, bumps, or indentations.
General Head and Neck Examination
Inspection Inspection begins when the patient arrives
Hair over
What are the hair’s texture and distribution like?
for the patient’s first interview. both the scalp and eyebrows should be examined. The
texture should be smooth, with even distribution over
Jerking
Is the head positioned in an upright, neutral posture?
the scalp and eyebrows. Coarse, dry, brittle hair with
or bobbing motions of the head may indicate a move- thinning of the eyebrows laterally may indicate hy-
ment disorder, while a head tilted to one side may pothyroidism, while thin fine hair may indicate hy-
suggest either a congenital or idiopathic torticollis, or perthyroidism.
the favoring of a good eye or ear with unilateral loss
of vision or hearing. The neck should be inspected for Thickening and ten-
Are the temporal arteries palpable?
symmetry of musculature (i.e., sternocleidomastoid or derness, particularly in elderly patients with jaw pain
trapezius), presence of webbing, unusual shortness, when chewing and headaches, indicate the presence
position of the trachea, or distension of large vessels. of temporal arteritis and necessitate a medical
referral.
Care-
Is there symmetry of facial features and movements?
fully observe the eyebrows, palpebral fissures, na- Palpate for size, consis-
Are the salivary glands normal?
solabial folds, and symmetry of movement of the tency, tenderness, and presence of nodules. Enlarged,
facial muscles. Asymmetries should be described as tender glands suggest infection or obstruction of the
occurring within a portion of the face or affecting salivary duct, while a nodule suggests a cyst or tumor.
the entire side of the face. Deficit of movement lo-
calized to a lower facial quadrant indicates a lesion Are the lymph nodes normal? Several superficial lym-
of the contralateral upper motor cortex or facial nu- phatic chains run through the head and neck and
cleus, while loss of movement affecting both upper should be inspected in cases where a patient is com-
and lower quadrants indicates a unilateral lower mo- plaining of neck stiffness, malaise, or fever, or re-
tor neuron lesion of cranial nerve (CN) VII, such as ports the presence of a “lump.” The patient should
Bell palsy.7 be encouraged to relax her or his neck by bending
the head slightly forward or to the side.8 Follow the
The skin
Are any abnormal skin coloring or lesions present? procedure outlined in the section on examination of
of the face should be observed as outlined in the the lymphatic system in this chapter. Systematically
above section for erythema, edema, puffiness, and move from the posterior aspect of the head anteriorly
toward the mandible, and then examine the neck, pay- with the lashes facing outward. With the eyes open,
ing close attention to the supraclavicular lymph nodes the superior eyelid should cover a portion of the iris
(often referred to as sentinel nodes), which are fre- but not the pupil, and the inferior lid should not in-
quent sites of metastatic disease.8 vert or evert. The lacrimal ducts on the inferior orbital
rim should be inspected for swelling or enlargement.
Thyroid Gland Table 27–5 describes disorders of the external eye.
The thyroid gland should be evaluated when a patient
presents complaining of fatigue, intolerance to cold Inspect the Conjunctivae, Cornea, and Sclera The con-
or heat, changes in skin, nails, or hair, or generalized junctivae are normally clear. The lower tarsal con-
muscle pain. junctiva may be inspected by gently pulling the lower
eyelid downward, but upper tarsal plate conjunctiva
Inspection Begin with the patient extending his or her (inside the superior eyelid) should only be inspected
neck to tighten the skin in the region, and inspect the when the presence of a foreign body is suspected. Ask
area for asymmetry. Next, ask the patient to swallow the patient to look downward, then pull the eyelid
and observe for the symmetry of the upward move- gently down and outward from the eye by the eye-
ment of the gland. Swallowing may further emphasize lashes, and evert the lid over a small cotton-tipped
an enlarged gland. applicator. The corneas are normally clear, with no
evidence of blood vessels. The lens should be trans-
Palpation Gently palpate the thyroid with the pads of parent, while the sclera should be white and only vis-
the fingers between the sternocleidomastoid (SCM) ible above the iris when the eyes are opened wide.
muscle and the cricoid cartilage, gently displacing the Many conditions may result in red eyes, as outlined
trachea if necessary. Position yourself either stand- in Table 27–6. In general, injection of the ciliary blood
ing to the front and side of the patient, or behind the vessels extending from the cornea into the conjunctiva
patient with your hands around the patient’s neck (in (called circumcorneal redness) indicates the need for
this case, be sure to explain to your patient what you medical referral, while generalized redness is less of
are doing). Care should be taken to examine both the a concern. The presence of scleritis is often a clue of
left and right lobes of the thyroid, as well as the isth- rheumatic disease.10
mus (which may be occasionally missing). Evaluation A yellowish color to the eyes may have several
of the thyroid should concentrate on size (no larger causes. In jaundiced individuals, the sclera may ap-
than 4 cm in an adult), consistency (should be smooth, pear yellow or brown, while in older individuals a
without a granular consistency), and for the presence senile hyaline plaque (a rust-colored pigmentation
of nodules. Nodules, if present, are evaluated for num- of no clinical significance) may be noted. A yellow-
ber, size, consistency (hard or soft), and tenderness.9 ish growth within the conjunctiva extending from the
While palpating the isthmus, ask the patient to swal- nasal side of the eye to the iris represents a pterygium,
low, and palpate the mobility of the gland. or damage caused by exposure to ultraviolet light. In
older individuals, white circular deposits of lipid may
Auscultation If the gland is enlarged, auscultate us- be present at the edge of the cornea, called an arcus
ing a stethoscope bell for vascular sounds (including senilis.10
bruits), which may be present in hyperthyroidism.
The pattern of the iris should
Inspect the Iris and Pupils
Eye be clear and easily observable. The pupils should be
The examination of the eye can be divided into the 2–6 mm diameter in size, equal (±0.5 mm),11 and
external and internal eye. round. Pupillary reaction to light (both direct and con-
sensual) and to accommodation should be evaluated
Inspection of the External EyeObserve the surrounding for symmetry.
structures of the eye, including eyebrows, orbital area
(including the set of the eye within the orbit), palpe- Palpation The eye and lid may be gently palpated for
bral fissures, eyelids, and lacrimal ducts. Examine the the presence of nodules and firmness. With the eyes
orbital area for edema (suggestive of renal disease) closed, press gently on the eye itself. Gentle pressure
or puffiness (suggestive of allergies). Stand above the should move the eye slightly into the socket. If the
patient and look down over the patient’s forehead to eye is very firm, this may represent glaucoma, hy-
observe if the eyeball protrudes beyond the superior perthyroidism, or the presence of a retro-orbital tu-
orbital rim, which is indicative of exophthalmos. Ex- mor, and should be correlated with other signs and
amine the eyelids for the ability to open and close symptoms.12 Palpate the lacrimal glands (in the lat-
completely and symmetrically, for redness, swelling, eral aspect of the superior eyelids) for enlargement,
flaking, and the presence of eyelashes on both lids, and depress them gently to observe for exudation of
TABLE 27–5. Common Disorders of External Eye
Name Pathology Examination Findings
Chalazion (meibomian Granulomatous cyst within eyelid Painless lump within eyelid, mobile
cyst)
Stye Acute Staphylococcus aureus infection of Painful, red bump at eyelid margin; presence
eyelash follicle of discharge
Blepharitis Chronic staphylococcus infection of eyelid Bilateral, painful redness at edge of eyelid;
margin crusting; potential loss of eyelashes
Cyst of Moll Cyst of sweat glands at eyelid margin Small, translucent swelling at edge of eyelid;
may be painful
Entropion Common condition of elderly, also secondary to Lower eyelid turns inward; eyelashes abrade
scarring of tarsal conjunctiva or keratitis cornea; painful red eye with discharge
Ectropion Common condition of elderly, also secondary to Lower eyelid turns outward; exposed tarsal
scarring of eyelid or paralysis of CN VII conjunctiva; watery eye
Papilloma Benign squamous cell neoplasm Skin-colored lump on eyelid; nonpainful
Hemangioma Benign neoplasm of abnormal blood vessels Soft red or blue swellings of eyelid;
nonpainful
Xanthelasma Lipid deposits within skin of eyelids; associated Yellow, soft, flat plaques, occurring mainly on
with hyperlipidemia nasal aspect of eyelids
Basal cell carcinoma Raised lump on eyelid, with ulcerated center,
(rodent ulcer) prone to bleeding
Squamous cell Progressively enlarging lump, often at
carcinoma canthi; may ulcerate and exude fluid
Dacryocystitis Infection of lacrimal sac (acute or chronic) Acute: swelling on of inner canthus on nasal
aspect; chronic: constant watering of eye
caused by obstruction of lacrimal duct
Dacryoadenitis Inflammation of lacrimal gland secondary to Tender swelling of lateral aspect of upper
infection, mumps, or sarcoidosis eyelid with erythema
Neoplasm of gland Can be mixed tumor (mesenchymal and Progressive enlargement of gland, hard,
epithelial), adenoid cyst, lymphoma, or irregular mass; displacement of eye
lymphosarcoma downward and inward
tears. Evaluate corneal sensation by touching a wisp of for the red reflex.10 Black opacities present in the red
cotton to the edge, and assessing for the blink response reflex represent the presence of “floaters” within the
(the normal response). A lack of response may indi- vitreous of the eye, but complete loss of the reflex in-
cate a lesion to cranial nerves V or VII, or adaptation dicates either the presence of a cataract within the lens
secondary to contact lenses. Examination procedures or retinal detachment.
for evaluation of visual acuity, visual field, and ex- Slowly approach the patient, maintaining visual-
traocular movements are also covered in Chapter 28. ization of the red reflex and adjusting the lens diopters
toward 0 to visualize the fundus. You may approach
Ophthalmoscopic Examination Begin in a darkened room, within 15 mm (0.5 inch) of the patient’s eye.10 The
with the patient focusing on a distant point above interior of the eye should be examined in a system-
your shoulder. Hold the ophthalmoscope in your right atic fashion. The fundus should be either yellow or
hand, to be placed in front of your right eye, to ex- pink with no discrete areas of pigmentation. Locate
amine the patient’s right eye. The index finger of the the retinal blood vessels, and inspect them for light
hand holding the ophthalmoscope should be used to reflexes and possibly venous pulsations. The loss of a
change the lens diopters. Your other hand should be light reflex or the presence of a “nicked” appearance
placed on the patient’s eyebrow or shoulder for sta- of the vessels where they cross each other suggests
bility. Standing approximately 12 cm (5 inches) away hypertensive changes. Trace the blood vessels back-
at a slight angle from the patient’s midline, set the ward and evaluate the optic disc. The margin should
lens diopters to +5 or +6 and direct the light of the be clear and well defined and the disc itself a yellow
ophthalmoscope into the patient’s pupil, examining to cream color. There may be a pigmented crescent
TABLE 27–6. Disorders Causing Red Eyes
Disorder Patient Symptoms Examination Signs
Conjunctivitis Bilateral red eyes, gritty/sticky feeling Generalized redness; swollen eyelids; profuse
discharge (purulent = bacterial; watery = viral),
normal pupil size
Scleritis Bilateral red eyes, watery, with severe pain Focal or diffuse redness; normal pupil
Iritis (iridocyclitis, Unilateral red eye, discharge, photophobia, Circumcorneal redness; decreased vision;
anterior uveitis) blurred vision, and pain constricted pupil
Keratitis Unilateral red eye, discharge, photophobia, Circumcorneal redness; decreased vision;
blurred vision, and pain corneal opacification
Subconjunctival Painless with no photophobia or visual Bright, well-demarcated focal area of redness
hemorrhage changes and with or without history of within the lower part of the conjunctiva
trauma
Hyphema (anterior Unilateral red eye, severe pain, blurred Bright, well-demarcated focal area of redness
chamber hemorrhage) vision, history of trauma within anterior chamber obscuring iris and
pupil; presence of fluid level
Corneal foreign body Watery eye, unilateral red eye, severe Circumcorneal redness; normal pupil; particle
pain/gritty feeling, photophobia noted on ophthalmologic exam
Acute glaucoma Unilateral red eye, severe pain and Circumcorneal redness; decreased vision; dilated
photophobia, blurred vision pupil; cloudy cornea
secondary to congenital or acquired myopia present

on either the temporal side of the disc, or completely
surrounding it.10 The macula, located approximately
two disc diameters lateral to the optic disc, is difficult
to visualize unless the examiner asks the patient to
look directly into the light. It appears as a yellow dot
surrounded by the dark pink fundus (Fig. 27–1).
All unusual findings in the funduscopic exami-
nation are described in terms of size and location
from the optic disc, using a clock positioning sys-
tem; all measurements are described in terms of disc
diameters.10,12 Table 27–7 describes abnormal findings
of the internal eye exam. Remember that the fundus
is difficult to observe in its entirety without the use of
mydriatic drops; consequently, patients with a history
of diabetes mellitus, hypertension, or seronegative
spondyloarthropathies should referred for a yearly ex-
amination to an ophthalmologist to monitor changes
secondary to these conditions.
FIGURE 27–1. Ophthalmoscopic examination. In a dark room,
Ear switch on the ophthalmoscope light, select the large round
Inspection of the External Ear Inspect the auricle for beam, and choose an appropriate intensity by shining on the
shape, size, symmetry, color, and position on the head. back of your hand. Hold the ophthalmoscope in your left hand
The color of the auricle should be the same as the rest for observing the patient’s left eye and right hand for right eye.
Start with the lens disc on 0 diopter and hold the ophthalmo-
of the facial integument (skin); a blue tinge may indi-
scope firmly against your own orbit. Ask the patient to look up
cate cyanosis, while pallor or rubor may indicate vaso-
slightly and over your shoulder and focus on a point directly
motor instability. The presence of deformities, cysts, ahead on the wall. Start about 38 cm (15 inches) from the pa-
or nodules should also be noted, paying particular tient at a 15-degree angle laterally. You may stabilize yourself
attention to lesions on the sun-exposed skin of the au- and the patient by placing the thumb of your other hand just
ricle, which may represent basal cell or squamous cell above the patient’s eyebrow. Observe the red reflex and then
carcinoma. Tophi are common within the periphery move in closely to observe the optic disc and retina.
TABLE 27–7. Abnormal Findings of the Internal Eye Examination
Finding Description Significance
Myelinated nerve fibers White area within fundus, with soft, ill-defined No clinical significance
margins, continuous with optic disc; may
obscure retinal blood vessels
Papilledema Loss of definition of optic disc; blurring margins Increased intracranial pressure
superiorly and inferiorly first, then temporally
and nasally; central vessels pushed upward,
veins become dilated
Glaucomatous cupping Blood vessels disappear at edge of disc or are Increased intraocular pressure
displaced nasally; disc becomes whiter
Drusen bodies Small spots of increased coloration of retina, Changes secondary to aging; may be a
which eventually enlarge and yellow precursor to senile macular degeneration
Hemorrhages Areas of bright red coloration in the fundus; May indicate poorly controlled or undiagnosed
dark red if located in deeper layers; also glaucoma; diabetic retinopathy
present as bright red dots (these represent
microaneurysms)
of the auricle, as are sebaceous cysts. Next, inspect the abnormal findings on the otoscopic examination and
external auditory canal for discharge and odor. A pu- the conditions they represent.
rulent, foul-smelling discharge indicates the presence Mobility of the membrane may be assessed
of infection or a foreign body, while a bloody or serous through the use of a pneumatic attachment on the
discharge may indicate a skull fracture secondary to otoscope14 ; however, this may be out of the scope of
head trauma. practice for chiropractors in some jurisdictions.
Palpation of the Ear and Mastoid Processes Palpate for Nose and Nasopharynx
nodules, tenderness, or swelling. Presence of a painful Inspection Observe for shape, size, color, and swelling.
auricle with palpation suggests external auditory in- The nasal area should be free of swelling, and the nose
flammation, while tenderness and erythema over the itself should be in the midline with skin the color of
mastoid processes suggest mastoiditis, a secondary the rest of the face. Any discharge should be described
bacterial infection from unresolved otitis media. as watery, mucoid, purulent, or bloody, and unilateral
Mastoiditis is a serious, progressive infection that or bilateral within the nares. Unilateral discharge sec-
should be referred to a medical practitioner ondary to head trauma may indicate leakage of spinal
immediately.13,14 fluid secondary to a fractured cribriform plate.
Otoscopic Examination Examination of the internal ear Palpation Use the pads of your fingers to gently press,
is accomplished by using the otoscope. To examine beginning at the bridge of the nose and progressing to
the left ear, face the patient’s left shoulder, and using
your left hand, hold the otoscope between the thumb
and index finger of the hand, resting the ulnar sur-
face against the patient’s head. Tilt the patient’s head
toward the opposite shoulder, and lightly grasp the
auricle, pulling it gently upward and outward with
your right hand. Insert the otoscope into the external
meatus to the depth of 1.0–1.5 cm (0.5 inches) (Fig. 27–
2).12,14
Inspect the external auditory canal for cerumen,
discharge, scaling, redness, lesions, or foreign bodies. FIGURE 27–2. Examination of the ear canal and drum using
The normal landmarks of the tympanic membrane the otoscope. Firmly but gently pull the ear up, back, and slight-
should be visible. Evaluate the membrane for color, ly outward; gently insert the otoscope into the canal in a slightly
contour, lesions, or perforations. A translucent gray down and forward position, and gently but firmly brace your
membrane is normal. Table 27–8 describes possible hand and the otoscope against the patient’s face.
TABLE 27–8.Commonly Encountered Conditions midline. The procedure for assessing the sense of smell
on Otoscopic Examination of the Ear is described more fully in Chapter 28.
Condition Findings
Maxillary and Frontal SinusesInspect the skin overlying
the sinuses for erythema or warmth. Next, palpate or
Otitis externa Redness; edema in external canal
percuss the area over the sinuses for warmth or ten-
with itching; pain with movement of
derness. Palpate with a firm contact with a finger or
the pinna; purulent discharge;
thumb, or percuss by tapping the same area with the
decreased hearing
pad of your finger. Warmth, erythema, or tenderness
Otitis media Red, bulging tympanic membrane with
of the sinuses may indicate an infection. Transillumi-
(bacterial) fever, pain, dizziness, vomiting, and
nation of the sinuses can be performed using a bright
irritability; discharge present in
light by contacting under the supraorbital ridge and
external canal if membrane
projecting upward for the frontal sinuses, or contact-
ruptures; decreased hearing
ing over the lateral aspect of the nose maxillary arch
Otitis media Retracted tympanic membrane with
and projecting into the mouth. The light from the oto-
(effusive) fluid level; feeling of fullness in ear;
scope is observed as a deep red glow; its absence indi-
no pain or hearing loss
cates that sinuses may be filled with fluid or congeni-
Cholesteatoma White shiny greasy flakes of debris
tally absent.12,14
visible through the tympanic
membrane or through a
perforation; possible discharge;
Mouth and Oropharynx
progressive hearing loss; tinnitus; Systematically examine this area by progressing from
possibly vertigo the lips to the teeth, gums, buccal mucosa, tongue,
Perforated tympanic If a result of a previous ear infection hard and soft palate, and, finally, to the oropharynx.
membrane that perforated the membrane, Inspect the lips for color, symmetry, texture, and
large patency present, usually within surface abnormalities. Dryness and cracking of the
the pars tensa; if a result of a lips may be present, either on the lips themselves or in
tympanostomy (tubes in ears), the corners of the mouth, and represent dehydration,
these may be present in the ear for riboflavin deficiency, or excessive lip licking. Lesions,
several years after the surgery vesicles, plaques, and ulcerations can represent infec-
tion such as secondary herpes virus, irritation, or skin
cancer such as basal cell or squamous cell carcinoma.
Up to 38% of squamous cell carcinomas occur on the
the tip and nasal vestibules. The bridge is assessed for lower lip.15 A bluish color indicates cyanosis, while a
bony firmness, displacement, tenderness, or masses. deeper red indicates acidosis.
The patency of the nares can be assessed through oc- Next, inspect the teeth for proper occlusion, pres-
clusion of each side with a finger and inhaling through ence of wear, notches, caries, and missing teeth. The
the other side; breathing should be easy and unob- gums and buccal mucosa are inspected for color,
structed. smoothness, and the presence of lesions. For a de-
scription of common lesions of the buccal mucosa,
Inspection of the Nasal Cavity This area is examined see Table 27–9. The gums or gingiva should be pink
through the use of a nasal speculum, or an otoscope with clearly defined margins at each tooth. The gums
with a nasal tip. Tip the patient’s head backward, should be palpated with a gloved hand for nodules,
hold the otoscope or speculum in the palm of one lesions, swelling, or bleeding.
hand, and support the hand with the fifth digit against The tongue is inspected for swelling, size, color,
the patient’s zygomatic arch, taking care not to touch coatings or ulcerations. It should be a dull red with
the nasal septum.12,14 The nasal vestibule, septum, in- a roughened surface. Inspect the inferior surface of
ferior and middle turbinates, and inferior and mid- the tongue by asking the patient to place the tip of
dle meatuses are visible with this view. Inspect for the tongue against the hard palate behind the upper
color, presence of discharge, and masses. The color of incisors. Next, to inspect the lateral surfaces of the
the turbinates should be a deep pink with a film of tongue, have the patient protrude the tongue, grasp
clear discharge. Bluish-gray turbinates with watery the tip with gauze and deviate it laterally to each side.
discharge indicate an allergic rhinitis, while increased Finally, palpate the tongue for swelling, varicosities,
redness with purulent discharge indicates infection. and nodules. The presence of ulcers, nodules, or thick
Pedunculated masses projecting from the mucosa rep- white patches suggests malignancy and indicates the
resent polyps. The nasal septum should be in the need for a medical referral.14 Up to 40% of intraoral
TABLE 27–9.Commonly Encountered Lesions • Hard, nontender lymph nodes are discovered in
of the Buccal Mucosa the head and neck, or enlarged nodules remain
unchanged after 2 weeks of monitoring.
Lesion Description • Circumcorneal injection, scleritis, or a foreign body
is discovered in the eye.
Fordyce granules Small, yellow-white macules; benign • Hypertensive changes of the fundus, papilledema,
Aphthous ulcers White circular lesions surrounded by or retinal detachment is noted on ophthalmoscopic
erythematous margin; self-limiting examination.
Leukoplakia Thick, white keratinized patch of • Infection is detected within the ear by otoscopic
mucosa; refer for biopsy as may examination.
be precancerous • A nodule, ulcer, or white plaque on the tongue,
Herpesvirus (acute) Multiple aphthous ulcer-like lesions; or mass in the hard palate, not in the midline, is
affects both gingival and buccal detected.
mucosa • Redness, swelling, and exudate are present on the
Koplik spots Gray-white macules with red tonsils.
margins, occur near parotid gland;
precursor to mumps
Candida albicans “Cheese-curd” appearance, with raw PHYSICAL EXAMINATION OF THE CHEST
appearance and bleeding when (CARDIOVASCULAR SYSTEM)
wiped off
Oral erythema Diffuse hemorrhagic ulcers on lips
This section focuses on the examination of the car-
multiforme and oral mucosa
diovascular and respiratory systems. A consider-
Hemangioma Dark purple or red stains; benign
able number of patients presenting to chiropractors
for musculoskeletal complaints may also have co-
existing problems arising from the heart, lungs, or
peripheral vasculature. Heart and lung disease are
squamous cell carcinomas begin on the floor of tongue common conditions affecting society today. These
or mouth.15 conditions usually result from risk factors that are
The hard and soft palates are observed for shape, entirely within society’s ability to control, such as a
color, and symmetrical movement. Bony nodules are sedentary lifestyle with insufficient exercise, a diet
not a remarkable finding in the midline of the hard high in fats, salt, and calories, smoking, and excessive
palate, representing torus palatinus; however, nod- alcohol consumption. Heart and lung disease present
ules not in the midline may represent a tumor and significant risks to the life of many patients. As pri-
should be investigated more thoroughly through re- mary contact practitioners, chiropractors carry some
ferral to a medical practitioner. Movement of the soft responsibility to identify risk factors, as well as to
palate is evaluated as part of the cranial nerve exami- screen patients for signs of these diseases.
nation. Depress the tongue with a wooden depressor
and observe the tonsillar pillars, tonsils (if present), Risk Factors and Red Flags
and posterior wall of the pharynx. The color and pres- As mentioned above, there are a number of risk fac-
ence of exudate should be noted. If the tonsils are ery- tors for heart and lung disease. These should be
thematous, hypertrophied, and coated with exudates, identified during the patient’s history. For heart dis-
infection is suspected.14 Finally, elicit the gag reflex by ease, the most common risk factors include a family
touching each side of the soft palate with the tongue history of heart disease, smoking, high blood pressure,
depressor and assessing the response. diabetes, and obesity. In addition to risk factors, there
are a number of red flags for signs of serious disease.
Red Flags for the Head and Neck Examination There is some evidence to suggest that the most com-
mon cardiovascular diseases chiropractors encounter
Consider a referral to the patient’s medical doctor for in practice are high blood pressure, atherosclerosis re-
further evaluation when9−12,14 sulting in coronary artery disease or peripheral vas-
cular disease, heart murmurs or rhythm irregular-
• A “rodent ulcer” lesion (basal cell carcinoma) or ity (rarely), and arterial aneurysms and congenital
flat, raised lesion of squamous cell carcinoma on anomalies (very rarely).16 It is likely that some patients
the ear, nose, eye (palpebral fissure), or other ex- will present with mild to moderate signs of congestive
posed skin of the head and neck is detected. heart failure, such as chest pain, dyspnea (shortness
• An enlarged gland or nodule is detected in the thy- of breath), edema, hypertension, and cyanosis17−19
roid. (Table 27–10).
TABLE 27–10. Common Clinical Signs and Symptoms of Cardiovascular Disease
Description Associated Conditions
Chest pain Myocardial infarction; angina pectoris; pulmonary

Significant retrosternal or precordial chest pain embolism
Squeezing, burning, or heavy pain referring to
precordium, neck, and jaws, lasting 2–10 min
Sudden pleuritic chest pain, dyspnea, respiration
>16/min
Acute dyspnea Congestive heart failure
History of high blood pressure and heart disease with
orthopnea and paroxysmal nocturnal dyspnea
Chronic dyspnea Congestive heart failure; anemia (blood loss, pallor,
weakness); hyperthyroidism (evidence of thyrotoxicosis)
Edema Congestive heart failure; other causes include liver
Generalized edema: distended jugular veins, bilateral disease and nephrotic syndrome
rales in basilar portion of lungs, dependent edema in
lower extremities (pitting edema in ankles and feet)
Hypertension Atherosclerosis; primary (essential) hypertension, or
Systolic: systolic is elevated but diastolic is not secondary to endocrine, renal disease
Diastolic: both are elevated
Cyanosis Congenital heart disease
Central cyanosis: history of cardiac symptoms from Congestive heart failure, mitral stenosis, arterial
birth or childhood, dyspnea, heart murmur, and (diabetes, intermittent claudication) or venous
possibly congenital heart failure obstruction (varicose veins, thrombophlebitis)
Peripheral cyanosis
Physical Examination mucous membranes of the mouth in cyanotic con-

As a screening pro-
Cardiovascular Screening Procedure genital heart disease (uncommon); and (c) dyspnea,
cedure, chiropractors should consider increased and shallow respiratory rate at rest, and
difficulty breathing during recumbency, somewhat
1. Looking for signs of cardiovascular disease relieved by sitting up (orthopnea); common in
(edema, cyanosis, dyspnea). cardiogenic pulmonary edema.
2. Assessing the pulses (upper and lower extremi- Palpate peripheral arterial pulses for heart rate,
ties). rhythm, pulse wave characteristics, and sometimes
3. Taking the blood pressure. obstructions. These can be detected by an examina-
4. Auscultating the heart. tion of radial, brachial, and carotid arterial pulses. The
radial pulses are useful to detect rate and rhythm.
Patients should be investigated further or referred to Larger-diameter arteries such as the brachial and
an internist or cardiologist if they exhibit risk fac- carotid arteries are better for detecting pulse charac-
tors and possible red flags for cardiovascular disease, teristics. For rate and rhythm, palpate the radial pulses
or abnormal results on the cardiovascular screening bilaterally. Compress the radial pulse at the wrist, just
examination. If there are any abnormal or suspicious lateral to the tendon of the flexor carpi radialis mus-
findings, the following examination should be consid- cle, with the pads of the index and middle fingers until
ered. a maximal pulsation is felt. Feel for rhythm. If regu-
lar, count beats over 15 seconds and multiply by 4. If
Cardiovascular Examination Observe for signs of irregular, count the beats over 60 seconds.
(a) edema, particularly around ankles and feet in Some causes of irregular rhythm may be sinus
congestive heart failure; localized to one extremity arrhythmia, extrasystole of either atrial or ventricu-
in peripheral vascular obstruction; (b) cyanosis; lar origin, and atrial tachycardia or fibrillation. Some
peripheral cyanosis (bluish discoloration of distal causes of irregular pulse characteristics are aortic re-
extremities or nail beds) in congestive heart failure flux or vasodilation for large-volume pulses, periph-
and mitral stenosis, or central cyanosis of skin and eral arterial vasoconstriction, or low cardiac output
for small-volume pulses. Pulsus bisferiens (pulse with TABLE 27–12. Risk for Organ Damage Associated
two “humps”) felt at the brachial pulse may be caused with Hypertension
by aortic stenosis with incompetence.17,19,20 All arte-
rial pulses should be assessed if the patient presents Target Organ Associated Risk
with signs and symptoms of peripheral vascular
disease. Heart Heart failure, myocardial infarction
Brain Transient ischemic attack (TIA) and stroke
Eye Hypertensive retinopathy
The proper protocol for
Take the arterial blood pressure
Kidney Hypertensive nephropathy
taking blood pressure requires a patient to be com-
Large blood Aortic dilatation, aortic valve reflux,
fortably seated for 5 minutes before the assessment,
vessels abdominal aortic aneurysm, dissecting
no caffeine at least 30 minutes prior to the read-
aortic aneurysm
ing, and the arm relaxed and supported. Hyperten-
sion is determined only after abnormal readings on
three consecutive evaluations unless the blood pres-
sure is severely elevated. Blood pressure readings can It is recommended that one use a good-quality
be taken in both arms. It is normal to have up to a stethoscope. Earpieces should fit snugly and the tub-
5–10 mmHg difference in readings between arms. A ing should be thick enough to minimize external
difference of 10–15 mmHg or greater suggests obstruc- sounds. Use the diaphragm (flat side) to pick up high-
tion in the arm with lower pressure or arterial com- pitched sounds (i.e., second heart sounds) and the bell
pression. Blood pressure varies depending on what (curved surface) to pick up low-pitched sounds (i.e.,
people are doing (e.g., sleeping versus exercising), and murmurs). Make sure you are familiar with the phys-
is almost always higher later in the day than in the iology of the cardiac cycle before proceeding. The fol-
morning. Regardless, the higher numbers are always lowing has been recommended as the sequence to fol-
used to determine normal from abnormal blood pres- low when examining the heart.23 While auscultating,
sure. listen for the normal first and second heart sounds (S1
Hypertension is determined by elevated systolic, and S2), as well as any abnormal heart sounds. Ta-
diastolic, or both pressures. Table 27–11 classifies ble 27–13 has further information on auscultation of
blood pressure readings. To reinforce the importance the heart.
of detecting and monitoring blood pressure, Table 27–
12 identifies some of the risks for end-organ compli- 1. The patient lies supine with head elevated to 30 de-
cations associated with hypertension. For more infor- grees. Inspect and palpate the precordium, second
mation on the classification of blood pressure, see ref- intercostal spaces bilaterally, and left sternal bor-
erences 21 and 22. der and apex (fifth left intercostal space). Assess
apical impulse in terms of location, amplitude, and
duration. If not found on palpation, try again with
Auscultation of the heart assesses
Auscultate the heart patient lying in the left lateral decubitus position
the timing of the heart contraction–relaxation cycle, and auscultate using the bell.
the patency of the heart valves, and the quality of
blood flow through the heart. Other sounds associ-
ated with the normal heart sounds (murmurs) usually
indicate abnormal blood flow in the heart (Fig. 27–3).
Classification of Blood
TABLE 27–11.
Pressure Readings
Blood Pressure
Reading (mmHg) Classification
<120/<80 Optimal blood pressure

Up to 130/85 Normal blood pressure
130–139/85–89 High normal blood pressure
140–159/90–99 Mild high blood pressure
160–179/100–109 Moderate hypertension
>180/110 Severe hypertension FIGURE 27–3. Auscultation of the heart: best locations for
hearing sounds and murmurs.
TABLE 27–13. Sounds Associated with Auscultation of the Heart
Heart Sounds Significance
Normal heart sounds Two sounds (S1, S2), sound like “lubb-dupp.”
S1 (“lubb”), lower-pitched, produced by closure of mitral and tricuspid vales. Coincides with carotid
pulse. Mitral valve best heard at heart apex, tricuspid valve best heard at lower left sternal border.
S2 (“dup”), higher-pitched, caused by closure of aortic and pulmonary valves and comes after peak
pulse wave. Aortic valve best heard at second right intercostal space, pulmonary valves best
heard at second left intercostal space.
Physiologic splitting Sounds like a split in S2 (“lubb da-dupp”) in inspiration, and reverts to normal during expiration
(“lubb-dupp”). Common in older children and physically fit young adults.
It is a normal variant.
Third heart sound S3 is low-pitched and comes after S2 (“lubb-dupp-dum”) in early systole.
S3 is normal during pregnancy, in children, healthy young adults, and athletes.
Abnormal in patients with leaky valves and poorly contracting ventricles.
Fourth heart sound S4 is low-pitched and soft, heard just before S1 (“da-lubb dupp, da-lubb dupp”).
Called fourth sound because it is heard after S3 even though heard before S1.
S4 in patients with history of hypertension, cardiomyopathy (hypertrophied atrium).
Murmurs Sounds produced from turbulent blood flow through the heart caused by either normal blood volume
through abnormal valve or abnormal blood volume through normal valve.
Either systolic or diastolic murmurs. To determine, gently palpate one carotid artery while
auscultating: systolic murmur if sound heard during ventricular systole; diastolic murmur if sound
heard during ventricular diastole.
Systolic murmurs Aortic or pulmonary stenosis and mitral regurgitation are common.
Some systolic murmurs are innocent. They are usually soft, best heard at upper sternal edge, and
have physiological splitting of S2 and normal pulses.
Diastolic murmurs Aortic regurgitation and mitral stenosis are common.
2. Using the bell, auscultate the lower left sternal bor- (harder, tortuous arteries). Palpate the carotid, bra-
der (interspaces 4 and 5 for tricuspid valves). chial, radial, aortic, femoral, popliteal, dorsalis pedis,
3. Using the diaphragm, palpate the other areas: and posterior tibial arteries. Compare bilaterally as
• Second right interspace—aortic valve well as to adjacent upper and lower arterial pulses.
• Second left interspace—pulmonic valve
• Fifth lateral left interspace—mitral valve
Observation Assess the color of the toes and foot on
standing. Toes and feet may become much redder on
PHYSICAL EXAMINATION OF THE PERIPHERAL standing (dependent rubor) in patients with severe
VASCULAR SYSTEM vascular occlusive disease.
A screen of the peripheral vascular system should be
considered in those individuals with a history of high Temperature of the Limbs The feet and lower limbs may
blood pressure, heart disease, diabetes, atherosclero- feel cooler compared to other body parts. This is not a
sis, or a family history of these conditions.24 Periph- reliable sign if present bilaterally, but is significant if
eral vascular disease is most commonly caused by coolness is detected unilaterally.
atherosclerosis. Intermittent claudication, redness of
the toes on standing (dependent rubor), coolness of Venous Filling TimeWith the patient supine, elevate the
the foot, and leg ulcers are the most commonly as- leg to 45 degrees for 1–2 minutes; then have the pa-
sociated clinical features. The following is the recom- tient sit with legs dangling over examination table,
mended screening procedure for the peripheral vas- and observe for venous filling. Venous filling should
cular system. occur within 15–20 seconds. Peripheral vascular oc-
clusive disease is usually present if filling time ex-
Peripheral Vascular Screening Procedure ceeds 1 minute. Look for presence of ischemic ulcers,
Peripheral Pulses Palpate pulses for evidence of de- such as nonhealing or slowly healing ulcers that occur
creased/obstructed blood flow or atherosclerosis spontaneously or secondary to trauma, usually on the
lateral aspect of lower leg. Patients with symptoms of that are adjacent to each other may appear as a larger
coldness, numbness, pallor, and weakness in a limb(s) mass, and are described as “matted.” The enlarged
should be referred for further evaluation of their pe- mass may be evaluated for pulsations (to ensure it is
ripheral vascular system. not a blood vessel), or transilluminated (to determine
if it is a cyst). Tender, warm, matted nodes indicate in-
Lymphatic System fection, while large, fixed, nontender nodes indicate
malignancy. Consider referral to the patient’s family
The lymphatic system is an important adjunct to eval- practitioner with the latter finding, and with the pre-
uation of the peripheral vascular system, Physical vious finding if nodes do not recede within 2 weeks.
examination of the lymphatic system should be con-
sidered in those patients complaining of swelling of
extremities, presence of a “lump,” redness or itching PHYSICAL EXAMINATION OF THE
in a area, or systemic symptoms such as fever, fa- RESPIRATORY SYSTEM
tigue, or shortness of breath.8 The lymphatic system
consists of the lymph nodes, thymus, spleen, tonsils, Risk Factors and Red Flags for Lung Disease
and Peyer patches. Evaluation of the thymus and ton- According to a recent survey, the most common lung/
sils was discussed in Physical Examination of the Head respiratory conditions encountered in chiropractic
and Neck above, while evaluation of the spleen is ad- practice are asthma, viral infections, emphysema or
dressed in Physical Examination of the Abdomen below. chronic obstructive pulmonary disease (COPD), and
Peyer patches occur within the mucosa of the small bacterial infections.16 Pneumothorax, atelectasis, lung
intestine, and as such are not accessible to evaluation or respiratory tumors, and occupational or envi-
(Fig. 27–4). ronmental disorders reportedly are rarely seen by
Inspection and palpation are the main methods chiropractors.16 For lung disease, the most common
of evaluation. Inspect each body area for prominent risk factors are smoking (direct or passive), chronic
nodes, edema, erythema, red streaks, and skin le- exposure to occupational inhalants (pneumoconiosis),
sions such as ulcerations. Next, palpate the superfi- immunosuppression (tuberculosis), living in regions
cial lymph nodes that drain the affected area. Those endemic to granulomatous and other infectious dis-
superficial nodes most accessible to evaluation are eases, and a family history of lung disease. The major
illustrated in Figure 27–4. Palpate gently with the pads red flags associated with lung disease are dyspnea,
of your second to fourth fingers. Superficial nodes are chronic cough, hemoptysis, and cyanosis.18,25,26
typically not palpable in healthy adults. If a node is
palpated, assess it for size, consistency, mobility, ten- Dyspnea Pneumonia, thromboembolic disease, spon-
derness, warmth, and discreteness.8 Enlarged nodes taneous pneumothorax, and asthma are the most com-
mon pulmonary causes of acute dyspnea. Pneumonia,
regardless of whether it is bacterial, viral, or tuber-
culous, is usually characterized by purulent sputum,
pleuritic chest pain, fever, and chills. Spontaneous
pneumothorax usually occurs in tall, thin individuals
with sudden onset of pleuritic chest pain and dysp-
nea after exertion, coughing, or air travel. In bronchial
asthma, there is usually a history of sudden respira-
tory distress with wheezing, especially after exposure
to inhalant allergens or air pollutants.
COPDs, such as emphysema, chronic bronchitis,
and chronic bronchial asthma, are common causes
of chronic dyspnea. Restrictive lung diseases (i.e., in-
terstitial lung disease, pleural fibrosis, and alveolar-
filling diseases) are uncommon in chiropractic
practice with the exception perhaps of chest wall
deformities (i.e., pectus excavatum and thoracic
kyphoscoliosis).
Chronic Cough It is important to differentiate acute

cough (<3 weeks) from chronic cough. Acute cough
FIGURE 27–4. Anatomical locations of the superficial lymph is usually caused by a viral or bacterial upper respira-
nodes most accessible to examination. tory tract infection. In most patients, cough from the
common cold usually resolves within 2 weeks. Expo- Observation of Quiet RespirationWith the patient sitting
sure to tobacco smoke is the most common cause of in a comfortable position, assess his or her normal,
chronic cough. In most nonsmokers, the usual causes quiet breathing in terms of rate, rhythm, depth, and
of chronic cough are postnasal drip, gastroesophageal effort. Also observe the relative time spent in inspi-
reflux disease, and asthma. For smokers, the usual ration versus expiration. The normal respiratory rate
causes of cough are chronic bronchitis and bronchiec- varies from 12–20 times per minute,28 with a regular
tasis. Patients with chronic cough may also have rhythm and a ratio of inspiration to expiration of 2:3.27
chronic dyspnea (COPD, restrictive lung disease). In quiet breathing, the diaphragm is the predominant
Other serious conditions, such as bronchogenic car- muscle and movement of the chest wall should be
cinoma (in smokers) and tuberculosis (immunosup- minimal. Accessory muscles such as the stern-
pression) may be associated with a chronic cough.26,27 ocleidomastoid and intercostals are typically active
The clinical presentation for COPD is usually chronic during abnormal respiration, requiring greater effort.
cough, dyspnea, and purulent sputum production. Table 27–14 presents examples of common abnormal-
For bronchogenic carcinoma it is hemoptysis, weight ities in rate and rhythm for quiet breathing.
loss, and chronic cough, usually in patients with a
history of heavy smoking. For tuberculosis, the pre- Palpation of the Chest Wall Gently palpate (especially
sentation today is typically in an immunosuppressed around areas of reported pain) the ribs and inter-
patient with chronic cough, hemoptysis, fever, and costal spaces for evidence of tenderness, muscle hy-
weight loss. pertonicity, masses, swelling, and bony or cartilagi-
nous abnormalities. To assess respiratory expansion,
Hemoptysis Some of the most common conditions pre- put the thumbs of both hands at the level of the tenth
senting with hemoptysis (expectoration of blood in ribs posteriorly and place both hands around the lat-
sputum) are bronchogenic carcinoma, tuberculosis, eral aspect of the rib cage with the fingers fanning
COPD, pulmonary embolism, and bronchiectasis. It in a superior and lateral direction. Ask the patient
is important to confirm by history and physical ex- to deeply inhale. Feel for a symmetrical expansion of
amination that blood in the sputum is from the lungs the rib cage during inspiration and a similar contrac-
rather than the nose, mouth, or throat. Hemoptysis tion during expiration. A tape measure may also be
should always be thoroughly investigated, as its asso- placed around the fourth intercostal space to measure
ciated conditions can be serious. chest expansion. The difference between forced expi-
ration and forced inspiration should be 5.75–7.62 cm
(2–3 inches).1,29 Unilateral delay or reduction in chest
Cyanosis Several pulmonary conditions may give rise
expansion may be a result of trauma, pleural effusion,
to central cyanosis. The most common clinical fea-
lobar pneumonia, chronic fibrotic disease, and pleu-
tures associated with central cyanosis arising from
ral pain. Bilateral reduction in chest expansion may
pulmonary disease are dyspnea, cough, sputum pro-
be seen in COPD, restrictive lung disease, and anky-
duction, wheezing, hemoptysis, and recurrent pul-
losing spondylitis.25,26
monary infections. COPD and restrictive lung dis-
eases are common pulmonary conditions associated
Percussion of the Chest Percussion of the chest wall cre-
with central cyanosis. The physical examination usu-
ates vibrations in the underlying lung tissues that pro-
ally reveals a blue or bluish-gray discoloration of the
duce audible sounds and suggests whether the tissues
skin and mucous membranes as a consequence of in-
are mainly air-filled, fluid-filled, or solid. Percussion
creased amounts of unsaturated hemoglobin.26
is usually performed to assess for areas of dullness
(lung consolidation, pleural effusion) or hyperreso-
Physical Examination of the Lungs
nance (emphysema, pneumothorax). Although chest
Screening Procedures If the history reveals any risk fac- percussion has a low sensitivity (10–20%), it has a
tors for lung disease, the following screening proce- high specificity (85–99%). Consequently, percussion
dure is recommended: should not be used as a screening test but as a con-
firmatory test in cases of suspected large pleural effu-
1. Observe for signs of red flags (dyspnea, chronic sion (flat sound), lobar pneumonia (dullness), chronic
cough, hemoptysis, cyanosis). bronchitis (resonance), and emphysema or pneumoth-
2. Take vital signs (temperature, pulses, blood pres- orax (hyperresonance).28,30
sure). Percussion should be performed on the anterior
3. Observe quiet respiration. and posterior chest from the apex to the base of the
4. Palpate the chest wall. lungs bilaterally. For anterior percussion, with the pa-
5. Percuss the chest wall. tient lying supine, start in the supraclavicular spaces
6. Auscultate the lungs. bilaterally and move inferiorly approximately two
TABLE 27–14. Common Abnormalities Observed During Quiet Breathing
Observation Abnormality Conditions
Respiratory rate and rhythm Rapid, shallow breathing; rapid, deep Tachypnea: restrictive lung disease, upper
breathing; prolonged expiration respiratory tract infection, pleuritic chest
pain; hyperpnea: exercise, anxiety, metabolic
acidosis; obstructive lung disease: asthma,
chronic bronchitis, COPD
Chest wall Barrel chest; funnel chest; pigeon chest; COPD, but is normal in infancy and possibly in
thoracic kyphoscoliosis old age; possible compression of heart and
great vessels resulting in murmurs; may
restrict lung expansion/function; restrictive
lung disease
Accessory muscles Recruitment of sternocleidomastoid Labored respiration caused by fixed chest wall
and/or intercostal muscles during abnormality (barrel chest), significant lung
respiration impairment, or diaphragm dysfunction
Chest expansion Reduced bilaterally (<1.5 inches) Ankylosing spondylitis, upper respiratory tract
Reduced unilaterally or delay in expansion infection with shallow breathing, cough, fever
Chronic fibrotic disease, pleural pain, pleural
effusion, trauma, lobar pneumonia
intercostal spaces at a time along the midclavicular an overall reduction in lung sounds. Adventitious
line to the level of the xiphoid process. At this level, sounds that are continuous are categorized either as
move laterally to percuss at the anterior axillary line wheezes (high-pitched, whistling, musical sounds)
to better assess the base of the lung fields. For female or rhonchi (lower-pitched, gurgling, loud or deep
patients, ask them to move their breasts laterally to sounds). Wheezing sounds are indicative of narrowed
ensure proper percussion of the chest wall. For pos- airways, while rhonchi suggest secretions in the large
terior chest wall percussion, ensure that the patient airways and may disappear for a short time after a
is comfortably seated with his or her arms crossed patient coughs.18,26 Adventitious lung sounds that are
in front. Percuss midway between the spinous pro-
cesses and the medial border of the scapula. Com-
pare the sounds at the same level bilaterally before
moving approximately two intercostal spaces lower.
At the base of the lung fields (below the inferior angles
of the scapulae) move laterally and compare sounds at
the posterior axillary line bilaterally. Percuss inferiorly
to the level of the thoracolumbar junction (Fig. 27–5).
Auscultation of the ChestAuscultation is an important

way of assessing air flow through the tracheo-
bronchial tree.28 However, a clear definition of
sounds is paramount. Vesicular sounds are normal
sounds heard around the periphery of the lungs. They
are gentle and rustling in quality, and are heard dur-
ing inspiration and fade during expiration. Tracheal
or bronchial sounds are normal sounds heard over
the suprasternal notch and are louder, higher-pitched,
and hollower in quality than the vesicular sounds.
Abnormal lung sounds are called adventitious.
Tracheal or bronchial sounds heard around the pe- FIGURE 27–5. Sites for percussion and auscultation of the
riphery are abnormal (adventitious sounds) and point lungs. Start at the top on one side and move to the other side
to consolidation of the lung. If significant airflow at the same level; then move downward following the same
obstruction is present, auscultation would reveal pattern, one level at a time.
TABLE 27–15. Chest Auscultation: Common Lung Sounds
Sound Heard Location Meaning
Vesicular (gentle rustling, fading during Lung periphery Normal

expiration)
Tracheal/bronchial (louder than 1. Over suprasternal notch 1. Normal
vesicular, hollow, higher-pitched, 2. Over lung periphery 2. Abnormal—consolidation
louder on expiration)
Wheezes (adventitious: continuous, Over airways that are narrowed Abnormal—asthma, COPD, bronchitis
high-pitched whistling)
Rhonchi (adventitious: continuous, Over large airways Abnormal—secretions in large airways, clear
lower-pitched gurgling) temporarily (cough)
Fine crackles (adventitious: soft, Over lungs and small airways Abnormal—pulmonary fibrosis (in late
high-pitched, and crisp; <10 msec) inspiration), bronchitis, bronchiectasis
Coarse crackles (adventitious: louder, Over lungs and airways Abnormal—pneumonia or heart failure (in early
lower-pitched; 20–30 msec) inspiration), bronchitis, bronchiectasis
discontinuous are called crackles. They are discrete, normal auscultation findings in both normal pa-
short (5–10 msec), popping sounds. Fine crackles are tients and in those presenting with common dis-
soft, high-pitched, clear, and short. Coarse crackles orders. For further information on the examina-
are louder, lower-pitched, and longer in duration (20– tion of the respiratory system, see references 28
30 msec). Conditions that may produce crack- and 30.
les include lung disease (pneumonia, conges-
tive heart failure, fibrosis) and airway disease
(bronchitis, bronchiectasis). Conditions that may PHYSICAL EXAMINATION OF THE ABDOMEN
produce wheezes include asthma, bronchitis, While the typical patient presenting to a chiroprac-
and COPD, while rhonchi are heard in chronic tor’s office will complain of low back, neck, or head-
bronchitis.25 ache pain, up to 11.9% of patients can present with
nonmusculoskeletal complaints, including up to 2.9%
Lung Auscultation To auscultate the breath sounds, use with abdominal pain and/or injury.16 Furthermore,
the diaphragm of the stethoscope (making sure it is disorders in many structures within the abdominal
warm before you place it on the patient). Auscultate cavity are capable of referring pain to the spine, which
both the anterior and posterior chest. Have the pa- may confound diagnostic decision making if the chiro-
tient breathe deeply through an open mouth to better practor is unaware of how to detect them. Examples of
hear the breath sounds. Be sure to pause if the pa- visceral disorders that may refer to the back include
tient becomes lightheaded or hyperventilates. Start hiatal hernia, duodenal ulcer, pancreatitis, cholecys-
with the anterior chest at the supraclavicular fossa titis, kidney infection/stones, and abdominal aortic
and move from side to side down the midclavicular aneurysm.31−34
line. Move down two intercostals spaces at a time un-
til just below the nipple line at the sixth intercostal Visceral Pain
space. Then move laterally to the anterior axillary line The viscera do not respond to direct insult such as
and auscultate bilaterally as well as one or two levels cutting or burning, because they contain only mecha-
down. Listen for breath sounds and the presence of nosensory and chemosensory receptors.35,36 There-
any adventitious sounds. Compare sounds bilaterally. fore, visceral pain is generated through mechanisms
Tracheal and bronchial sounds are normally heard where these receptors are activated. For example,
over the trachea and suprasternal notch, respectively. mechanosensory stimulation results in pain through
There is a transition from bronchial to bronchovesic- expansion or obstruction of a hollow viscus or ex-
ular sounds in the first and second intercostal spaces pansion of a solid organ contained within a cap-
anteriorly over the large airways, especially on the sule (such as the liver or spleen), while chemosen-
right, and at the same level between the scapulae sory stimulation arises through inflammation of the
posteriorly. Below this level, all sounds should be peritoneum or vascular compromise of any struc-
vesicular in quality. Breath sounds are usually louder ture causing ischemia.35 Nociceptive sensations are
in the upper anterior chest. Table 27–15 summarizes transmitted through the sympathetic portion of the
FIGURE 27–7. Two common methods of referring to location

in the abdomen. On the left, the segmental method; on the
right, the quadrant method.
The abdomen can be divided by using either a quad-
rant system or a regional system. To examine the ab-
domen, have the patient lie supine in a warm room,
FIGURE 27–6. Common referral patterns for chest and ab- with the abdomen exposed from xiphoid process to
dominal viscera. pubis, and with a pillow under the patient’s head and
under the flexed knees for comfort.37 By convention,
autonomic nervous system (ANS), synapsing in lam- the examiner should be positioned on the right side
inae I and V of the spinothalamic tract and laminae II of the patient for all maneuvers, unless otherwise in-
and VIII of the spinoreticular tract, the same pools of dicated. Examination should follow the sequence of
neurons where somatic sensory afferents synapse.35,36 observation, auscultation, percussion, palpation (light
This may explain the phenomenon of “referred pain,” and deep), and special maneuvers (Fig. 27–7).
where higher cortical centers misinterpret nociceptive
stimuli as arising from somatic structures rather than
Physical Examination
visceral structures. These two qualities of visceral pain
(i.e., decreased sensory innervation relative to somatic Inspection Observe the exposed abdomen with a tan-
tissues and referred pain) account for the clinical dif- gential light, noting skin color, abdominal contour
ficulties that may arise with the patient who presents (scaphoid, protuberant, distended), flank contour
with pain that appears to be of somatic origin, yet may (concave, flat, or bulging), and the presence of scars,
be a result of visceral pathology (Fig. 27–6). The side- veins, striae, ecchymosis, nodules, or masses.37 As-
bar “Historical Cues to the Presence of Abdominal sess the superficial venous drainage pattern of the ab-
Disorders” lists cues from the patient’s history that domen by placing the pads of your index fingers next
may alert one to the presence of referred pain from to each other on a visible vein. Draw them apart by
abdominal disorders. several centimeters, then release one finger and ob-
serve the direction of filling. Repeat the maneuver for
the other finger. Veins above a line drawn horizon-
Historical Cues to the Presence of tally through the umbilicus should drain in a cepha-
Abdominal Disorders lad direction, while those below the line should drain
Pain that has a remitting and relapsing effect that is not caudally. Abnormal patterns of drainage may indi-
explained by physical motion or rest. cate portal hypertension (all veins draining in a radial
Complaints of pain that are described as “cramping” or pattern away from the umbilicus) or obstruction of
“colicky,” or that cause the patient to writhe. the inferior vena cava (all veins draining cephalad).38
Pain aggravated by ingestion of certain foods, such as cof- Have the patient inhale and hold his or her breath, or
fee, alcohol, or fatty foods, or that is relieved with food or raise the head from the pillow to accentuate unseen
antacids. masses, especially within the abdominal wall, or to
History of long-standing alcohol consumption. reveal a diastasis recti or umbilical hernia.37 Observe
Patients who are taking anticoagulant medication. for abdominal movement, including the smoothness
Recent changes in bowel habits, such as bloody stools or of the normal movements of reciprocal respiration, as
steatorrhea. well as peristalsis (considered an abnormal finding).
The pulsations of the abdominal aorta may be visible
in thin patients, but increased pulsations may indicate

the presence of an abdominal aortic aneurysm.
Auscultation Perform auscultation next to ensure that

the frequency and intensity of bowel sounds are
not disturbed through palpation or that an abdom-
inal aneurysm will not be compromised. Use the
diaphragm of the stethoscope to listen for bowel
sounds and the bell for bruit assessment. Bowel
sounds should be present in all four quadrants
and occur at a rate of 5–35/min.37 Increased bowel
sounds with a high-pitched quality may indicate
gastroenteritis, obstruction, or simply hunger. Ab-
sence of bowel sounds for more than 5 minutes may
indicate peritonitis, paralytic ileus, or obstruction.
Other abdominal sounds that may be encountered FIGURE 27–9. Locations for percussing abdominal organs.
include bruits in the arteries (make sure to assess
over all major arteries), friction rubs over the liver
justed for age and gender differences.37 Percussion
or spleen, or a venous hum over the epigastric re-
of the spleen occurs in the left midaxillary line.
gion and umbilicus (indicative of increased collat-
Again, begin in an area of tympany and move cau-
eral circulation between portal and systemic venous
dally until the tone becomes dull. The spleen should
systems).37,38
span the sixth and tenth rib. Next, percuss the low-
est intercostal space in the mid-axillary line during
Percussion Percussion is performed next to indirectly both inspiration and expiration. Tympanic sounds
evaluate the size and consistency of internal organs should remain through both maneuvers; loss of tym-
and to assess for the presence of fluid, air, or masses. pany may indicate an enlarged spleen.37 Finally,
As with auscultation, make sure to percuss in all four percuss the gastric air bubble in the left epigastric
quadrants, noting the tone in all areas (tympany over region.
air-filled organs such as the stomach or intestines;
dullness over solid organs). After general percussion,
Palpation Light palpation is performed next, using
the liver, spleen, and stomach should be individually
the pads of your fingertips. Palpation should be per-
evaluated for size (Figs. 27–8 and 27–9).
formed in all four quadrants, ending with the area
The size of the liver is evaluated through per-
of complaint. Concentrate on evaluating muscular re-
cussion along the midclavicular line, beginning from
sistance, tenderness, and the presence of superficial
an area of tympany and moving toward dullness.
masses. If evaluating muscular resistance, placing a
Determine the lower border by percussing from the
pillow under the patient’s knees and asking the pa-
periumbilical region and moving toward the costal
tient to breathe slowly through the mouth may remove
margins. Find the upper border by beginning above
voluntary guarding. Involuntary muscular resistance
the nipple region in an area of tympany and move
can indicate rigidity secondary to peritoneal irrita-
toward the lower rib cage. The typical liver span
tion, which may be confirmed by examining for areas
is approximately 6–12 cm (2–5 inches) when ad-
of cutaneous hypersensitivity by lifting and lightly
pinching skin folds, or by scratching the skin with
a pin. An exaggerated pain response to the stimulus
indicates hypersensitivity, possibly as a result of peri-
toneal inflammation.37 Next, palpate by using mod-
erate pressure with the same contact. As before, all
four quadrants should be palpated for tenderness and
masses. This level of palpation is also useful for eval-
uating the movement of those organs commonly dis-
placed with respiration, such as the liver and spleen
(Fig. 27–10).
FIGURE 27–8. Percussion technique. Lay the bottom hand Deep palpation is the final step, and is used to eval-
flat against the abdomen and strike the distal phalanx of the uate abdominal organs and to detect deep masses.
middle finger sharply with a slightly flexed finger from the top The same contact is used, this time with a deep and
hand to elicit a percussion note. even pressure, supporting your contact fingers with
with acute cholecystitis—then the patient may have

cholecystitis.37,39
Next, palpate the spleen. Standing on the right
of the patient, reach across the patient to place your
left hand under the patient’s costovertebral angle and
rest your right hand below the patient’s left costal
margin. Pressing upward into the patient’s abdomen,
ask the patient to inhale deeply while you observe
whether the edge of the spleen is palpable. An al-
ternate maneuver is to repeat this examination with
the patient lying laterally recumbent on the right. The
spleen should not be palpable; if so, it is most likely
FIGURE 27–10. Palpation for abdominal aortic aneurysm. enlarged.37
To palpate the kidneys, begin by standing at the
side of the patient facing cephalad. Reaching across
your other hand. Structures commonly felt at this level the patient, place your hand underneath the patient’s
of palpation include aortic pulsations, sections of the flank and lift. Place your other hand on the pa-
colon, and a full urinary bladder or enlarged gravid tient’s abdomen underneath the costal margin. Ask
uterus. All masses identified should be evaluated ac- the patient to inhale while you simultaneously press
cording to the following characteristics: location, size, into the abdomen deeply, attempting to capture the
shape, consistency, tenderness, pulsations, mobility, lower pole of the kidney. Anatomically, the right kid-
and movement with respiration.37 Ask the patient to ney sits lower in the abdominal cavity, and is there-
lift his or her head from the table to tighten the ab- fore more frequently captured; the left is normally
dominal wall, thereby revealing whether a mass is not captured.37,39 The kidneys should be evaluated
superficial or deep. A mass deep to the abdominal for smoothness, firmness, and tenderness. As with
wall will no longer be felt, while a superficial mass the liver, the presence of nodules or pain should be
will remain palpable. Evaluate the umbilicus and peri- noted. The presence of kidney tenderness can be fur-
umbilical area for the presence of bulges, nodules, or ther evaluated through a kidney punch test. The pa-
protrusions. tient is placed in a sitting position, and the examiner
Next, specific structures within the abdomen may percusses the costovertebral angle with a fist. Pain
be palpated. For the liver, stand on the patient’s right with this maneuver is indicative of renal calculi or
side facing cephalad and place your right hand on infection.37−39
the abdomen with your fingers just below the area of Begin palpation of the abdominal aorta by placing
liver dullness. Ask the patient to inhale deeply and your hands on the patient’s epigastric area and feeling
press into the abdomen to evaluate the liver edge. If for a transmitted epigastric pulse. Next, measure the
felt, it should be smooth, nontender, and even; pres- aortic width by placing your hands palm-down with
ence of tenderness, nodules, or irregularities should the index fingers on either side of the pulsating area.40
be noted.37,39 An alternate technique is to stand facing Authors vary on the measurement necessary to de-
caudally, hook your fingers under the patient’s costal termine the presence of abdominal aortic aneurysm,
margin below the area of liver dullness, and again ask which is generally greater than 3.0–5 cm (1–2 inches)
the patient to inhale and feel for the liver’s edge.37,39 after accounting for skinfold thickness.40
Finally, the liver may be evaluated for tenderness by The presence of an inguinal mass suggests a her-
percussing over the lower right costal region with a nia or enlarged lymph nodes. Evaluation of the lym-
fist. phatic system is dealt with more completely under
Palpate the gallbladder using the same position, Lymphatic System above. A direct hernia will produce a
with your fingers below the liver margin at the lat- bulge over the subcutaneous inguinal ring (in the dis-
eral margin of the rectus abdominus muscle. An tal third of the inguinal ligament) or in the femoral tri-
asymptomatic gallbladder is nonpalpable, while a ten- angle, while an indirect hernia may present as a mass
der, enlarged gallbladder is indicative of cholecystitis, in the scrotum (if large enough).41 The direct hernia
and a nontender, enlarged gallbladder may indicate can be best palpated by using the pads of the index and
obstruction of the common bile duct.37 A confir- middle fingers, and having the patient cough gently.
matory physical examination maneuver for chole- Transmission of the cough indicates the presence of a
cystitis is to have the patient take a deep breath hernia. Evaluation of an indirect herniation involves
during deep palpation in this region; if the patient palpation through the scrotum in the male, which may
experiences pain and stops inhalation—this is called be out of the scope of practice of chiropractors in many
the Murphy sign, which is frequently associated jurisdictions.
Special Maneuvers represents a clinical presentation that may necessitate

Superficial Abdominal Reflexes Lightly stroke the ab- urgent medical referral. Referral of a patient should
domen with the sharp point of a reflex hammer, begin- be considered in the follow circumstances:
ning at the edges of the four quadrants and moving
toward the umbilicus. The umbilicus should deviate • Evidence of a pulsatile abdominal mass larger than
toward the side stroked. Decreased reflexes may be 3.0 cm (1 inch), accounting for skinfold width, or
seen in individuals who have had the abdominal wall when an abdominal bruit is auscultated. If larger
stretched through obesity or pregnancy; an absent re- than 5 cm (2 inches), consider urgent referral.
flex may indicate a pyramidal tract lesion.37−39 • Evidence of peritoneal inflammation, particularly
with autonomic reflexes such as sweating, nausea,
a raised temperature, and forward flexed posture;
Evaluation for AscitesAscites may be suspected in an consider emergency referral.
individual who demonstrates bulging of the flanks • Evidence of an enlarged spleen, liver, or kidney, or
and the presence of a tympanic bubble in the cen- an abdominal mass, particularly when the patient
ter of the abdomen with flank dullness while supine. displays other constitutional signs and symptoms
The shifting dullness maneuver determines if the bor- such as fatigue and weight loss; consider referral
der between the areas of tympany and dullness shifts, to the family doctor.
which can indicate a fluid level. Ask the patient to • Evidence of a direct hernia or suspicion of an indi-
move from supine to lateral recumbent; if the borders rect hernia; consider referral to the family doctor.
demarcating the area between tympany and dullness • For further information on examination of the ab-
do not move, a fluid level is not demonstrated. A pos- domen, see references 37–39.
itive test occurs when the tympanic border shifts to-
ward the midline with the area of dullness moving
toward the recumbent side. A second maneuver, the SUMMARY
fluid wave, is performed by having an assistant press
1. The physical examination should be used by the
his or her forearm and hand along the midline of the
chiropractic student/clinician to confirm a diag-
patient’s abdomen, tap one of the patient’s flanks, and
nosis or create a hierarchical differential diagnosis,
palpate for the presence of a fluid wave on the other
as generated from and supported by the patient’s
side. Palpation of a fluid wave may be indicative of
history.
the presence of ascites.37−39
2. The chiropractic student/clinician should con-
sider the roles of effective communication and cul-
Evaluation for Peritoneal IrritationRebound tenderness tural sensitivity in an effective physical examina-
can be considered somewhat unnecessary, because tion. The student/clinician should acquire skills
other maneuvers during the abdominal examination in observation and inspection, perform tests in a
can elicit signs of peritoneal irritation; if the exam- skilled manner, and use a firm, comfortable, and
iner chooses to perform it, it should be reserved until purposeful touch.
the end of the examination. For this maneuver, press 3. Important cues from the history that indicate the
your hand into the patient’s abdomen at a point dis- need for a more specific and detailed physical ex-
tant to the area of complaint and withdraw it quickly. amination arise from the review of systems. Those
If peritoneal irritation is present, then a sharp pain complaints relevant to a specific system should
will be elicited in the painful region. If localized in prompt further evaluation by the clinician using
the lower right quadrant region, appendicitis may be the procedures outlined in this chapter.
suspected.37 A confirmatory maneuver for appendici- 4. Cues suggesting that a potentially serious condi-
tis includes the iliopsoas test by flexing and abducting tion or pathology is present are termed red flags.
the patient’s straight leg at the hip, applying down- Red flags for skin include: a pigmented lesion
ward pressure, and asking the patient to resist. Repro- found on sun-exposed areas that is asymmetrical,
duction of pain suggests irritation of the lateral iliop- has an irregular border, is a different color than
soas muscle. This is similar to the test for obturator other moles, and is greater than 6 mm and rapidly
muscle, where the patient’s leg is flexed to 90 degrees growing. Red flags for the head and neck include: a
at the hip and knee and the hip is rotated medially and “rodent ulcer” lesion or flat, raised lesion of squa-
laterally. Reproduction of pain will indicate irritation mous cell carcinoma, an enlarged gland or nodule
of the obturator muscle.37,39 in the thyroid, hard, nontender or enlarged lymph
nodes, circumcorneal injection, scleritis, or foreign
Red Flags body, papilledema or retinal detachment, nodule,
Although the patient presenting with an abdominal ulcer or white plaque on the tongue, or mass in the
complaint is not typical in a chiropractor’s office, it hard palate not in the midline, redness, swelling,
and exudate present on the tonsils. Red flags for the 2. Use the “ABCD” characteristics. The following in-
heart include: very high blood pressure, peripheral dicate the likelihood of malignancy:
vascular disease, heart murmurs or rhythm irreg-
ularity, chest pain, dyspnea (shortness of breath), Asymmetry—skin lesion/mole is asymmetrical
edema, hypertension, and cyanosis. Red flags for Border irregularity
the lungs include: dyspnea, chronic cough, hemop- Color variation—different color from other moles
tysis, and cyanosis. Red flags for the abdomen in- (e.g., blue, blue-black)
clude: pulsatile abdominal mass larger than 3.0 cm Diameter—greater than 6 mm and rapidly grow-
(1 inch), abdominal bruit, peritoneal inflammation ing
(sweating, nausea, raised temperature, forward-
flexed posture), enlarged spleen, liver, or kidney, 3. In general, red eye complaints that demonstrate
abdominal mass, fatigue and weight loss, and circumcorneal injection (redness caused by injec-
hernia. Red flags should be actively investigated tion of the blood vessels that begin at the corneal
by the clinician and referred to the appropriate edge and extend outward) should be referred for
practitioner. medical evaluation. This can represent serious con-
5. In the examination of a region of the body, a sys- ditions such as iritis, keratitis, and acute glaucoma.
tematic pattern of inspection, palpation, percus- Other conditions requiring medical evaluation in-
sion, and auscultation should be followed. In addi- clude hyphema (anterior chamber hemorrhage),
tion, the use of special diagnostic tools such as the corneal foreign bodies, and scleritis.
stethoscope, ophthalmoscope, and otoscope com- 4. As a screening procedure, it is highly recomme-
plete the diagnostic workup. nded that chiropractors (a) observe for signs of
disease (edema, cyanosis, dyspnea), (b) assess vi-
tal signs, (c) assess the pulses (upper and lower
ACKNOWLEDGMENTS extremities), (d) take the blood pressure, and
(e) auscultate the heart of every patient on the ini-
The authors gratefully acknowledge the assistance of Fabio
tial examination. Why? Because high blood pres-
DiStefano, Forest Eaton, Eric Klein, Katie Sloma, and the Media
sure and cardiovascular disease are common in
Services Department of CMCC, particularly Bryan Groulx and
society today and may contraindicate chiroprac-
Jay Bowes.
tic care as well as threaten the patient’s life!
5. Historical and physical cues that should alert the
suspicious clinician to the presence of viscerogenic
QUESTIONS back pain include pain not relieved by rest or ag-
gravated by activity; pain that is described as col-
1. What is the purpose of the physical examination?
icky or crampy in nature; pain that can be linked
2. What observed characteristics of a skin lesion may
to ingestion of certain foods (e.g., fatty meals, alco-
help you determine whether it is benign or malig-
hol, caffeine); patients with a long-standing history
nant?
of alcohol ingestion or who are taking anticoagu-
3. Of all the types of “red eye” complaints that
lant medication; and changes in bowel movements
may present at a chiropractor’s office, which ones
(e.g., diarrhea, steatorrhea).
should be referred for medical attention?
4. What is the recommended screening procedure for
the cardiovascular system of a new patient? Why?
5. What historical clues should make a chiropractor KEY REFERENCES
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C H A P T E R
28
NEUROLOGIC EXAMINATION
Rand S. Swenson
O U T L I N E
INTRODUCTION Visual Fields
NEUROLOGIC HISTORY Extraocular Motions
BASICS OF THE NEUROLOGIC EXAMINATION Upper Eyelid Position
ELEMENTS OF THE EXAMINATION Pupillary Reactions
Motor Systems Facial Sensations
Strength Jaw Muscle Strength
Deep Tendon (Myotactic) Reflexes Facial Strength and Movement
Superficial and “Pathologic” Reflexes Hearing
Muscle Bulk Palate and Pharynx Strength
Coordination Tongue Strength
Muscle Tone Voice
Abnormal Movements Higher Mental Function
Station Language
Gait Registration
Sensory Examination Memory
Light Touch Concentration
Vibration Calculation
Pinprick Abstraction
Temperature Constructional Ability
Joint Position Sense Affect
Autonomic Examination Thought Content
Cranial Nerves SUMMARY
Olfaction QUESTIONS
Fundus Examination ANSWERS
Visual Acuity KEY REFERENCES
5. To understand the significance of the observations

OBJECTIVES
made through the neurologic examination.
1. To understand the goals and objectives of the neu- 6. To appreciate the position of the neurologic exam-
rologic examination. ination in diagnosis.
2. To recognize the role of the neurologic history in
formulating the examination.
3. To know the elements of the nervous system that
INTRODUCTION
can be evaluated through the examination.
4. To understand the examination procedures that The neurological examination is an important com-
can be employed to examine the testable portions ponent of the evaluation of patients seeking chiro-
of the nervous system. practic care. Findings may lead to a diagnosis or to
537
the recognition of underlying neurologic disease that complaint. Many neurologic symptoms are poorly de-
could impact management. Additionally, examina- scribed or described in vague terms. These include
tion findings may be important in indicating the need complaints of “dizziness,” “numbness,” “heaviness,”
for further testing and in determining what specific and “weakness,” which often mean something com-
tests would be likely to aid in the evaluation of the pletely different to the patient then they do to you.
patient. There are certain elements of the examina- Therefore, it is critical to precisely characterize these
tion that should routinely be performed on most new terms whenever possible. For example, does “dizzi-
patients or in patients with new complaints. These ness” mean that the patient is faint or light-headed,
include basic tests of strength, sensations, reflexes, have the illusion of movement (vertiginous), or is un-
and gait. The potential yield from these procedures steady when walking? Inability to precisely charac-
is high and the amount of time required to perform terize these complaints often leads to an unsatisfying
them is minimal. While having a routine is useful, evaluation. You must have some appreciation for the
many aspects of the examination are guided by the onset, timing, frequency, precipitants, and functional
history. As a general rule, symptomatic body parts significance of the symptoms. It is always helpful to
require greater attention than other regions. Cervi- be able to provoke symptoms because this will give
cal problems require more extensive testing, includ- you first-hand information of mechanisms and the pa-
ing evaluation of all four limbs. This is because both tient’s reactions. It will also give you the ability to
upper and lower limb neurologic function can be af- check the examination during these episodes. Any-
fected by injury to neural structures in the neck, such thing that relieves or improves symptoms is useful
as the nerve roots and the spinal cord. Complaints information.
of dizziness require more detailed evaluation of eye
movements, coordination, and auditory function. Pa-
BASICS OF THE NEUROLOGIC EXAMINATION
tients who describe difficulty walking (ataxia) require
extensive evaluation of proprioceptive sensory func- The neurologic exam has both tactical and strategic
tion, strength, reflexes, and coordination of the legs. objectives. These are somewhat hierarchical in nature.
Symptoms of “numbness” or tingling indicate the On the simplest (tactical) level is the performance of
need for a more detailed sensory examination, and the test or observation. It is critical to be able to identify
reports of weakness require more detailed testing of abnormalities in the patient’s performance. It is often
strength. important to know additional tests that can confirm
Some complaints, such as the common, benign an abnormal finding. Next, it is important to recognize
headache syndromes (tension-type and migraine), what component of the nervous system is impaired in
should not produce abnormalities in the neurologic order to produce that abnormal test finding. Again,
examination. Similarly, the usual patient with non- it is important to confirm any suspected abnormality
specific low back pain or myofascial pain syndromes by using other tests that evaluate the same nervous
should not have any objective abnormalities on the system component. Therefore, it is important to know
examination. Therefore the neurologic examination is several ways of testing each part of the system, even
one important factor in helping to determine which if one primary method is used for screening. Finally,
headache patient, low back pain patient, or myofas- on a strategic level, it is important to be able to put
cial pain patient requires further evaluation. your findings in context of the patient’s overall pre-
sentation in order to reach a diagnosis or to decide on
additional testing. While the goals of the neurologic
NEUROLOGIC HISTORY
exam are simply stated, they may be difficult in prac-
The history is important in your approach to the tice. In difficult cases, it is important to recognize the
neurologic examination. At the end of a history, you abnormality and then enlist the assistance of special-
should have a hypothesis of what the findings will be ized testing or consultation to explain your findings.
on the examination and also a series of questions that Of course, the great majority of chiropractic patients
you would like the examination to address. For ex- have a normal neurological examination and, at a min-
ample, if the patient is complaining of left arm symp- imum, this helps to provide assurance of the integrity
toms, you should be interested in evaluating sensory of the nervous system prior to deciding on a treatment
and motor function of that limb, as well as coordi- plan.
nation of the limb. In many circumstances, you will This chapter discusses many tests and procedures
hypothesize that the neurologic examination should that can be used in the neurological examination.
be normal and will perform your screening exam to However, the ultimate goal of all of these tests is to
determine whether your hypothesis is correct. History evaluate the integrity of each of the functional com-
taking begins with a complete understanding of what ponents of the nervous system. The functional com-
the patient means when describing his or her primary ponents that can be assessed by the examination are
NEUROLOGIC EXAMINATION 539
limited in number because many of the tracts and tems: either they are functioning normally or they are
nuclei of the central nervous system do not have not. As a part of the strategic goal of the exam, the
specific, identifiable functions that permit clinical as- finding of abnormality should be explainable in con-
sessment (Table 28–1). The relatively small number of text of the patient’s presumed diagnosis. If not, either
nervous system components that can be tested limits the presumed diagnosis should be reevaluated or an-
the scope of the neurologic examination. In uncompli- other explanation should be sought for the finding.
cated cases, the neurologic examination can be com- Similarly, a normal neurological examination should
pleted in less than 5 minutes. be interpreted in context of the patient’s presumed
Each of the functional components of the nervous problem. For example, it would be unusual for a pa-
system has particular findings when damaged and tient with myelopathy (damage to the spinal cord)
can be further examined by using several special- to have a completely normal exam, while the patient
ized tests or procedures. At the end of the neurolog- with myofascial pain would be expected to be nor-
ical exam, you should be able to come to one of two mal neurologically. When viewed in this light, being
conclusions regarding each of the neurological sys- able to perform and recognize a normal neurologic
TABLE 28–1. Functional Components of the Nervous System
Functional Component Possible Exam Findings Special Tests and Procedures
Peripheral nerves Sensory and motor examination in a pattern Electromyography (EMG), nerve
compatible with peripheral nerve injury. conduction velocity (NCV),
Possible Romberg sign. quantitative sensory testing?
Nerve roots Sensory and motor examination in a pattern EMG, NCV.
compatible with nerve root injury. Provocative
(stretch, compression) tests.
Nerve plexuses Sensory and motor examination in a pattern EMG, NCV.
compatible with plexus injury
Autonomic nervous system Orthostatic blood pressures, Horner Orthostatic testing, tilt-table testing,
syndrome, loss of sweating, bladder and quantitative tests of sweating,
sexual abnormalities. beat-to-beat cardiac variability,
responsiveness of pupils to various
eyedrops.
Lower motor neuron Weakness, severe atrophy, and fasciculations. EMG.
Corticospinal tract (upper motor Spastic weakness with overactive reflexes and Cortical magnetic stimulation.
neurons—UMNs) upgoing toes.
Dorsal columns Problems with joint position sense, vibratory Somatosensory evoked potentials
sense, and well-localized touch below the (SSEPs).
lesion. Romberg sign.
Spinothalamic tract Problems with pain and temperature sensation
below the level of the lesion.
Basal ganglia (extrapyramidal) Abnormal movements at rest or abnormal PET scanning (mostly experimental).
tones (rigidity) and postures. Delay in
postural reactions.
Cerebellum Incoordination of voluntary movement, reeling
gait, excessive rebound, dysarthria,
dysdiadochokinesia.
Cranial nerves Abnormalities with specific cranial nerve Varies by the particular cranial nerve.
functions.
Medial longitudinal fasciculus The medial-going eye does not track in
horizontal gaze with nystagmus in the
lateral-going eye.
Higher mental functions Problems with language, memory, judgement, MRI, blood flow studies (single photon
insight, problem solving, visuo spatial emission tomography—SPECT),
function, calculation, concentration. neuropsychological test batteries.
examination is as important as being able to identify tions,” including many elements of language, mem-
an abnormality. ory, and higher cognitive functions. Finally, there is
It is a common concern among practitioners who a great deal of the peripheral nervous system that
do not see many patients with abnormal neurological can be tested. Basically, the peripheral nervous system
exams that they may not be able to recognize an ab- can be divided into the cranial and somatic portions
normality when it is present. While this is a very real of the nervous system and can be subdivided into
concern, performing examinations on a wide range of sensory, motor, and autonomic components. Further-
normal patients is also an effective way of becoming more, peripheral nerves can traverse several anatom-
familiar with the range of normal, thereby recognizing ical sites where they are vulnerable to disease and
abnormality. This provides one strong rationale (but damage. These sites include the nerve roots, plexuses,
not the only one) for the performance of important and the various nerve branches. Additionally, mo-
and routine components of the neurologic exam tor nerve fibers require integrity of myoneural junc-
on patients even when they are not suspected of tions and the muscles. Any reasonable evaluation
problems. of the peripheral nervous system requires detailed
It must be noted that many highly symptomatic knowledge of the anatomy of the peripheral nervous
patients can have completely normal neurologic ex- system.
aminations. Most pain syndromes, for example, are Most of the neurologic exam can be completed by
not reflections of damage to the nervous system. skillful observation of the patient performing a va-
In fact, the perception of appropriate levels of pain riety of simple tasks and in the context of the his-
may be taken as an indication that pain transmission tory and general physical exam. However, in practice,
pathways are intact. Additionally, many neurologic it is generally necessary to perform some selective
syndromes, such as migraine and epilepsy, can (and tests of each nervous system component in order
usually do) give a normal exam between episodes. to determine its integrity. This assures that critical
Nonspecific low back and neck pain, as well as my- parts won’t be overlooked. Additionally, although
ofascial pain syndromes, as mentioned above, often most elements of the nervous system may be tested
have normal examinations. Also, many pain-related in a variety of ways, it is really only necessary to
phenomena, such as hyperesthesia, referred pain, and do as many tests as it takes to ensure the integrity
muscular guarding, are explainable by normal neuro- of the system. Often, close observation is all that is
logic processes and are not reflective of damage to the necessary.
nervous system. In the process of performing a neurologic exam, the
Because of the common clinical problems that general physical and orthopedic examinations should
present to chiropractors, evaluation of certain com- not be ignored because they can occasionally provide
ponents of the nervous system assumes a relatively information regarding the etiology of a patient’s neu-
greater importance in a chiropractic practice. For ex- rologic complaint. Physical findings may suggest a
ample, it is important to identify the patient with systemic disorder affecting the nervous system (such
nerve root damage or spinal cord damage because as bruits in the neck, the stigmata of rheumatologic
these may well be present in patients having back or disease, signs of systemic or local infection, signs of
neck complaints. The finding of such damage often systemic emboli or of clotting disorder). Also there are
alters your evaluation and treatment of the patient findings that may suggest endocrine disorders, which
and, in some instances may contraindicate treatment can result from pituitary dysfunction. Vital signs and
altogether. orthostatic blood pressures may give clues regarding
There is a “basic irreducible minimum” in order autonomic dysfunction or the presence of other dis-
to claim that you have fully examined the parts of the ease processes.
nervous system that can be checked (see Table 28–1). With each aspect of the exam, you should be able to
This is a relatively short list of nervous system com- identify which part or parts of the nervous system you
ponents that have clearly recognizable signs when in- are testing, and then you should know which other
jured. These functional components fall into several parts of the exam can be useful in confirming or refut-
categories. For example, there are several tracts, ining your hypothesis of damage. The intermediate goal
cluding the dorsal columns, the spinothalamic tract, of the exam is to determine whether portions of the
the corticospinal tract (also known as upper motor nervous system are damaged or not, permitting you
neurons), and the medial longitudinal fasciculus, that to fit this with your overall diagnostic hypothesis.
can be checked. There are several neurologic sys-
tems that are checked as a functional unit, includ-
ELEMENTS OF THE EXAMINATION
ing the cerebellum and the extrapyramidal systems
(basal ganglia). There are several functions that are It is often helpful to have a routine in which to per-
lumped under the rubric of “higher mental func- form the examination. This improves the efficiency
and also helps prevent major omissions. Typically, the be examined explicitly with a series of tests or ma-
neurological examination is broken into motor exam, neuvers, while many can be examined by simple ob-
sensory exam, cranial nerve examination, and higher servations made during the course of the history and
mental function exam. Various subtests are performed physical exam. The important thing is to determine
in each area (Table 28–2). Some of these areas should whether these neurologic systems are functioning and
TABLE 28–2. Neurologic Exam
Examination Element Neurologic System Tested
History taking Language function, thought content, intelligence, affect, recall of recent and
remote events (assess higher mental functions).
Sensations of the body Peripheral nerve, nerve root, spinal cord tracts, thalamus, cortex.
Pin and temperature sense Peripheral nerve, spinothalamic tract, thalamus.
Light touch Peripheral nerve, spinothalamic tract, thalamus.
Vibration, joint position sense Peripheral nerve, dorsal columns, thalamus, cortex.
Test strength Upper motor neuron (UMN) or lower motor neuron (LMN) lesion. UMNs
Pronator drift? represented by motor cortex and corticospinal tract. LMNs are motor
Toe walking/heel walking? neurons and their axons (in nerve root and peripheral nerve). Functional
Climb a step/hop on a foot? tests of strength are good for screening. Direct muscle testing for specific
Get up from chair or squat? muscle groups.
Myotatic (tendon) reflexes Tests lesion of LMNs (decreased) and UMNs (increased reflex).
Plantar response—Babinski response Babinski response indicates UMN damage.
Muscle bulk—atrophy? Atrophy mild (disuse) or severe (LMN lesions).
Muscle tone Rigidity (extrapyramidal disease), spasticity (UMN lesion), decreased tone (LMN
lesion).
Coordination Cerebellum is primary control of coordination. May be affected by weakness or
Rapid alternating movement abnormal muscle tone.
Finger-to-nose test
Gait Many systems invloved in walking. Strength needed (UMN or LMN lesions),
Normal walking vestibular system, cerebellum, extrapyramidal system, joint position
Tandem walking sensation.
Station—standing balance With eyes open, difficulty suggests vestibular or cerebellar problems. If stable
Eyes open with eyes open, but unstable with eyes closed, this suggests problems with
Eyes closed joint position sense (peripheral nerves or dorsal columns).
Observe face Facial nerve or corticobulbar tracts (if weakness is only lower face). Mask face
with parkinsonism.
Visual fields Retina, optic nerve, optic tract, visual cortex.
Extraocular movements Tests strength of eye muscles and integrity of extraocular cranial nerves (III, IV,
Six positions VI).
Dysconjugation? Internuclear ophthalmoplegia if MLF is damaged.
Nystagmus? Nystagmus may be seen with problems of inner ear, cranial nerve VIII,
brainstem or cerebellum.
Eyelid position Severe ptosis with cranial nerve III damage, minor ptosis with sympathetic
damage.
Pupils Large pupils with damage to parasympathetics, small ones with sympathetic
damage.
Tongue strength Hypoglossal nerve or brainstem.
Jaw strength Trigeminal nerve or brainstem.
Palate strength Vagus nerve or brainstem.
Voice—dysarthria? May be with weakness of tongue, palate, larynx or problems with coordination
(cerebellum) or control (brainstem).
Hearing Inner ear or cranial nerve VIII.
Weber test? Weber test differentiates conductive from sensorineural loss.
Facial sensations Trigeminal nerve or spinal trigeminal tract (lateral brainstem).
to do as few or as many tests as needed to be assured It is often useful and efficient to test patients by
of that. The outline for a basic neurologic screening using functional tasks. These can include such ma-
exam is included in Table 28–3. neuvers as having the patient hold his or her arms
horizontally out in front with the palms up and the
Motor Systems eyes closed. Diffuse weakness of the upper limb often
The motor examination includes assessment of many results in “pronator drift,” that is, a downward drift of
elements of the nervous system. The corticospinal the affected limb with the hand turning in (pronating).
tract (upper motor neurons) is the principal com- A straight downward drift of the limb without prona-
mand neuron for voluntary motor function and can tion is not common with organic disease. The limb
be damaged anywhere from the cerebral cortex to may also drift erratically with proprioceptive sensory
the spinal cord. The cerebellum is involved in co- loss. In the case of the lower limbs, it is helpful to have
ordinating motor function, and the extrapyramidal the patient walk on the toes and then on the heels,
system (basal ganglia, etc.) is important in govern- watching to see the position maintained by the foot
ing resting tone, postures, and the initiation of move- and toes during the stance phase of walking. Hav-
ment. The nerve roots, peripheral nerves, myoneural ing the patient hop on each foot, rise from a squat,
junction, and muscles are critical links in the motor or climb a stair is also a useful test of more proximal
control system. Also, remember that the control of muscle function.
normal movement requires proper sensory feedback. Some assessment should be made of effort and of
Therefore, some sensory abnormalities may appear the reason for weakness. For example, some patients
as motor problems. Typically, motor system evalu- “give up” on the test of strength. This is usually re-
ation involves testing of strength, reflexes, atrophy, flected as initially good buildup of force, followed
coordination, tone, and abnormal movements. Gait by a sudden collapse. This has been termed “break-
and station (standing posture) are also examined be- away” or “collapsing” weakness and is not a pattern
cause they are frequently abnormal in motor prob- that is associated with true neurologic injury. This type
lems but also may be affected by damage to sensory of “weakness” should be noted, although it must be
systems. interpreted carefully because there are many poten-
tial causes, ranging from pain to the voluntary em-
Strength This is tested on a graded scale of 0 to 5, bellishment of symptoms. For example, even a neu-
with 0 representing absolutely no visible contraction rologically normal muscle cannot be contracted to a
and 5 being normal. A grade of 1 is visible con- normal degree when movement produces significant
traction but no movement; 2 is some movement but amounts of pain. This is a common explanation for
not enough to counteract gravity; 3 is against grav- “breakaway” weakness. Determining whether a pa-
ity but unable to resist any additional force; and 4 tient has “breakaway” weakness is usually not diffi-
is against gravity with some additional force but not cult if you vary the amount of force that you apply
normal. Obviously, there is a lot or room between 3 during the muscle test. With true neurologic weak-
and 5, and the determination is somewhat subjective. ness, the force that the patient can apply doesn’t vary,
Some individuals expand this into a 9-point scale by while force may vary markedly with a “breakaway”
the addition of + symbols in cases where strength pattern. When this pattern is seen, more objective as-
is between numbers. Still others will expand it to a pects of the motor exam must be relied upon for the
13-point scale by the addition of – symbols when a assessment of neurological injury.
muscle tests just below a level. While there is value The goal of strength testing should be to decide
in having a scale beyond the original 5 points (par- whether there is true “neurogenic” weakness and to
ticularly for patients that fall between 3 and 5), it establish a pattern for this weakness. The remainder
must be remembered that this testing is well short of of the motor exam will permit determination of the
the precision suggested by a 13-point scale. Normal part of the nervous system that is at fault to pro-
must be assessed in relation to the patient’s age and duce this weakness. For example, evaluation of mus-
general conditioning. The assessment is also aided cle tone and reflexes will help to categorize the weak-
if the patient has a normal (asymptomatic) side for ness into upper motor neuron (UMN) or lower motor
comparison. neuron (LMN) type. These two types of weakness are
There are several muscles and movements that are very different in clinical characteristics and in the por-
commonly tested because they represent various lev- tions of the nervous system that are malfunctioning.
els of the nervous system. Cranial nerve–innervated Upper motor neuron weakness is caused by damage
muscles are discussed later (see Cranial Nerves below). to the corticospinal tract anywhere in its course from
Several of the more common movements, along with the cerebral cortex through the brainstem and spinal
their particular peripheral nerve and nerve root level, cord. This typically results in increased reflexes along
are listed in Table 28–4. with a spastic type of increased tone. On the other
TABLE 28–3. Outline of a Suggested Screening Neurologic Examination
Step Reason
Listen to the patient during history. To assess higher cognitive function and language.
Screening sensory exam—light touch with fingers Looking for a pattern of sensory loss suggestive of myelopathy,
over extensive body regions asking the patient to radiculopathy, peripheral neuropathy, or damage to sensory
compare the two sides. Explore the areas of systems above the foramen magnum.
abnormality and any symptomatic body region
with a pin in a systematic fashion.
Vibratory sense at the feet. Looking for signs suggestive of polyneuropathy or of dorsal
column involvement.
Observation of patients with upper limbs held Looking for pronator drift (suggestive of global weakness),
steady in front with fingers spread. Push on tremor, weakness, excessive rebound (loss of checking,
hands and suddenly release them. suggestive of cerebellar damage).
Evaluate coordination (such as with a rhythmic, Looking for incoordination suggesting abnormal cerebellar
rapid alternating movement or finger-to-nose function, proprioception deficit, or severe weakness.
testing).
Observation of the limbs with them resting in the Looking for abnormal postures or movements at rest, mostly
lap. suggesting extrapyramidal abnormality or possible motor
neuron disease (if fasciculations).
Strength testing. Best screened with functional Evaluating distribution and degree of strength loss looking for a
tests such as grip, supporting the arms, walking pattern of weakness suggestive of damage to a nerve, nerve
on toes/heels, climbing a small step, etc. root, plexus, spinal cord, brainstem, or cortex.
Reflexes (biceps, triceps, brachioradialis, patellar Looking for signs of upper or lower motor neuron involvement
and ankle jerk). to help localize weakness.
Plantar stimulation. Looking for suggestions of upper motor neuron damage
(Babinski sign).
Passive movement of limbs to check tone. Looking for rigidity (extrapyramidal), spasticity (UMN), or
decreased tone (cerebellar or LMN).
Steadiness on standing with eyes open and closed. Looking for increased sway with eyes open (cerebellar,
vestibular, or extrapyramidal) or only when the eyes are
closed (proprioceptive—dorsal columns or peripheral nerves).
Walking and tandem walking. Looking for weakness (UMN or LMN), rigidity (extrapyramidal),
incoordination (cerebellar), or vertigo.
Look at the eyes and eyelids. Looking for eye muscle weakness with dysconjugate gaze or
ptosis (oculomotor nerve or sympathetics). Also, pathological
fatigability (suggestive of neuromuscular disease).
Six positions of gaze. Looking for weakness of eye movement or nystagmus
(suggesting vestibular or cerebellar problems).
Inspect the face. Looking for weakness of the whole side of the face (facial nerve
problem) or just the lower face (damage to corticobulbar
connections between cortex and pons).
Look in the mouth. Looking for atrophy of the tongue (lower motor neuron) or for
abnormal movements (myoclonus or fasciculations).
Check the strength of the tongue, jaw, and palate. Looking for focal weakness indicating damage to cranial nerve
or brainstem. Tongue weakness can sometimes result from
UMN damage.
Check facial sensations—may screen with light Looking for asymmetry in a pattern compatible with damage to
touch of fingers (ask about symmetry), may test the trigeminal nerve or the central pathways conveying facial
corneal reflex. sensation.
Check hearing by rustling fingers near the ears on Looking for asymmetry of hearing. Use Weber test to
each side. determine whether this is sensorineural or conductive.
Listen to voice and ask about swallowing. Global tests of lower cranial nerve function. If abnormal, more
testing needed of these structures.
TABLE 28–4. Strength Testing*
Movement Tested Main Muscles Nerve Root Levels Peripheral Nerve
Shoulder
Shrug (elevation) Trapezius C2-5 Spinal accessory
Abduction Deltoid/supraspinatus C5 (6) Axillary/suprascapular
External rotation Infraspinatus/teres minor C5 (6) Suprascapular
Internal rotation Pectoralis major C5-7 Lateral pectoral
Adduction Latissimus/pectoralis C6-8 Subsapular/pectoral
Flexion Deltoid/corachobrachialig C5-6 Axillary/musculocutaneous
Elbow
Flexion Biceps/brachialis C5-6 Musculocutaneous
Brachioradialis C5-6 Radial
Extension Triceps C6-7 Radial
Wrist
Flexion Flexor carpi muscle group C6-7 Median/ulnar
Extension Extensor carpi radialis C6-7 Radial
Extensor carpi ulnaris C7-8 Radial
Pronation Pronator teres C6-7 Median
Supination Supinator C5-6 Radial
Finger
Flexion Flexor digitorum muscle group C7-8 Median (ulnar)
Extension Extensor digitorum C7-8 Radial
Abduction and adduction Interosseus muscles C8-T1 Ulnar
Thumb abduction Abductor pollicis C8-T1 Median
Hip
Flexion Iliopsoas L2-3 (L4) Lumbar plexus
Extension Gluteus L5-S2 Inferior gluteal
Abduction Gluteus medius L5-S1 Superior gluteal
Adduction Adductor muscle group L2-4 Obturator
Knee
Flexion Hamstring L5-S1 Sciatic
Extension Quadriceps L2-4 Femoral
Ankle
Dorsiflexion Tibialis anterior L4-5 (S1) Peroneal
Plantar flexion Gastrocnemius/soleus S1 (S2) Tibial
Inversion Posterior tibial L5 (S1) Tibial
Eversion Peroneal muscle group L5 (S1) Peroneal
Great toe
Dorsiflexion Extensor hallucis L5 (S1) Peroneal
Plantar flexion Flexor hallucis (S1) S2 Tibial
* Movements and the principal muscles, nerves, and nerve roots involved in the movement. Parentheses indicate a smaller contribution.
hand, lower motor neuron weakness, produced by in the muscle, sensory axons that synapse with mo-
damage to the anterior horn cells or their axons that are tor neurons, motor axons that transit the nerve roots,
found in the peripheral nerves and nerve roots, results nerve plexuses, and the peripheral nerves to reach the
in decreased reflexes and decreased muscle tone. Ad- muscle (see Fig. 28–1). Reflexes are graded in a num-
ditionally, there is usually atrophy out of proportion ber of ways. The most common method includes a
to the amount of disuse produced by the weakness. rather arbitrary scale which starts at 0, representing
no response even with reinforcement, to 4+, which
Deep Tendon (Myotactic) Reflexes The commonly tested indicates an abnormally brisk reflex accompanied by
tendon (myotactic) reflexes include the biceps, triceps, sustained clonus. “Normal” reflexes are rated 2 or 2+.
brachioradialis (radial periosteal), patellar, hamstring, “Trace” reflexes, 1 or 1+, are sluggish or diminished,
and Achilles. The reflex arc includes stretch receptors while 3 or 3+ reflexes are brisk. Reflexes rated at 4
tor neuron disease (a very important distinction in

determining the location of the neurologic problem).
In general terms, hyperactivity of reflexes is an indi-
cator of damage to upper motor neurons (i.e., corti-
cospinal tract), while hypoactivity indicates damage
to the reflex arc (see Fig. 28–1). This can include injury
to the lower motor neuron (i.e., the motor neuron be-
ginning in the spinal cord and going out to the muscle)
or to the sensory axons from the muscle. Asymmetry
of reflexes may be explained by an increase on one
side (suggestive of upper motor neuron lesion) or a
decrease on the other side (suggestive of lower motor
neuron lesion). Determination of the abnormal side is
clear if there is lateralized weakness or another sign
indicating upper or lower motor neuron injury. These
signs include spasticity (UMN), atrophy (LMN), fas-
FIGURE 28–1. Circuitry of the myotatic reflex. Lesions ciculations (LMN), Babinski sign (UMN), or loss of
anywhere along the reflex arc depress the reflex. Lesions superficial reflexes (UMN).
that damage upper motor neurons (the descending pathways
through the brain and spinal cord) typically result in overly brisk Superficial and “Pathologic” Reflexes Abdominal, cre-
reflexes.
master, and plantar reflexes comprise the superficial
reflexes. It is usually not necessary to test all of these
have unsustained clonus, with 4+ being reserved for reflexes; the plantar response is the most useful. When
reflexes with sustained clonus. Reflexes rated as 1 or the sole of the foot is stimulated (in a pattern that
3 may be normal. However, they may be abnormal if extends from the heel along the lateral aspect of the
coupled with other motor abnormalities. Examining foot and then across the metatarsal heads toward
many normal patients is critical to an appreciation of the base of the great toe), the normal response is for
the range of normal. the great toe to flex at the metatarsophalangeal joint.
There are several factors that can help with the as- If no response is elicited, a deeper and faster (i.e.,
sessment of normality of reflexes. The most important more intense) stimulus should be used. If a volun-
of these is symmetry. Normal individuals will have tary withdrawal (fast jerking of the foot away from
symmetrical reflex responses, and it is unusual that the stimulus) is elicited, a less intense stimulus may
a neurological disorder affects both sides of the body be tried. Other methods to obtain a reproducible and
simultaneously and equally. interpretable response include stabilization of the foot
The “spread of reflexes” is an important sign or the use of a simultaneous stimulation by running
of hyperreflexia, which should not be overlooked. the knuckles down the anterior shin (Oppenheim re-
“Spread” is when muscles around another joint are flex). The classic “pathologic reflex” is the Babinski
activated when a reflex is tested (e.g., hip flexors or ad- response (upgoing toe). In this response, there is a rel-
ductors when the patellar reflex is tested). Sustained atively slow and tonic upward movement of the great
clonus (repeated muscle contraction when a muscle is toe, which remains in that position beyond the du-
passively stretched) is an indicator of pathologically ration of the stimulus. Usually there is fanning of the
increased reflexes. This is most commonly examined other toes as well. This is quite different from the rapid
at the ankle, although it may be tested at the wrist upward jerk of the toe, which generally represents a
or knee. Some normal individuals with very brisk re- withdrawal (“tickle”) response and is voluntary. The
flexes can have a few beats of clonus on both sides, first movement of the great toe (at the metatarsopha-
though this should be symmetrical. There are several langeal joint) is the defining factor in whether the toe
reflexes that that have been classified as “pathologi- is upgoing or downgoing (i.e., either a Babinski or a
cal,” including Hoffmann and Tromner reflexes. These plantar response).
are actually just reflections of very brisk finger flexor The normal superficial reflexes are mediated at
reflexes and may be normal in some people. Of course, supraspinal levels and are therefore diminished or
if they are present on one side and not the other, abolished by lesion of upper motor neurons. Of
or if they are accompanied by neurological weak- course, these can also be abolished if lower motor neu-
ness, their presence suggests damage to upper motor rons to the region are extensively damaged (severe
neurons. LMN lesion). The Babinski response is a strong indi-
Reflexes are generally the best way of defining cator of upper motor neuron injury. These responses
whether weakness is the result of upper or lower mo- should be placed in the context of the remainder of the
motor exam when evaluating upper and lower motor Lower extremity coordination can be tested in the
neurons. supine position by having the patient attempt to place
the heel of one foot on the opposite knee and subse-
Muscle Bulk Muscle bulk is primarily assessed by in- quently tap or slide the heel down the shin to the an-
spection. Symmetry is important and the findings kle. This should be done with each leg. Other tests of
should be compared against the patient’s overall lower limb coordination include tapping of the foot on
body habitus and handedness. Generalized wasting the examiner’s hand, or asking the patient to draw a
or cachexia should be noted as well. Areas of par- number in the air with his or her foot. If the patient can
ticular attention should include the shoulder (where stand and walk, it is usually only necessary to eval-
the contours of the bones may reveal wasting) and the uate gait in order to assess lower limb coordination.
hands. Palpation of the web of the thumb may be a clue The patient who can stand on either foot for 10 seconds
to wasting of intrinsic hand muscles. Some areas can without excessive sway does not need further testing
be evaluated by inspection alone, such as the thenar of leg coordination.
and hypothenar regions. Some areas may be better as- Tests of coordination examine several neurologic
sessed by measurement. Measurement of the circum- systems. Strength is required for all of these tests.
ference of the thigh or leg (generally 12.7 cm [5 inches] Excessive rebound (or loss of checking) is sugges-
below the tibial tuberosity or above the patella) or of tive of cerebellar injury on the side of the abnormal-
the arm or forearm (for example, 5 cm [2 inches] be- ity. Similarly, difficulty with rapid alternating move-
low or 10 cm [4 inches] above the medial epicondyle) ments (dysdiadochokinesia) or marked overshoot or
may provide useful information that can be assessed undershoot when attempting to hit a target (inten-
over time. Atrophy is most severe after denervation tion tremor) suggests cerebellar problems on that side.
of a muscle (as with LMN lesions). This usually takes Repetitive over- and undershoot during voluntary
at least a week to start being evident when there is an movement may reflect as “intention tremor.” Extreme
acute nerve lesion. It increases with time from the on- slowness of movement can be produced by extrapyra-
set of LMN damage. Atrophy may also be secondary midal disease (such as Parkinson disease). Of course,
to disuse. However, in this case there is usually a clear problems with any part of the motor systems may af-
substrate (bedrest, cast, etc.) and the atrophy tends fect coordination. For example, coordination can be
to be more diffuse and associated with less strength influenced by a marked alteration in muscle strength
change. or muscle tone, or if the patient is having abnormal
movements. Therefore, although tests of coordination
Coordination This is usually tested as part of a sequence are mainly directed toward assessing cerebellar func-
of movements. Typically, the patient is asked to hold tion, you must decide whether other problems in the
his or her hands in front with the palms up, first with motor system are affecting these tests.
the eyes open and then closed (as when examining
pronator drift, above). It is usually good form to in- Muscle Tone Muscle tone may be increased or de-
struct the patient to prevent movement of the hands, creased, with increased tone being much easier to de-
and to exert some force either toward the floor or in tect. Tone can be assessed by one of two means. The
attempting to push the hands apart. This force can most common method is for the examiner to passively
be used to assess the strength of the patient and then move the patient’s limb (especially at the wrist). The
should be released suddenly and without warning. second method involves evaluating arm swing (with
After a short excursion, the patient should check this the patient standing). Tone is often easily checked
movement, and this checking should be symmetrical. by having the patient stand with the arms hanging
The patient may then be asked to touch his or her loosely at the side. When the patient’s shoulders are
nose and, subsequently, the examiner’s finger. This moved back and forth or rotated, the arms should dan-
can be repeated a few times to assess the smooth- gle freely. Increased tone is usually reflected as the
ness and accuracy of the movement. Further assess- arms being held stiffly both in the standing position
ment can be obtained by having the patient perform and when walking. The lower limbs can be evaluated
a rapidly repeated movement, such as tapping the with the patient seated and the legs dangling. Move-
thumb and forefinger together, or by having the pa- ment of the feet should result in gentle swinging of
tient clap the hands. This test can be made somewhat the legs of a brief duration. Increased tone results in
more difficult by having the patient repeatedly strike abrupt restriction in the excursion of the feet.
first the palmar and then the dorsal aspect of one There are two patterns of pathologically increased
hand against the palm of the other. This, of course, tone: spasticity and rigidity. Spasticity is found with
must be done with each hand, and you are evalu- upper motor neuron injuries and manifests as a
ating rhythmicity and speed in performance of the marked resistance to the initiation of rapid passive
movement. movement. This initial resistance gives way, and then
there is less resistance over the remaining range of single motor neuron). These can be felt and often seen.
motion (clasp-knife phenomenon). Rigidity is an in- These are random and involuntary occurrences and
crease in tone that persists throughout the passive do not result in movement of a joint. Fasciculations
range of motion. This has been termed “lead pipe” may reflect damage to lower motor neurons, either the
rigidity and is common with extrapyramidal disease, cell body or the motor axon located in the nerve root
especially Parkinson disease. or peripheral nerve. Of course, if the fasciculations
Many older individuals have paratonia. This is a are a result of LMN lesions, one would expect some
phenomenon in which the patient is essentially unable weakness, decreased tone, and (after awhile) atrophy.
to relax during passive movements. You will note that Also, one would expect that the fasciculations would
the resistance is irregular and generally greatest when remain in a single group of muscles more than tran-
you change the pattern of movement. Of note, most of siently. Fasciculations may also be a finding in mus-
these individuals have apparently normal tone when cle overuse, or a sign of local muscle irritation. Also,
you test them in a standing position with the arms there are some individuals who have “benign fascic-
dangling (as described above). Extreme paratonia is ulations,” particularly in the calf muscles. Of course,
common in patients with dementia. these are not associated with weakness or other motor
system abnormalities.
Abnormal Movements There are a number of types There are several other, less common, abnormal
of abnormal movements, including tremor, chorea, movements. Chorea is a rapid, fleeting, random, and
athetosis, dystonia, hemiballism, and fasciculations. nonstereotyped movement that is worsened by anx-
Each of these has clinical implications that require dis- iety and that can be suppressed for short periods
cussion. Tremor is the most common abnormal move- by conscious effort. These abnormal movements dif-
ment seen in practice. Three characteristics are of par- fer from tics because tics are stereotyped and repeat
ticular importance. These include the symmetry (or within the same muscle groups. Tics may affect the
asymmetry) of the tremor, the rate of the tremor (ba- voice, as well, and consist of repeated throat clear-
sically, whether it is fast or slow, i.e., faster or slower ing, sniffing, or coughing. Multiple vocal and mo-
than 7 cycles per second [cps]) and the circumstances tor tics are seen in Tourette syndrome. Athetosis is
under which the tremor is present (i.e., whether it a slow, writhing, snake-like movement of a body part
is worst at rest, during sustained postures, or when or parts. Dystonia is a sustained twisting of the body,
moving). Physiological tremor comes in two types. usually the trunk or neck (where it is called torticol-
Rapid (>7 cps) tremor is characteristic of states with lis). Hemiballism is a flinging motion of one side of
increased sympathetic function (think of the last time the body, potentially resulting in falls. Involuntary
you had too much coffee). This is most commonly movements are seen in a number of clinical situa-
secondary to anxiety, but may occur with increased tions. Chorea, athetosis, and hemiballism are reflec-
adrenaline (such a pheochromocytoma) or thyrotox- tions of basal ganglia disease. This may be congenital
icosis. A slower tremor must be classified with re- (a type of cerebral palsy), postinfectious (Sydenham
gard to the conditions in which it is most evident. chorea), hereditary (Huntington chorea), metabolic
If it is present predominantly at rest, and decreases (Wilson disease), or cerebrovascular.
with movement, this suggests extrapyramidal disease
such as Parkinson disease. In Parkinson disease, the Station Station is the ability to maintain an erect pos-
tremor is frequently asymmetrical and is usually as- ture. One should be able to stand both with the eyes
sociated with other signs (bradykinesia, rigidity, or open and closed with a relatively narrow base of sup-
delayed postural corrections). Tremors that are severe port (the feet close together). You should record ex-
on sustained postures (such as with the hands out- cessive sway, falling to one side, or marked worsen-
stretched), but that may worsen slightly with action, ing in the ability to stand when the eyes are closed.
are characteristic of essential tremor (this is also seen in Excessive sway with the eyes open is common with
“senile” tremor or familial tremor). Essential tremors cerebellar or vestibular problems. This may be to one
are absent at rest and are often worsened by anxiety. side (and commonly is with vestibular disorders) or
They are often asymmetrical and characteristically af- may be to both sides (especially with conditions that
fect the use of writing and eating implements. Damage affect the midline portion of the cerebellum, such as in-
to cerebellar systems (particularly the hemispheres or toxication). You must consider the possibility of other
dentate connections) often produces a tremor that is explanation, such as the patient not having enough
most pronounced during voluntary actions. strength to stay upright or severely delayed reactions
The second most common type of abnormal move- to destabilization (such as with Parkinson disease).
ment that is seen in practice is fasciculation. These are Some patients can stand well with the eyes open,
twitches in muscle (actually, contraction of a single but have marked increase in instability with the eyes
motor unit, i.e., all of the muscle fibers attached to a closed. This is suggestive of a disorder of conscious
proprioception (i.e., joint position sense, as may may walk as if they are “walking on eggs,” and pa-
be seen with peripheral neuropathy or dorsal col- tients with spinal stenosis may walk with a stooped
umn/medial lemniscus dysfunction). This is termed (“simian”) posture.
a Romberg sign. Proprioceptive problems on one side
can be brought out by testing stance on one foot. Of Sensory Examination
course, there are other tests of conscious propriocep- This part of the exam assesses whether the sensory
tion, including evaluation of joint position and vibra- system is intact. The sensory system begins in the skin
tion sense in the feet. These data must be correlated receptor and proceeds through the sensory nerve fiber,
with the findings when testing station. the plexus, and nerve roots to the spinal cord. There
are two main projection tracts (the dorsal columns and
Gait This is an important part of any neurologic exam. the spinothalamic tracts) that relay sensory informa-
It is particularly important to observe the symmetry tion to the cerebral cortex.
of the gait, the ability to walk with a narrow base, the The sensory system covers all sensitive portions of
length of the stride when walking at a normal pace, the body (basically, everywhere), and therefore test-
and the ability to turn with a minimum of steps and ing must be focused. The focus is provided by patient
without loss of equilibrium. When observing a normal symptoms and by some screening. Additionally, this is
person from behind, the medial parts of the feet strike the most subjective portion of the exam and you must
a line and there is no space visible between the legs at consider patient cooperation when trying to make an
the time of heel strike. This is a narrow-based gait and accurate assessment of the situation. One additional
deviation from this can be measured in the amount of aspect of the sensory exam that must be considered:
distance laterally each foot strikes from the line that Pain is usually not a sign of dysfunction of the sen-
the body is following. Tandem walking (the ability to sory system. Additionally, hyperesthesia (abnormally
walk on a line) may be used to evaluate for stability of increased sensitivity) and hyperpathia/hyperalgesia
gait, recognizing that many normal, elderly patients (perception of innocuous stimuli as painful) are usu-
have trouble with this. ally pain-related phenomena rather than a sign of in-
Damage to virtually any part of the nervous sys- jury to the nervous system. Pain, particularly deep,
tem may be reflected in gait. An antalgic gait, or the aching, or burning pain, often does not help very
limp caused by pain, is familiar to all practitioners. much in the localization of the painful stimulus be-
Patients with unilateral weakness may favor one side, cause of the frequent referral of this type of pain. In
and if the weakness is spastic (i.e., from upper motor this part of the exam, you are looking for areas of di-
neuron damage), the patient may hold the lower limb minished sensory input.
stiffly. The patient will drag the weak limb around It is critical to remember that you are attempting
the body in a “circumducting” pattern. A staggering to recognize potential damage to portions of the ner-
or reeling gait (like that of the drunk) is suggestive vous system. Therefore, the sensory exam must cre-
of cerebellar dysfunction. Generally, the patient with ate a meaningful pattern suggesting peripheral nerve,
true vertigo will tend to fall to the same side repeat- nerve root, or tract damage. Patchy areas of reported
edly (especially with the eyes closed). A patient with asymmetry (but not loss) of sensation that overlap
foot drop will tend to lift the foot high (steppage gait). physiological distributions and which do not create
Hip girdle weakness often results in a “waddle,” with a recognizable pattern are not particularly useful in
the hips shifting toward the side of weakness when the examination. It is also important to remember
the opposite foot is lifted from the floor (of course, that this part of the exam is the most highly subjec-
if both sides are weak, the hips will shift back and tive. It is not uncommon for patients to overinterpret
forth with each step). In Parkinson disease, patients or underinterpret during the sensory exam, and you
generally have difficulty initiating gait. The steps are must carefully consider whether you can rely on these
usually short, even though the gait is narrowly based. findings.
If severe, the patient may be propulsive (the patient
may even fall). Patients who are “glue-footed” (slid- Light Touch Large areas of the body can be screened
ing their feet along the ground rather than stepping with light touch. This may not identify all lesions of
normally) may be suffering from damage or degen- tracts or peripheral nerves, but when combined with
eration of the frontal lobes or the midline portion of the patient’s history, it will give you an idea of where
the cerebellum. When injury to these areas is severe, to invest most of your time in the sensory exam. With-
the patient may be severely retropulsive (tending to out any sensory complaints and with the patient re-
fall over backward repeatedly). Dorsal column injury porting symmetrical touch sensation, there is a high
may result in a gait in which the patient “stamps” the likelihood that more detailed sensory testing will be
feet, and usually also needs to look at the feet in order normal. However, it would be useful to test vibra-
to walk. Patients with painful neuropathy of the feet tory sense and either thermal or pin sensation in at
least one point in each limb to evaluate the integrity The pattern is going to help you decide whether
of the spinothalamic tract and dorsal columns from you are dealing with a peripheral injury (polyneu-
each limb. ropathy, mononeuropathy, radiculopathy, or mono-
neuritis multiplex) or damage to central nervous
Vibration Vibration sensation is tested by applying a system tracts (particularly the spinothalamic tract, in
vibrating, low-frequency tuning fork to a bony promi- this case). For example, the sensory loss may be in the
nence in the distal limb. The question is whether the distribution of a peripheral nerve branch, a nerve root,
patient can detect the vibration. On some trials it is or part of a plexus. It may also be in a stocking dis-
good form to place the tuning fork on the body while tribution suggesting polyneuropathy (gradient from
it is not vibrating in order to determine whether the proximal to distal in the lower limbs). The sensory
patient is just reporting the pressure as vibration. The loss may involve a large area of the body (suggesting
threshold for vibration can be tested (if necessary) by central nervous system tract injury), it may follow arti-
palpating the bone to which the tuning fork is ap- ficial boundaries of surface anatomy (suggesting hys-
plied. When the patient can no longer feel the vibra- teria, especially if it has a sharp border), or it may
tion, you will be able to determine how much trans- appear in the pattern of a sensory level around the
mitted vibration you can still feel at that point. It is trunk (suggesting spinal cord injury). A “suspended”
also easy for you to make comparison from one side sensory loss, one that is abnormal in the arms but
to the other. If the patient is unable to detect vibra- preserved in the legs, may be present with lesions
tion distally, the tuning fork should be moved prox- inside the spinal cord such as syringomyelia. Pin-
imally. If the patient can feel it more proximally, but prick is probably the most appropriate way to exam-
not distally, this suggests polyneuropathy as the eti- ine the sensory distribution of peripheral nerve or root
ology. If the patient cannot detect vibration in the injury.
distal extremity, the tuning fork should be progres-
sively moved up the limb and then the body un- Temperature In a practical setting, this is usually tested
til you find a location where the patient can detect by using a room-temperature metal instrument (such
vibration. as a tuning fork), applying it first to one side and then
Loss of vibration sense suggests either damage to to the other side of the body. Ask if the feeling is sym-
the large-diameter fibers of the peripheral nerves or metrical. This may be more sensitive for detecting
to the pathway in the spinal cord (dorsal columns) lesions of the spinothalamic tract than is pinprick
or brain (medial lemniscus). Of course, injury to the (although both pin and temperature sensation are
thalamus can abolish all modalities of sensation on transmitted to the cortex by this tract). Diminution of
the opposite side of the body. As with any sensory temperature sense has a similar clinical significance
loss, you should attempt to construct a pattern of as decreased pinprick sensitivity (see Pinprick above).
loss (see Pinprick below). Vibratory sense can be used
to help differentiate hysterical hemianesthesia. Even Joint Position Sense This is tested at the great toe and
with complete loss of all sensation on one side of the (less commonly) at the fingers, by holding the other
body a patient should be able to detect vibration when digits out of the way and then moving the finger or
the tuning fork is placed over either side of a bone that toe up or down. The patient should be asked to tell
extends to both sides of midline. Usually this is best which direction the digit has gone. The digit must be
tested on the skull or over the sides of the manubrium held by the sides to prevent clues from pressure. It
of the sternum. is moved in smaller and smaller increments to deter-
mine the threshold for movement. Joint position and
Pinprick This is evaluated by determining whether vibration sensations are mediated by the larger fibers
the patient is able to detect the sharpness when be- in peripheral nerves and, subsequently, by the dorsal
ing touched with a pin (do not use the same sharp column/medial lemniscus pathway. Therefore, severe
object for different patients because of concerns for polyneuropathy can diminish position sense and dor-
disease transmission). It is best to compare one side sal column damage may also abolish it. Position sense
with the other, especially if there is one asymptomatic should be tested in patients complaining of gait dis-
side, or to compare with other intact regions of the turbance although vibratory sense is probably more
body. It is good form to periodically mix sharp stim- sensitive for detecting either peripheral nerve injury
uli with a “dull” stimulus to assure yourself that or dorsal column injury.
the patient is accurately reporting that he or she
is able to detect “sharp” and not just feel the ob- Autonomic Examination
ject (i.e., touch). Remember that you are trying to The routine clinical examination has few ways of as-
detect a pattern of decreased sensation, not just find sessing the integrity of the autonomic nervous sys-
some isolated spots of sensory loss. tem (ANS). Clues to the need for evaluation are often
obtained from the patient’s history, with complaints

of orthostatic light-headedness, problems with blad-
der and bowel function, or erectile difficulties. Some
of these can be confirmed, such as by recording
blood pressure and pulse with the patient lying,
sitting, standing, and standing for a prolonged pe-
riod. Any drop of 10 mmHg or more in diastolic
or 20 mmHg or more in systolic pressure should be
investigated.
The pupils can be visualized. Large pupils are a
sign of sympathetic excess or parasympathetic defi- FIGURE 28–3. Shearing of olfactory nerve filaments with oc-
ciency (see Cranial Nerves below). Conversely, small cipital trauma. It is less prominent with frontal trauma. (With
pupils can be a sign of sympathetic deficiency or permission from Reeves AG. Disorders of the nervous system).
parasympathetic excess (possibly from medicines or
eyedrops). Cranial Nerves
The pattern and quantity of sweating can be help- The cranial nerve exam can be performed quite
ful. However, this can be difficult to assess accurately. quickly and does provide significant information re-
Because sweating is under purely sympathetic con- garding brainstem and vestibular function. Some cra-
trol, deficiency in one body region (for example, the nial nerves, particularly the olfactory nerves, are only
head) can be a helpful sign of damage to the sympa- tested when indicated by the patient’s presentation.
thetic nervous system in that region. Others provide enough information that routine test-
The constellation of miosis (small pupil), ptosis ing is reasonable. Patients who are noted to have
(slight drooping of the upper lid because of weakness dysarthria (slurred or otherwise abnormal speech),
of a sympathetically controlled muscle), and anhidro- who complain of dizziness or ataxia, or who have vi-
sis (lack of sweating on one side of the face) constitutes sion problems or other specific neurologic complaints
Horner syndrome. This can happen with damage to are particular candidates for cranial nerve testing.
any part of the sympathetic pathway to the eyes, com-
monly near the apex of the lung or in its course anterior Olfaction The olfactory nerve is not always tested un-
to the cervical vertebrae (see Fig. 28–2). Injury to the less the examination is for head trauma, change in
lateral part of the cervical spinal cord can do this as mental status, or seizure (Fig. 28–3). It should be tested
well. with an aromatic compound (rather than a nasal irri-
tant), and identification of the aroma is adequate ev-
idence of integrity of the system. If the patient says
that he or she can smell it, but can’t identify it on either
side, this is probably normal (only approximately 80%
of people can identify coffee, for example). There are
specialized kits for more sophisticated testing; how-
ever, this is usually not necessary.
Fundus Examination The fundus is the only place where

a nerve and blood vessels can be directly observed.
Although detailed examination of the fundus may re-
quire dilation of the pupil, the optic disc (optic nerve
head) and the blood vessels emanating from it are typ-
ically visible in all but those with severe eye problems
such as cataracts. It is worthwhile getting used to look-
ing at the optic disk region because there are several
possible abnormalities that can be detected with a lit-
tle practice. Vascular disease is often visible in the eye
grounds. Silver wire changes, arteriovenous nicking,
and exudates may be seen with vascular disease such
as occurs with hypertension, hyperlipidemia, and
FIGURE 28–2. Sympathetic innervation of the iris and sweat diabetes. Although papilledema (blurring of the mar-
glands of the face. (With permission from Reeves AG. Disorders of the gins of the optic disc) is a late sign of increased in-
nervous system: A primer (Internal medicine series) Year Book Medical tracranial pressure (or a sign of a rapid increase), the
Publishers 1981 Chicago, Il.) presence of normal venous pulsations in the region of
FIGURE 28–4. Use of pinhole to correct for abnormalities

of visual refraction when measuring visual acuity. (With permis-
sion from Reeves AG. Disorders of the nervous system: A primer (Internal
medicine series) Year Book Medical Publishers 1981 Chicago, Il.)
the optic disk is a demonstration of normal intracra-

nial pressure. However, venous pulsations cannot al-
ways be visualized in normal patients and observation
requires some practice. Atrophy (whiteness of the disk
with sharp margins) implies long-standing damage to
optic nerve fibers. FIGURE 28–5. Technique for confrontation examination of vi-
sual fields. (With permission from Reeves AG. Disorders of the nervous
Visual Acuity The neurologic exam is not concerned system.)
with refractive problems with vision. Therefore, test-
ing with a pocket eye chart or even with the ability to subtle deficits. With this method you may actually be
read small newsprint (with each eye) is a good demon- able to outline the physiological blind spot, which is a
stration of adequate visual acuity. Of course, any good check on reliability of detailed mapping. Auto-
rapid recent change is of concern and requires some mated Goldman visual field tests are usually reserved
explanation. for patients who report some visual field disturbance
One method of determining whether the patient’s and may be very useful in following the condition.
visual problem is refractive is to have the patient try to Most optometrists can perform this procedure.
read an eye chart through a pinhole (Fig. 28–4). This Visual loss may be monocular (suggesting pathol-
assumes that the patient does not have an obvious ogy in front of the optic chiasm (including the eye-
problem, such as a cataract obscuring vision. Refrac- ball itself) or binocular (Fig. 28–6). If it occurs in the
tive problems should improve by at least a couple of temporal visual field of both eyes, it likely represents
lines, while neurologic damage to the visual system pathology at the optic chiasm. If the visual field loss
will not improve. This can be a useful screening test to is in homonymous (overlapping) portions of the vi-
determine patients who might need new glasses from sual field of both eyes, it is probably from pathology
those who require further neurological evaluation. If a behind the optic chiasm (optic tracts, lateral genicu-
patient has decreased visual acuity (and doesn’t have late, optic radiations, or visual cortex). Sparing of cen-
something blocking vision such as a cataract), try to tral vision usually occurs with damage to the occipi-
get the patient to look through a pinhole. If vision im- tal cortex that spares the temporal pole of the cortex
proves, the problem is a refractive problem rather than (usually as a consequence of posterior cerebral artery
retinal or nerve damage. strokes). Homonomous superior quadrantanopia is
usually from lesions of the optic radiations as they
Visual Fields These can be tested in several ways. The course through the parietal lobe, while inferior quad-
usual methods in the office require the patient to stare rantanopia is from temporal lobe damage.
at your nose with one eye covered. By moving your
fingers in the periphery of the visual field, you can Extraocular Motions In performing this test, the eyes
determine whether the patient is actually able to see move in an H-shaped pattern termed the “six posi-
your fingers (Fig. 28–5). With a very cooperative pa- tions of gaze” (Fig. 28–7). The finger should not be
tient, you may ask whether the patient can see your too close to the face (because this will force conver-
entire face clearly while continuing to stare at your gence at the same time). It is important to note whether
nose. This is usually sufficient. You must note the loca- each eye can follow the finger fully in all directions,
tion of visual loss in each eye and also whether the loss whether gaze is conjugate in all directions, whether
is in the same portion of the visual field of each eye. movements are smooth in all directions (or are they
When mapping the extent of the field, fingers are usu- ratchety), and whether there is nystagmus. The pa-
ally enough, but for more detailed mapping, a small tient should also be asked if there is diplopia (dou-
red object (such as a fireplace match) may detect more ble vision) in any direction of gaze and whether the
FIGURE 28–6. Visual field deficits following injury to selected portions of the optic system. The numbers correspond to the location
of injury depicted on the drawing. The visual fields appear as they would from the patient’s perspective. Note that all lessions posterior
to the optic chiasm produce homonymous (overlapping) visual field deficits, whereas lesions anterior to the chiasm typically produce
monocular visual problems. (Adapted by permission from Reeves AG. Disorders of the nervous system).
the direction of the diplopia (i.e., vertical or horizon-

tal). For example, horizontal diplopia that is greatest in
right lateral gaze suggests either weakness of the right
lateral rectus or of the left medial rectus. This simpli-
fies your analysis. Vertical diplopia suggests weak-
ness of one or more of the four muscles that move the
eyes vertically (the superior or inferior rectus or the
superior or inferior oblique muscles). If the vertical
diplopia is worse in upgaze, there is either weakness
of the superior rectus or of the inferior oblique, while
if it is worse in downgaze, either the inferior rectus
or the superior oblique are at fault. A peculiar gaze
abnormality may be caused by lesions of the medial
FIGURE 28–7. Eye positions for testing extraocular muscle
longitudinal fasciculus in which the lateral-going eye
function. (With permission from Reeves AG. Disorders of the nervous
system.)
works well but the medial-going eye doesn’t follow
across the midline (also, the lateral-going eye has nys-
tagmus). This condition does not affect the activation
diplopia is vertical or horizontal. If there is nystag- of the medial rectus occurring during convergence,
mus (to-and-fro oscillations of the eyes), you must and therefore can be distinguished from a medial rec-
note whether it is pendular (even in speed and ampli- tus palsy. This condition, called internuclear ophthal-
tude to both sides) or jerk (faster in one direction than moplegia, usually results from multiple sclerosis.
another) nystagmus. If it is jerk nystagmus, you must It is sometimes difficult to decide which specific
name the direction of the fast component, and specify muscle is weak and producing the diplopia. In this
whether it is rotatory (clockwise or counterclockwise), case, it may be very helpful to find the particular eye
vertical (upbeat or downbeat), or horizontal (to the position (of the H-shaped six positions of gaze) that
left or right). You must also note whether the nystag- produces the greatest degree of separation of the two
mus is worse with the eyes looking in one direction or images. You then must know which muscle is partic-
another, and whether the direction of the nystagmus ularly active in each eye to reach that position. If it is
shifts with different positions of the eyes. A few beats horizontal diplopia, the greatest separation should be
of nystagmus in a horizontal direction at the end of in pure horizontal eye movement. If the patient com-
the range of eye movement (end-point nystagmus) is plains of vertical or skew diplopia, the greatest sepa-
usually normal. ration should be in the vertical position. The eye with
If the patient cannot move an eye in a specific di- the weak muscle will always be the one that is project-
rection, you should be able to determine the mus- ing the image that is perceived as being farthest from
cle and nerve that might be involved by know- the center of vision and the most blurry. You can deter-
ing the muscles that are most active when the eye mine which eye this is by covering one eye and asking
moves in that direction (see Fig. 28–7). There are which image disappears. Alternatively, you can have
six muscles controlling the movement of each eye the patient look through a colored lens with one eye
and three cranial nerves. The abducens nerve sup- and ask the patient to identify the colored image. By
plies the lateral rectus muscle (cranial nerve [CN] knowing which eye is projecting the image that is far-
VI), the trochlear nerve (CN IV) supplies the su- thest from the middle, you will know which eye is
perior oblique muscle, and the oculomotor nerve abnormal. By knowing which muscle is particularly
(CN III) supplies all of the others (the medial, superior, active (being tested) in this eye in this position, you
and inferior rectus muscles and the inferior oblique). will be able to determine which muscle is weak. It
Of course, this lack of movement may result from dis- must be noted that double vision that persists with one
ease of the muscle itself or of the nerve to the muscle, eye closed does not have a neurologic cause. Rarely,
and this must be decided on the basis of the clinical this may occur with abnormality of the eye. How-
picture, the other neural structures involved (or not ever, much more often the problem is of a psychiatric
involved), and the pattern of weakness. If this has nature.
been long-standing (such as in people with a history There are many potential eye movement problems
of “lazy eye” or congenital eye movement problems), seen in clinical practice. The most common of these
the patient may not recognize diplopia. On the other occurs with damage to a single cranial nerve, often
hand, any new dysconjugate eye movement results associated with head trauma or with vascular dis-
in a complaint of diplopia. You can infer the muscles ease. Difficulty with elevation of the eyes is often seen
involved in the diplopia by knowing the direction of in the elderly and may be caused by diffuse cortical
gaze that produces the greatest degree of diplopia and or basal ganglion disease (which also tends to make
eye movements ratchety rather than smooth when fol- using the eyes for awhile, suggests a myoneural junc-
lowing a finger). Vertical eye movement may also be tion disease (such as myasthenia gravis). Droop may
affected by lesions in the rostral midbrain, such as also be seen in myopathies that affect the extraocular
by pineal tumors pressing on the rostral midbrain, muscles or face (such as ocular dystrophy, oculopha-
termed Parinaud syndrome. Destruction of the pons, ryngeal dystrophy or Kearns-Sayre syndrome). Less
damaging the paramedian pontine reticular forma- commonly, there may be apparent retraction of the up-
tion, will abolish conjugate gaze to the ipsilateral side. per eyelid or lag in downward movement of the lid
“One-and-a-half syndrome” occurs when the medial when the patient looks down (lid lag). This can result
longitudinal fasciculus is damaged on the same side as from hyperthyroidism.
the paramedian pontine reticular formation (the con-
tralateral eye is the only one that can move voluntarily Pupillary Reactions When examining the pupils, there
in a horizontal direction, and then it can only move lat- are a number of questions that need to be asked. Are
erally). Damage to the frontal eye fields in the frontal the pupils within 1 mm of the same size at rest? Are
cortex (usually with a stroke) will decrease the abil- they regular and round in shape? Do they react evenly
ity of the eyes to move voluntarily to the contralateral and to the same degree with light? Do they react
side, but they should move fine with vestibuloocular evenly and to the same degree when gaze is shifted
reflex testing (see below). Occipital cortex lesions will from a far object to a near object (accommodation)?
diminish the ability of the eyes to smoothly track ob- A number of clinical problems can affect the pupils.
jects moving toward the side contralateral to damage. Compression or damage to the outermost nerve fibers
Pendular nystagmus is usually a sign of long-term of CN III will result in a large pupil (loss of constric-
diminished visual acuity with poor fixation reflexes. tion). This can happen with extrinsic compressive le-
It is usually not caused by disorders of the brain per sions or with inflammation of the meninges (usually
se. Jerk nystagmus is likely to be caused by vestibular chronic). Because the outer fibers can be selectively
or vestibulocerebellar pathology. Inner ear vestibular affected, pupil dilation may or may not be associated
problems usually produce horizontal or rotatory nys- with other signs of damage to CN III (such as paresis
tagmus. When the vertigo (i.e., the illusion of move- of extraocular muscles, diplopia, or ptosis).
ment) and nystagmus are caused by inner ear prob- Damage to sympathetic pathways anywhere in
lems, the patient usually complains of marked vertigo their course from the hypothalamus, down the brain-
and nausea, and there may be some hearing abnor- stem and cervical spinal cord, and out through the
mality. Additionally, when the inner ear is at fault, upper thoracic nerve roots may produce a small pupil
the degree of nystagmus is usually much greater in and a slight amount of ptosis (see Fig. 28–2). When this
one particular direction of gaze (usually the same di- is associated with anhidrosis on that side of the face,
rection as the fast phase of the nystagmus). Also, the this makes up the constellation of symptoms called
direction of the nystagmus doesn’t change when look- Horner syndrome. Acute Horner syndrome is often
ing in different directions. With injury to brainstem associated with conjunctival injection on that side.
structures or to the cerebellum, usually the vertigo is When Horner syndrome becomes chronic, patients of-
relatively mild in comparison to the nystagmus, and ten arch their eyebrow on that side (using facial mus-
there may be vertical nystagmus (which always must cles to help get the upper lid out of the way). The most
be considered to be pathological). Additionally, nys- common location of injury will be in the neck (cervi-
tagmus may change in direction as the eyes move in cal sympathetics) or along the carotid artery (carotid
different fields of gaze (“gaze-shifting nystagmus”). plexus). In these cases, the loss of sweating will be re-
stricted to the face. If the pathway is damaged in the
Upper Eyelid Position As a part of the examination of upper thoracic region, it will affect sympathetic activ-
the face you should look for symmetrical position ity in the arm as well, and if it is caused by damage to
of the upper eyelid (it is best to check this in relation the central nervous system pathways, the entire side
to the pupil location). If the patient complains of mus- of the body may have diminished ability to sweat.
cular fatigue, intermittent diplopia, or drooping of the Occasionally, you may encounter a pupil that re-
upper lid (ptosis), it is good to check for progressive acts completely, but very sluggishly. This can be ac-
drooping of the upper lid when the patient sustains companied by sluggish myotatic reflexes in the body
upgaze. Ptosis may be seen with CN III lesions (usu- and is called Adie tonic pupil. It is of no clinical signif-
ally a very evident droop). When ptosis is caused by icance. Another abnormality is the Argyle-Robertson
CN III damage, there is almost always some diplopia pupil, where the pupil reacts to accommodation but
and some paresis of gaze present. Minor ptosis may be not to light. Argyle-Robertson pupil was originally
seen in Horner syndrome (see Pupillary Reactions be- described with neurosyphilis, but is much more com-
low). Progressive drooping on sustained upgaze, or a monly seen with diabetes. Of course, when confronted
history of worsening droop later in the day or after with pupillary abnormalities, one should be aware of
FIGURE 28–8. Trigeminal innervation of facial sensation.

(With permission from Reeves AG. Disorders of the nervous system.)
any medications the patient is on and any eyedrops

he or she is using. There are pupillary abnormalities FIGURE 28–9. Deviation of the jaw on opening to side of weak-
that aid in the assessment of coma, but they are not ened pterygoid muscles. Broken arrow represents loss of right
discussed here. pterygoid strength. (With permission from Reeves AG. Disorders of
the nervous system.)
Facial Sensations Facial sensations are best screened by
light touch of both sides of the face in the distribution sitivity. In fact, there are often “trigger zones” where
of each of the branches of the trigeminal nerve (the severe, but brief paroxysms of pain are produced by
forehead, the cheek, and the chin). Ask if both sides light stimulation. Decreased facial (or oral) sensitiv-
feel the same. For most patients without any com- ity in the patient with facial pain should prompt the
plaints in the face or any suspicion of cranial nerve search for diagnoses other than trigeminal neuralgia.
abnormality, this is a sufficient screen for trigeminal
nerve (CN V) problems (Fig. 28–8). When there is sus-
picion of problems or when more detailed testing is Jaw Muscle Strength Jaw strength is tested by hav-
necessary, there are a number of other modalities that ing the patient forcibly open the mouth (it will de-
can be checked (similar to the general sensory exam viate toward a weak side) and then by having the
described above). Because the face is very sensitive to patient move the jaw from side to side (Fig. 28–9).
temperature, you may apply a cold object (such as a Some patients with temporomandibular joint abnor-
room-temperature tuning fork) to each side of the face mality have asymmetrical motions, but typically, the
and ask if it feels the same (again in the distribution of jaw ends up near the midline. The examination may be
each branch). A pin may be used, looking for asymme- extended by having the patient bite down while pal-
try in the distribution of the three branches of CN V. If pating the masseter and temporalis muscles. If neces-
there is a sensory decrease in the ophthalmic division sary, further confirmation can be obtained by having
of CN V, there should be a decreased corneal reflex on the patient bite down on a tongue blade and seeing
that side. The corneal reflex is the blinking that should whether the bite is stronger on one side than the other.
occur in both eyes when the outer part of the cornea is The innervation of the muscles of mastication is from
touched with a wisp of cotton. A response that is less the motor root of the trigeminal nerve.
brisk when touching one side supports an assessment
of trigeminal nerve damage. If there is some suspi- Facial Strength and Movement Much of the examination
cion of hysterical sensory loss, you may apply a vi- of facial strength can be accomplished by simple ob-
brating tuning fork to each side of the midline of the servation during history taking. Look for drooping of
face. Trigeminal nerve injuries do not affect vibratory one corner of the mouth, flattening of the nasolabial
sense, because this is felt in the skull; thus it should fold on one side, or widening of the palpebral fissure
be preserved and symmetrical even with facial hemi- of one eye. Any of these suggest facial weakness on
anesthesia. Additionally, hysterical sensory loss in the that side. This can be confirmed with strength testing
head typically follows artificial boundaries such as if there is any suspicion of abnormality. Have the pa-
the hairline or the jawline, neither of which demarcate tient look up and look for symmetrical wrinkling of
the borders of the trigeminal nerve distribution. the forehead. Have the patient close the eyes tightly
It is noteworthy that the most severe pain problem and look for symmetry while trying to open the eyes.
affecting the trigeminal nerve, trigeminal neuralgia Have the patient show you the teeth, again looking
(tic douloureux), is not associated with a loss of sen- for symmetry. It can be very useful to have the patient
(together called sensorineural deficit), or a result of

mechanical problems with sound conduction on the
other hand (termed conductive deficit). If the patient
localizes sound to the side of diminished hearing, the
problem is with transmission of the sound wave into
the inner ear (conductive hearing deficit), while lat-
eralization to the “good ear” indicates that the lesion
is sensorineural (i.e., the hair cells or the nerve). Note
that it is nearly impossible to affect hearing by dam-
age to the central nervous system. Therefore, hearing
loss indicates a problem outside of the central nervous
system.
FIGURE 28–10. Left facial weakness following lesion of the
right motor cortex. (With permission from Reeves AG. Disorders of Palate and Pharynx Strength The palate is tested by
the nervous system.) asking the patient to open the mouth and observ-
ing the normal elevation of the palate when saying
“ahh.” On the other hand, the patient with a nor-
puff up his or her cheeks; look for symmetry and to
mal voice, who has no problems swallowing (such
see if air escapes from one side. You may tap on the
as choking or nasal regurgitation), probably does not
inflated cheeks to see if air escapes. It is important to
need any additional testing. If there is any question,
note whether the weakness is of the entire side of the
watching the patient swallow 4–6 ounces of water is
face or if it is much greater around the mouth than the
also quite useful, especially if the patient shows no
forehead and eye. Weakness of the face that is greater
sign of aspiration and can talk normally immediately
at the corner of the mouth than the eye is character-
afterwards.
istic of damage to corticobulbar pathways and occurs
With unilateral vagus nerve (CN X) lesions, the
with injury to the central nervous system above the
palate elevates toward the intact (strong) side (Fig.
mid-pons (Fig. 28–10). This may be associated with
28–11). This is often best seen by looking at the base
other upper motor neuron signs in the limbs (as often
of the uvula (where the uvula attaches to the soft
happens with a stroke).
palate) because the tip of the uvula may be congeni-
A “mask face,” with marked decrease in facial ex-
tally distorted. Additionally, palatal weakness will af-
pressions and a decrease in spontaneous blink rate is
fect the voice, especially some hard consonants such
frequently seen with Parkinson disease. This does not
as a “G” or “K” sound, and pharynx weakness affects
result in true weakness, however. Twitching of mus-
swallowing.
cles around the eye is common with fatigue, usually
In certain circumstances, particularly if patients
representing a benign condition called “myokymia.”
complain of problems with swallowing, the gag reflex
A less common condition results in the entire side
of the face having some tonic muscular activity with
superimposed “twitching.” This is termed hemifacial
spasm and is a result of irritation of CN VII. Tonic but
variable activity of the muscles around the eye, usu-
ally resulting in some actual eye closure, is present in
blepharospasm.
Hearing Regrettably, hearing problems are common

and may be tested with rustling of the fingers about
10 cm (4 inches) from the opening of the ear canal.
Finger rustling is particularly useful because it pro-
duces a high pitch (most hearing loss is in the higher
frequencies). This is done on each side, and the two
sides are compared. If there is asymmetry of hearing,
place a vibrating tuning fork on the vertex (best with
a C256 or C512) and ask the patient if the sound is
louder in either ear (Weber test).
The Weber test is useful in determining if the hear- FIGURE 28–11. Elevation of palate away from weakened right
ing problem is a result of problems with the vestibulo- side (Rideau or curtain sign). (With permission from Reeves AG.
cochlear nerve (CN VIII) or hair cells on the one hand Disorders of the nervous system.)
syllables or “explosions” of sound (called scanning

speech).
Higher Mental Function

Obviously, there are many functions that fall under
the rubric of “higher mental functions,” and it is not
possible to test them all. Additionally, many of these
FIGURE 28–12. A. Normal vectors of tongue protrusion. B. are actually tested by the astute examiner during the
Weakness without atrophy of right side of tongue with left corti- course of an interview, such as when obtaining the
cobulbar lesion. C. Weakness and atrophy (and fasciculations) patient’s history. Therefore, it is rarely necessary to
with lesion of hypoglossal nucleus or nerve. The tongue always directly test any of these functions. However, for the
deviates toward the weak side whether the lesion is nuclear sake of completeness, a brief description of the ex-
or supranuclear. (With permission from Reeves AG. Disorders of the
amination is included. There is a screening examina-
nervous system.)
tion, called the Mini Mental State Examination, that is
used by many practitioners to screen patients requir-
may be tested. This requires that the posterior part of ing more detailed examination.
the pharynx (not the soft palate) be touched first on
one side and then the other. There should be a brisk Language There are several elements that contribute to
contraction of the pharyngeal muscles and elevation normal language function. In this regard, we are not
of the soft palate, bilaterally. It is not necessary (and considering problems that make language difficult to
not desirable) to have the patient retch. Contraction understand (see the discussion of dysarthria under
of muscles on one side but not the other indicates Voice above). Problems with language typically also
problems with CN X, while lack of contraction on ei- affect the ability to read and write in a similar manner
ther side when stimulating one side of the pharynx to their difficulty with the spoken word. Testable ele-
indicates problems with the glossopharyngeal nerve ments of language include naming (the ability to ver-
(CN IX). This is not routinely tested. bally identify objects), comprehension (e.g., the abil-
ity to understand instructions), fluency (the ability to
Tongue Strength The tongue is innervated by the hy- generate a normal rhythm of language), and repetition
poglossal nerve (CN XII) and will deviate toward (the ability to repeat complex phrases). Of course, if
the weak side when protruded (Fig. 28–12). Strength the patient understood your questions and responded
can be tested more specifically by having the patient appropriately, with normal phrasing and good com-
wag the tongue rapidly from one side of the mouth mand of words, then there is little point in direct test-
to the other. The patient will have difficulty getting ing. However, if there are questions, you may wish to
the tongue to go toward the strong side. Having the test these elements.
patient push the tongue on the inside of the cheek is Naming is tested by having the patient name ob-
another test, with the tongue pushing weakly away jects and parts of objects (don’t just ask for the patient
from the weak side. Inspection is best done with the to name a “watch,” but also for the patient to name the
tongue at rest in the floor of the mouth. Inspection of strap, buckle, and perhaps stem or crystal). Of course,
the tongue may reveal atrophy (indicative of lower the patient’s level of education and baseline verbal
motor neuron weakness) or fasciculations, which are prowess must be considered. Repetition is tested by
very concerning for the possibility of motor neuron using certain complex phrases, such as “no ifs, ands,
disease. or buts” and “if she were here, he would go.” Compre-
hension is generally evaluated by obtaining appropri-
Voice Listen to the voice for evidence of dysarthria. ate answers to complicated questions in the history.
This may be because of problems moving the lips (dif- If patients answer appropriately, they probably un-
ficulty with “P” or “B” sounds), the tongue (problems derstood in the first place. If there is a question, you
with “D” or “L” sounds), or palate (hard consonants should ask the patient to follow some complicated
like “G” and “K”). Also, listen for “hoarseness,” command without nonverbal cues. Fluency is evalu-
which may relate to local pathology of the larynx ated independent of content (a person may be fluent
or to paralysis of a vocal cord (vagus nerve). If the and make absolutely no sense).
hoarseness lasts for more than a month (in other The first decision that you must make relative
words, if it is not simply laryngitis), someone should to problems with speech and language is whether
look at the vocal cords to see if there is weakness the problem is dysphonia (a problem in the larynx),
or a mass. “Drunken” slurred speech may occur dysarthria (a problem with cranial nerves or the
with cerebellar problems, which may also produce cerebellum), or aphasia (problems with the cere-
an ataxic type of speech with accents on the wrong bral cortex). Problems with the larynx or cranial
nerves/cerebellum will not interfere with the content problem is “subcortical” (such as with strokes). Most
of speech, only the ability to generate it. Problems patients with cortical dementias (such as Alzheimer
of the cortex (aphasia) usually affect the ability to disease) improve little, if at all.
process written language in a manner that is similar
to the problems with spoken language. The aphasias Concentration Concentration is usually tested by hav-
require further classification. ing patients subtract serial 7s down to 65 or spell
Aphasias of any sort will usually affect naming. It “world” backwards. This can be affected by many
may be necessary to have the patient come up with problems including the results of head injury or the
smaller or more obscure parts of objects because the effects of many medications or illnesses.
ability to generate relatively simple nouns may be pre-
served with minor aphasias (dysphasia). All primary CalculationSubtracting serial 7s (see Concentration
aphasias affect the ability of the patient to repeat com- above) or adding coins (depending on education) is
plicated phrases, while “transcortical” aphasias pre- the usual method of testing.
serve the ability to repeat (they are like a parrot). The
primary aphasias are generally classified as expressive Abstraction There are several ways to test the ability to
(motor, Broca), receptive (sensory, Wernicke), or con- abstract. These include the interpretation of proverbs
ductive. In motor aphasia, the ability to generate ap- (e.g., a person who lives in glass houses shouldn’t
propriate words is lost and therefore naming, repeti- throw stones) or similarities (e.g., How is a tree like a
tion, and fluency are markedly affected. In pure motor blade of grass?).
aphasia, comprehension is preserved and the patient
is usually very frustrated because of recognition that This can also be tested in several
Constructional Ability
verbal output is inappropriate. Sensory aphasias pri- ways. For example, asking the patient to “draw a map
marily affect comprehension. Therefore, repetition from your house to this office” or to copy a figure.
and naming are affected (although to a lesser de- Several types of figures can be used, from simple to
gree than motor aphasias) and the patient can usually more complex. Copying a drawing of a cube is very
get short phrases out appropriately. However, longer useful because this ability is often affected in patients
phrases and conversation usually become a “word with visuospatial problems.
salad” with fluent verbal output that doesn’t make
sense. Conductive aphasia has some elements of each Affect It is important to assess mood. This can be done
of these, but with greater fluency than motor aphasia by asking about it; however, it is often reflected in the
and a greater recognition of the deficit than the pure way patients appear (their affect). Do they appear de-
sensory aphasia. It is important to make some assess- pressed? Are they anxious? All of these may be im-
ment of language function before you proceed with portant in the overall evaluation.
any other elements of the mental status examination
because language problems will severely affect results Thought Content Occasionally, patients with more se-
on the rest of the test. vere thought disorders are encountered. Bizarre or
poorly integrated thoughts can suggest serious un-
Registration Registration is the process of immediate derlying psychiatric illness.
recall and is usually tested by asking the patient to
repeat a short string of numbers or several unrelated
SUMMARY
objects that you can use subsequently to test memory.
This is obviously affected by conditions that impair 1. The neurologic examination is an easy and impor-
the ability to concentrate. tant component of the chiropractic evaluation. It
allows each testable component of the nervous sys-
Memory Sometimes memory is so bad that patient’s tem to be evaluated. In many chiropractic patients,
will not remember how old they are or the day and the exam will be normal, which in itself is a valu-
date. Of course, not knowing the precise date is not unable contribution to the overall assessment.
common, but the inability to get close (the right part 2. The emphasis of the examination should be driven
of the month, the right month, or the right year) indi- by the patient’s history, with greater emphasis
cates progressively higher levels of problems. Mem- placed on those elements that might be explaining
ory is typically tested by having the patient recall the the patient’s complaints. Additionally, any abnor-
several objects that you asked him or her to register mality in the clinical examination must be evalu-
(see Registration above) after 5 minutes with distract- ated with attention to what the abnormality is say-
ing tasks in between. If the patient can’t remember, ing about the nervous system. It is not enough to
prompts are often given. If the patient improves with say that there is a Babinski response or a Romberg
prompting, that suggests that the cause of the memory sign; rather, it is necessary to know what this is
telling you about the integrity of the various func- prominent. Autonomic nervous system problems
tional components of the nervous system. Espe- are often recognized in the process of taking a his-
cially with subtle findings, it is very helpful to tory. They often reflect as bladder or bowel prob-
confirm abnormalities by using different tests that lems or as orthostatic hypotension. Evaluation of
examine the same system. When the history indi- vital signs and looking for the Horner syndrome
cates it, higher mental functions are evaluated by in the head and trophic changes in the extremities
the mental state exam. is important.
3. The elements of the nervous system that can be 5. When each of these functional components have
evaluated through examination include the cranial been tested and found to be intact, the neurologic
nerves, medial longitudinal fasciculus, dorsal col- examination can be reliably reported to be normal.
umn, spinothalamic tract, corticospinal tract, basal Of course, many severely symptomatic patients
ganglia, cerebellum, peripheral nerves, nerve roots can have normal neurological exams. It is impor-
and nerve plexuses, lower motor neurons, and au- tant for you to consider whether the finding of a
tonomic nervous system. normal neurologic exam is compatible with your
4. Cranial nerves are tested by observation of the face overall assessment of the patient. In those cases
and eyes, by listening to the voice, and by consid- where you find an abnormal exam, it is critical to
ering patient’s complaints with regard to vision, have an explanation for the finding, either directly
hearing, speech, swallowing, or vertigo. The me- related to the patient’s diagnosis or as a product
dial longitudinal fasciculus is evaluated while ex- of some other process that is being appropriately
amining conjugate lateral gaze. The dorsal column managed.
pathways are examined by testing vibration, posi- 6. The neurological examination adds to the history
tion sense, ability to stand with the eyes closed and other parts of the exam (such as the orthopedic
(Romberg maneuver), and the ability to perform examination) to provide the information necessary
accurate movements with the hands (such as fin- to make a reasonable diagnosis and arrive at an
ger to nose) or feet (such as heel to shin) with effective treatment plan.
the eyes closed. Determining whether the patient
can symmetrically detect temperature or pinprick
sensation tests the spinothalamic tract. Damage to QUESTIONS
the corticospinal tract (upper motor neurons) pro-
1. How does the history contribute to the neurologic
duces a constellation of findings characterized by
examination?
weakness and usually associated with increased
2. What structures can be examined through the neu-
reflexes, increased tone (spasticity, clasp-knife),
rologic examination?
and pathological reflexes such as the Babinski
3. What is the significance of lower motor neu-
response. Basal ganglia (extrapyramidal) disor-
ron weakness versus upper motor neuron weak-
ders often produce abnormal movements when
ness? How can they be distinguished from one
the patient is at rest (e.g., tremor, chorea, atheto-
another?
sis, hemiballism, dystonia) and may produce ab-
4. How can a sensory exam be performed without
normal increase in tone (“lead-pipe” rigidity) and
testing the entire body?
bradykinesia (mask face, slow/shuffling gait, diffi-
5. How can the exam be used to distinguish vertigo
culty initiating movement). Cerebellar abnormali-
arising from the inner ear from that caused by dis-
ties are usually reflected in a loss of coordination,
orders of the central nervous system?
although they may result in change in tone (usu-
6. How are patients selected for detailed testing of
ally decrease in tone) and gait disturbance (such
higher mental function?
as a reeling gait, retropulsion, or staggering to one
side). Peripheral nerves, nerve roots, and nerve
plexuses are evaluated by examining their sensory
ANSWERS
and motor functions. They are recognized by the
pattern of sensory loss and by the distribution and 1. The history is used to identify areas of the ner-
character of motor abnormality (i.e., lower motor vous system that require specific attention. This
neuron findings in the appropriate distribution). is particularly important in selecting regions for
Lower motor neuron problems are recognized by detailed sensory and motor testing as well as for
the constellation of weakness, atrophy, and hypo- identifying symptoms that would direct particu-
tonia, as well as by the decreased reflexes that usu- lar attention to systems controlling balance, coor-
ally accompany these lesions in the affected areas. dination, and eye movement. History may be the
When lower motor neuron problems affect the an- only clue to the presence of autonomic abnormal-
terior horn cell itself, sustained fasciculations are ity or higher mental function abnormality. It also
leads to primary hypothesis generation, that is, to a your hypothesis of the patient’s condition. Again,
hypothesis of what is happening in the patient and, this is best done with more than one modality.
therefore, what would be the anticipated findings 5. Vertigo is typically caused by peripheral problems
on the neurologic exam. Frequently, the hypothesis with the inner ear or the vestibular nerve or by
is that the patient should have a normal neurologic central problems with the brainstem or cerebel-
examination. In this case the finding of a normal lum. Obviously, testing is quite different for these
exam is reassuring. conditions. Vertigo caused by central nervous sys-
2. A limited number of nervous system structures tem pathology often results in nystagmus that is
can be evaluated in the neurologic exam. These more severe than the dizziness that is reported by
include: peripheral nerves, nerve roots, nerve the patient. Additionally, nystagmus from brain-
plexuses, autonomic nervous system, lower motor stem or cerebellar disease may shift direction with
neurons, corticospinal tract (upper motor neu- different eye positions, can include vertical nys-
rons), dorsal columns, spinothalamic tract, extra- tagmus, and is often associated with other signs
pyramidal tract cerebellum, cranial nerves, me- or symptoms of central nervous system disease
dial longitudinal fasciculus, and higher mental (such as double vision or cerebellar signs). Pe-
functions. ripheral causes of vertigo result in nystagmus,
3. Lower motor neuron weakness is caused by dam- which is in proportion to the degree of vertigo re-
age to the anterior horn neurons or their axons ported. It may be accompanied by nausea, but is
(anywhere in the pathway, from the spinal cord out not accompanied by other brainstem or cerebellar
to muscles). These injuries cause decreased muscle abnormalities.
tone and atrophy, and a decrease in muscle stretch 6. Patients are tested for screening of higher men-
reflexes, when they cause weakness. Upper motor tal function during the process of history taking.
neuron weakness is caused by damage to descend- Complaints of cognitive problems by the patient or
ing motor tracts in the spinal cord, brainstem, or family are clear clues to the need for some exam-
cerebrum. These injuries, after a brief acute stage ination. Close observation throughout the history
during which there may be decreased muscle tone, of the patient’s affect, the logical flow of speech,
produce increased reflexes and spasticity, often ac- the use and comprehension of language, the fund
companied by pathological reflexes such as the of knowledge, and the orientation to personal and
Babinski response. Basically, lower motor neuron recent events can usually identify those who need
weakness is a result of peripheral nervous system more testing in this area.
problems, while upper motor neuron weakness is
a result of central nervous system disease.
4. There are two elements to a sensory examination. KEY REFERENCES
First, screening examinations select portions of the Bradley WG, ed. Neurology in clinical practice, 3rd ed. Boston:
anatomy that are commonly affected. These would Butterworth-Heinemann, 2000.
typically include the distal parts of the extremities DeMyer WE. Technique of the neurologic examination, 4th ed.
and, with spinal problems, possibly the trunk. Ar- New York: McGraw-Hill, 1994.
eas of common peripheral nerve damage, such as Haerer AF. DeJong’s the neurologic examination, 5th ed.
the fingers and feet, or commonly affected nerve Philadelphia: Lippincott, 1992.
root distributions (i.e., C6, C7, C8, L4, L5, S1), are Reeves AG. Diseases of the nervous system: A primer Year Book
Medical Publisher, 1981.
often screened. It is typically useful to screen with
Ross RT. How to examine the nervous system, 3rd ed. Stamford,
the light touch from your fingers and with a pin. Vi- CT: Appleton and Lange, 1999.
bratory sense in the feet is often a good screen for Rowland LP, ed. Merritt’s neurology, 10th ed. Philadelphia:
generalized peripheral nerve problems. The sec- Lippincott Williams and Wilkins, 2000.
ond method, which is complementary to the first, Victor M, Roper AH. The clinical method of neurology. In:
is detailed screening in symptomatic areas or in Principles of neurology. New York: McGraw-Hill, 2001:
areas that would commonly be affected based on 3–11.
C H A P T E R
29
ORTHOPEDIC EXAMINATION
Edward Rothman and Haymo Thiel
O U T L I N E
INTRODUCTION Observation
PRINCIPLES Palpation
Case History Movement
Chief Complaint Provocative Tests
Etiology Elbow
Timing Observation
Quality and Quantity Palpation
Aggravating and Relieving Factors Movement
Associated Symptoms Provocative Tests
Relevant Medical History Wrist and Hand
Abbreviated History in the Acute Trauma Observation
Presentation Palpation
Orthopedic Examination Movement
General Physical Approach Provocative Tests
Observing the Whole Person Hip
Inspecting the Area of Complaint Observation
Clinical Method and Formulating an Orthopedic Palpation
Differential Diagnosis Movement
A REGIONAL APPROACH Provocative Tests
Cervical Spine Knee
Observation Observation
Palpation Palpation
Movement Movement
Provocative Tests Provocative Tests
Thoracic Spine Ankle and Foot
Observation Observation
Palpation Palpation
Movement Movement
Provocative Tests Provocative Tests
Lumbar Spine and Sacroiliac Joints CONCLUSION
Observation SUMMARY
Palpation QUESTIONS
Movement ANSWERS
Provocative Tests KEY REFERENCES
Shoulder Girdle REFERENCES
561
studied in London, Paris, and Rheims. His textbook

OBJECTIVES
covered the basics of trauma surgery, with many of the
1. To review the role of the orthopedic examination techniques ahead of their time. Hugh Owen Thomas
in chiropractic. and Robert Jones established the foundation of mod-
2. To explain the role of the case history as it relates ern orthopedic surgery in Britain in the late nineteenth
to choosing the appropriate physical examination century.
procedures for specific orthopedic problems. Chiropractic orthopedics became a special inter-
3. To review aspects of the orthopedic examination est in the United States as an attempt by a group
that are common to most clinical presentations. of chiropractors to improve the musculoskeletal ex-
4. To promote an understanding of the clinical amination skills of practitioners, rather than to cre-
method necessary to formulate an orthopedic dif- ate a therapeutic specialty. The orthopedic movement
ferential diagnosis. in chiropractic began after World War II alongside a
5. To promote an appreciation of the concepts of sen- few other specialty societies. Brief instruction in the
sitivity, specificity, and efficiency as they relate to orthopedic sciences was offered as early as 1906 and
the interpretation of the outcome of provocative was taught through these early years by chiropractic
tests. educators such as Solon Langworthy, Benedict Lust,
J. H. Craven, M. J. Pullman, Gustave Haas, and W. L.
Jolivette.7 However, it was not until 1954 that a greater
interest in developing a higher level of orthopedic skill
INTRODUCTION
arose within the profession. At that time a group of chi-
Outside the chiropractic profession, orthopedics is ropractors, led by Alvin Hancock, proposed that the
generally considered synonymous with a surgical spe- Los Angeles College of Chiropractic Graduate School
cialty. There are medical physicians who describe and the California Chiropractic Educational Societies
their practice as nonsurgical orthopedics or ortho- form a specialty society in chiropractic orthopedics.
pedic medicine. This usually involves pharmaceuti- The primary impetus arose out of a desire to com-
cal intervention and injection therapy. Occasionally, plete a more detailed examination and report for in-
manual therapy techniques are employed. However, surance patients who had received traumatic injuries.7
these are most commonly performed by physical ther- Various postgraduate certificate courses sprouted up
apists under the prescription of medical physicians. around America, offered by various educational in-
James Cyriax, a London orthopedic surgeon, was a stitutions. The National College of Chiropractic of-
pioneer in nonsurgical orthopedic medicine. Besides fered a course with Joseph Janse and R. N. Kissinger.
some unique approaches to therapeutics, Cyriax de- Northwestern College of Chiropractic followed with
veloped special examination procedures that empha- a course taught by Robert Solheim. In 1962, Maynard
sized a functional approach.1 Lipe, who initiated the Los Angeles College of Chiro-
Orthopedic surgeons can trace their specialty to practic postgraduate orthopedics course, introduced a
Imhotep who, 5000 years ago in Egypt, wrote a trea- similar course at Western States Chiropractic College
tise on trauma and fracture.2 The word orthopedic in Portland, Oregon. Incidentally, Lipe authored the
came from the title of a textbook written by Nicolas first definition of chiropractic orthopedics. The def-
Andry, a French physician, published in 1741, about inition emphasized the “noncutting” treatments of
correction and prevention of skeletal deformities orthopedic conditions. Examinations for board cer-
in children.3 Innovations in orthopedic surgery tification were announced in 1973. Candidates were
moved rapidly after the introduction of anesthe- required to complete 300 hours of course work pro-
sia in 1846. Early surgery was limited to control- vided by an accredited institution prior to sitting for
ling bleeding, draining abscesses, repairing muscles the examination.7 Recently, the newly formed College
and tendons, reducing dislocations and fractures, of Chiropractors in Britain has adopted a similar or-
and performing amputations. London was a cen- thopedic subspecialty.8
ter of orthopedic surgery in the eighteenth century. This chapter addresses provocative tests and ma-
The practice was established in the United States by neuvers used during the orthopedic or musculoskele-
surgeons such as Philip Syng Physick, who trained tal examination. It emphasizes that designating these
under John Hunter (1728–1793), considered by many various maneuvers as the “orthopedic” examination
as the father of all surgery.4 It wasn’t until 1830 is an artificial label, because it is often impossible
that Samuel W. Gross published the first orthope- to separate orthopedic provocative maneuvers from
dic textbook in the United States.5 However, John the neurological examination in assessing the muscu-
Jones published the first US surgical textbook in loskeletal system. Therefore, this chapter should be
1775 and it covered wounds and fractures.6 Jones considered along with Chapter 28, “Neurologic Ex-
served an apprenticeship in Philadelphia and later amination.” Finally, the orthopedic examination in
ORTHOPEDIC EXAMINATION 563
chiropractic, as well as in other manual medicine management of a physical condition, illustrating “the
professions, has come to include functional examina- axiom that failure to understand the problem is not
tion procedures that are used to develop treatment proof of psychogenicity or malingering.” The authors
programs. Unfortunately, space does not allow a thor- point out that there are flaws in the usual criteria clin-
ough treatise of functional examination procedures; icians apply to identify patient embellishing of the
some of these are covered in Chapter 30, “Manual condition. Suspicions of secondary gain should be ex-
Examination.” pressed, if appropriate, but must be based on an entire
clinical picture.
Recording details of the history is important in
PRINCIPLES managing orthopedic problems. A detailed history, as
pointed out above, is paramount in establishing an
Case History accurate diagnosis. It is also necessary for the man-
Throughout the world an anecdotal tale is commonly agement of the condition and in dealing with medi-
presented to medical and chiropractic undergradu- colegal issues, which, unfortunately, are becoming an
ates; the story may differ slightly depending on the increasing part of treating injured people. Generally,
lecturer. The implication is that close to 90% of all diag- pain, swelling, loss of movement or altered function,
nostic impressions are achieved through the patient’s and body part distortion are the most common ortho-
history. Of the remaining 10% necessary to solve the pedic complaints encountered in a musculoskeletal
diagnostic puzzle, it is said that 9% are provided by the practice and must be recorded accurately with all as-
examination and 1% are left to laboratory tests. An in- sociated facts.
teresting study evaluated this parable and found that
82% of diagnoses are made by the history, 9% by the Chief Complaint The reason the patient is seeking care is
examination, and 9% by laboratory tests.9 Cases sup- the first thing that must be established. The complaint
porting this thesis are presented in studies across the should be recorded in the patient’s own words and
spectrum of orthopedic diagnosis. For example, the placed between quotation marks. This is useful for
history obtained in a single-page questionnaire was a number of reasons, the least of which is to avoid
found almost as accurate and more sensitive than the any confusion or misinterpretation by the clinician.
Phalen test, and considerably more accurate than the Writing the patient’s chief complaint as a quote is a
Tinel sign in diagnosing carpal tunnel syndrome when safeguard against the overzealous clinician including
electrodiagnostic tests were used as a gold standard.10 diagnostic impressions in the database.14
Pain distribution was found to be of great benefit in di- The complaint should be followed by a unit of
agnosing leg pain secondary to disc herniation.11 The time that the patient has been experiencing the pre-
history of pain on coughing, straining, and sneezing, senting symptom or problem. This affects the algo-
along with a feeling of coldness in the legs, was found rithm the clinician will follow. “Right shoulder pain
a reliable indicator of lumbar nerve root involvement extending to the lateral mid arm × 2 weeks,” is an
in another study by the same authors.12 Unreliable de- example of recording a chief complaint with a unit of
tails in the history of patients with leg pain included time. In some instances, a patient may come in with
subjective decrease in strength and sensory loss. Di- a list of complaints, sometimes written. These com-
agnostic accuracy and consistency were improved by plaints may be connected, suggesting a single disease
combining the history and description of the com- or causative injury. Therefore, it is important to keep
plaint with the examination findings. an open mind and first look at the problem list in its
Many orthopedic conditions involve pain and loss entirety. Patients often have a tendency to jump from
of function secondary to personal injury. Unfortu- one item of their health history to the next without
nately, this can influence the diagnosis and progno- finishing the description of any single item. At these
sis, even affecting clinical management at times. Most times, establishing the primary concern or complaint
patients will give honest descriptions of the accident is most beneficial for the clinical thought process. Ask-
and resulting injury. However, when litigation or coming the question, “Can you tell me what bothers you
pensation is involved, conscious or unconscious ma- the most?,” will help the patient in communicating the
lingering or symptom embellishment can cloud the primary problem.
evaluation and affect clinical judgment.
Of equal concern is a contagious condition that EtiologyThe setting in which the problem occurred
affects some chiropractors, physicians, insurers, and and any identifiable causes are important factors in
defense attorneys. It is called “malingerophobia.”13 determining the etiology of a complaint. Limiting
Thimineur et al., in a case report of a patient with the inquiry to a brief description of the precipitating
lacunar infarct in the left parietal area, presents an ex- event may lead to a misunderstanding of the problem
ample of how “malingerophobia” can influence the and direct the clinical thought process away from an
accurate diagnosis. Therefore, the clinical interview numerical rating scales are simple, efficient, and ef-
must be open-ended to allow for broad descriptions fective methods of gaining an understanding of a
of these case elements (e.g., How did this happen?). patient’s perceived pain level. For some patients, at-
Open-ended histories allow for the gathering of all tempting to accurately describe a symptom or quan-
facts and hidden clues necessary for appreciating a tify a level of pain with a cardinal number is an impos-
presenting problem and all the factors that go into sible task. In these instances, it can be helpful to get
making an educated diagnosis. Maintaining a curios- the person to relate or compare the current condition
ity about a patient’s problem and allowing full de- to the way the patient felt prior to the injury or onset
scriptions can uncover other issues possibly related to of the condition. This can be accomplished by asking
the chief complaint, or lead one away from a simple the patient, “What could you do before this problem
explanation when there is a more complicated under- (accident, injury, symptom, etc.) that you cannot do
lying disease process. Understanding the mechanism now?” This question encourages the patient to think
of trauma is paramount to arriving at a proper di- about the problem and describe it in ways beyond
agnosis and developing a treatment plan for many vague adjectives such as terrible, horrible, and severe.
orthopedic presentations. Directions of impact, body
position, force, and device of trauma are details that Aggravating and Relieving Factors Establishing the thi-
must be gathered and recorded during the history. A ngs that make the problem better or worse is an im-
thorough understanding of these factors is not only portant factor in determining the anatomic substrate
important for developing a functional diagnosis, but and pain-generating tissue of the presenting condi-
it will also direct patient management. tion. It is also a significant aid in appreciating the
pathophysiology of the condition. An example of this
Timing Recording the duration of the complaint was can be seen in the patient complaining of back pain.
discussed above; however, time with regard to the If activity or carrying objects increases the pain, one
complaint has several other facets influencing a clin- is directed toward the joints, muscles, and connective
ician’s approach to the chief complaint. The history tissues as the source of the pain, rather than the ab-
of the presenting complaint or injury must also in- dominal organs. If carrying or physical activity is not
clude a detailed chronological review. For example, an issue in generating back pain, the problem may be
“The current problem can be traced back 10 years caused by intraabdominal organ disease or disease of
when . . . however, 4 years ago . . . then, 2 months the bony vertebral bodies. Aggravating and relieving
ago. . . . ” Accurate information on the timing of in- factors are considered and analyzed together during
creased pain or periods of relief or reduced pain must the clinical interview, but inquiries into these factors
also be obtained, because it constitutes an important should be made separately. When asked together, that
factor toward establishing a diagnosis and directing is, “What things make you feel better and what things
treatment. make you feel worse?,” patients tend to concentrate
on the second part of the question.13
Quality and Quantity Vague descriptions given by some
patients of the presenting complaint should be fol- Associated Symptoms Associated symptoms have a re-
lowed by a question such as, “Could you tell me more lationship to the presenting complaint. They are not
about what that (the complaint) is like?” You may not other symptoms the patient may be experiencing or
always get the answer you were expecting, but it may symptoms indicating a distinct and separate problem.
provide for a better understanding of the problem or Associated symptoms are related to the chief com-
at least lead you toward other questions so that you plaint through timing and distribution. They may not
can determine the quality of the complaint. This is im- always be coincident with the complaint, but at least
portant for establishing the anatomical substrate and they should be conforming. Establishing associated
gaining a deeper appreciation for the complaint. A symptoms considerably increases diagnostic accu-
clear description, for example, may help to differenti- racy. For example, back pain with weight loss, fatigue,
ate between referred and radicular symptoms. and anorexia may indicate neoplasm. It is not always
Attempts to quantify the severity of a patient’s easy to establish or differentiate associated symptoms.
symptoms is not only useful for getting an appre- Often they can only be uncovered in the clinical in-
ciation of the patient’s suffering but also to assess terview by asking directed questions. Associating the
treatment outcome. A variety of tools are used to ob- chief complaint with what may appear to be an un-
tain measurements of pain, including questionnaires related symptom takes an educated knowledge base
that patients can complete in the office or at home. and clinical experience. For the novice clinician, an
However, these are often cumbersome and provide aid often used to uncover associated symptoms is the
little clinical benefit, being more useful for research systems review of current conditions or symptoms.
or litigation purposes. Visual analogue scales and By systematically going through the body’s systems
or anatomy, for example, head, eyes, ears, and throat, to accompany an expedient examination is appropri-
the clinician can uncover symptoms that may be as- ate. For example, the American College of Surgeons
sociated with the chief complaint or discover a health recommends obtaining an “AMPLE” history:
problem not realized by the patient before. A classic
example is local knee pain that is referred and caused • Allergies
by hip disease. • Medications
• Past illnesses
Relevant Medical History The medical history includes • Last meal
all hospitalizations, surgeries, and major medical • Events preceding the provoking event
events. Although a complete medical history should
be recorded, certain aspects have special importance However, for the problems typically presented to
in evaluating an orthopedic event. For example, it is chiropractic offices and the forms of treatment on offer,
important to know of a past history of rheumatoid this approach may be less applicable. Nevertheless,
arthritis in a patient for whom manipulation is con- chiropractors do see some emergency cases or acutely
sidered for treatment of neck pain, or that someone ill patients. In these cases, it is important to quickly
complaining of low back pain had several episodes determine whether the patient should be sent imme-
of renal calculi. Hence, the medical history can pro- diately to a hospital emergency department or can be
vide important clues regarding management and di- managed conservatively in the office and at home. It
agnosis. There may be evidence of medical history would be inappropriate to question the patient about
observed during the examination. If an operation had every little past medical detail or to obtain a complete
been described by the patient, a surgical scar should be family medical history. An illustration would be the
visible. Conversely, if during an examination a surgi- patient who presents following an automobile acci-
cal scar is observed, the patient should be questioned dent or other injury raising enough concern to suspect
about previous operations. a cervical spine fracture. In this case, a detailed history
All medications the patient is currently taking and, for that matter, physical examination would be
should be recorded. This includes medications that suspended in favor of a radiographic examination.
were prescribed by physicians, as well as over-the-
counter medications. Being aware of the medications Orthopedic Examination
a patient is taking can reveal a medical condition the General Physical Approach Most of this chapter details
patient forgot to mention; for example, a patient might a regional approach to physical examination with an
relate taking a diuretic or angiotensin-converting en- outline of provocative tests. The terms “tests, ma-
zyme (ACE) inhibitor but fail to mention that he or she neuvers, and procedures” are used interchangeably.
is suffering from hypertension. The patient who fails It cannot be overemphasized that the orthopedic ex-
to mention that he or she has previously sought care amination is not the sum of numerous provocative
for the chief complaint from other practitioners may maneuvers. It would be erroneous to solely rely on
be taking codeine. This can alert you to that important these various tests and maneuvers to reach a diagno-
detail and should lead you to ask further questions. sis. Such an approach would be a mathematical exer-
The social history is often considered separately cise. That is, 10 “positive” tests means that a patient’s
but for our purposes, it is considered within this sec- problem is one thing, while 13 “positive” tests means
tion. With regard to orthopedic problems, it is impor- it is something else. This approach has multiple inher-
tant to find out details about a patient’s job. Knowing ent problems. It is one taken by a technician and not a
that a patient sits behind a steering wheel or in front physician. The orthopedic examination is not the sum
of a computer for 8 hours a day can give you valu- of numerous provocative maneuvers.
able diagnostic clues. Employment issues must also When presented with a clinical problem, step back.
be considered. For instance, a lathe operator may be First, look at the person with the complaint and do
able to work with a stiff knee but this may be dan- not zero in on the painful area, attempting to secure
gerous for an 18-wheel truck driver. In the same vein, as many positive maneuvers as possible. The clini-
having an understanding of a patient’s home situa- cal process requires astute observation of detail and
tion may provide some insight into possible issues of an appreciation of the entire forest, not just the trees.
secondary gain or abnormal illness behavior, as well Furthermore, it takes a sufficiently broad and detailed
as direct wider management decisions regarding the knowledge base with clinical experience to observe
provision for a stair lift or prescribed home care. and interpret collected data. An old German proverb
states, “Was man weiss, man sieht” (what one knows,
Abbreviated History in the Acute Trauma PresentationFor one sees). However, this may present a trap for the
patients who arrive for consultation having just expe- less critical. If one is taught or accepts that a certain
rienced trauma, especially head trauma, a brief history sign or symptom suggests one thing, that may be all
one will “see.” Therefore, it is essential to always view gait differences and abnormalities is developed over
facts and information with a critical eye. The way in time through direct observation. It is one of the most
which the patient is approached for the examination difficult examination skills to teach didactically.13
is important in gaining the patient’s confidence. It is There are a number of permutations of gait with
only possible to adequately examine a patient who crossover between neurology, orthopedics, and func-
is in pain by having gained the patient’s trust. This tional examination. Gait is dependent on an intact
is best obtained by conducting the examina- nervous system, normal bones and joints, normally
tion calmly, methodically, and without “muddling functioning muscles, and normal foot biomechanics.
about.”3 An established sequence for conducting an The patient with an antalgic or limping gait may
orthopedic examination involves observation of the have pain anywhere in the kinematic chain of the
patient, inspection and palpation of the area, estimat- lower extremity, including the lower back. There-
ing gross active ranges of motion, and provocation fore, a careful and systematic examination of the legs,
and appreciation through movement, compression, hip, pelvic joints, and spine must be undertaken.
and traction. Also, remember that it is possible for a patient to
have more than one thing wrong at one time and
Observing the Whole Person The first aspect of this por- the antalgic gait may be caused by a combination of
tion of the examination may sound arcane. However, problems.
it is an aspect that is overlooked by many clinicians.
Specifically, consider how you (the examiner) feel. Inspecting the Area of Complaint The area and adjacent
What kind of feelings does the patient evoke in you? areas of the complaint must be fully exposed. A back,
Do you feel sad or uncomfortable? Does the patient shoulder, or elbow cannot be examined through a
evoke sympathy or empathy? The reflective clinician shirt; a knee cannot be examined through trousers.
will identify these feelings and consider them because When examining any area of the body, compare the
they may direct or influence the remainder of the inter- counterpart and adjacent areas. If the right knee is
actions with the patient. As you look at your patient, examined because of pain, complete the same exam-
what can you tell about posture, physical develop- ination of the left knee. If the back and left leg are
ment, body proportions, nutrition, apparent mental examined because of local and radiating pain, exam-
state and attitude toward you and about the present- ine the right leg. If the patient complains of right arm
ing problem? Although your observation should be pain, examine the cervical spine, shoulder, elbow, and
methodical, it should never sacrifice an appreciation the left arm. Look, feel, and move the painful area and
of the whole person. adjacent joints. Look for deformity, swelling, bulges,
Specific examples of body postures, habitus, or de- masses, atrophy or wasting, shortening or contrac-
formities that can be observed during the orthopedic tion, and changes of skin color. Feel for temperature
examination could fill up this entire chapter. Again, changes, soft-tissue swelling, masses, joint effusion,
a broad knowledge base and a critical eye are the and tenderness. Have the patient move the painful
most important factors in developing good observa- area and observe not only the way in which the joint
tion skills. It is also important to have seen a wide or body part moves, but also the patient’s reaction and
range of conditions. An example of a body attitude facial expressions when movement is completed or at-
commonly seen in the chiropractic office is the pa- tempted. Passively move the painful joint or the joints
tient with a trunk list away from the painful leg. This on either side of the painful area and again observe the
suggests a posterolateral disc herniation. In children, area and the patient’s reaction.15
body proportions are extremely helpful in diagnos- Inflammation is the body’s reaction to injury. From
ing conditions. Skeletal changes may be the first sign a mechanical viewpoint, acute injury is generally
of Marfan syndrome. Patients showing difficulty in caused via two methods: sudden severe loads that
arising from the seated position may have Parkinson cause macrotrauma or temporal repetitive loads that
disease or pelvic girdle weakness, suggesting a my- produce microtrauma.8 Macrotrauma results in im-
opathy. Muscle atrophy can indicate a neuropathic mediate tissue damage beginning with the inflam-
process, as well as a myopathic one. Focal atrophy is matory response.9 The classic signs of inflammation,
an important observation in assessing a patient with originally described by Celsus and Virchow, are red-
a known radiculopathy. It may indicate that an im- ness, swelling, pain, heat, and altered function.16 The
mediate surgical consultation is in order. A ruptured presence of these signs and symptoms is easily appre-
muscle or tendon will show up as a bulge in the ex- ciated by observation and palpation. They are gen-
tremity, as seen in Achilles tendon or biceps muscle erally short-lived and differentiated from chronic in-
ruptures. flammation primarily by the patient’s history. Chronic
A most difficult aspect of this part of the exam- inflammatory changes usually come about after
ination is the observation of gait. Interpretation of 3 months.17 Fibrotic tissue one might feel with deep
palpation is a possible result of the chronic inflamma- inflamed. A noncapsular pattern, such as seen in acute
tory response.17 tendonitis or with a joint mouse, does not primarily
When palpating the area of complaint, always affect the capsule. An example of a noncapsular
touch in a graded method. It may be tempting to pattern as described by Cyriax is the “sign of the
immediately poke and press into the area; however, buttock.”1 This is appreciated as a combination of a
this manner of investigation will limit the informa- limited straight-leg raise with limited and painful hip
tion you gather and affect your relationship with the flexion and a flexed knee joint. Passive examination
patient, possibly resulting in a loss of confidence. Start of hip ranges of motion reveals a sense of greater than
by laying your hand gently on the affected area. In this normal motion, but there will be active resistance from
way, you can assure the patient that you will examine the patient because of pain. There is no locking or pas-
slowly and will not unnecessarily cause pain. Further- sive resistance of movement. Experience is necessary
more, you can get information with light touch that for a complete appreciation of this phenomenon.
you cannot get with immediate deep palpation. This
includes a gross appreciation of temperature, soft- Clinical Method and Formulating an Orthopedic
tissue swelling, joint effusion, dysesthesia, and pain Differential Diagnosis
tolerance. Increasing pressure to a controlled firm- The goal of the patient interview (history) and phys-
ness will allow you to find the tender area or locate ical examination is to formulate a list of reasonable
swelling without causing the patient needless con- and testable hypotheses that form the differential di-
cern. Firm palpation, without poking, will give you agnoses. They are explanations for the combination
information about patient apprehension seen in cases of presenting symptoms, signs, physical examination
such as in an unstable joint, for example, recurrent results, and ancillary tests, for example, laboratory,
patellar dislocation. x-ray, or electrodiagnosis, recorded in a descending
With few exceptions, observe active ranges of mo- order of possibility. The working diagnosis or the di-
tion first. Again, look not only at the local movement, agnosis with the greatest probability that defines the
but also look at the patient’s reaction and facial ex- patient’s problem is the one used to develop the man-
pression during the exercise. Can you detect reactions agement or treatment plan. The word diagnosis is de-
to pain? Are there reactions of apprehension suggest- rived from combining two Greek words, gnosis, mean-
ing an unstable joint or impending dislocation? Com- ing to know or understand, and dia, meaning through
pare ranges of motion to the opposite limb and, for or thorough.14 Therefore, diagnosis suggests that the
the spine, with contralateral movement. There are clinician understands the condition thoroughly. Be-
wide variations of “normal” and the patient’s body cause this is not always the case, “working” is used as
type and physical condition must be taken into con- a modifier.
sideration. It is better to use common sense in inter- Throughout the session with the patient, the expe-
preting ranges than to rely on charts. However, the rienced doctor continually formulates and eliminates
accepted norms should be known and used as base- many potential differential diagnoses. However, the
lines. Assess not only the global ranges, but also look skilled practitioner does not record the possibilities in
for painful arcs, lags in movement, ratchet-type move- the database but waits to the end of the clinical process
ment, smoothness of movement, stiffness, and com- to consider all possible explanations for the presenting
pensation for movement losses. problem.
Move the joint passively following observations Our view of orthopedic differential diagnosis is
of the active ranges of motion. Can you obtain greater based on two simple aphorisms. Probably apocryphal,
ranges than the patient could actively? If so, this may they still hold great meaning and are traditions in
indicate a problem with the tendon or muscle because medical education. The first aphorism commonly
pain caused by muscle contraction and voluntary ac- used in medical teaching is “When you hear hoof-
tivity is eliminated during passive movement. Much beats, look for a horse, not a zebra.” The provoca-
of what can be gained through this part of the ex- tive tests discussed below in the regional approach to
amination relies greatly on experience. Passive as- the orthopedic examination (see A Regional Approach)
sessment of joint ranges of motion is very impor- should be used to prove or disprove hypotheses. You
tant for the functional examination. Hammer15 and should have the “horse” or hypothesis in mind before
Cyriax,1 among others, are exceptional contributors to moving on to the appropriate provocative tests. There
this aspect of manual and orthopedic medicine. One are times when you may identify a “zebra”; there-
of Cyriax’s contributions is the concept of capsular fore, you should keep other possibilities in mind when
and noncapsular patterns of joint analysis. These pat- moving on to provocative maneuvers. Also, there is
terns are best appreciated while carrying out passive the disconcerting possibility that it is a horse but you
ranges of motion. Cyriax refers to a capsular pattern do not hear hoofbeats.14 We also recommend that you
as one that occurs when a joint capsule is shortened or take some advice from the bank robber Willie Sutton.
while the double straight-leg test has poor sensitiv-

ity and specificity and is not an efficient procedure to
carry out in the low back examination.
Ultimately, one should be able to separate clusters
of findings and group them in a meaningful manner.
This is the approach we advocate for formulating a
working diagnosis or group of diagnostic impressions
that best define the orthopedic problem. Clustering
the historical information in a meaningful manner and
choosing provocative maneuvers that can efficiently
and effectively aid in defining the problem is the chal-
lenge for the inexperienced practitioner. The second
part of this chapter deals with the provocative tests
FIGURE 29–1. Evaluating provocative tests.
used to evaluate clinical problems by a regional ap-
proach. Not every possible test that one could perform
When asked by a reporter why he kept robbing banks, for a specific joint or area is included. Instead, we ad-
he replied, “Because that’s where the money is.” The vocate an approach that includes the application of
provocative tests used to evaluate a condition should the principles of sensitivity, specificity, and efficiency
be chosen for efficiency and effectiveness. Diagnosti- in deciding what tests to perform during the orthope-
cally, our experience shows that there is no better out- dic examination.
come by performing 10 provocative maneuvers when
one or two tests can answer your question. Choose the
A REGIONAL APPROACH
tests that will provide the greatest amount of informa-
tion with the least amount of effort (Fig. 29–1). The first part of this chapter discussed a general ap-
The clinician should have a utilitarian understand- proach to gathering a database used for develop-
ing of sensitivity, specificity, and efficiency. These ing differential and working diagnoses. This section
concepts are important in helping to distinguish the describes a regional approach to the orthopedic exam-
clinical usefulness of named provocative tests and will ination. Again, it is important to note that the orthope-
lead the astute clinician to “where the money is.” Sen- dic examination cannot be separated from the neuro-
sitivity for the purposes of the orthopedic examination logical examination. This section describes tests that
is an expression of how often the correct positive find- have some evidence as being accurate and efficient
ing is obtained in those expressing a particular condi- methods of identifying specific problems. After hav-
tion. It may also mean the likelihood that a negative ing conducted an extensive literature search regard-
test result correctly indicates that a condition is not ing orthopedic tests, we selected those studies that, to
present. Specificity is the measurement of how often varying degrees, approached provocative tests with
the correct negative answer is found in those that do regard to diagnostic accuracy.
not have the suspected condition. It is also the expres- We strongly advocate a commonsense approach
sion of the likelihood that a positive test result will to the examination. Along with experience and a crit-
correctly indicate a specific condition. For example, ically collected knowledge base, common sense is the
the reproduction of unilateral shooting leg pain with foundation of clinical practice. Consider and evaluate
a straight-leg raise of 45 degrees is a fairly sensitive the information needed to make a reasonable diagno-
test for lumbar radiculopathy, but it is not a specific sis in light of each patient’s needs. Mistakes are made
test because it does not identify the level of the lesion when the examiner goes off on a tangent and is fol-
nor the cause. lowing insignificant aspects of the clinical presenta-
Efficiency of a test is the percentage of times that tion. Base your use of provocative tests on simplicity
the test provides the correct answer. Efficiency can be and common sense. In all orthopedic tests, there is an
expressed by adding the true positive (TP) and true issue of interpretation or, from our view, overinterpre-
negative (TN) findings for any specific test and di- tation.
viding that sum by the number of all tests, including When examining a patient, aside from observa-
false positive (FP) and false negative (FN) findings for tion, palpation, and movement, provocation of signs
a specific condition (i.e., TP+TN/TP+TN+FP+FN). and symptoms is an integral component of the or-
Understanding efficiency as a parameter for the appli- thopedic examination. One either compresses struc-
cation of any test procedure will not only save time but tures and tissues or stretches structures and tissues.
also increase the diagnostic yield of the examination. It is not always necessary to remember a long list
For example, the straight-leg raise test has proven effi- of tests named after individuals who recognized and
ciency in evaluating suspected lumbar radiculopathy, catalogued the signs and symptoms. Furthermore, it
is not necessary to complete all the variations and off” of a spinous process may indicate a serious prob-
permutations of each provocative test that were dis- lem, especially when there is a history of trauma. For
covered, often by “professional rivals.” It is necessary instance, the flexion component of the whiplash injury
to understand the entire anatomy of the area tested, as could produce rupture of the supraspinous ligament
well as the quality and quantity of the applied stresses, or dislocation of the posterior elements. Forceful in-
that is, compression, traction, and torsion. With re- juries and direct blows can cause vertebral body crush
gard to recording findings, write succinct narrative fractures or fractures of the posterior elements with
descriptions of elicited signs and symptoms from the dislocation. If any of these or similar scenarios are sus-
provocative maneuvers. Avoid recording the results of pected, the patient’s neck should be stabilized with
any test by using the + symbol or writing positive in a Philadelphia collar and an x-ray examination per-
whatever form. One purpose of good medical records formed immediately. If palpation elicits tenderness,
is to allow another practitioner to easily interpret your note the location and the amount of pressure needed
examination findings for the continuity of care. Good to cause the pain. Deep tenderness at one area, usually
medical records are also important for you to evalu- the facet joint, is commonly appreciated in interseg-
ate a patient’s improvement or worsening condition mental dysfunction and is less likely with spondylo-
in order to maintain or change management. Consid- sis. Paraspinal tenderness is commonly found with
ering there are many descriptions and interpretations sprains and strains caused by both macrotrauma, as
of evoked signs and symptoms, it is essential that clear in a sports injury, and microtrauma, such as postural
descriptions of findings be recorded. With regard to strain. Be careful about overinterpreting tenderness.
ranges of motion, we give a few ways in which to Olson et al. found no correlation between disabil-
record the amount of movement. Of greater impor- ity secondary to neck pain and palpatory tenderness
tance than the method adopted for recording limits of and ranges of motion.20 The level of spasm will help
movement are the notations regarding elicited symp- established the severity of the injury. Palpate for en-
toms, signs, and reasons for any limitations. For in- larged lymph nodes and masses as well as for ten-
stance, it is important to note whether muscle spasm derness, spasm, and swelling. Move on to palpate the
restricted movement or movement was restricted sec- supraclavicular fossae, noting any lymphadenopathy,
ondary to pain. masses, or prominence of a cervical rib. Is a Tinel sign
elicited at the Erb point? This may suggest some ir-
Cervical Spine ritation of a single nerve traveling through the outlet
Observation In the previous section on general obser- or irritation of the plexus. It is not a specific sign but
vation, we advocated observing the entire patient. The gives a diagnostic clue. Complete the palpation by
same holds true for the regional approach to exam- inspecting the anterior neck surface and deeper struc-
ination. Look at the head and neck as a unit from tures, looking for enlarged lymph nodes, masses, and
all perspectives. Are there functional deformities, for swellings. Is the thyroid gland enlarged? Is the trachea
example, head and neck list or torticollis caused by midline?
spasm versus congenital and developmental defor-
mities such as congenital torticollis, Klippel-Feil syn- Movement It is important to get an appreciation of ac-
drome, or permanent anterior head carriage with loss tive and passive movements, not just for diagnostic
of curve secondary to spondylosis? Are there any purposes but also as an outcome measure. Observing
masses in the neck such as a goiter? Look for any ranges of motion can give the astute clinician infor-
changes, asymmetries, or swelling in the supraclav- mation about pain behavior and patient sensitivity.
icular fossae, as may be the case with a lung apex Active ranges of motion can be evaluated by simply
tumor. Are there any rashes, skin lesions, or signs of asking the patient to move the head in each of the
direct trauma, such as contusions and abrasions? Fi- directions of movement. This evaluation should be
nally, look at the upper extremities and note any ab- done with the patient sitting erect. There are advo-
normalities, such as signs of ischemia (color changes cates of obtaining exact measurements of each sepa-
and trophic changes, coldness on palpation) in one rate movement; however, this is not necessary in the
or both hands. Unilateral changes suggest thoracic general treating practice. There are different ranges
outlet syndrome caused by a cervical rib, while bi- of motion reported in various sources. In the United
lateral changes are more likely signs of Raynaud phe- States, the latest edition of the AMA Guides to Impair-
nomenon or disease.18,19 ment is usually used as the definitive source. In actual
practice, specific degrees of movement measured by
Palpation Begin palpation in the midline, starting at various methods ranging from simple goniometers to
the occiput and moving down. Midline tenderness in electrical goniometers and double inclinometers, and
the interspinous spaces is common after whiplash in- other such devices, is neither efficient nor, more im-
juries. A palpable spinous process step defect or “step portantly, clinically relevant. Recording approximate
degrees or describing movement in relationship of one likely in the form of an intervertebral disc herniation.
body part to another is sufficient. Variations and de- This sign has a 68% sensitivity.22
creases to population normal, as seen in conditions There are multiple names and variations for the
such as spondylosis, must be taken into considera- common cervical compression test. Thoughtful caution
tion when noting losses following injury or in eval- must be applied before carrying out any compres-
uating pain. Flexion is usually accomplished with a sive maneuver, especially when there is a history of
person touching or approximating the chin to the ster- trauma. The examiner must be reasonably certain that
nal manubrium. Normal flexion is about 60 degrees. there is no vertebral instability or dislocation before
Recording the distance between chin and chest and applying force. The Jackson test, maximum cervical
observing how many of the patient’s fingers can be compression test, and Spurling test are all variations of
placed between the two is one method. Extension is the procedure. The term Spurling sign is used by some
usually accomplished to 70 degrees, with the plane to indicate elicited radicular symptoms. We do not rec-
of the face parallel to the ground. Rotation can be ommend the Spurling variation of striking your hand
recorded as the distance of the chin to each shoul- placed on the patient’s head. Direct axial compression
der or by approximating degrees, with approximately with the head held in the neutral position and com-
80 degrees considered normal. Lateral bending is ob- pression with the head slightly extended and rotated
served by asking the patient to bring the ear to the neu- may intensify or produce pain and paresthesia in all or
tral shoulder or uplifted shoulder, with, depending on any part of the upper extremity. Occasionally, pressure
the source, 35 degrees considered normal. Difficulty should be held for 30 seconds or more. The elicited
with lateral bending is common in spondylosis. symptoms may follow specific dermatome levels,
Contralateral muscle spasm and pain must also be usually at the distal aspect of the extremity, being
considered. An inability to laterally bend during flex- more diffuse proximally. Arm pain is not necessar-
ion may indicate a problem with the atlanto-occipital ily always seen in radiculopathies. Pain may be lim-
and atlantoaxial joints.19 ited to the shoulder, especially in a C5 radiculopathy,
Appreciation of passive ranges of motion is influ- or may just be present or elicited over the ipsilat-
enced by the examiner’s experience and tactile skills. eral periscapular area, probably because of involve-
Fjellner et al., in a small but elegant study, demon- ment of the dorsal primary rami. The elicitation or
strated that many of the passive general motion ex- enhancement of radicular symptoms is 100% sen-
aminations were reliable but passive intersegmental sitive for the diagnosis of a lateral rupture of a
movement appreciation had poor reliability.21 Passive cervical disc.23 Conversely, the reduction or oblit-
motion range and end feel in lateral flexion and rota- eration of radicular symptoms with traction of the
tion were the most reliable. The authors of this study cervical spine may confirm or reinforce the suspi-
classified each examination procedure with the fol- cion of a cervical radiculopathy secondary to disc
lowing categories: herniation. Be cautious with interpretation of these
maneuvers. Focal or local pain produced with com-
• Motion range as reduced, normal, or increased pression may simply indicate a facet joint as the pain-
• End feel as hard, normal, or empty generating structure. Pain with traction may indicate
• Joint play as reduced, normal, or increased muscles, tendons, or ligaments as the pain-generating
• Muscles as shortened or of normal length structures.
• First rib as reduced or normal movement The shoulder depression test is another maneuver
that suggests that the source of shoulder or arm pain is
Information gained through evaluation of passive the cervical spine. In this maneuver, the head is later-
movement can help identify capsular versus noncap- ally flexed passively away from the symptomatic side
sular patterns. Although imperfect, the appreciation and the shoulder of the symptomatic extremity is de-
of joint function with a classification such as the one pressed; thus the nerve root is tractioned and, possibly,
above can be used for making therapeutic decisions brought in closer contact with the space-occupying le-
as well as for establishing the differential diagnosis. sion. Consideration must also be given to a lesion of
the brachial plexus, pain coming from stretched myo-
Provocative Tests The arm abduction sign, also called the fascial structures or underlying shoulder problems
Bakody sign, is sometimes simply observed during the (Fig. 29–2).
clinical interview. The patient with arm pain who is Pain distribution and history provide further clues
unaware of this relieving position can be asked to per- in diagnosing problems involving the cervical spine
form the maneuver. The patient will find relief with with or without upper extremity symptoms. It is not
the shoulder abducted and the elbow flexed, resting always possible to establish the level of disc hernia-
the forearm on top of the head. This sign suggests a tion without magnetic resonance imaging (MRI) stud-
radiculopathy secondary to an extradural lesion, most ies. Degenerative processes of the facet joints and
seen in early childhood.3 The curve may be either

S- or C-shaped. To accentuate a curve in suspected sco-
liosis, have the patient bend forward approximately
30 degrees when either standing or sitting. An exag-
geration of the normal kyphosis can be seen in all age
groups. When present in a child or adolescent and
combined with abnormal lateral curves, it is called a
kyphoscoliosis. This is a potentially serious deformity
with possibilities of progressive deformity and ensu-
ing respiratory and/or neurological problems. If de-
tected, the patient should be evaluated by a pediatric
orthopedist.
There are many different degrees of an exagger-
ated kyphosis. When observed in adolescents or chil-
dren, it could indicate secondary epiphysitis, Scheuer-
mann disease, or osteochondritis. In underdeveloped
countries, or in a patient from a poor family where
nutrition is compromised, it may suggest rickets. In
children and adults, an increased kyphosis could just
simply suggest a bad posture as seen in the up-
per crossed syndrome. It may also be a compen-
satory curve for an increased lumbar lordosis. If the
curve is more acutely angled, it could be from a
vertebral fracture caused by either trauma, osteo-
porosis, malignancy, or infection such as tuberculosis
(Pott disease).
Palpation Palpation of the paraspinal muscles can de-

tect local muscle spasm or taut muscle fibers that were
FIGURE 29–2. Shoulder depression test. As the examiner not observed during the inspection. Any tenderness
laterally flexes the patient’s head away from the involved side, should be noted, not just regarding its location but
the ipsilateral shoulder is passively depressed.
also indicating the degree of pressure needed to elicit
it. Be cautious of midline tenderness or step-off of a
intervertebral discs without herniation or rupture spinous process. This may indicate vertebral fracture.
may present with arm symptoms. In these cases, the Focal tenderness with deep palpation over the facet
progression of symptoms is slow and the distribution joints may signify a specific motion segment as the
is diffuse.24 pain generator.
Thoracic Spine Movement Gross ranges of motion of the thoracic spine

Observation Although not strictly part of the thoracic are generally not measured. Movement is usually ap-
spine examination, always examine the skin of the preciated as the lumbar ranges of motion are assessed.
trunk for any unusual or sinister-looking lesions. Ob- Flexion and extension are quite limited in this region.
serve the shape, size, and color of moles. A chiroprac- Extension is generally fixed and is more an appreci-
tor’s office is often the only place where a routine and ation of a patient’s posture. Therefore, the angle of
close inspection of the trunk takes place. Malignant minimum kyphosis can be calculated and compared
lesions, such as melanomas, are frequently first iden- to full flexion. The angle of minimum kyphosis is re-
tified by chiropractors. Café-au-lait spots may suggest ally used to determine impairment secondary to anky-
neurofibromatosis, especially when associated with losis and, therefore, beyond the scope of this chapter.
scoliosis.19 Flexion can be best approximated while the patient
The thoracic curve, when observed from the side, is seated and is usually about 45 degrees. Trunk ro-
is convex or gently kyphotic, and, as with the rest of tation is also measured with the patient seated. Nor-
the spine, there should not be any lateral curves. A mal rotation is approximately 40 degrees to each side
high shoulder, prominent hip, or protruding scapula with all but less than 5 degrees occurring in the tho-
can suggest an abnormal lateral curve or scoliosis. It racic spine.19 Rib excursion can be approximated by
is usually first identified in adolescence but may be simply observing or by direct measurement. This is
accomplished by taking the chest circumference at the areas. Chiropractors, more than most other health care
nipple line at full exhalation and then at full inspira- professionals, tend to examine the spine in toto, even
tion. The two values are subtracted, averaging 6 cm when the complaint is focal, such as “low” back pain.
(2.4 inches) difference in an adult. A difference of less Note the location of any tenderness and degree of
than 2.5 cm (1 inch) suggests ankylosing spondylitis.19 pressure producing the tenderness in the paraspinal
Passive movements are part of the functional exami- muscles. Palpate the spinous processes and inter-
nation and are covered in Chapter 30. spinous spaces. A step defect, usually evident at the
lower lumbar spine, suggests spondylolisthesis. It
Provocative Tests To our knowledge, there are no sen- may be easier to palpate the spinous processes and
sitive provocative maneuvers specifically for the tho- for a step defect with the patient seated and flexed,
racic spine. Furthermore, considering the possible or in the lateral recumbent position with the patient’s
clinical scenarios, provocative tests are, for the most hip and knee joints flexed. Palpate the sacroiliac joints
part, unnecessary. Compression from the shoulder looking for tenderness and swelling. This may be seen
when the trunk is rotated may localize pain to a seg- with mechanical back pain, but do not overlook sys-
ment or specific area. Percussion of the spinous pro- temic or rheumatic conditions or even an infection if
cesses may evoke sharp focal pain suggesting fracture the patient has multifocal symptoms, especially if the
or infection. Springing or lateral compression of the patient looks ill or is feverish. Renal disease must be
ribs may evoke sharp pain suggesting a rib fracture. considered if there is pain and deep tenderness over
the kidney area(s). The abdomen and inguinal areas
should also be examined in patients presenting with
Lumbar Spine and Sacroiliac Joints
low back pain. Rigidity, unusual tenderness, masses
Observation Observe the lumbar spine and pelvis as or organomegaly, and lymphadenopathy require fur-
part of the whole. Look for any skin lesions, including ther investigation, not only in their own right but also
cysts over the inferior sacrum and coccyx. Observe for as a cause for low back pain.
any deformities or changes to the normal posture and
curve. The gentle thoracic kyphosis should gradually Movement As noted in the previous spinal sections, it
transform into the normal lumbar lordosis. Look for is clinically unnecessary to obtain accurate and spe-
lateral curves suggesting scoliosis. Increased lordotic cific measurements of ranges of motion. It is impor-
curves are usually signs of lower crossed syndrome or tant, however, to get an overall appreciation of each
poor abdominal muscle tone. Loss of the curve with movement. Flexion, extension, and lateral bending
slightly flexed posture and flexion of the hips and should be observed individually. Global rotation is
knees is sometimes seen in spinal stenosis.19 The il- neither examined nor measured, because so little oc-
iac crests should be relatively level. Unleveling of the curs in the lumbar spine. Each of the movements may
crests may indicate scoliosis or other deformity, such be recorded or described in different ways. As with
as a leg-length inequality. Observe for any asymmetry the other spinal ranges, they can be used for treat-
or atrophy of the gluteal muscles. ment outcome measures. Normally, forward bending
Patients with acute back pain and lumbar radic- is the combination of thoracic, lumbar, and hip flex-
ular syndromes may present with a mild to marked ion. Therefore, for clinical purposes more information
trunk list. A lateral list away from the painful leg usu- can be gained by observing the smoothness (or lack)
ally suggests a posterolateral disc herniation, while of movement and noting the interspinous distances
a lateral list toward the painful leg suggests a medi- through the arc of flexion. In manual medicine prac-
ally oriented herniation. There may be mild spasm tices, this is also useful as part of the functional exam-
of the erector spinae muscles. This does not always ination. Be observant, because hip flexion can account
cause an obvious trunk list. Patients may also present for most of the motion. Full, true lumbar flexion is
with an anterior list or a flexion antalgia. It is our ex- about 60 degrees. The distance from the fingertips to
perience that this indicates spasm of the psoas mus- the floor can be measured or recorded. Another way is
cles and other hip flexors. Occasionally, these pa- to describe the body area the patient can approximate
tients also have an abdominal crease or indentation with the fingertips, for example, “fingers reach mid
of the lower abdominal wall, a sign of the so-called tibia without pain.” Lumbar extension is observed by
facet syndrome, which may also be seen in osteo- asking the patient to bend backward without bend-
porotic patients suffering from vertebral compression ing the knees. Maximum lumbar extension is about
fractures. 30 degrees. Lateral flexion is noted in each direction.
It also approximates 30 degrees. It can be described
Palpation Palpation of the lumbar spine and sacroil- in the relationship of the fingertips to lateral aspect
iac joints is simply the continuation of the spinal ex- of the lower extremities, for example, “the patient can
amination that began with the cervical and thoracic touch fingertips to lateral knee joint line.”
Provocative Tests A myriad of tests and diagnostic ma- leg pain secondary to tight hamstring muscles.
neuvers have been described for assessing the lum- However, patients can usually describe the difference
bar spine. In our opinion, very few of these tests give when questioned closely about the quality and local-
accurate data. Performing the exhaustive list of these ization of their symptoms.
maneuvers is neither an efficient nor effective ap- Various permutations of the SLR have been de-
proach to the clinical assessment of a patient, because scribed to increase either the sensitivity of the test or
their overall diagnostic yield is so low. its specificity by identifying different impinging tis-
Although we do not have explicit proof, we feel sues which, for example, may help to differentiate leg
relatively safe in saying that the straight-leg raising test symptoms caused by a piriformis syndrome versus
(SLR), or test of Lasègue, is the most commonly used or- a disc herniation. However, we could not find any
thopedic test in evaluating low back pain. It was first supporting evidence for these variations. Most com-
described by Lazarevic, a Yugoslav physician in 1880, monly, the SLR is reinforced by dorsiflexing the ankle
but he was never given credit for the test.14 Lasègue of the raised leg. Another reinforcement method is to
never described the test in publication. It was named internally rotate the lifted leg. Both methods place in-
in honor of him by his student, Forst, in his French creased tension on the sciatic nerve. Another method
MD dissertation.14 There are many versions of the test to evaluate involvement of the tensed sciatic nerve is,
that are used for various reasons, including identify- once leg pain or paresthesia is reported, to flex the
ing meningeal irritation. knee, eliminating the tension on the nerve. The sci-
In our literature search, we found no other test atic pain should ease off. Again, care must be taken
evaluated as vigorously as the SLR. Of particular note not to misinterpret a tight hamstring muscle group
was a systematic review of this test with pooled sta- for sciatica.
tistical results for the accuracy of diagnosing herni- The CSLR was first described by Fjerstajn in 1901,
ated discs, performed by Devillé et al. The authors after he observed a worsening of pain when the
found the test highly sensitive but limited because asymptomatic leg was raised. This sign produced a
of its specificity.25 They noted the problems and lim- predictive value of 97%, while the SLR alone had a pre-
itations of previous studies, indicating that there is dictive value of 64%. In another variant of the CSLR,
limited diagnostic accuracy of the test. The positive there is the suggestion of the possibility of the presence
predictive value, based on the diagnostic odds ra- of a medial disc herniation when pain is produced
tio of pooled studies, increased when the suspected in the asymptomatic leg upon raising of the painful
herniated disc was confirmed by the cross straight- leg.
leg raising sign (CSLR). The CSLR is referred to as Other nerve tension tests can be carried out for
the well leg raise sign by some authors. In a sim- lower extremity pain when a herniated disc is sus-
ilar vein, Vroomen et al. found, in a systematic re- pected. The femoral nerve stretch is performed with the
view of the literature from 1965 to 1994, the SLR to be patient lying prone on the examination couch. The
the only sign to be consistently reported sensitive for affected leg is raised with the knee flexed and, de-
sciatica caused by disc herniation and the CSLR the pending on which author is honored, an attempt is
only sign to be specific.11 The SLR is performed in made to touch the heel to either the ipsilateral or the
different ways, depending on an author’s interpre- contralateral buttock. Another version is to lift the
tation and attempts at increasing diagnostic yield. thigh off the couch with the knee flexed by grasp-
Whatever way is chosen, it is important to first rule ing under the distal thigh or knee. Pain produced in
out hip disorders. The test is performed with the pa- the distribution of the femoral nerve and over the
tient supine. The examiner raises each leg separately anterior thigh may suggest the rare occurrence of a
from the examination couch by grasping the ankle prolapsed upper lumbar disc. Because these maneu-
and insuring that the knee does not flex. The an- vers effectively extend the posterior joints of the lum-
gle at which pain is produced in the elevated leg is bar spine, primarily at the lumbosacral joint, local
noted and recorded. Although low back pain may pain in the absence of distal symptoms suggests pri-
be elicited, the test is not considered positive unless leg marily these joint complexes as the pain generators
pain or paresthesia is produced. Leg symptoms evoked (Fig. 29–3).
between 30 and 60 degrees suggest nerve root im- The different permutations and evoked responses
pingement or irritation, with some authors report- of the SLR test have also been used to implicate the
ing that leg symptoms below 40 degrees are in- sacroiliac joint as the source for a patient’s symp-
dicative of nerve root impingement as a result of toms. However, these different provocative maneu-
disc herniation.25 Results elicited with the SLR are vers have, at best, questionable diagnostic value for
unrelated to the size or position of the disc her- evaluating back pain. The heel-to-buttock maneu-
niation identified on computed tomography (CT) ver, also known as the Yeoman test, seems to be the
scans. False positives may be noted because of most commonly reported test for sacroiliac pain. For
statements that a commonsense approach and a solid

understanding of the underlying anatomy are vital to
the clinical process.
Shoulder Girdle
Observation General inspection of the shoulder girdle
is part of the overall observation of posture. For a spe-
cific complaint involving the area, a more detailed ex-
amination is carried out from the front, side, back, and
above. It helps to have the patient seated for the latter.
First, look at the contour of the shoulder girdles. They
should appear rounded when viewed from the front.
The line extending from the trapezius shelf, across the
acromioclavicular joint, over the superior aspect of the
glenohumeral joint, and down the lateral aspect of
the humerus should be relatively smooth. Significant
alterations of this line could indicate an orthopedic
problem, depending on where the contour changes.
For example, sharp elevation of this imaginary line
over the acromioclavicular joint may indicate a sub-
luxation or dislocation. A “C” shape to the line as it
extends down the arm so that a straightedge placed
along the lateral arm touches the acromion and lat-
eral epicondyle of the elbow, without touching any-
thing in between, is indicative of an anterior dislo-
cation of the glenohumeral joint. An indentation to
the line at the superior lateral border of the humerus
suggests deltoid atrophy, possibly as a consequence
of disuse or axillary nerve palsy. Inspect the shoulder
FIGURE 29–3. Femoral nerve stretch. With the patient prone, from the side. Note any swelling that, depending on
the examiner lifts the thigh to extend the hip while stabilizing the location, may mean acromioclavicular arthritis or cal-
pelvis. Note that there is provocation of several structures; cific supraspinatus tendonitis. Are the shoulders ex-
that is, the femoral nerve is stretched, the hip is extended, the ceptionally rounded forward? This could suggest de-
sacroiliac joint is stressed, and the lower lumbar spine is ex- veloped pectoral muscles, offsetting weaker shoulder
tended at the end-point. retractors, as seen with the upper crossed syndrome.
Observing from the back, are the scapulae of equal size
nonspecific low back pain, a combined provoca- and position? Asymmetry may suggest conditions
tive test of seated trunk rotation, extension, and such as Klippel-Feil syndrome or Sprengel deformity.
compression from the shoulders, the Kemp test, ap- Are the scapulae prominent? Usually this indicates a
pears to be the most commonly used. Walsh con- postural problem. True winging of one scapula sug-
cluded, in a retrospective analysis of patient files, that gests paralysis of the serratus anterior muscle, most
the various maneuvers used to provoke symptoms likely because of a lesion on the long thoracic nerve.
have limited clinical value once nerve root compres- If a winged scapula is suspected, it is more likely
sion or irritation has been ruled out.26 identified or brought out with resisted testing, accom-
Sacroiliac joint pain provoked with a cross-leg ma- plished by having the patient push off from a doorway
neuver or test, also called the Patrick test (see Hip be- or room corner. Deformities of the clavicle are most
low), and the Gaenslen test, where the lower extremity easily identified by observing, from above, the seated
on the side of the painful sacroiliac joint is lowered patient.
from the examination couch and forced downward
(extended), are two methods purported to confirm a Palpation Palpate the area of complaint first gently,
mechanical sacroiliac joint lesion. However, is neither then more thoroughly. Palpate all landmarks (e.g.,
sensitive nor specific for conditions of the sacroiliac acromioclavicular joints) and along the clavicle. The
joints. Provocation tests must be viewed in clusters superficial anterior, lateral, and posterior portions of
rather than singly, and when evaluated as such, are di- the subacromial space can be palpated while pas-
agnostically beneficial. This refers back to our opening sively abducting the arm and internally and externally
rotating it. Sharp tenderness may indicate bursitis, If movement cannot be initiated, there is the distinct
tendinitis, or tears, especially when occurring in the possibility of a restricted glenohumeral joint because
mid arc of abduction. Palpate the anterior and lat- the previously obtained motion was scapular.
eral aspects of the glenohumeral joint. Tenderness and
swelling can suggest anything from infection to cal- Provocative Tests Provocative maneuvers should be
cific supraspinatus tendinitis. The biceps tendon is carried out in a thoughtful manner based on the pa-
usually exquisitely tender at the bicipital groove when tient’s history and description of the complaint. No
it is inflamed, as in biceps tendinitis. Finally, do not ne- provocative maneuver should be done routinely. If
glect the supraclavicular fossae and axillae, palpating there is a question of shoulder instability, the exam-
for any masses or enlarged lymph nodes. ination should include diagnostic tests to assess this
possibility. If impingement of a structure is suggested,
Movement Movement of the involved shoulder must the provocative tests should reflect this possibility.
be compared to its counterpart. This may be done, As with most of the orthopedic examination, his-
getting a gross idea of motion, by having the patient torical features combined with a few maneuvers can
reach behind the head, moving the hands down the identify a specific problem. Litaker et al., in a ret-
posterior neck and upper back, and recording the ver- rospective review of 448 patient records, identified
tebral level approximated. This is followed by hav- three features in the history and physical examination
ing the patient reach up from behind and again not- found in all rotator cuff tears.22 The definitive diagno-
ing the vertebral level reached. In the first case, the sis of a rotator cuff tear is made on arthroscopic ex-
patient must abduct, externally rotate, and then amination with double contrast arthroscopy having a
adduct the arm. The second movement primarily in- sensitivity and specificity of up to 96%.22 Ultrasonog-
volves internal rotation and adduction. A better ap- raphy is variable, with studies revealing sensitivity
proach is to assess each movement individually. We ranging from 83% to 98% and specificity ranging from
find playing a game of “Simon says” helpful. That is, 57% to 98%.22 In the group of patients with established
the examiner moves individually through each move- rotator cuff tears, Litaker et al. found that the combina-
ment and the patient mimics the movement. Each tion of night pain, an impingement sign, and a painful
movement is completed bilaterally, that is, abduction arc had a sensitivity of greater than 97% but a speci-
from the side with the palm up (at least 170 degrees), ficity of less than 10%. They classified night pain as
flexion from the front with the thumb up (at least an inability to stay asleep because of shoulder pain.
165 degrees), extension by bringing the elbow back The impingement sign was identified with the exam-
while flexed (at least 55 degrees), external rotation iner moving the externally rotated arm of the supine
from 90 degrees of shoulder abduction (at least patient to full elevation (at least 170 degrees), followed
70 degrees), internal rotation from 90 degrees of by internal rotation. It was considered present if there
shoulder abduction (at least 70 degrees), and adduc- was a significant increase in pain. The painful arc was
tion with elbows extended and arms brought across noted after the examiner had brought the arm up to
chest from 90 degrees of shoulder abduction (at least full abduction and the patient had actively lowered
40 degrees). Observing patterns of usually asymmet- the arm within the abduction plane. Intense pain be-
ric movement and initiation of pain at points within tween 70 and 120 degrees and minimal pain at full
an arc of movement aids the examiner in identifying elevation was considered significant.
the anatomic substrate for the problem. For instance, A variation of the impingement sign described
shoulder pain in the 70–120-degree arc of movement above and taken from Litaker’s paper has also been
suggests supraspinatus tendon involvement or rota- called the drop arm test. The difference between the two
tor cuff inflammation under the area of the acromion. is the identified sign, being an inability to hold the arm
Pain later in the arc of abduction suggests impinge- up against gravity at 90 degrees or less. Because the
ment under the coracoacromial ligament. If there is deltoid muscle can maintain the arm in elevation at
difficulty in initiating movement, a rotator cuff tear and beyond 90 degrees, there is no identifiable weak-
may be the problem. Increased movement beyond ness above this point. This test has been commonly ac-
normal in external rotation may indicate a tear of the cepted as being pathognomonic of a rotator cuff tear.
subscapularis muscle. Comparing active to passive However, it only has 78% reliability for detecting ro-
ranges of motion is also important. This helps to dif- tator cuff tears.23
ferentiate muscular or tendon involvement from cap- Ure et al. found the clinical examination is most
sular or joint problems. If active and passive ranges reliable for impingement syndrome when compared
are found moderately restricted in abduction, hold to other shoulder conditions.23 The authors evalu-
the scapula at the inferior angle, restricting scapular ated several methods to elicit an impingement sign,
movement, and try to passively abduct the arm again. including the ones described by Neer (forced full
flexion of the arm while fixing the scapula), Jobe gested when the patient experiences a sudden sharp
(abduction to 90 degrees with forced internal ro- pain, or a distinct increase in the underlying pain,
tation), and Hawkins (forced internal rotation with or if the patient notes that symptoms have been re-
the arm held in 90-degree flexion and slight ad- produced. Specificity of the anterior release test is
duction while applying a downward force onto the questionable, considering the likelihood that many
acromioclavicular joint). They found Jobe’s to be the other conditions such as tendinitis and impingement
most sensitive (Fig. 29–4). could cause symptoms in this described position for
The Neer test has been described in several ways, the test.
including a method where the humeral head is pushed Buchberger described methods to differentiate
toward the underside of the acromion while the arm acromioclavicular lesions from subacromial impin-
is held in full elevation. It has been consistently found gement.30 However, he extrapolated the testing meth-
to evoke pain in suspected impingement syndrome. ods with his interpretations seemingly based on his
In an interesting study by Çalis et al. on the diag- understanding of kinesiology. He did not complete
nostic accuracy of various provocative shoulder ma- any reliability studies.
neuvers, it was found that tests that were highly Zaslov, in a prospective study, differentiated be-
sensitive had a low specificity, while highly specific tween outlet syndromes secondary to underlying in-
ones were not particularly sensitive.27 They estab- stability as most commonly seen in patients younger
lished that the Hawkins maneuver was the most than age 50 years, especially in young athletes, and
sensitive test for impingement (92.1%), closely fol- intraarticular pathology.31 In 115 patients, his test,
lowed by the Neer test (88.7%); Jobe’s method was not described as the internal rotation resistance strength test,
evaluated. had 88% positive predictive value, 88% sensitivity,
Instability syndromes, especially occult instability, and 96% specificity. The maneuver is performed while
cannot be reliably assessed by physical examination. the arm is held in 90-degree abduction and 80–85 de-
Clinically, only 53% are identified without ancillary di- grees of external rotation. The patient is asked to first
agnostic imaging.23 The apprehension test has been clas- resist external rotation and then resist internal rota-
sically used to identify instability. Rowe and Zarins tion in this position. It is considered provocative for
described the test as “positive” when both pain and subacromial pathology if apparent weakness of inter-
patient apprehension with further passive movement nal versus external rotation was provoked. Pain by
of the shoulder was produced.28 It is performed by itself, although exacerbated with the maneuver, is not
externally rotating the shoulder held at 90 degrees of considered a positive finding (Fig. 29–5).
abduction while pressing forward on the humerus. In further attempts to differentiate acromioclav-
This is specifically for glenohumeral instability and icular problems from other abnormalities, O’Brien et
most specifically for recurrent anterior dislocation. al. proposed a test to distinguish acromioclavicular
Other tests for stability include the anterior and pos- joint abnormalities from labral tears, called the ac-
terior drawer test described by Gerber and Ganz.29 It tive compression test.32 The findings from a prospec-
is performed with the patient supine on the examina- tive study with 318 patients revealed 100% sensitiv-
tion couch and the shoulder unsupported. With the ity, 98.5% specificity, and a positive predictive value of
shoulder in 90-degree abduction, slightly flexed and 94.6%. The test has two parts. First, the patient’s arm is
externally rotated, passive anterior and posterior brought to 90 degrees of forward flexion, adducted 10–
movements are performed. Clicks, pain, and appre- 15 degrees, and maximally internally rotated. Down-
hension are considered “positive” findings. Later ward pressure is brought to bear on the arm while the
studies found that with occult instability, patients patient resists. If pain is elicited, the second part of the
were not apprehensive with passive movement. Con- maneuver is completed; that is, the arm is maximally
sidering the conservative nature of chiropractic prac- supinated and downward pressure is applied. If this
tices, occult instability is one cause of shoulder pain decreases or eliminates the pain, the test is considered
the chiropractor is more likely to see versus gross “positive.” The authors found that pain localized to
instability secondary to recurrent dislocation. Gross the acromioclavicular joint or superior aspect of the
and Distefano described the anterior release test, a shoulder was diagnostic of an acromioclavicular joint
method found to be 91.9% sensitive and 88.9% specific, problem, while pain or a painful click described as
with an 87.1% positive predictive value as compared within the glenohumeral joint indicates an abnormal-
with operative findings.24 With the patient supine on ity of the glenoid labrum (Fig. 29–6).
the examination couch, a posterior-directed force is There are two other maneuvers to assess the shoul-
placed over the humeral head while the arm is pas- der for the possibility of a labral tear. Liu et al. consid-
sively abducted to 90 degrees and fully externally ro- ered the diagnostic accuracy of what has come to be
tated. Provocation occurs when the pressure over the known as the crank test.33 The maneuver can be per-
humeral head is released. Occult instability is sug- formed with the patient either upright or supine. In
A B
FIGURE 29–4. Tests to elicit an impingement sign. A. Neer

test. The examiner forces the patient’s arm into full flexion while
fixing the scapula. B. Jobe test. The examiner internally rotates
the arm held at 90 degrees of abduction. C. Hawkins test.
The examiner internally rotates the arm held at 90 degrees of
C
flexion.
A B
FIGURE 29–5. Internal rotation resistance strength test (IRRST): During the first part of the test (5A) the patient resists external
rotation and then resists internal rotation (5B).
the upright position, the patient’s arm is brought to humeral groove. Substantial pain may also be elicited
160 degrees of abduction in the scapular plane. While during resisted testing of the muscle. The Speed test,
the elbow is kept in a flexed position, the humerus is a common provocative maneuver, was evaluated for
alternately internally and externally rotated as pres- sensitivity and specificity by Bennett.35 The test is per-
sure is applied along the long axis of the humerus formed by putting a downward force on the patient’s
from the elbow. The test is performed in exactly the arm while it is in full supination and held in 90 de-
same way for the supine patient. A labral tear is con- grees of flexion at the shoulder. The elbow is fully ex-
sidered when pain with or without a click is provoked, tended during the procedure. Pain experienced in the
usually during external rotation. Liu et al. found anterior aspect of the shoulder, as the patient resists
91% sensitivity, 93% specificity, and 94% positive the downward force of the examiner, is considered to
predictive value preoperatively of the crank test in be indicative of biceps tendinitis. When compared to
62 patients. Based on a smaller cohort of patients, arthroscopic findings, the Speed test was found to be
Mimori et al. reported on a variation of the crank test 90% specific but only 13.8% sensitive, and with a pos-
with a 100% sensitivity and 90% specificity.34 The ma- itive predictive value of 23%. The poor sensitivity is
neuver is completed with the patient seated and the consistent with the one found by Calis et al.’s study.27
arm held in 90 degrees of abduction and slight external In summary, there are several provocative ma-
rotation. With the elbow flexed, the forearm is max- neuvers to help sort out shoulder pain. Diagnostic
imally supinated and maximally pronated. The test imaging and arthroscopy are the only ways to defini-
is considered pathognomonic for a labral tear when tively diagnose shoulder pain that cannot quickly be
pain is most severe or increased in the pronated posi- appreciated from the history and physical examina-
tion (Fig. 29–7). tion. As is true for the rest of the musculoskeletal
Biceps tendinitis can be suspected when there is system, there are many functional examination proce-
significant tenderness over the tendon near or at its dures used to develop a diagnosis and treatment plan.
FIGURE 29–6. Active compression test. Pictured is the sec- FIGURE 29–7. Crank test. Pressure is applied along the long
ond portion of the test, when downward pressure is exerted axis of the humerus as it is internally and externally rotated.
on the arm with the patient resisting. Note that the arm is held
in full supination. ties can be observed and the carrying angle measured.
The carrying angle should average approximately
For these, we can only refer the reader to other sources 11 degrees in males and 13 degrees in females.19 Cu-
(see Key References below). bitus varus describes a decreased angle and cubitus
valgus an increased angle. The most common cause
Elbow of a change in the carrying angle is an old supra-
Observation Some elbow abnormalities, such as those condylar fracture.19 Of concern in alterations of this
caused by problems with growth or development angle is the development of ulnar tardy palsy, a pro-
or those secondary to poorly healed injuries, for ex- gressive weakness (often slow and delayed, hence
ample, gunstock deformity caused by a malunited “tardy” as a descriptor) of ulnar nerve innervated
supracondylar fracture, are readily seen on examina- muscles. Electrodiagnostic studies are helpful if this is
tion. Generally, however, visual inspection of the el- suspected.
bow is limited to obvious signs of fracture, swelling,
and joint effusion. The earliest sign of effusion is Palpation Palpate all bony landmarks of the elbow.
a spreading out of the soft tissues observed when Tenderness over the epicondyles usually indicates
the elbow is flexed. This is a result of the disper- tendinitis or epicondylitis, that is, tennis elbow with
sal of fluids under compressive forces brought on by tenderness over or just distal to the lateral epicondyle,
elbow flexion. There may be some swelling in the and golfer’s elbow with tenderness over the medial
region of the radiohumeral joint. A focal swelling epicondyle. Tenderness over the medial epicondyle
overlying the olecranon process without ecchymo- may also mean an ulnar collateral ligament tear,
sis is usually indicative of an olecranon bursitis. This sprain, or fracture of the epicondyle. Ulnar collat-
may require drainage. Rheumatoid nodules may be eral ligament sprains are most commonly a result
identified about the swollen elbow joint. As the pa- of throwing injuries.36 Palpation deep into the space
tient stands in the anatomic position, most deformi- between the radial head and humerus on the lateral
aspect is best accomplished during passive supination may be elicited, but ferreting out entrapment neu-
and pronation of the forearm. Exquisite tenderness in ropathies about the elbow usually requires clinical
this area is seen in injuries of the radius, osteoarthritis, neurophysiological studies.
or osteochondritis desiccans.19,36 Tenderness over the Lateral epicondylitis or tennis elbow is the most
olecranon is present in bursitis and fracture. However, prevalent elbow injury.3 It is caused by a tear, often
these conditions are obvious on observation. There is a microtear, on or near the insertion of the com-
a triangle formed by the olecranon and condyles. Al- mon extensor tendon on the lateral epicondyle of
terations in the symmetry of the triangle may indicate the humerus. Because inflammation, both acute and
elbow subluxation or dislocation.19 chronic, is a part of this syndrome, stressing the wrist
extensors will accentuate pain. There are varieties of
Movement Ranges of motion can be grossly appreci- ways to produce pain at the elbow and modifica-
ated. Full extension is 0 degrees when the arm and tions of the test when elbow pain is secondary to this
forearm are straightened. Loss of full extension can be problem.19,36 The tennis elbow test, Thomsen test, Cozen
secondary to a number of conditions, including mus- test, and reverse Mills test are essentially the same pro-
cle contracture, osteoarthritis, rheumatoid arthritis, or cedure with the goal of producing a strain at the exten-
old, poorly healed fractures. The inability to achieve 0- sor insertion point. The provocative maneuver to elicit
degree extension is recorded as a “–” (negative) value, pain at the lateral elbow or lateral proximal forearm
for example, –5 degrees. Extension past normal or is accomplished when the examiner applies a down-
hyperextension is recorded in degrees. Up to 15 de- ward force on top of a patient’s clenched fist as the
grees is considered normal.19 Hyperextension, after patient resists any movement. The patient’s wrist is
deformity is ruled out, may indicate generalized joint dorsiflexed, the elbow extended, and the forearm fully
hypermobility, as in Ehlers-Danlos syndrome. To ap- pronated. Keeping the wrist radially deviated during
preciate flexion, ask the patient to bring the hands to the procedure produces further strain at the insertion
the front of the shoulders. Any asymmetry will be ob- site. This latter variation is also known as the Thomsen
vious. If measured with an arthrodial protractor, nor- test.36
mal flexion equals about 145 degrees. Supination and Medial epicondylitis or golfer’s elbow is suggested
pronation can be grossly observed by asking the pa- when there is pain at the medial epicondyle. Besides
tient to turn the palms upward and downward while the expected tenderness, often as exquisite as in ten-
holding the elbows against the trunk and flexed at nis elbow, and possible mild swelling, pain can be
90 degrees. Supination is approximately 80 degrees elicited by reversing the testing procedure described
and pronation is about 75 degrees. As with assessing in the preceding paragraph. Tenderness and pain may
movement in all joints or regions, compare active with extend from the tip of the medial epicondyle to the
passive motion. pronator teres and flexor carpi radialis muscles. The
examiner provokes pain by having the patient resist
Provocative Tests Continuing our approach to pro- wrist extension while holding a clenched fist that is
vocative diagnostic manipulative maneuvers, the in palmar flexion with the elbow fully extended, and
elbow is examined primarily by stressing or straining forearm supinated. This is also known as the Mills test
tendon attachments to identify sites of injury. Elbow in some circles.
pain is usually secondary to overuse injuries, often Instability can be assessed by alternately applying
connected to sports or recreation and occupational varus and valgus force as the patient’s elbow is held in
exposure.36 Examples of these problems include 20 degrees of flexion. The examiner is looking for in-
lateral epicondylitis seen in racket sports, medial creased mobility in comparison to the asymptomatic
epicondylitis secondary to golf and similar activities side or patient apprehension. There are more specific
where the arm trails with a weight, olecranon bursitis methods, such as the posterolateral rotatory instability
seen in competitive wrestlers and grid football (North test, or lateral pivot shift test, to evaluate for gross insta-
American) players, and collateral ligament sprains bility. This test is concerned with laxity of the lateral
caused by throwing sports. Because of the elaborate collateral ligament to the point that the humeroulnar
network of nerves innervating elbow structures and joint is allowed to subluxate, resulting in a humerora-
traveling past the joint, there are a variety of nerve dial joint dislocation. It is unlikely this condition will
injuries and entrapment syndromes occurring about be encountered in the average chiropractic office. The
the elbow. These include pronator teres syndrome, test is best done with the patient laying supine on the
commonly mistaken for carpal tunnel syndrome, examination table. The arm is taken over the pa-
cubital tunnel syndrome, and, uncommonly, entrap- tient’s head while the shoulder is externally rotated.
ment of the radial nerve through various structures, The examiner stands at the head of the table and
including the arcade of Frohse. A Tinel sign or tin- actively supinates the patient’s forearm while apply-
gling dysesthesia elicited with tapping over a nerve ing a combination of valgus stress, axial compression,
and elbow flexion. There will be great apprehension Palpation Beginning with the lateral aspect of the
in the patient suffering from this type of instability. wrist, tenderness of the anatomical snuffbox may indi-
cate a scaphoid fracture, but tenderness in this area is
Wrist and Hand also commonly found after wrist sprains. To help dif-
Observation Look for any signs of deformity, cuts, ferentiate scaphoid fracture from sprain, move to the
scars, wounds, swellings, and muscle atrophy by in- dorsal aspect of the scaphoid. If the dorsal aspect in
specting the hand and wrist from the palmar, dorsal, this area is quite tender to palpation, a fracture is more
lateral, and medial aspects. Following trauma, a ra- likely than a sprain.19 Tenderness at the dorsolateral
dial deviation deformity of the wrist may indicate a wrist, localized over the tendon sheaths of the abduc-
Colles fracture, especially with abnormal prominence tor pollicis longus and extensor pollicis brevis, espe-
of the ulna. An unusually prominent ulna may also cially with thickening of the sheaths, strongly suggests
mean a Madelung deformity. Palmar deviation of the tenosynovitis, possibly stenosing, as in de Quervain
distal radius and ulna may indicate a Smith fracture. disease. Diffuse tenderness over the joints of the hand
Ulnar deviation, without a history of trauma, may may be the first sign of rheumatoid arthritis or os-
suggest rheumatoid arthritis. Flexion of the fingers at teoarthritis, though osteoarthritis tends to spare the
the metacarpophalangeal joints accompanied by ten- metacarpophalangeal joints.3,19
don and synovial sheath thickening at the palm is
characteristic of a Dupuytren contracture. A trigger Movement Movement at the wrist can be quickly
finger usually occurs at the middle finger. With sud- screened by having the patient press the palms of the
den extension of the finger, actively or passively, the hand together while slightly raising the elbows. Any
finger will involuntarily flex. Deformities of the fin- obvious loss of dorsiflexion will be easily appreciated.
gers with expansion of joints, prominent osteophytes, This is followed by having the patient press the backs
or nodules are present in various arthritides. Nodules of the hands together while bringing the elbows to the
are not pathognomonic for rheumatoid arthritis; how- horizontal plane to appreciate palmar flexion. Lastly,
ever, in patients with rheumatoid arthritis, nodules gross appreciation of motion is completed by having
give a 90% chance of a positive rheumatoid factor. The the patient medially and laterally deviate the hands,
nodules seen in osteoarthritis at the distal interpha- noting any differences. If measuring with a goniome-
langeal joints are called Heberden nodes; at the prox- ter or arthrodial protractor, make sure that the fore-
imal interphalangeal joints they are called Bouchard arm is stabilized. Normal values are approximately
nodes. 60 degrees each for flexion and extension, 20 degrees
Note the size and location of any swelling, which for radial deviation, and 30 degrees for ulnar devi-
could indicate a ganglion cyst, a synovial cyst, rheum- ation. Grossly examine movement of the fingers by
atoid nodules, or a tumor. Ganglion cysts are most having the patient open and close fists and abduct
common over the dorsal wrist with small ones accen- and adduct fingers in the horizontal plane. It is un-
tuated by palmar flexion. If there are two discrete areas necessary in the general orthopedic examination to
of swelling in the palmar aspect of the distal forearm accurately measure individual movements of the dig-
and the palm, see if you can push one area across its at all joints. When done, it is usually for impairment
the surgical wrist (cross fluctuation). This can sug- rating purposes.
gest a palmar ganglion as seen in rheumatoid arthritis
and tuberculosis.19 Swelling over the lateral aspect of Provocative Tests Provocation of pain, crepitus, and
the distal radius and at the base of the thumb could paresthesia is accomplished by passively moving the
indicate tenosynovitis or de Quervain disease. Dif- wrist, hand, and fingers through all planes of move-
fuse swelling could mean anything from a sprain to ment. There are few specific provocative maneuvers
an inflammatory disease. Complex regional pain syn- for the wrist and hand. The Finkelstein test is a diag-
drome should be considered if there is generalized nostic manipulation for the consideration of tenosyn-
swelling of the wrist and hand with a glossy appear- ovitis of the abductor pollicis longus and extensor
ance to the skin and tenderness to very light touch. pollicis brevis, also called de Quervain disease. The
There may also be cyanosis of the nail beds, sug- test is accomplished by having the patient place the
gesting Raynaud phenomenon or disease, especially thumb across the palm and grasping it by closing
when the patient describes extreme sensitivity and the fingers across the thumb and pressing it into the
hand pain during cold weather. Thenar, hypothenar, palm. The examiner then moves the wrist into its full
and interosseous muscle wasting suggest nerve dam- range of ulnar deviation, while keeping pressure on
age. Widespread wasting of the forearm muscles, es- the proximal phalanx of the thumb. Exquisite pain
pecially bilaterally, suggests several neurological con- along the tendons suggests tenosynovitis. Swelling
ditions, including multiple sclerosis, or a myopathy and tenderness along these tendons, as noted in the
such as muscular dystrophy. previous palpation section, is also present in this
condition and increases the diagnostic yield for this

condition.
Carpal tunnel syndrome (CTS) is a common prob-
lem or suspected problem encountered in clinical
practice. Patients are usually between 30 and 50 years
of age when CTS is diagnosed, with 0.5% of the gen-
eral population reporting the diagnosis.37 The ques-
tion of whether the patient with wrist pain and radial
hand paresthesia truly has CTS can only be defini-
tively answered with electrodiagnostic studies. The
strongest correlation with nerve conduction studies is
taken from the history, that is, radial hand paresthe-
sia and nocturnal exacerbation of symptoms.38 Bland,
in the preceding citation, demonstrated that a single-
page questionnaire was almost as accurate and more FIGURE 29–8. Modified Phalen test. A compressive force is
sensitive than the commonly used Phalen test and applied to the wrist held at 60 degrees of flexion.
“much more accurate” than eliciting a Tinel sign.
Megele demonstrated 64% sensitivity for Tinel sign in pelvic obliquity or tilting, deformity, or muscle wast-
CTS in another study.39 The usual sensitivity for this ing. Asymmetry of the pelvis could indicate spinal
sign averages around 65%.40 Interestingly, the flick sign scoliosis, short leg, an adduction, abduction, or ro-
showed higher degrees of sensitivity for CTS than did tational deformity, or a functional deformity. Gluteal
the other provocative maneuvers,37,39 again indicat- muscle wasting can be secondary to infection, disuse,
ing that history is more reliable than provocative ma- polio, or pelvic girdle atrophy, suggesting myopathy.
neuvers in diagnosing CTS without nerve conduction Also, consider that an increased lumbar lordosis could
study. The flick sign is described by the patient when be secondary to a flexion contracture of the hips. A
asked, “What can you do to make your symptoms go pointing sign may be elicited by asking the patient to
away?” The patient then demonstrates a flicking or point to the site of pain. With hip joint disease, patients
shaking movement of the hand and wrist. will point to the groin.
There are several different provocative maneuvers Next, observe the hips from all sides as the pa-
to elicit paresthesia suggesting CTS, including the use tient walks. It is difficult to accurately analyze gait and
of a blood pressure cuff as a tourniquet over the fore- locate sources of abnormal gait patterns. This takes
arm for 1–2 minutes, stretching the median nerve practice and experience. Gait is usually examined as
by dorsiflexing the wrist, direct compression into part of the neurological examination. With regard to
the palm for a minimum of 30 seconds, and having orthopedic problems, pay attention to the stance and
the patient hold a tight fist for 60 seconds. The Phalen swing phases, looking for any changes or differences
test and Tinel sign appear to be the most commonly between sides. Location and causes of pain can often
performed maneuvers for the differential diagnosis of be teased out. Look for and note signs of stiffness,
CTS. The Phalen test is described in various ways by shortening or contracture, and weakness, particularly
different authors but essentially involves some sort of secondary to gluteal insufficiency. Avoid confusing
passive flexion of the wrist, which is maintained for general fatigue or lack of effort with true muscle
60 seconds. The sensitivity for this maneuver runs be- weakness.
tween 10% and 91%.37 Average delay times for symp- Assessing leg-length differences is best done with
toms to occur with the above provocative maneuvers the patient lying supine on the examination table and
can range from 15.7 to 19.5 seconds.39 Anecdotally, assuring a square presentation by making sure the an-
we find that combining 60◦ of passive palmar flexion terior superior iliac spines are at right angles and the
with wrist compression by applying a squeezing force trunk and legs are parallel to the sides of the couch.
from the sides decreases the delay times. Tinel sign is A gross appreciation is obtained by looking at heel
a paresthesia elicited by tapping over the true palmar and medial malleolus symmetry. Any perceived dif-
wrist. One must consider the false positives often ob- ferences should be followed by consideration of il-
tained with these maneuvers. For example, the Tinel iac crest levels. If there is an apparent shortening of
sign can be elicited in the asymptomatic hand in up a limb, place one thumb over each anterior superior
to 45% of the cases (Fig. 29–8).37 iliac spine and hook the fingers around so that the
index finger is on top of the greater trochanters. If
Hip there is a difference in thumb-to-finger distance from
Observation With the patient standing, examine the one side to the other, the problem probably lies below
hip and pelvis from the front, sides, and back. Look for the trochanters.19 Measurements can be made with
a tape measure between the anterior superior iliac flexed knee at a time up toward the chest. Noting
spines and the tips of the medial malleoli, between symmetry of motion is just as important as getting
the umbilicus and the tips of the medial malleoli, or a specific degree measurement. Flexion should be ap-
between the greater trochanters and the tips of the lat- proximately 120 degrees. Internal and external rota-
eral malleoli. However, there is poor reliability with all tion are appreciated with the patient lying supine on
of these methods. Small leg-length inequalities have the examination table with the hip and knee flexed to
always been a great part of the chiropractic culture. 90 degrees and the foot held above the examination
We do not offer a long discussion about this other table. In this manner, external rotation is appreciated
than to note that a large proportion of the population as the examiner moves the foot medially. Internal ro-
has a small degree of leg-length asymmetry, bringing tation is observed as the foot is brought off the exami-
the clinical significance of a slightly shorter leg into nation couch in a lateral direction. In this manner, they
question. should each amount to approximately 45 degrees. In-
To determine whether one femur is shorter than ternal rotation is best observed while the patient is
the other or one lower leg is shorter than the other, prone and the knees flexed up to 90 degrees. The ex-
the knee heights are compared while the knees are aminer then internally rotates both hip joints, making
bent and feet kept flat on the table in perfect align- a V with the knees forming the apex. A comparison
ment. If one knee appears in front of the other, a for symmetry can be made. The range in this position
contralateral shortened femur is suggested. A knee is approximately 35 degrees. Combined movements
that is higher than the other, in this position, suggests can be appreciated by having the patient cross an an-
lower leg shortening. The femur and tibia can be di- kle over the contralateral shin and bringing the knee
rectly measured if this is the case. Length of the femur back as far as possible. This will induce full external
is measured from the greater trochanter to the lateral rotation of the ipsilateral hip. Adduction and abduc-
knee joint line. The tibia is measured from the me- tion are appraised while the patient is supine. For test-
dial knee joint line to the tip of the medial malleolus. ing abduction the examiner should stabilize the pelvis
Radiographic methods of measurement are, of course, by holding down over the patient’s contralateral an-
more accurate. terior superior iliac spine. During adduction the ipsi-
lateral pelvis should be stabilized in a similar fashion.
Palpation Palpation of the hip and pelvis is conducted The full arc is observed as the patient moves the fully
in all four quadrants: anterior, posterior, medical, and adducted straight leg over its partner into full abduc-
lateral. Note any areas of tenderness. For instance, tion. The arc is approximately 65 degrees with approx-
tenderness directly over the greater trochanter is a imately 25 degrees taken up by adduction. Extension
sign of bursitis. However, if the tenderness is diffuse, is best done while the patient stands or lies prone.
involving the tensor fascia lata muscle and iliotib- Normal motion ranges between 10 and 20 degrees. A
ial tract, an iliotibial tract friction syndrome is sug- unilateral loss of extension may be the first detectable
gested. Tenderness over the posterior aspect of the sign of hip joint effusion.19 If there is a loss of move-
greater trochanter more likely means a tendinitis of ment, the examiner must determine whether it is sec-
one of the external hip rotators. Inguinal and femoral ondary to a fixed deformity or a contracture. If the
lymph nodes should not be overlooked. Tenderness hip is held in flexion and a deformity is established, it
and a mass or swelling over the inguinal ligament is noted as fixed-flexion deformity. As with all gross
may mean a hernia, but this is best evaluated with the joint movements, be cognizant of the various causes
male patient standing and palpation of the inguinal for loss of movement. Pain and patient effort may be
ring performed through the scrotal sac. The adduc- the only causes for a perceived loss. For the reasons
tor longus muscle and insertion of the iliopsoas mus- noted in previous sections, all ranges should be exam-
cle at the lesser trochanter can be palpated with the ined actively and passively.
knee slightly flexed and hip externally rotated and ab-
ducted. Tenderness in these areas is most commonly Provocative Tests The hip examination is a very impor-
secondary to an adductor strain or iliopsoas tendini- tant part of the pediatric orthopedic examination. The
tis. With the patient lying on the side, the contralateral pediatric orthopedic examination is a specialty and
hip and ischial tuberosity can be palpated. Tenderness beyond the scope of this chapter. However, because
over the ischial tuberosity could indicate a bursitis or congenital hip disease or dysplastic hips may remain
a hamstring tendinitis. undiagnosed until adulthood with an average age at
diagnosis of 34.5 years,41 examination of an unstable
Movement Movement can be appreciated grossly or neonatal or infant hip is worthy of mention. There are
measured directly by several methods with goniome- a number of methods to clinically stress the infant hip.
ters or inclinometers. To get an appreciation of hip The Ortolani test and Barlow test are the two tests that
flexion, the patient, while lying supine, brings one appear to be most commonly taught in undergraduate
programs and discussed in the orthopedic pediatric bar spine extended or arched while lying supine on
literature. Neither test, however, can be relied upon the examination table. A fixed-flexion deformity or
to detect neonatal hip instability unless a dislocated contracture of a hip can be teased out by passively
hip is present at the time of the examination.39 The and fully flexing the contralateral hip by bringing
ability to perform these tests and to accurately de- the flexed knee to the chest. This is accomplished as
tect an unstable hip greatly depends on education and the patient lies supine on the examination couch and
experience. keeps the other leg fully straight. If the problem ex-
The Ortolani test must be carried out on a relaxed ists, the leg on the side of the involved hip, that is, the
child.19 While the infant lies supine, flex the knees by hip lying on the table, will either rise or the knee will
grasping them and flexing the hips to 90 degrees while begin to flex. This is reported to be very reliable even
smoothly and gently abducting each hip. This is ac- if both hips are affected.3
complished as the examiner applies gentle downward Hugh Patrick, a neurologist, described a test he
pressure. A click may be heard or a jerk felt at almost called fabere sign for the motions simultaneously tested
full abduction (almost 90 degrees), as the femur moves at the hip, that is, flexion, abduction, external rota-
out of its normal relationship with the acetabulum.19 tion, and extension. It has become to be known by this
Restriction of abduction may indicate an irreducible name as well as by Patrick test, sign-of-four, and crossed-
dislocation.19,42 leg test. The examiner places the lateral malleolus of
The Barlow test is done to assess for possible in- each ankle alternately on the supine patient’s oppo-
stability if the Ortolani test is unproductive. It is ac- site knee while applying gentle downward pressure
complished by attempting to subluxate or dislocate on the flexed knee. Pain and range of motion are ob-
the hip while stabilizing the infant’s pelvis by grasp- served and recorded. Patrick felt that pain of the hip
ing the sacrum and pubis with one hand and apply- appreciated under the inguinal ligament was a sign of
ing firm backward pressure with the other. The exam- hip arthritis, that is, degenerative hip disease. How-
iner applies backward pressure by grasping each hip ever, this test may also elicit pain in a variety of con-
separately with the thumb placed over the anterome- ditions, including avascular necrosis. The location of
dial aspect of the hip. If subluxation is achieved with the provoked pain gives a clue regarding the prob-
the Barlow method but not with the Ortolani method, lem. Pain at the sacroiliac joint may suggest anything
check weekly. Reduction is accomplished by revers- from sacroiliitis to a sprain; gluteal pain may suggest
ing the movement. Instability persisting for 3 weeks tendinitis or a strain of the gluteal muscles or external
or more should be investigated with diagnostic imag- hip rotators. Pain over the greater trochanter suggests
ing and the hip then splinted.3,19 tendinitis or bursitis. Further compression of the hip
The Trendelenburg sign or test can be observed with- joint can be reinforced by exerting a compressive pres-
out provocation during gait. To closely evaluate the sure through the long axis of the femur at the flexed
possibility of this sign, have the patient stand, without knee, forcing the hip against the acetabulum.
assistance, on each leg separately, while lifting the con-
tralateral knee to approximate 90 degrees. Normally, Knee
the hemipelvis of the lifted leg will elevate, tilting the Observation Swelling, effusion, alignment, and defor-
pelvis toward the weight-bearing leg secondary to mity are best observed during weight bearing fol-
gluteus medius and minimus activity. The patient lowed by a supine non-weight-bearing position on the
should be able to hold this position for 30 seconds. examination table. Swelling confined to the synovial
The test is considered “positive” if the hip of the lifted cavity and suprapatellar area suggests joint effusion,
leg drops. This can occur as a result of gluteal weak- hemarthrosis, and pyarthrosis. If the swelling extends
ness or paralysis secondary to myopathy, nerve injury, beyond the joint capsule, there should be a concern for
or polio, or as a consequence of gluteal inhibition sec- infection, tumor, or major bony injury. Fracture must
ondary to chronic pain, or hip disease, for example, be considered if ecchymosis is present. Obliteration
coxa vera, dislocation, and severe degenerative hip of the lateral patella hollows may be the first sign of
disease.3,19 Be cautious of false positives that can oc- effusion.19 Commonly, however, most swelling is not
cur if there is a proprioception or balance problem and secondary to joint effusion but is a result of focal prob-
the patient cannot maintain the one-leg stance or in an lems such as infrapatellar bursitis, prepatellar bursitis,
athlete secondary to hip abductor fatigue. anserine bursitis, meniscal cysts, and popliteal ten-
The Thomas test was first described by Hugh dinitis leading to a Baker cyst.
O’Thomas in 1876 to assess the hip for a fixed-flexion Valgus and varus deformities are best seen with
deformity.3 It can also be used as part of the functional the patient standing. A meterstick, yardstick, or tape
examination to assess for a capsular hip pattern or ex- measure starting at the midpoint of the inguinal liga-
ceptionally tight quadriceps muscles. The patient may ment, that is, the hip, should pass straight through
“hide” a fixed-flexion deformity by keeping the lum- the midpoint of the knee and ankle to the second
metatarsal. Of historical interest: Varus was a Ro- Focal tenderness over the tibial tubercle could mean
man general famous for being knock-kneed. Valgus Osgood-Schlatter disease in children, or in adults, it
is the Latin word for bowlegged. The meanings of the could mean anything from tendinitis to avulsion frac-
words, as anatomical descriptions, have been reversed ture. Locate any areas of swelling. Pay attention to
through time. surface temperature of the skin. A warmer area over
Inspect the quadriceps muscle group, especially one knee when compared to the other suggests in-
noting any signs of muscle wasting, loss of bulk, or flammation or, possibly, infection.
asymmetric muscle development. Muscle tone should Gently grasp the skin and connective tissue above
also be observed under contraction. If the foot is in- the patella, that is, quadriceps tendon, and pull up.
verted during quadriceps contraction, the vastus me- This allows an assessment of the synovial mem-
dialis muscle becomes prominent and loss of tone to brane in the suprapatellar pouch. In chronic in-
this muscle, important to patella stability and align- flammatory conditions such as rheumatoid arthritis
ment, can be easily seen. If the patella rides higher and villonodular synovitis the synovial membrane is
than normal in relation to the joint line, it may thickened.19 Small amounts of effusion (<10 mL) may
mean patella alta, patellar fracture, ruptured patel- be detected by moving the fluid into the opposite knee
lar ligament, or avulsion of the tibial tubercle. How- gutter with stroking movements of the hand. This is
ever, great consideration must be given to anatomical considered to be more reliable than the patellar tap test
variations before reaching a conclusion. If the patella where the patella is tapped or pushed against the fe-
does not move superiorly, as it normally should with mur to push fluid up into the suprapatellar pouch.3
quadriceps contraction, confirm tendon rupture by The fluid displacement test is completed by first push-
placing an index finger along the upper border. In ing any fluid present in the suprapatellar pouch down
this condition there should be loss of normal soft- and then stroking the medial side of the knee to ex-
tissue resistance.19 Also, look for any asymmetric press any fluid in the main joint into the lateral aspect.
gaps around the patella suggesting other ligament This is then followed by stroking the lateral aspect
disruptions. while watching for a fluid bulge to appear over the
The Q-angle, or quadriceps muscle angle, has been medial aspect of the knee. The popliteal fossae should
suggested as an important measurement in evaluating not be overlooked. Palpate each fossa first with the
knee pain secondary to knee and lower extremity kine- knee flexed and then with the knee extended. When
matics, including overpronation of the ankles. It is the knee is flexed, the roof of the fossa is relaxed and
measured by drawing two bisecting lines. The first deep palpation is possible. With the knee extended,
line connects the anterior superior iliac spine to the the semimembranosus bursa can be observed and pal-
midpoint of the patella. The second line connects the pated. Popliteal tendinitis, Baker cyst, semimembra-
midpoint of the patella to the tibial tubercle. The angle nosus bursitis, and other masses must be considered
is defined as the acute angle formed between these two in the differential diagnosis of posterior knee pain.
bisecting lines. There are gender-based ranges, with
females showing slightly larger Q-angles than males. Movement You can get an appreciation of full exten-
Normally, Q-angles range from 11 degrees to 18 de- sion by having the sitting or supine patient straighten
grees but, generally, a Q-angle of less than 15 degrees the knees. Full extension is recorded as 0 degrees with
is judged to be optimal. Q-angles greater than 15 de- any loss of full extension noted as x degrees of flex-
grees are considered to be predictors of knee problems ion deformity. Be cautious however, and first exam-
secondary to poor lower extremity kinematics. How- ine the movement passively before making a conclu-
ever, in at least one study, no correlation was found sion regarding a flexion deformity. Knee extension
between greater than normal Q-angles and lower ex- may be limited secondary to patient effort because of
tremity kinematics in runners.43 pain or joint effusion. There may also be a limitation
secondary to a bucket handle meniscus tear, which
Palpation If the patient complains of knee pain, try to may be appreciated by a springy end feel block.19 A
reproduce it by palpating all anatomical landmarks, rigid block to full extension may mean a fixed-flexion
such as patellae, condyles, and epicondyles, as well deformity.19 If there is limited extension that is not
as the soft tissues, that is, muscles, tendons, and liga- caused by a fixed-flexion deformity, record it by in-
ments. Consideration must be given to osteochondri- dicating how many degrees of extension to 0 the pa-
tis desiccans, most commonly involving the medial tient lacks. Extension beyond 0 degrees that is seen
femoral condyle.19 Fractures, ligamentous ruptures while the patient stands, or that is accomplished by
such as the medial collateral ligament, and tendini- the examiner passively during the supine examina-
tis or bursitis must be considered. Joint line tender- tion, is defined as genu recurvatum. If this is severe,
ness is nonspecific and could be present in everything examine the knee and other joints in consideration of
from degenerative joint disease to a torn meniscus. joint laxity for the rare Ehlers-Danlos syndrome. Mild
hyperextension is more common in girls than boys is applied to the proximal leg as the knee is fully ex-
and recorded as x degrees of hyperextension. Flexion tended and to the lateral joint line as the knee is held at
can be measured in degrees starting from 0 degrees 30 degrees.
during full extension while the patient lies supine on Stressing the cruciate ligaments tests the stability
the examination couch and the examiner supports the of the knee in an anterior-to-posterior plane. The tests
thigh. In this way, normal flexion can range up to must be done bilaterally to compare any unphysio-
165 degrees, but 135 degrees is considered normal. logic excursion between the limbs. Increased passive
Another method of recording knee flexion is to note movement may be subtle. If the injury is minor, a bi-
the heel-to-buttock distance in the prone patient (1 cm lateral comparison is the only way to tease it out. The
approximately = 1.5 degrees).19 This method is useful tests can be done at a variety of knee flexion angles,
for detecting small differences, and hopefully clinical that is, 90 degrees to 70 degrees, as the patient lies
improvement, during a treatment program. supine on the examination couch or sits with legs dan-
gling off the side of the couch. We could not find any
Provocative Tests The knee is another joint for which recent studies definitively supporting one approach
a plethora of provocative maneuvers have been de- over another based on sensitivity or specificity.
scribed. Much can be gained clinically by simply ob- The anterior drawer test is accomplished by sharply
serving, palpating, and passively moving the knee pulling forward on the leg while grasping it proxi-
joint through ranges of motion and applying com- mally below the knee joint. If the maneuver is per-
mon sense gained through anatomical knowledge and formed with the patient lying supine, the foot is fixed
clinical experience. Essentially, provocative maneu- by the examiner sitting on it, the knee is flexed to
vers can be divided into two types. First are those 90 degrees, and care is taken to ensure that quadri-
maneuvers that stress the joint and its connective ceps and hamstring muscles are relaxed. Normally,
tissues to reveal instability caused by overstretched there should not be any excursion of the tibia. The test
or torn ligaments. Second are those maneuvers that is considered remarkable if there is 1 cm or more of
stress, compress, or place the joint in a compromis- anterior excursion. If there is this amount of displace-
ing position in an attempt to identify internal and ment, a torn anterior cruciate is most likely. One false
external derangement. Lateral, medial, anterior, and positive of concern occurs with a ruptured posterior
posterior instability of the knee may range from sub- cruciate ligament. In this case, if there is a posterior
tle to frank. There are four check ligaments that can displacement of the tibia as compared to the femur,
be injured, or sprained, to an extent that produces the forward excursion may simply be movement back
instability and pain. The collateral ligaments cover to a normal anatomic position and not secondary to
the medial and lateral joint surfaces, providing lat- an anterior cruciate tear. The anterior drawer test can
eral or side-to-side support. Two internal cruciate liga- be reinforced by externally rotating the leg by 15 de-
ments provide anterior-to-posterior and posterior- grees and then internally rotating by 30 degrees. At
to-anterior support. When evaluating a knee for 15 degrees of external rotation, a degree of rotational
instability, start slowly by using maneuvers that, at instability can be detected, thus suggesting disruption
first, gently stress the joint in the direction of clinical of not only the anterior cruciate but also the medial
concern. collateral ligament. With the knee rotated internally to
There are various forms of valgus stress testing. In- 30 degrees by applying a rotational force at the ankle,
stability of the medial collateral ligament is first eval- anterolateral stresses are introduced and increased ex-
uated by attempting to abduct the leg while slowly cursion suggests involvement of the posterior cruciate
extending the knee fully. If the medial collateral lig- as well as the anterior cruciate. A variation of this test
ament is ruptured, the medial joint space will open with internal rotation is the pivot shift test.3 It is per-
up, the leg will move into valgus, and there will be formed when a combination of valgus strain, internal
quite a bit of apprehension and pain. Severe valgus rotation, and forward pressure on the tibia is applied
may indicate cruciate ligament rupture as well.19 If as the knee is flexed and extended.
this method fails to demonstrate instability, bend the Variations of the anterior drawer test are the
knee to approximately 30 degrees and while holding Lachman tests.19 There are two forms. The first test, the
the ankle, press against the lateral joint line, attempt- manipulative Lachman test, is completed passively. The
ing to open up the medial joint. As with all provoca- second form is an active test, hence the name active
tive tests, it is imperative that you compare sides be- Lachman test. The manipulative Lachman test is similar
cause some opening of the joint is normal. Varus stress to the anterior drawer test, completed on the supine pa-
testing evaluates the lateral collateral ligament by at- tient but with the knee flexed to 15 degrees and the fe-
tempting to produce a varus deformity. The tests are mur stabilized by the examiner grasping it distally as
carried out in the same way as those for valgus stress the tibia is brought forward. Excursion of the tibia with
testing but, for varus stress testing, medial pressure a spongy end feel, detected by placing the thumb in
the anterior joint line, is a clinically significant finding companied by crepitus, suggests a problem with the
suggesting a torn anterior cruciate ligament. The active articular cartilage. This can be reinforced by having
Lachman test is accomplished with the knee flexed at the patient contract the quadriceps muscle as down-
30 degrees and supported by a pillow under the joint. ward pressure is applied to the patella. Marked pain
The patient is asked to extend the leg. Viewed from the is seen in conditions such as chondromalacia patellae
medial side, if positive, there will be anterior sublux- and retropatellar osteoarthritis.
ation of the tibial plateau as the quadriceps contracts Internal knee joint syndromes secondary to dam-
and posterior subluxation as it relaxes. This maneu- aged or torn menisci can be established with a num-
ver can be reinforced by applying resistance at the ber of different diagnostic manipulative maneuvers.
ankle. It is important to have an appreciation of the anatomy
The posterior drawer test is accomplished in a simi- of these fibrocartilaginous pads. The semilunar me-
lar manner to the anterior drawer test. The difference dial meniscus is thinner and narrower anteriorly while
is that posterior pressure is applied to the proximal thicker at the posterior horn. The anterior and poste-
tibia to observe posterior excursion of the tibia, indi- rior horns are attached to the intercondylar eminence
cating a torn posterior cruciate ligament. Variations and have an additional attachment by a small slip of
of this test and other signs can clarify the diagno- tissue from the posterior horn to the posterior cruci-
sis. One variation is the quadriceps active test. With this ate ligament. The peripheral circumference is firmly
maneuver, the patient is supine and the knee flexed to attached to the tibial plateau by the coronary ligament
90 degrees. The examiner supports the thigh with one and the posterior oblique ligament. The lateral menis-
hand and stabilizes the patient’s foot with the other cus is more circular and uniform in width than the
hand. While watching the flexed knee, have the pa- medial meniscus. The anterior and posterior horns of
tient push the foot forward attempting to slide it down the lateral meniscus also attach to the intercondylar
the table surface. If there is a ruptured posterior cru- eminence with close proximity to the anterior cruci-
ciate ligament, there will be anterior displacement of ate ligament but have no attachment to any structure
the tibia as the quadriceps contracts. Reportedly, this in the popliteal hiatus or lateral collateral ligament.
test has a 98% sensitivity without any false positives in Both menisci have accessory ligaments present in a
normal knees or knees with confirmed anterior cruci- large proportion of the population. The menisci are
ate rupture.14,44 extremely important to knee joint health and function.
Sometimes, the diagnosis of posterior cruciate lig- They are responsible for stability, load transmission,
ament rupture can be made on observation alone. This shock absorption, and joint lubrication. It is important
can be done when a posterior sag sign is observed. With to note that they are essentially avascular and hence
the patient supine and the thigh supported by the ex- heal poorly.
aminer’s hand or a pillow and the knee flexed at ap- Diagnosing meniscal lesions without immediate
proximately 20 degrees, rupture of the posterior cru- benefit of MRI examination or arthroscopy is challeng-
ciate ligament will cause the tibia to subluxate back- ing and depends on the examiner’s skill, knowledge
ward when gentle backward pressure on the anterior base, and experience. Following significant trauma,
proximal tibia is applied.19 This maneuver can also be a pop or clunk may or may not be felt or heard
done with the hip and knee flexed to 90 degrees. The as the knee is taken through ranges of motion. Ef-
examiner supports the leg at the ankle and observes fusion may be present but the extent varies widely.
for any posterior excursion of the tibia. The sign can Often there is only a focal bogginess appreciated by
still be observed even if the patient does not fully relax the examiner.3,19,45 A number of provocative tests are
the thigh muscles because the hamstrings tend to pull described in the orthopedic literature. However, no
the tibia backward.3 single test has been found sensitive or specific.42
The patella may also be unstable with a tendency to Therefore, by performing several maneuvers in com-
subluxate or dislocate secondary to a previous injury bination, the clinical diagnostic accuracy may in-
of the attached muscles and tendons. The apprehen- crease. Clinical diagnosis has been found to be more
sion test is an attempt by the examiner to produce the sensitive for medial meniscus lesions than lateral
sensation in the patient that the patella is about to dis- meniscus lesions.45
locate. It is performed while the knee is kept in slight There are actually two McMurray tests, one for
extension and the examiner manipulates the patella the medial meniscus and a variation for the lateral
in all directions. If there is a tendency to recurrent meniscus.19 The maneuver to test the medial meniscus
dislocation, the patient will display great apprehen- is performed with the patient supine on the examina-
sion as a sense of dislocation is realized. Along with tion couch and the hip flexed to 90 degrees. The exam-
this maneuver, the examiner can assess the patella by iner’s thumb and index finger are wrapped along the
pressing it against the femur and slightly grinding joint line with the index finger placed along the medial
it. The reproduction of pain, usually sharp and ac- joint line. The knee is passively flexed and extended
while the leg is abducted and the foot externally ro- given to ganglions arising from the pes anserine in-
tated during the flexion phase. A pop, click, or clunk sertion when medial masses are found.19
heard or felt along the medial joint line when accom-
panied by pain is suggestive of a tear of the medial Ankle and Foot
meniscus.3,19,45 The examiner must be cautious of false Observation Evaluation of the foot and ankle can be
positives. McMurray, in 1942, noted false positives of placed into three categories: acute injury, chronic
clicks with this maneuver in absence of tears. These problems including pain and instability, and func-
clicks are not accompanied by pain. To test the lat- tional or biomechanical approach. This section con-
eral meniscus, the test is repeated but with the leg centrates on the first two categories, leaving the third
adducted and the foot internally rotated during the for other authors and forums. The ankle is the most
flexion phase.19 The pop, click, or clunk heard or felt commonly injured joint complex in the body, account-
and the pain experienced by the patient is, of course, ing for 10% of all emergency room visits.46,47 The
perceived on the lateral side. majority of these injuries are sprains.48 With this in
The Steinman test produces joint line pain and, pos- mind, the examiner should look for swelling and ec-
sibly, a clunk when the tibia is rotated internally and chymosis but keep in mind that these signs may be-
externally.45 During the maneuver the patient sits at come less prominent with time. Ecchymosis, espe-
the end of the examination couch with the lower legs cially when extensive, suggests fracture that cannot
dangling over the side, that is, knees at 90 degrees. be ruled out without an x-ray examination. Of course,
The patient must keep the legs relaxed during this the history of the complaint will dictate the specifics
diagnostic manipulative procedure. of the examination. Signs of edema must be differen-
The Apley test, sometimes called the Apley grinding tiated from swelling. Swelling may progress to edema
test, is performed with the patient prone on the examin the injured ankle with time; however, edema may
ination table.3,19,45 The thigh stays on the couch and also mean a systemic disease, especially if pitting is
the leg is brought up so that there is a 90-degree angle present. Signs of swelling and ecchymosis will drift, as
at the knee. The examiner internally and externally ro- they are gravity-dependent. Therefore, the examiner
tates the tibia by grasping the heel and simultaneously must be aware of this pathophysiologic fact and con-
applying downward axial pressure through the leg sider a more proximal site of injury. Diffuse swelling
into the knee. This test has also been described with or edema can often be seen in chronic problems such
the examiner stabilizing the patient by placing a knee as in the poorly resolved ankle sprain.49 Wounds
on the posterior thigh.45 Sharp pain experienced by with skin puncture may indicate open fracture. Frank
the patient is suggestive of a meniscal tear, that is, ligament rupture is often evident as a bulge or mass.
medial meniscus during external rotation and lateral Rapid swelling within 2 hours of injury and an egg
meniscus during internal rotation.19 shape over the lateral malleolus suggests complete
If a meniscal tear is suspected, MRI examination rupture of the lateral ligament.19 Achilles tendon rup-
should be completed, because plain radiographs are ture is evident as a lump or mass, often at the distal
not helpful. However, there is some controversy re- gastrocnemius.
garding the need for MRI examination if arthroscopic Trophic changes may be present either in the
surgery will be performed anyway. It is our experience acutely injured foot and ankle or in the patient present-
that this thought varies among orthopedic surgeons to ing with a chronic problem. Therefore, careful inspec-
whom we have referred patients for further evaluation tion of signs not suggestive of acute injury must take
or treatment. The primary argument against immedi- place. For example, skin ulcers, cyanosis, and signs
ate arthroscopic surgery is its invasive nature. MRI ex- of gangrene could mean diabetes or peripheral vas-
amination has accuracy rates between 90% and 98%, is cular disease. Do not overlook the state of the nails.
noninvasive, and has a very high negative predictive Any asymmetry and deformity should be noted and
value, although false positives have been reported.45 described. This could include significant differences
There are different MRI scans that can be ordered, in size, shortening, and angulation. Deformities may
including fat-suppression techniques, gradient recall be congenital or acquired. The most common defor-
acquisition in the steady state (GRASS), and three- mity is the adducted forefoot or metatarsus adduc-
dimensional Fourier transform imaging, that may in- tus, seen in early childhood.3 Other deformities in-
crease the diagnostic yield. clude congenital talipes equinovarus, or clubfoot, and
Meniscal cysts are another problem that must be equinus deformity, where the heel does not touch the
considered in patients with knee pain. They gener- ground. More common in adults are hallux valgus and
ally lie in the joint line and can be felt as firm, tender hammertoes.
masses on palpation. They are sometimes associated
with meniscal tears.19,45 Lateral cysts are more com- Palpation Palpation should not be limited to the area of
mon than medial cysts. Consideration must also be complaint or injury, but should include all soft tissues,
joints, and bones of the foot and ankle. There is always performed with the patient supine on the examina-
the possibility of concurrent injury, such as fracture tion couch. Similar to drawer tests in the knee, the
of the proximal fibula with extensive disruption of examiner attempts to pull the foot up or forward with
the interosseous membrane and ligaments, that is, the a hand grasping the heel while the other hand sta-
Maisonneuve fracture.47 In this case, the distal dam- bilizes the distal anterior lower extremity. Anterior
age may be missed if careful palpation distal to the ob- translation, or laxity of the foot, or talus subluxation
vious injured site is not undertaken. In chronic condi- is assessed and a bilateral comparison made. There
tions, palpation can be conducted in an orderly global are differences reported in the literature as to what
pattern that is not always possible in the acute injury. constitutes a remarkable finding. Translations that are
Moving distally, the examiner starts at the distal leg between 2 and 4 mm or more suggest a ruptured
and palpates the malleoli and surrounding area, mov- ATFL.46,47 The examiner may also detect a dimpling
ing to the lateral and medial ligaments and Achilles of the anterior skin on the affected side called a suc-
tendon, and continuing into the foot, plantar, and dor- tion sign.46 Varus and valgus stress testing can also be
sal aspects. Attention is given to bones, joints, and carried out, as in the knee, by passively manipulating
soft tissues, including the plantar fascia, because plan- the foot, stressing the medial and lateral sides. A side-
tar fascitis is a common problem. The tibiofibular lig- to-side comparison is usually essential to appreciate
ament is approached anteriorly. It has anterior and focal laxity.
posterior attachments, but elicited tenderness tends Integrity of the syndesmotic ligaments, the ante-
to be just over the ankle joint line.19 If the talus can rior and posterior talofibular ligaments, the inferior
be moved laterally while the heel is grasped and lat- transverse ligament, and the interosseous ligament
eral displacement produced, a tibiofibular tear is the can be appreciated by squeezing the patient’s tibia and
cause.19 Tenosynovitis can occur at several locations fibula at a point 15–20 cm (6–8 inches) below the knee.
in the ankle and foot. Signs of local swelling, tender- This maneuver, sometimes referred to as the squeeze
ness, and thickening, when linear, indicate the condi- test, is considered to be suggestive of injury to the
tion. Common sites include the long flexor tendons syndesmotic ligaments if marked pain is produced in
behind the medial malleolus and peroneus tendon the ankle.46
behind the lateral malleolus. Forcing the foot into Rupture of the Achilles tendon is usually seen
the end ranges of motion and producing pain along as described above in the observation section. The
these tendons suggest tenosynovitis when the palpa- Thompson test is also used to evaluate this possibility.
tory findings are present, that is, plantar flexion and The examiner simply squeezes the patient’s midcalf.
eversion for flexor tendons and plantar flexion and Normally, this pressure causes plantar flexion of the
inversion for the peroneus tendon. foot. If the Achilles tendon is ruptured, the foot will
not plantarflex.19,46
Movement Ranges of motion should be examined ac- A test that has shown some predictive reliability
tively and passively. In acute injury, care must be taken in chronic problems, primarily instability following
not to cause further damage and it must be determined lateral ankle sprain, is a deficit in balance.50 Along
that the ankle is mobile. As always, compare sides for with examinations of joint position sense, distal mo-
asymmetry. Grossly, the ankle should move through tor, sensation, and ranges of motion, assessing one-
approximately a 60–70-degree arc of full dorsiflexion leg-standing time with eyes open and closed helps
to full plantar flexion, with the majority of movement in diagnosing a functional instability. Objectively, the
taking place in plantar flexion. Measured with a go- test is best done on a force platform. Comparisons are
niometer, there should be approximately 15–20 de- made between the problematic or injured ankle and
grees of dorsiflexion.19,46 Plantar flexion averages the uninjured ankle because definitive times for one-
55 degrees. Inversion and eversion, performed ac- leg standing have not been established.
tively, ranges from 10 degrees to 25 degrees.19,46,47 If
dorsiflexion is restricted, try having the patient bend
CONCLUSION
the knee. If there is a greater range, the perceived lim-
itation was probably secondary to tight calf muscles. We have presented methods of orthopedic examina-
Movement should be checked passively as well. Pain tion and offered some thoughts on the interpretation
elicited at end-points of movement may indicate a and evaluation of diagnostic manipulations. The key
damaged ligament. to improving diagnostic yield appears to lie in the
experience of the clinician and the clinician’s ability
Provocative Tests Provocative tests in the foot primar- to use critical thinking. There is also an undefined
ily stress ligaments and tendons.46 The anterior drawer element, or intuition, that some clinicians use to ar-
test challenges the integrity of the anterior talofibu- rive at the right answer. This may be most obvious in
lar ligament (ATFL). This diagnostic manipulation is the decision process chiropractors use when deciding
where and how to perform an adjustment or manipu- niometers, inclinometers, or other devices. Provo-
lation. The analytical methods chiropractors use have cation of signs and symptoms is accomplished by
been difficult to validate when studied in a reduc- performing tests that have demonstrated the abil-
tionistic model. However, chiropractors appear to use ity to achieve specific results in given conditions.
methods that take into consideration a number of clin- 4. An orthopedic differential diagnosis is based on a
ical facets and diagnostic clues, often ones that have clinical history, including a description of the chief
proven difficult to define or teach. complaint, its etiology, characteristics, and aggra-
Our observations have lead to the conclusion vating and relieving factors; carefully consider as-
that many chiropractors, especially students and new sociated symptoms, relevant medical history, and
graduates, often approach the orthopedic examina- anything that comes to light in the review of sys-
tion as an arithmetic problem, that is, an addition of tems, as well as any findings elicited in the pro-
“positive” tests. The application of critical thinking is cess of the orthopedic examination. A thorough
then lost along with an ability to integrate all aspects understanding of the clinical presentation, includ-
of a case. This results in inaccurate and, possibly, ining responses to provocative testing, of the various
correct diagnoses. The astute clinician must appreci- orthopedic conditions is essential in formulating a
ate all factors of a problem, including patient history, differential diagnosis.
history of the complaint, psychology of the patient, 5. Provocative tests possess inherent limitations,
anatomy, physiology, and pathology. It is less impor- which may be expressed in terms of sensitivity,
tant to memorize a plethora of test names than to un- specificity, and efficiency. Sensitivity refers to the
derstand each presenting problem through a broad ability of a test to provoke a positive finding in
and deep knowledge base of anatomy and physi- someone with a condition the test aims to detect.
ology, coupled with the experience of seeing many Specificity refers to the ability of a test to pro-
problems that have confirmed diagnoses. This allows voke a negative finding in someone who does not
the integration of diagnostic maneuvers or tests with have a condition the test aims to detect. Efficiency
these factors to increase the accuracy of the working is a combination of sensitivity and specificity and
diagnosis. refers to the ability of a test to arrive at a correct
answer (i.e., positive when a condition is present,
negative when a condition is absent).
SUMMARY
1. Orthopedics became a special interest of chiroprac-
tors in the United States as an attempt to improve QUESTIONS
the musculoskeletal examination skills of practi-
1. Define sensitivity, specificity, and efficiency.
tioners. The orthopedic examination is based on
2. Which provocative maneuver has the greatest sen-
the principle that the musculoskeletal system re-
sitivity for the diagnosis of cervical radiculopathy
sponds in a predictable way and that accurate test-
secondary to lateral disc prolapse?
ing and observation of the musculoskeletal will
3. Which sign has a positive value greater than a
assist in arriving at a diagnosis.
straight-leg-raising test for a lumbar disc prolapse?
2. A thorough case history is essential in formulat-
4. Which sign or test has the highest predictive value
ing an accurate working diagnosis because 82% of
for carpal tunnel syndrome?
diagnoses are made from the case history alone,
A. Phalen test
while 9% are arrived at through examination and
B. Tinel sign
9% by laboratory investigations. It is essential to
C. Flick sign
obtain a case history prior to beginning the ortho-
D. Finkelstein test
pedic examination to provide a focus to the ex-
5. The anterior drawer test for the ankle challenges
amination and a framework for understanding its
the integrity of which ligament?
results.
A. Anterior talofibular ligament
3. An orthopedic examination typically consists of
B. Deltoid ligament
observation, palpation, assessment of movement,
C. Calcaneofibular ligament
and provocation of signs and symptoms in the af-
D. Naviculocuneiform ligament
fected area. Observation may be visual with the
naked eye, or aided by various instruments. Pal-
pation is a highly developed skill in chiropractors,
ANSWERS
and depends on experience and a thorough under-
standing of the underlying anatomy. Assessment 1. Sensitivity = true positive + false negative
of movement includes active, passive, and resisted Specificity = true negative + false positive
range of motion, and may be measured with go- Efficiency = All tests (TP+TN+FP+FN)
2. Cervical compression eliciting unilateral arm pain. 5. Shands AR. The early history of orthopedic surgery in
3. Crossed straight-leg raising sign has a 97% predic- Philadelphia. Clin Orthop 2000;374:6.
tive value. Straight-leg raising alone has a predic- 6. Friedenberg ZB. Musculoskeletal surgery in eighteenth
tive value of 64%. century America. Clin Orthop 2000;374:13–14.
4. Flick sign. 7. Wentz DS, Green BN. The evolution of chiropractic or-
thopedists: A bootstrapping of clinical skills. Chiropr
5. Anterior talofibular ligament.
Hist 1995;15(2):93–101.
8. College of Chiropractors. Membership bulletin. Reading,
UK: College of Chiropractors.
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445–450.
Cibulka MT, Koldehoff R. Clinical usefulness of a cluster of
11. Vroomen PCAJ, de Krom MCTFM, Knottnerus JA. Di-
sacroiliac joint tests in patients with and without low
agnostic value of history and physical examination in
back pain. J Orthop Sports Phys Ther 1999;29(2):83–92.
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D’Arcy CA, McGee S. Does this patient have carpal tunnel
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12. Vroomen PCAJ, de Krom MCTFM, Knottnerus
Deville WLJM, van der Windt DAWM, Dzaferagic A,
JA. Consistency of history taking and physical
Bezemer PD, Bouter LM. The test of Lasègue. Systematic
examination in patients with suspected lumbar nerve
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root involvement. Spine 2000;25(1):91–97.
Spine 2000;25(9):1140–1147.
13. Thimineur M, Kaliszewski, T, Sood P. Malingering
Hertel J. Functional instability following lateral ankle
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Hudgens WR. The crossed straight leg raising test. N Engl J
2000;64(7):399–401.
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14. Sapira JD. The art and science of bedside diagnosis.
Litaker D, Pioro M, El Bilbeisi H, Brems J. Returning to the
Baltimore: Munich, Urban and Schwarzenberg,
bedside: Using the history and physical examination to
1990.
identify rotator cuff tears. J Am Geriatr Soc 2000;48:1633–
15. Hammer, WI. Functional soft tissue examination and
1637.
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McRae R. Clinical orthopedic examination, 4th ed. New York:
Churchill Livingston, 1997.
16. Leadbetter WB. An introduction to sports-induced
Mimori K, Muneta T, Nakagawa T, Shinomiya K. A new pain
soft-tissue inflammation. In: Leadbetter WB, Buckwal-
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Munich, Urban and Schwarzenberg, 1990.
17. Rothman ER, Greenstein GM. Treatment management.
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Ther 1998;21(4):232–236.
18. Cotran et al., eds: Robbins: Pathological basis of disease.
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Wentz DS, Green BN. The evolution of chiropractic ortho-
20. Olson SL, O’Connor DP, Birmingham G, Broman P,
pedists: A bootstrapping of clinical skills. Chiropr Hist
Herrera L. Tender point sensitivity, range of motion,
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Bailliere Tindall, 1982. 516.
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1993;96:382–386. of the bicipital groove. Arthroscopy 1998;14(8):789–796.
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25. Devillé WL, van der Windt DA, Dzaferagic A, Beze- 37. D’Arcy CA, McGee S. Does this patient have carpal
mer PD, Bouter LM. The test of Lasegue: a systematic tunnel syndrome? JAMA 2000;283(23):3110–3117.
review of the accuracy in diagnosing herniated discs. 38. Bland JDP. The value of the history in the diagnosis
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26. Walsh MJ. Evaluation of orthopedic testing of the low 445–450.
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C H A P T E R
30
MANUAL EXAMINATION OF THE
PATIENT
Donald R. Murphy and Craig Morris
O U T L I N E
INTRODUCTION Push-Up Test
IDENTIFYING THE PRIMARY PAIN GENERATORS Mandibular Movement Pattern Test
Joint Dysfunction Breathing Movement Pattern Test
Muscle Dysfunction Active Straight-Leg Raise Test
Disc Derangement Cervical Stability Test
Neural Tension or Irritation Cervical Flexion Movement Pattern Test
Skin and Subcutaneous Dysfunction Sit-to-Stand Movement Pattern Test for Postural
EVALUATION OF FAULTY MOVEMENT PATTERNS Dysfunction
Modified Hip Extension Movement Pattern Test CONCLUSION
Stepping Test SUMMARY
Hip Abduction Movement Pattern Test QUESTIONS
One-Legged Stand/Squat Test ANSWERS
Revel Test KEY REFERENCES
Shoulder Abduction Movement Pattern Test REFERENCES
have not been tested in this manner. The diagnosis

OBJECTIVES
of a patient should rarely, if ever, be dependent on
1. To discuss broad categories under which many any single test. The patient assessment is a process in
common musculoskeletal complaints may be clas- which, based on the findings of history and exami-
sified, as well as a few of the examination proce- nation, as well as on experienced-based intuition, a
dures designed to detect them. level of suspicion is raised concerning the most impor-
2. To review the concept of movement patterns, as tant factors in the diagnosis. In some cases, the level
well as some of the most common movement pat- of suspicion will be high, based on definitive findings
tern tests. from tests with good reliability and validity. In other
cases, the level of suspicion will be lower, based on less
definitive findings and/or on tests that have a lower
INTRODUCTION
or unknown level of reliability and validity. In either
The purpose of the manual examination is to gather in- case, there will be certain diagnoses in which the level
formation leading to the establishment of a diagnosis of suspicion will be stronger than in others.
of the most important features of each patient’s prob- The suspicion or working diagnosis can then serve
lem. There are a variety of manual methods of vary- as a hypothesis that can be tested with the most im-
ing reliability and validity that can be used to this end. portant diagnostic tool: a trial of treatment. Those
Some of the manual techniques described in this chap- pain generators and key dysfunctions that appear
ter have good reliability and validity, whereas others to be most suspicious can be treated, and the result
have questionable reliability and validity; others still of this treatment monitored. If the desired result (as
593
measured by the manual examination tools presented of interexaminer reliability but reasonable degrees of
here, as well as by questionnaire-based outcome mea- intraexaminer reliability over time. However, most of
surement instruments) is achieved, the diagnosis was the studies performed to date have been fraught with
likely correct. If the initial trial of treatment proves methodological errors. For example, in most of the
unsuccessful, alternative combinations of pain gener- studies that have assessed reliability, movement re-
ators and key dysfunctions must be considered. In this striction was analyzed as an isolated procedure rather
manner, a systematic approach can be taken to diag- than as part of the combination with such findings as
nosis that takes into account the multifactorial nature loss of joint play and pain provocation that is com-
of most pain syndromes, as well as the varying degree monly used in clinical practice.7–15
of reliability and validity of the manual examination The method most commonly used to palpate the
procedures that are available to detect these multiple intersegmental joints of the spine includes a combina-
factors. tion of restriction of joint play and pain provocation
as well as joint motion and position. The palpating
fingers are placed just over the zygapophyseal joints
IDENTIFYING THE PRIMARY PAIN
(z joints) in an area in which avoidance of overlying
GENERATORS
muscle is maximized (Fig. 30–1). The joint is contacted,
Spinal pain syndromes comprise the majority of com- and a gentle but firm pressure applied. Resistance to
plaints in chiropractic practice.1 There are several clin- motion and pain provocation should be assessed, and
ical entities believed to be common pain generators, often, if there is joint dysfunction present, reactive
which can be detected, or at least suspected, by means spasm of the overlying muscle will be felt.
of the manual examination. These entities include Using these criteria, a high level of reliability has
joint dysfunction, muscle dysfunction, internal disc been demonstrated in the cervical spine16,17 and in the
derangement, and neural tension or irritation. lumbar spine.18 In addition, a high degree of sensi-
tivity and specificity has been demonstrated in iden-
Joint Dysfunction tifying a painful segment and in identifying a seg-
Joint dysfunction has been defined as “loss of joint ment at which wasting of the multifidus muscle has
play movement that cannot be produced by voluntary occurred.19–23 In the sacroiliac joints, palpation for
muscles.”2 It is widely believed that joint dysfunction movement restriction, with or without pain provoca-
plays a prominent role in the production and perpet- tion, is reliable24–27 and valid,26,28,29 particularly when
uation of spinal pain, as well as causing “chain reac- multiple tests are used. Reproduction of the patient’s
tions” of dysfunction to occur in areas remote from the pain on palpation of a joint implicates it as at least one,
involved joint.3 That is, joint dysfunction is felt to be if not the sole, pain generator.
both a pain generator and a key dysfunction. Brodeur In most of the studies on reliability of motion pal-
and Delre measured the stiffness at various segments pation, a substantial percentage, and in some cases all,
in the thoracolumbar spine and found that stiffness of the subjects were asymptomatic, thereby reducing
was greater in patients with low back pain than in nor- reliability.7–12,14,15,30,31
mal controls.4 Latimer et al. compared stiffness and It is likely that with repeated palpation, changes
pain provocation to posterior-to-anterior pressure in occur in the tissues around the palpated joint. It is
25 patients with low back pain (LBP) at baseline and likely that irritation to the joints and soft tissues from
after the pain had decreased by 80%.5 They found the palpation itself will produce restriction of mo-
that there was a significant decrease in both mea- tion and tissue texture changes. For this reason, it
sures with decrease in pain intensity. No change was has been recommended that the chiropractic physi-
seen in controls. Interestingly, nine subjects showed cian try to draw conclusions with regard to motion
stiffness improvement on the order of 14–37%. Maher palpation findings without excessively palpating the
et al. showed that trained therapists can detect stiff- patient. Some patients, because of the thickness of the
ness changes that vary by 9%.6 This suggests that these overlying tissues, general stiffness, or other factors,
changes in a patient can, at least some of the time, be are more difficult to palpate than others. This also may
detected clinically. affect accuracy and should be taken into consideration
Traditionally, the primary method of detecting loss with larger patients.
of joint play is motion palpation. A variety of meth- Intraexaminer reliability is greater than inter-
ods of motion palpation have been used, and the lev- examiner reliability.32 There is a high likelihood that
els of ability of those who use motion palpation differ. a doctor will perceive the same findings in the same
This makes studying the general usefulness of this patient when examining the patient on separate occa-
tool problematic. There are several studies that indi- sions. This suggests that the chiropractic physician can
cate motion palpation, at least in the manner in which be confident in the palpatory changes that are found
it was carried out in each study, has variable degrees following treatment. Just as practical is the patient’s
MANUAL EXAMINATION OF THE PATIENT 595
FIGURE 30–1. Motion palpation

of the cervical zygapophyseal
joints. (Reprinted with permission
from Murphy DR, ed. Conservative
management of cervical spine syn-
dromes. New York: McGraw-Hill,
2000.)
input as to what changes have occurred and agree- static palpatory asymmetries. If there is bilateral in-
ment between doctor and patient as to these changes. volvement, the segments directly above or below the
Research has been published in recent years as- involved segment can be used, keeping in mind the
sessing ways in which the art of motion palpation can slight differences in resistance that can be found in
be more reliably and accurately used. Several useful different segments discussed earlier. Some patients,
tips have come out of this research. One factor that is because of body fat or muscle, generalized hypermo-
important to consider is the particular segment that bility or stiffness, or other factors, are more difficult to
is being palpated. Viner et al. showed that stiffness palpate than others. This must be considered in each
naturally increases progressively from the L1-L2 seg- patient and incorporated into the determination on
ment to the L5-S1 segment.33 Also, stiffness in seg- the degree to which the doctor can rely on his or her
ments is altered by the amount of overlying adipose findings.
tissue. Tenderness threshold also varies at different Many chiropractic physicians feel that it is best to
levels of the spine. Keating et al. showed that in normal palpate each joint in a variety of directions of move-
subjects the pressure pain threshold was greatest in ment. This can be done with the patient in the seated,
the lumbar spine, followed by the thoracic spine, and prone, or supine position, depending on doctor pref-
was least in the cervical spine.34 These factors should erence, area of the spine being examined, and patient
be considered when performing motion palpation. comfort. Examples in the cervical spine are flexion
Latimer et al. found that reliability of palpation for (Fig. 30–2), extension (Fig. 30–3), rotation (Fig. 30–4),
stiffness in the lumbar spine was greater when less and lateral flexion (Fig. 30–5).
force was used in palpation.35 It is therefore recom-
mended that the clinician use as little force as possible Muscle Dysfunction
when assessing joint function. It is believed that muscle dysfunction can serve as
It is often helpful to qualify one’s findings by us- both a generator of pain and as a perpetuating fac-
ing the z joint on the opposite side as a control joint. If tor and may arise as a result of joint dysfunction.
palpation findings at this joint are different than that One theory of joint dysfunction is based on so-called
noted on examining the joint on the involved side, dysafferentation, where there is an assumed imbal-
particularly if the doctor’s finding of less resistance to ance between afferent input from nociceptors and that
motion when compared to the involved joint is con- from mechanoreceptors in the joint capsule.37 Thus,
cordant with the patient’s report of less pain provoca- nociceptive afferent neuronal input enters the dor-
tion when compared to the involved joint, the findings sal horn relatively unchecked. Joint nociceptors have
can be considered more reliable. Architectural asym- an interneuron-mediated connection to gamma mo-
metry of the regional anatomy must be considered,36 tor neurons in the ventral horn.38,39 The gamma motor
and it is important that the doctor focus on resistance neurons regulate muscle tone by regulating the sen-
to motion and pain provocation, and not be fooled by sitivity of the muscle spindle. It is hypothesized that
FIGURE 30–2. Motion palpation of the C0-C1 joint in flexion. (Reprinted with permission from Murphy DR, ed. Conservative management of
cervical spine syndromes. New York: McGraw-Hill, 2000.)
FIGURE 30–3. Motion palpation in the lower cervical spine in FIGURE 30–4. Motion palpation in the lower cervical spine in
extension. (Reprinted with permission from Murphy DR, ed. Conserva- rotation. (Reprinted with permission from Murphy DR, ed. Conserva-
tive management of cervical spine syndromes. New York: McGraw-Hill, tive management of cervical spine syndromes. New York: McGraw-Hill,
2000.) 2000.)
involved. In either case, the muscle may, through this

process, be susceptible to the development of myofas-
cial trigger points and involvement in faulty move-
ment patterns. The combination of chronic muscle
hypertonicity and disuse, in turn, could theoretically
lead to the development of muscle tightness, in which
not only has the contractile, dynamic aspect of the
muscle become hypertonic, but the viscoelastic con-
nective tissue has become shortened or contractured.
This theory, although intriguing, has yet to undergo
rigorous investigation and cannot be considered more
than speculation.
It has been suggested that there might be certain
muscles that are particularly susceptible to becoming
either hypertonic or tight, and certain muscles that are
particularly susceptible to becoming inhibited. These
are listed in Tables 30–1 and 30–2. Practitioners who
utilize so-called “movement patterns” in their search
for possible key links in the chain of dysfunction in the
muscular system take into account this supposedly
different muscle response.
The detection of muscle dysfunction primarily is
through palpation and muscle-length tests. Muscle-
length tests are performed by placing the muscle to be
examined in a position of maximal resting length. Pas-
sive overpressure is then applied to the muscle, and
the “end feel” is detected. A normal muscle should
have a normal, compliant end feel, offering a degree
of resistance to stretch but not excessive resistance.
FIGURE 30–5. Motion palpation in the lower cervical spine in A hypertonic muscle should present with a distinct
lateral flexion. (Reprinted with permission from Murphy DR, ed. Con- increase in resistance to stretch, and a tight muscle
servative management of cervical spine syndromes. New York: McGraw- should demonstrate markedly increased resistance to
Hill, 2000.)
stretch.
Examination of the upper trapezius muscle us-
joint dysfunction can alter the efferent activity of the ing this method has good interexaminer reliability
gamma system, causing abnormal alteration in spin- among experienced practitioners.41 With the patient
dle sensitivity and leading to alteration in muscle tone supine, the doctor places one hand on the point of
(Fig. 30–6).40 This could potentially lead to either an the shoulder on the involved side. The other arm cra-
increase or decrease in tone, depending on the muscle dles the patient’s head and the head is flexed forward
FIGURE 30–6. The mechanism by which

joint dysfunction alters muscle tone.
(Reprinted with permission from Murphy DR,
ed. Conservative management of cervical spine
syndromes. New York: McGraw-Hill, 2000.)
TABLE 30–1. Muscles That Have a Tendency to Become Hypertonic or Tight
Temporalis Sternocleidomastoid Upper Trapezius Rhomboids
Masseter Suboccipitals Levator scapulae Pectoralis major and minor

Scalenes Latissimus dorsi Erector spinae Rectus abdominis
Quadratus lumborum Psoas Rectus femoris Tensor fasciae latae
Hamstrings Triceps surae Iliacus
Reprinted with permission from Murphy DR. Dysfunction in the cervical spine. In: Murphy DR, ed. (Conservative management of cervical spine
syndromes.) New York: McGraw-Hill, 2000:75.
and laterally, and rotated toward the side of involve- tive motion injury to the myofascial tissues.43 These
ment. The ipsilateral hand is used to push the shoul- generally do not cause referred pain themselves, but
der caudally to lengthen the muscle until the restric- can cause local pain within the muscle. Adhesions
tive barrier (the point at which resistance to stretch can, however, cause entrapment of peripheral nerves,
is first detected) is met (Fig. 30–7). The clinician then which, in turn, can cause radiating pain and neuro-
feels for the amount of resistance to further stretching logic symptoms such as paresthesia.44 Both are com-
the muscle provides. Normally, the shoulder should mon sources of spinal pain, and can be detected reli-
move caudally several additional degrees with little ably via palpation.17,45–47
resistance. When attempting to identify TrPs as pain gener-
A myofascial trigger point (TrP) is defined as “a hy- ators, it is considered important to first understand
perirritable spot in skeletal muscle that is associated the referred pain patterns of each muscle. In this way,
with a hypersensitive palpable nodule in a taut band. based on the patient’s identification of the location of
The spot is painful on compression and can give rise to his or her pain (the use of a pain drawing is help-
characteristic referred pain, referred tenderness, mo- ful here), the doctor can determine which muscles re-
tor dysfunction, and autonomic phenomena.”42 TrPs quire examination. Palpation of those muscles that are
are thought to develop as a result of a localized short- reported to cause pain in the involved area is then
ening of a fascicle of muscle fibers in which a group carried out. This palpation should be directed, first,
of sarcomeres, rather than establishing normal rest- at identifying taut bands within the muscle. When
ing length, remain in a state of contracture. These a taut band is located, a careful search should be
trigger points are felt to result in referred pain, with made for a nodular locus within the band. This should
each muscle causing pain to be referred in a fairly pre- then be gently, but firmly, compressed and the pa-
dictable pattern.42 In some muscles, the referred pain tient should be asked if this causes pain. If it does,
is quite remote from the locus of the TrP. Myofascial the patient should then be asked if this causes the pain
adhesions are thought to develop as a result of acute that the patient has been experiencing. This is important,
injury, constant pressure, or tension injury, or repeti- because provocation of the same pain or symptoms
TABLE 30–2. Muscles That Have a Tendency to Become Inhibited
Longissimus Cervicis
Rectus Capitis (Lower Cervical/
Suprahyoids Anterior Upper Thoracic Extensor) Serratus Anterior
Longus capitis Multifidus (lower Middle trapezius Triceps

cervical/upper thoracic
extensor)
Longus colli Semispinalis cervicis (lower Lower trapezius Transverse abdominis
cervical/upper thoracic
extensor)
Gluteus maximus Gluteus minimus and medius Vasti Multifidus
Tibialis anterior
Reprinted with permission from Murphy DR. Dysfunction in the cervical spine. In: Murphy DR, ed. (Conservative management of cervical spine
syndromes.) New York: McGraw-Hill, 2000:75.
a herniated disc arises from inflammation of the nerve

or the meninges, causing chemically induced sponta-
neous impulses to be propagated along the nerve.52
Inflammatory nerve pain can also arise secondary to
lateral canal stenosis.53 Neural tension can arise from
entrapment of a nerve anywhere along its course, from
the intervertebral foramen to the many muscular and
other soft-tissue entrapment sites in the periphery.54
The pain of neural tension presumably arises from ei-
ther depolarization of nociceptors in the nerve trunk
itself,55 or, as with chemically induced nerve pain,
from spontaneous impulses being generated along the
axons of the nerve.56 Either of these phenomena can
cause pain that refers into the extremity, and often
FIGURE 30–7. Muscle-length test for the upper trapezius. does so in the absence of neurologic deficit.
(Reprinted with permission from Murphy DR, ed. Conservative manage- Neural tension or irritation as a pain generator can
ment of cervical spine syndromes. New York: McGraw-Hill, 2000.)
be detected through neural tension tests that are de-
signed to stretch peripheral nerves and nerve roots
strongly suggests that at least one of the primary pain and assess for the reproduction of the patient’s pain.
generators has been identified. In addition to the pres- The most basic of these in the lumbar spine is the
ence of the taut band, the nodular TrP, and referred straight-leg raise, which applies stretch to the sciatic
pain, one may also detect a “twitch response” to snap- nerve and its contributing nerve roots. This test is
ping palpation of the TrP, in which this palpation pro- sensitive enough in a patient with an inflammatory
duces a localized contraction of the involved fascicle radiculopathy (radiculitis) because the nerve root in
of muscle fibers. this condition is thought to be irritable and will re-
spond to even mild tension testing.
Disc Derangement In the presence of less irritable lesions, a greater
Disc derangement is a condition in which intradiscal degree of tension in testing may be required using the
material, likely the nucleus pulposus, has migrated slump test.54 The patient is seated on the table and is
or accumulated in the periphery of the annulus, and asked to “slump,” or place the entire spine in a flexed
sometimes partially or completely through the lay- position, while the doctor maintains a neutral posture
ers of the annulus.48 It can be a very painful disorder in the cervical spine. The doctor applies overpressure
and the patient with acute disc derangement will com- to the thoracic spine to make sure that full flexion is
monly exhibit antalgia. In examining a patient for the reached. The patient is asked if this produces symp-
presence of disc derangement, the McKenzie proto- toms, particularly reproduction of the chief complaint.
col has been demonstrated to be reasonably reliable49 The patient is then asked to flex the cervical spine and
and valid.50 Using this protocol, the patient is taken place his or her chin on the chest. Gentle overpres-
through a series of maneuvers that load the spine in sure is again added. The patient is again asked if this
certain directions. In the presence of disc derange- produces symptoms. The patient is then asked to ex-
ment, specific directions of loading will tend to ei- tend the knee, and then to dorsiflex the ankle. Again,
ther increase or peripheralize the pain (cause the pain the patient is asked about reproduction of symptoms
to extend into the extremity) or to decrease or cen- (Fig. 30–9).
tralize the pain (cause the pain to move out of the If symptoms are elicited in the fully slumped po-
extremity and take a more proximal location) sition, or at any point after the cervical flexion com-
(Fig. 30–8).48 A consistent pattern of peripheraliza- ponent is introduced in the test, the patient is then
tion and centralization strongly suggests the presence asked to extend the cervical spine. If this eases the
of disc derangement as the primary pain generator. symptoms, neural tension is implicated.
A detailed description of the McKenzie method is In the cervical spine/upper extremity there are a
beyond the scope of this chapter and can be found variety of brachial plexus tension tests, as well as an
elsewhere.48,51 upper cervical neural tension test. The brachial plexus
tension test is both sensitive and specific22 in detecting
Neural Tension or Irritation neural tension in the upper extremity.
Pain of neural origin is thought of primarily with re-
gard to radiculopathy secondary to disc herniation. Skin and Subcutaneous Dysfunction
However, while this is a common cause of radicular Dysfunction in skin and subcutaneous tissues has
pain, there are other causes. Nerve pain secondary to been described in terms of a hyperalgesic skin zone
FIGURE 30–8. The centralization phenomenon. Muscle-length test for the upper trapezius. (Reprinted with permission from Murphy
DR, ed. Conservative management of cervical spine syndromes. New York: McGraw-Hill, 2000.)
(HSZ).57,58 This is an area of skin that has developed ther by placing the fingers on either side of the
increased sensitivity such that stimuli that are nor- hyperalgesic area and gently moving them apart
mally innocuous become painful. In addition to this, (Fig. 30–10A) or by offsetting the fingers so that a fold
there develops increased tension in the tissue. This of skin can be stretched between them (Fig. 30–10B).
tension is considered by many clinicians to be palpa- In either case, the skin is gently lengthened until the
ble. There are several methods by which an HSZ can be restrictive barrier is engaged and the resistance at this
detected. One simple method is assessing what Lewit barrier is assessed. Increased resistance at the barrier
refers to as “skin drag.”59 This involves lightly run- combined with the report of pain during springing
ning a finger over the skin and assessing the friction in palpation of the barrier are considered signs of HSZ.
the involved area. An HSZ will exhibit increased fric- Skin rolling is a third method of detecting areas of
tion, presumably because of the excessive moisture. increased tension in the skin over the spine. With this
The patient will also report that the area is more sen- method, the fingers are used to roll the skin along adja-
sitive than the same anatomical location on the other cent to the spine and areas of increased resistance are
side of the body. noted. Findings of skin and subcutaneous dysfunc-
Skin stretching is another method of detecting tion by using this procedure correlate with findings of
HSZ. With this procedure, the skin is stretched ei- joint dysfunction found by using motion palpation.60
FIGURE 30–9. Slump test.
Unfortunately, these methods of palpation have been

developed empirically and reliability has not yet been
evaluated.
EVALUATION OF FAULTY MOVEMENT

PATTERNS
A number of clinicians have described faulty move-
ment patterns that they feel are important in perpet-
uating spinal pain. The detection of these patterns
requires the patient to engage in certain movements
with the clinician observing the manner in which these
movements are carried out.
Modified Hip Extension Movement Pattern Test

This is a variation of a test originally developed by
Janda. Originally, a “sequence” of muscle contraction
was suggested to occur during hip extension. This
FIGURE 30–10. A. Skin stretching with the fingers parallel. B.
sequence of muscle contraction starts in the ipsilat-
Skin stretching with the fingers offset. (Reprinted with permission
eral hamstring, followed by ipsilateral gluteus max- from Murphy DR, ed. Conservative management of cervical spine syn-
imus, contralateral lumbar erector spinae, ipsilateral dromes. New York: McGraw-Hill, 2000. Originally adapted from Lewit
lumbar erector spinae, contralateral thoracolumbar K, Liebenson C. Palpation—Problems and implications. J Manipulative
erector spinae, and ipsilateral thoracolumbar erec- Physiol Ther 1993;16(9):586–590.)
tor spinae. During normal gait, the pattern of mus-
cle contraction has been described as occurring in an
structed to lift one leg into extension and the doc-
above–down, rather than below–up, sequence,31 and
tor observes the pelvis, lumbar, and cervical spine
the lumbar erector spinae contract prior to the gluteus
(Fig. 30–11). The movement should occur smoothly
maximus.61 It has been suggested that the purpose of
with early and strong contraction of the gluteus max-
the contraction of the erector spinae prior to that of the
imus muscle. There should be virtually no movement
gluteus maximus is to stabilize the spine prior to ex-
of the lumbar spine and no contraction of the cervi-
tension and elevation of the tested leg, but this is sim-
cal muscles. A faulty pattern could include any of the
ply theoretical. However, the test may still be useful
following:
for the purpose of assessing the ability of the intrinsic
stability mechanism of the lumbar spine and pelvis,
as well as for detecting hyperactivity of the cervical • Late and/or incomplete contraction of the glu-
muscles. teus maximus, indicative of inhibition of the glu-
The patient is asked to lie prone with the feet hang- teus maximus and suggesting dynamic pelvic
ing off the end of the table. The patient is then in- instability.
FIGURE 30–11. The hip extension movement pattern test.

(Reprinted with permission from Murphy DR, ed. Conservative manage-
ment of cervical spine syndromes. New York: McGraw-Hill, 2000.)
• Lateral or rotational movement of the lumbar

spine, indicative of dynamic instability of the lum-
bar spine.
• Extension (“hinging”) at the lumbosacral junction
(also called “false hip extension”), indicative of
tightness of hip flexors and/or dynamic instability
of the lumbar spine.
• Activation of the cervical erector spinae, upper
trapezius, rhomboid, or levator scapulae mus-
cles, indicative of hyperactivity of the involved
muscle(s).
FIGURE 30–12. The stepping test. (Reprinted with permission
Furthermore, any of the above faulty patterns can from Murphy DR, ed. Conservative management of cervical spine syn-
occur in combination, so there are a variety of pos- dromes. New York: McGraw-Hill, 2000.)
sible patterns that might be detected. Studies show
good interexaminer reliability of the findings of lat- the finding was due to an alteration of the program for
eral movement, rotation, or extension of the lumbar gait.
spine on the hip extension test. To perform the stepping test, the patient stands
with eyes closed or wearing a blindfold, with arms
Stepping Test outstretched, horizontal to the floor, and parallel to
This test was first developed by Unterberger, and later each other. The head should be perfectly straight. Ear
discussed by Fukuda.63,64 It was believed by these au- muffs are used to obliterate hearing. The clinician in-
thors to be a test for peripheral vestibular dysfunc- structs the patient to step alternately as if marching,
tion, although later work refuted this. Hickey et al. raising his or her knees to 45 degrees of hip flexion at
looked at 49 normal controls and 26 patients with a moderate pace (Fig. 30–12). This is carried on for 50
a history of persistent, poorly compensated periph- steps. The normal finding is that after 50 steps the pa-
eral labyrinthine dysfunction.65 They found no cor- tient should have rotated no more than 30 degrees to
relation between the presence of vestibular pathol- either side. An abnormal finding is where the rotation
ogy and findings on the stepping test. Gordon and in either direction is greater than 30 degrees within 50
Fletcher stimulated the somatosensory system with steps.
rotational signals without vestibular stimulation by
having normal subjects walk on a rotating treadmill Hip Abduction Movement Pattern Test
while blindfolded.66 After 2 hours of walking they This test was also developed by Janda and is con-
found a significant increase in rotation on the step- sidered a test of the activity of the lateral stabilizing
ping test. Because there was no vestibular stimula- muscles of the pelvis, specifically the gluteus medius.
tion during treadmill walking, they concluded that To perform this test, the patient lies with the tested
shoulders in case the patient starts to fall. The patient

is then asked to raise one leg so that the elevating an-
kle is alongside and approximates the height of the
opposite knee. The patient is graded on a pass or fail
as to whether the patient can safely maintain this one-
legged stance. The opposite leg is then tested in the
same manner. If the patient passes the initial screen
on each leg, the test can be immediately continued
while patient and doctor maintain the same starting
position as in the screen, with one foot elevated. How-
ever, the patient is now instructed to close the eyes on
command. The patient is graded on the length of time
he or she can maintain a stable stance, up to 10 sec-
onds. The patient is then tested in the same manner
for the opposite leg. A normal finding is the ability
to maintain a stable stance for 10 seconds on each leg
FIGURE 30–13. The hip abduction movement pattern test.
with the eyes closed. An abnormal finding is where
the patient is unable to maintain a stable one-legged
side up. It is very important that the patient not be stance for 10 seconds, indicative of postural instability.
rolled forward or backward. The lower leg should be
bent 45 degrees at the hip and 90 degrees at the knee. Revel Test
The lower leg thus forms a crook in which the upper This test was developed by Revel to evaluate the
straight leg can rest between the lower knee joint and kinesthetic sensibility of the cervical spine.67 Heikkila
ankle. The patient is asked to slowly abduct the hip et al. showed that there was significant correlation
while the doctor observes the manner in which this between this test and tests of oculomotor reflexes,
movement is carried out (Fig. 30–13). which, in conjunction with normal cervical kines-
A normal finding is abduction of the hip without thetic sensibility, provide for normal eye-head-neck
rotation of the leg. The hip abduction should occur coordination.68 Dysfunction of this coordination, as
to approximately 30 degrees before the onset of iliac demonstrated by Revel test, occurs in patients with
crest elevation. An abnormal finding is where external chronic nontraumatic neck pain67 and with neck pain
rotation at the hip occurs during abduction and is con- after whiplash.69,70
sidered indicative of hyperactivity of the piriformis This test is carried out with the patient seated 90
and/or inhibition of the gluteus medius muscles. A cm (35.4 inches) from a 40-cm (15.7-inch)-diameter tar-
second abnormal finding is where flexion occurs at the get that has concentric circles 1 cm (0.4 inch) apart.
hip during abduction, indicative of hyperactivity of The patient is blindfolded and wearing earmuffs with
the iliopsoas and/or inhibition of the gluteus medius an affixed laser pointer. The head is aligned so that
muscles. A third abnormal finding is the observation the laser pointer is positioned at zero on the target
of backward rotation of the pelvis during abduction, (Fig. 30–14). The patient is instructed to remember this
indicative of inhibition of the gluteus medius. Another position, and then to maximally rotate the head to the
abnormal finding is the observation of hiking of the left and hold this position for 2 seconds. The patient is
hip prior to abduction, indicative of hyperactivity of then instructed to return to the starting position. After
the quadratus lumborum and/or inhibition of the glu- this is done, a measurement is taken as to how far from
teus medius muscles. the zero position the pointer rests (indicated as + or
−, depending on whether the patient over- or under-
One-Legged Stand/Squat Test shot the starting position). This is then repeated with
This test assesses postural stability. It has not been repositioning from rotation to the right, flexion, and
well validated, but its strength lies in its practicality extension. A normal finding is a repositioning error
and simplicity, and the ease by which pre- and post- of 3 cm (1.2 inches) or less in all directions. An abnor-
treatment comparisons can be made in a manner that mal finding is where the repositioning error is 3 cm
can be appreciated by both doctor and patient. (1.2 inches) or more in any direction. This is thought
This test is most safely and effectively performed to represent poor head repositioning as a consequence
in two parts: first as a screen to optimize patient safety of faulty afferent input from the cervical muscles.
and then as a test once the screen is passed. To per-
form the screen, the patient must be barefoot. The Shoulder Abduction Movement Pattern Test
doctor stands directly behind the patient with arms This test assesses the efficiency of scapular stabi-
outstretched close to, but not touching, the patient’s lization during movements of the upper extremity.
FIGURE 30–15. The shoulder abduction movement pattern

test. (Reprinted with permission from Murphy DR, ed. Conserva-
tive management of cervical spine syndromes. New York: McGraw-Hill,
2000.)
is suggestive of upper trapezius hyperactivity. If the

superior angle of the scapula moves superiorly, it is
suggestive of levator scapulae hyperactivity. If the su-
perior angle of the scapula moves superiorly and me-
FIGURE 30–14. Revel test. (Reprinted with permission from Mur- dially, it is considered to represent rhomboid hyper-
phy DR, ed. Conservative management of cervical spine syndromes. New activity. Failure of the scapula to rotate with elevation
York: McGraw-Hill, 2000.) as the shoulder abducts is indicative of hyperactivity
of the upper trapezius and levator scapulae and/or
Abduction is used because it most easily allows inhibition of the middle and lower trapezius. When
the visualization of all the components of scapular the inferior angle of the scapula moves away from the
stabilization and is useful in assessing coordination of body wall during or after abduction when returning
the muscles involved.71 The test is believed to be use- the arm to its starting position, is proposed that there
ful in assessing the balance between the upper, mid- is inhibition of the serratus anterior. Any of the above
dle, and lower trapezii, and the stabilization capacity faulty patterns can occur in combination.
of the serratus anterior. Alteration of this movement
pattern is thought to place increased strain on both Push-Up Test
the cervical spine and the rotator cuff. This test is per- The purpose of this test is to assess the functional abil-
formed with the patient seated with the patient’s arm ity of the scapular stabilizers. It is particularly useful in
resting on the thigh. The clinician stands behind the assessing the stabilization capacity of the serratus an-
patient and the patient is instructed to abduct the arm terior, because it has been observed that subtle insuf-
as far as possible (Fig. 30–15). ficiency of this muscle is not always revealed with the
A normal pattern is where the first 30–60 degrees shoulder abduction test. The patient lies prone with
occurs solely at the glenohumeral joint, with contrac- his or her hands on the floor preparing to do a push-
tion of the upper trapezius to stabilize the scapula, but up maneuver. Keeping the knees on the floor, the pa-
not to a degree that would create scapular movement. tient pushes up until the elbows are fully extended
After this, the scapula rotates such that the acromion (Fig. 30–16).
process moves superiorly, the superior angle of the A normal pattern is where the movement is
scapula moves inferiorly, and the inferior angle of the smooth with the scapulae moving laterally as the pat-
scapula moves laterally. The scapula should remain tern is carried out and the scapulae are maintained
firmly against the body wall. A faulty pattern is any against the body wall. Winging of the inferior angle
deviation from the normal. If the scapula rises before of the scapula is indicative of inhibition of the ser-
the shoulder reaches 30–60 degrees of abduction, it ratus anterior muscle. Elevation of the shoulders is
Mandibular Movement Pattern Test

Developed by Skaggs, this test assesses the coordina-
tion of the muscles involved in mandibular opening.73
The patient can be seated or standing and is asked to
slowly open the mouth. A normal pattern is where
the mandible undergoes only depression during the
initial phase of opening, followed by protrusion to
full opening. An abnormal pattern is where there is
protrusion of the mandible during the initial phase
of opening, indicative of hyperactivity of the lateral
pterygoid and/or inhibition of the mandibular de-
pressors.
FIGURE 30–16. The push-up test. (Reprinted with permission
from Murphy DR, ed. Conservative management of cervical spine syn- Breathing Movement Pattern Test
dromes. New York: McGraw-Hill, 2000.)
Normal breathing is carried out primarily by the di-
aphragm, which contracts to depress the abdominal
contents, thus increasing the volume of the thoracic
indicative of hyperactivity of the upper trapezius
cavity and creating a pressure gradient that forces
and/or inhibition of the middle and lower trapez-
air to rush into the lungs. During exercise or other
ius muscles. Medial rotation of the scapula, in which
high-intensity physical activity, the accessory breath-
the inferior angle of the scapula moves medially,
ing apparatus is used. This involves contraction of the
is indicative of hyperactivity of the upper trapez-
scalenes, upper trapezius, levator scapulae, sternoclei-
ius and/or levator scapulae, and/or inhibition of the
domastoids, and pectoralis minor to elevate the shoul-
middle and lower trapezius. Any of the above faulty
ders and rib cage to allow for further increase in the
patterns can occur in combination. Paine and Voight
volume of the thoracic cavity so that more air can get
presented another method for evaluating the activ-
in. With faulty breathing, the accessory breathing ap-
ity of the serratus anterior.72 The patient stands fac-
paratus is used for breathing, a function it is not meant
ing a wall with his or her hands against the wall be-
to perform.
low waist level and the fingers pointing downward
With the patient standing, the clinician stands be-
(Fig. 30–17). The patient presses against the wall.
hind the patient and watches the patient’s breathing,
Winging of the inferior angle of the scapula suggests
paying particular attention to the clavicles. The lateral
inhibition of the muscle.
rib cage can be palpated as well. It is important that
the patient does not know that his or her breathing is
being evaluated, in order to avoid self-consciousness
and possible alteration of the patient’s natural breath-
ing pattern. A normal pattern is where the abdomen
protrudes, followed by the lower rib cage flaring out
laterally, and then the upper ribs rotating superiorly
during inhalation. The shoulders and clavicles should
remain relaxed and motionless. A faulty pattern is
where the clavicles rise and a furrow develops behind
the clavicles. Contraction of the scalenes and stern-
ocleidomastoids may also be seen on inhalation, with
little or no movement of the abdomen and lower ribs.
This is believed to be indicative of a faulty breathing
pattern, which places inordinate strain on the mus-
cles that make up the accessory breathing apparatus,
particularly the scalenes, and predisposes them to de-
veloping myofascial trigger points.
Active Straight-Leg Raise Test

Originally developed by Mens et al., this test was pos-
FIGURE 30–17. The wall push test. (Reprinted with permission itive in 14 of 15 female patients with pelvic pain that
from Murphy DR, ed. Conservative management of cervical spine syn- began during their most recent pregnancy or within
dromes. New York: McGraw-Hill, 2000.) 3 weeks of delivery.74 This finding correlated closely
Cervical Stability Test

This test allows the assessment of the deep cervical
flexors and the ability of these muscles to maintain
stability of the cervical spine. The deep cervical flex-
ors, when acting as stabilizers, must have both a short
reaction time (brought about by the type II fibers) and
a long endurance capacity (brought about by the type
I fibers). This procedure tests both functions as well as
the balance between the deep cervical flexors and the
sternocleidomastoid (SCM) muscle. Watson and Trott
found that patients with headache performed signifi-
cantly poorer on this test than healthy controls.76 Tre-
leavan et al. also found this in patients with postcon-
A cussion headache.77
The patient is tested in the supine position and the
clinician passively prepositions the head in the neutral
position with the chin slightly tucked. The clinician
tells the patient that he or she is going to let go of the
head and that the patient should continue to hold it
in this exact position. The clinician then lets go of the
patient’s head and observes (Fig. 30–19).
A normal pattern is where the head position is
maintained without excessive shaking. A faulty pat-
tern is where the chin pokes forward, the head shakes
excessively, the entire cervical spine flexes, or the
head drops into extension, indicative of inhibition
of the deep cervical flexors and/or hypertonicity of
the SCMs, thus producing dynamic instability of the
cervical spine. The presence of shaking suggests that
B transformation of type I to type II fibers has taken
place in the deep cervical flexors.
FIGURE 30–18. A. Active straight-leg raise. B. Active straight- Cervical Flexion Movement Pattern Test
leg raise with medial-to-lateral pressure.
Janda developed this test to assess the quality of
coordinated muscle activity in rising from a re-
with the finding of excessive mobility at the pubic cumbent position. It is thought that proper cervical
symphysis as assessed by radiographs taken with the flexion involves a balance between deep cervical
patient bearing weight on one leg. The test is reliable
and has a high sensitivity and specificity.75 The pa-
tient is tested in the supine position with the legs
out straight. The examiner asks the patient to ac-
tively raise one leg without bending the knee. The
examiner asks the patient if there is any pain and/or
difficulty associated with this movement. The exam-
iner also observes for rotation of the pelvis or trunk
or difficulty with maintaining stability. The exam-
iner then applies medial to lateral pressure to the
pelvis, first in its anterior aspect, and then in its pos-
terior aspect (Fig. 30–18). This is then repeated for the
other leg. A normal pattern is where there is no pain
and/or difficulty with actively raising the straight leg.
Little or no pelvic rotation occurs during leg rais-
ing. A faulty pattern is where there is pain and/or
difficulty that improves with lateral to medial pres- FIGURE 30–19. The cervical stability test. (Reprinted with per-
sure on the pelvis, indicative of so-called dynamic mission from Murphy DR, ed. Conservative management of cervical spine
pelvic instability. syndromes. New York: McGraw-Hill, 2000.)
flexors (longus capitis, longus colli, and rectus capitis a result of instability or postural dysfunction from the
anterior) and the SCM, each of which flexes the lower half of the body.
lower cervical spine and extends the upper cervical
spine. Donaldson et al. demonstrated, using dynamic CONCLUSION
surface electromyelograms, that in headache patients
who had myofascial trigger points in the SCM, there The manual examination of the patient provides im-
tended to be increased maximum amplitude of con- portant information that should help in establishing a
traction of the SCM during cervical flexion compared diagnosis and determining the primary pain genera-
to those patients without TrPs in these muscles.78 Bar- tors and factors that might result in the perpetuation of
ton and Hayes showed that the SCMs of patients with spinal pain. While the manual examination has been
unilateral neck pain and headache took longer to relax criticized for subjectivity and lack of reliability, there
after contraction than pain-free controls after cervical are many manual procedures that have shown good
flexion.79 Interestingly, this finding involved both reliability and validity. It is essential that the clinician
SCMs, even though the pain was unilateral. This sug- be aware of the degree of reliability and validity of
gests that the greater relaxation time was not related each procedure, so that the clinician can determine
to pain, but to alteration in the program for cervical how much credence to give each finding. Those pro-
flexion. cedures that are known to have good reliability and
The test is performed with the patient lying supine. validity should be given greater emphasis in weigh-
The clinician places a finger at the midpoint of the pa- ing the evidence, and those with lesser or unknown
tient’s sternum and instructs the patient to raise his reliability and validity should receive less emphasis.
or her head off the table and touch the chin to the The information compiled from the history, the gen-
point at which the finger is placed. A normal pattern eral physical examination, and the manual examina-
is where the chin tucks slightly first, and then the pation should be put together to produce a diagnostic
tient’s head smoothly rolls off the table while the cer- hypothesis.
vical spine flexes. A faulty pattern is where the chin
pokes out at the beginning of the movement and SUMMARY
remains protruded throughout, indicative of hyper-
1. Many common musculoskeletal complaints may
tonic SCMs and suboccipitals and/or inhibited deep
be classified under one of the following four
cervical flexors.
categories: joint dysfunction, myofascial trigger
Sit-to-Stand Movement Pattern Test for points, disc derangement, and neural tension or
Postural Dysfunction irritation. Motion palpation may be used to de-
tect joint dysfunction, myofascial palpation may
This test has been proposed in order to determine
be used to detect trigger points, loading tests may
whether a patient’s postural faults lie in the upper half
be used to detect disc derangement, and neural
of the body or may be a compensatory posture from
tension tests may be used to detect neural tension
instability in the lower half of the body. The patient
or irritation.
should be standing barefoot with the doctor standing
2. A number of clinicians have described faulty
behind the patient. A stool or backless chair is placed
movement patterns that they feel are important in
directly behind the patient for later use. The patient
perpetuating spinal pain. The detection of these
should be aware of this chair so that the patient can
patterns requires the patient to engage in cer-
confidently sit down on it later when so instructed.
tain movements and then the clinician observes
The doctor makes note of key postural faults such as
the manner in which these movements are car-
a high shoulder, prominent scapula, or hyperactivity
ried out. Some of the common movement pattern
of musculature unilaterally or bilaterally. Once these
tests include modified hip extension, stepping,
findings are noted, the patient is then instructed to
hip abduction, one-legged stand/squat, Revel,
sit down on the chair or stool with as little extra mo-
shoulder abduction, push-up, mandibular move-
tion, such as body rotation or foot movement, as pos-
ment, breathing, active straight-leg raise, cervical
sible. As the patient assumes the seated position, an
stability, scapular stability, cervical flexion, and
immediate comparison is made between the seated
sit-to-stand.
posture of the upper half of the body with that noted
in the standing posture. If there is little to no postural
change, the faulty posture is considered to originate
QUESTIONS
from a more local dysfunction. If there is moderate to
significant postural change observed during this test, 1. Define joint dysfunction.
the faulty posture noted in the upper half of the body 2. What is the primary means of identifying myofas-
is considered to be more compensatory in nature and cial trigger points on examination?
3. Describe the methodology of the slump test. Liebenson CS, ed. Rehabilitation of the spine: A practitioner’s
4. What findings on the modified hip extension test manual. Baltimore: Williams and Wilkins, 1996.
would be suggestive of dynamic instability in the Morris C, ed. Conservative management of low back syndromes.
lumbar spine? New York: McGraw-Hill, 2002.
5. What dysfunction is suggested by a positive active Murphy DR, ed. Conservative management of cervical spine
syndromes. New York: McGraw-Hill, 2000.
straight-leg raise test?
Nicholson L, Adams R, Maher C. The reliability of a discrim-
6. What are the four most common faulty patterns ination measure for judgments of non-biological stiff-
found with the cervical stability test? ness. Manual Ther 1997;2:150–156.
Richardson C, Jull G, Hodges P, Hides J. Therapeutic exer-
cise for spinal segmental stabilization in low back pain. Ed-
ANSWERS inburgh: Churchill Livingstone, 1999.
1. Loss of joint play movement that cannot be pro- Troyanovich ST, Harrison DD. Motion palpation: It’s time
duced by voluntary muscles. to accept the evidence. J Manipulative Physiol Ther
1998;21(8):568–571.
2. Identifying known referred pain patterns and pal-
Vleeming A, Mooney V, Snijders CJ, Dorman TA, Stoeckart
pation. R, eds. Movement, stability and low back pain: The essential
3. The patient is seated on the table and is asked to role of the pelvis. New York: Churchill Livingstone, 1997.
“slump,” or place the entire spine in a flexed posi-
tion, while the doctor maintains a neutral posture
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C H A P T E R
31
THE CLINICAL APPLICATION
OF SELECTED EXAMINATION
AND DIAGNOSTIC INSTRUMENTS
IN CHIROPRACTIC
Keith Wells
O U T L I N E
INTRODUCTION REFLEX HAMMERS AND NEUROLOGICAL
THERMOMETERS AND FEVERS ASSESSMENT
BLOOD PRESSURE CUFF AND HYPERTENSION HAND GRIP STRENGTH AND THE DYNAMOMETER
OPHTHALMOSCOPE AND HEADACHE GONIOMETERS AND INCLINOMETERS
OTOSCOPY AND EAR INFECTIONS NEUROCALOMETER AND THERMOCOUPLE
TUNING FORKS, FRACTURES, AND DEVICES
VIBRATION SENSE SUMMARY
ANTERIOR RHINOSCOPY AND QUESTIONS
COCAINE ABUSE ANSWERS
STETHOSCOPE AND THE HEART KEY REFERENCES
STETHOSCOPE AND THE LUNG REFERENCES
as the electrocardiogram and thermocouple devices.

OBJECTIVES The goals are to assist students and practitioners in
1. To review some of the commonly used diagnostic understanding the application of these instruments
instruments in chiropractic. for conditions commonly seen in chiropractic practice,
2. To review some of the conditions that may be de- and interpreting the results from these tests in mak-
tectable by examination with common diagnostic ing confident diagnostic and management decisions.
instruments. Application may mean the chiropractor’s direct use
3. To discuss the development of decision-making of instruments or a decision to refer to an appropri-
skills for clinical management based on examina- ate physician or technician who provides a particular
tion results. service.
4. To develop an understanding of selected diagnos- The Job Analysis of Chiropractic indicates that field
tic instruments that are not routinely used but that practitioners routinely perform physical exam pro-
may be important for diagnostic decision making cedures on new patients and routinely perform re-
and clinical management. gional exam procedures on each visit.1 Practition-
ers place relatively high importance on performing
these activities. The Job Analysis distinguishes the
INTRODUCTION
physical examination from the neuromusculoskeletal
This chapter reviews a selection of common diagnos- examination, which is also considered routine and of
tic instruments, as well as selected instruments, such high importance. The respondents to the survey rated
611
knowledge of performing and interpreting specific as- affects 24% of the US population and increases to
pects of the physical examination as moderately to 70% among persons age 65 years and older.2 Because
very important, while other components of the exam- chiropractors tend to treat their patients more fre-
ination were considered to be of little to no impor- quently than other practitioners, the profession can
tance. One examination procedure that was consid- make a significant contribution to the public health
ered very important (extremely important was the high- by routinely screening and monitoring blood pres-
est score on the scale) was the head and neck exami- sure. Hypertension is defined as a diastolic pressure of
nation. However, the Job Analysis did not break down 90 mmHg or higher, a systolic pressure of 140 mmHg
the head and neck examination into components, so or higher, or both, on three separate occasions. While
it is unknown as to how the survey respondents in- it is true that some patients in hypertensive crisis ex-
terpreted the meaning or subdivisions of this exam. perience headache, this symptom is subjective, incon-
For example, it cannot be ascertained from the sur- sistent, and does not correlate with measured levels of
vey results how many practitioners perform an oph- blood pressure. Many patients have very high blood
thalmoscopic examination or consider it important. pressure and are unaware of that fact.
Nevertheless, it appears a significant portion of chiro- Blood pressure should be measured with the pa-
practors consider performance and knowledge of the tient sitting with the back supported and the arm
overall physical examination (including neuromuscu- exposed without clothing that can act as a tourni-
loskeletal) as significant and reasonably necessary to quet. The pressure is best measured with the patient
their clinical practice. This chapter addresses specific in a gown with generous arm openings. The patient
examination tools and diagnostic instruments, and should be at rest for several minutes before the mea-
conditions that are either likely to appear in chiroprac- surement. The arm should be supported at the heart
tic offices, or that have a specific application to chiro- level and the patient should exert no effort holding
practic practice even if the condition itself is seldom up the arm. The blood pressure cuff should cover ap-
encountered. proximately 80% of the patient’s upper arm. The first
sound heard is the systolic pressure, regardless of the
sound loudness or quality. The last sound heard is
THERMOMETERS AND FEVERS
the diastolic pressure, again regardless of how loud it
Vital signs, including temperature, pulse, respira- is or its quality. Visualized needle movement on the
tions, and blood pressure, are a routine part of chi- aneroid sphygmomanometer does not correspond to
ropractic practice. Chiropractors encounter patients accurate pressure measurement. The same is true of
with systemic arthritides such as gout or rheuma- mercury devices—fluctuations of mercury levels are
toid arthritis “sometimes” on the frequency scale.1 not indicative of pressure measurement. Only sounds
The rheumatic/collagen vascular diseases frequently are used for measuring pressure. The cuff should not
cause low-grade fevers (less than 101˚F [38.3˚C]) and be repeatedly inflated during a single measurement.
sometimes cause fevers in acute “flare-ups.” Patients If repetition of the measurement is necessary, com-
that present with joint pains, unexplained bone pains, pletely deflate the cuff, ask the patient to hold the arm
or vague symptoms of systemic illness should be sus- overhead and repeatedly clench the fist a few times
pected of having a fever. A low-grade fever may be a to drain the arm of venous blood, and then repeat the
clue to previously undetected systemic lupus erythe- measurement.
matosus or metastatic cancer. The temperature screen The Joint National Committee on Prevention,
takes little time with modern electronic instruments Detection, Evaluation and Treatment of High Blood
and can be obtained simultaneously with blood pres- Pressure (JNC) published its sixth consensus report
sure or pulse. on hypertension in 1997 (JNC VI).2 Table 31–1 lists the
categories by which the JNC VI defines hypertension.
Recent investigation into sustained high-normal
BLOOD PRESSURE CUFF AND HYPERTENSION
systolic (130–139) and diastolic blood pressures
Sixty-one percent of chiropractors that responded to (85–89) suggests a significantly increased risk of ad-
the survey had made the diagnosis of high blood pres- verse cardiovascular events (myocardial infarction,
sure, with 69% employing comanagement and 66% stroke, and congestive heart failure).3 Chiropractors
employing referral among their management deci- are therefore encouraged to routinely measure the
sions. These results confirm that a significant num- blood pressure in order to manage patients in pre-
ber of practitioners are paying attention to the prob- ventative lifestyle changes such as diet modification
lem of hypertension among their patients. The only and exercise. It is recommended that patients with
way to “not see” hypertension in practice is to avoid stage 3 hypertension on the first chiropractic visit be
measuring the blood pressure. Hypertension is very referred on an urgent or emergent basis to a medi-
prevalent, especially in industrialized countries. It cal physician. Even though the pressure may become
THE CLINICAL APPLICATION OF SELECTED EXAMINATION AND DIAGNOSTIC INSTRUMENTS IN CHIROPRACTIC 613
TABLE 31–1. Blood Pressure Measurements remaining within normal levels, and preferably no
more than 120 mmHg. Even though systolic blood
Systolic Diastolic pressure appears to be within normal limits, this is not
(mmHg) (mmHg) the case if the pressure has elevated from initial base-
lines in the first two trimesters. Any increase in pres-
Optimal <120 <80 sure under these circumstances should prompt urgent
Normal <130 <85 referral to the obstetrician or family practitioner.
High normal 130–139 85–89 For practitioners who treat children, accurate pres-
Stage 1 hypertension 140–159 90–99 sure measurement is more complex. Appropriate cuff
Stage 2 hypertension 160–179 100–109 size is a must and, as in the adult, length of the cuff
Stage 3 hypertension >180 >110 (bladder) is not the primary concern even though im-
portant. Rather, it is the width of the cuff and the sur-
face area it covers (80% of the upper arm) that matter
most. A narrow and short cuff for a child may cause a
lower during the visit, the fact that the pressure is false high reading. This is important because the cause
able to reach stage 3 levels in the first place is cause of hypertension in a child is most likely secondary to
for concern. Patient anxiety and/or pain cannot be the conditions such as renal artery stenosis or coarctation
explanation in most circumstances for such pressure of the aorta. There are several sizes of child blood pres-
levels. The referral decision holds even if only one pa- sure cuffs ranging from neonates to older children that
rameter meets the stage 3 criteria. For example, a di- can be obtained for a practice that treats children of
astolic blood pressure of 118 mmHg with a systolic different ages.
blood pressure of 166 mmHg still requires prompt Some patients may exhibit apparently low blood
attention. pressure measurements or make the claim they have
When a patient complains of dizziness, especially “low blood pressure.” It must be remembered that
with postural changes, as in arising from the seated “normal” blood pressure is an average of a large pop-
or supine position, the doctor should measure the ulation and is not static. Blood pressure constantly
orthostatic (postural) vital signs. This refers to mea- fluctuates with body position changes, activity, sleep,
surement of the supine, seated, and standing blood and other physiologic influences. If a patient’s pres-
pressure and pulse rates. The purpose is to exclude sure falls below the usual standards (90 mmHg sys-
intravascular volume loss as the cause of dizziness, tolic blood pressure and 60 mmHg diastolic blood
such as chronic bleeding from the gastrointestinal (GI) pressure), consider whether the patient complains
tract or acute volume loss during GI illness that causes of light-headedness/dizziness on postural change
vomiting and/or diarrhea. In the case of volume and inspect the patient’s body habitus. Smaller and
loss, the systolic blood pressure decreases a total of more petite individuals often have lower blood pres-
20 mmHg over both position changes, and the pulse sures than the “120/80” norm and not infrequently
rate increases a total of 10 beats per minute. Even if have systolic blood pressure measurements less than
these minimum criteria are not met, the pattern of de- 100 mmHg.
creasing blood pressure and increasing pulse rate may In summary, because chiropractors are portal-of-
still appear. This pattern may be significant in a patient entry providers in most jurisdictions and because they
with a history that indicates possible volume loss. If typically see patients more often than other providers,
there is no such pattern, it is unlikely the patient is chiropractors can provide blood pressure measure-
dizzy because of volume depletion, and other causes ment and monitoring for public health reasons.
(e.g., cervicogenic or autonomic) are more suspect.
Pregnant women should be monitored for hyper-
OPHTHALMOSCOPE AND HEADACHE
tension related to pregnancy. The patient may have
preexisting hypertension or may have had previously Proficient use of the ophthalmoscope is an art and re-
normal blood pressure. In either case, the pregnancy quires time and practice to develop skills sufficient
may be complicated by the hypertension of pregnancy to recognize the classic abnormalities. Chiropractors,
(a diagnosis of exclusion), preeclampsia, or eclamp- in most jurisdictions, are not legally allowed to use
sia. The latter two conditions are potentially life- pupillary dilating agents to enlarge the field of view
threatening for both mother and baby. The pregnant on the retina. Fortunately, many findings of interest
woman’s systolic blood pressure is expected to incre- related to headache are within view in most patients
mentally decrease over the first 24 weeks of pregnancy without the use of dilating drugs. Deliberate practice
because of hormonal influence and vascular smooth- with the ophthalmoscope, as with any other instru-
muscle relaxation. The systolic blood pressure ment, will result in greater confidence and proficiency.
then slowly increases over the rest of the pregnancy, The amount of time required to examine the optic disk
of swelling and protrusion toward the examiner, en-

gorged veins, and loss of venous pulsation.
Giant cell arteritis (temporal arteritis) may cause
“pale papilledema” (a swollen, pale cup and disk
from loss of the normal yellow color) and the patient
may complain of visual disturbance from ischemic
optic neuropathy. This condition is rare (18 cases per
100,000 persons) and is found in people age 50 years
and older, most likely in white women of European
ancestry.4 It may overlap with polymyalgia rheumat-
ica. There may be systemic symptoms such as fever,
malaise, fatigue, anorexia, and weight loss. Headache
is the most common initial symptom, as well as the
most common symptom. There may be pain at the
affected artery with swelling and nodularity. In 100
temporal arteritis patients, visual symptoms were the
presenting symptom in 7 and present in 30 patients
at the time of diagnosis. The visual symptoms in-
clude possible amaurosis fugax, diplopia, and various
partial visual field losses. The vision loss is painless
and may be permanent. The symptoms are often uni-
lateral but may become bilateral in about 10 days.4
FIGURE 31–1. PanOptic ophthalmoscope from Welch Allyn. There may also be jaw claudication during chewing
from facial artery involvement, as well as tongue pain
and infarction.5 Pain and stiffness in the neck, shoul-
area of the fundus is in most situations minimal. Prac- ders, and pelvic girdle suggest overlapping polymyal-
ticing on eye models, as well as on live persons, can gia rheumatica and appeared in 39 of 100 patients at
develop proficiency. There has also been a recent addi- diagnosis.4
tion to the diagnostic optical instrument armamentar- Headache related to organic brain disorders such
ium. The Welch Allyn Company of Skaneatlas, New as primary tumors, metastasis, and other masses com-
York, has developed the PanOptic ophthalmoscope, prises less than 10% of all types of headaches, and not
which allows the examiner greater ease in viewing all organic brain problems necessarily cause headache
the retina through the undilated pupil (Fig. 31–1). The even though the potential exists.6 In a study of
field of view is larger, the ability to see through small 402 adult patients with chronic headache and no other
pupils is enhanced, and the examiner may use the neurologic symptoms, only 15 (3.7%) had major or-
dominant eye to examine both patient eyes without ganic abnormalities. Of these patients only three had
coming too close to the patient’s face. primary brain tumors, or 0.7% of the total cohort.
It is reasonable to screen the fundus in headache There was one case of metastasis and the rest were
patients in addition to the usual neurological and chi- varied pathologies, such as subdural hematoma and
ropractic examination, although the yields of more cysts.7 The yield of mass lesions in patients present-
unusual and serious causes of headaches are admit- ing with headache is low, but special attention should
tedly low compared to the more common types of be given to patients with atypical headaches that do
headaches. Headache is one of the most common con- not fit into the common classifications. Patients with
ditions/complaints seen in chiropractic practice.1 Chi- unexplained neurologic symptoms or findings such
ropractors typically treat headache patients without as visual disturbances or cranial nerve palsies should
comanagement or referral. Occasionally, a headache also receive special attention.
may result from a serious cause, such as brain tumor, Brain metastasis is the most frequent neurologic
hypertension, central nervous system (CNS) infection, complication of systemic cancers (20–40% of patients
or giant cell arteritis. These conditions may cause reti- older than age 20 years), and metastatic brain tumors
nal findings visible on ophthalmoscopic examination. are about 10 times more common than primary brain
Increased intracranial pressure from a tumor or in- tumors. Statistically, most metastasis to the brain is
fection may cause papilledema. Hypertension may from lung and breast cancers, although melanoma has
also cause papilledema accompanied by retinal hem- the highest tendency to spread to the brain.8 It is possi-
orrhages in severe cases. The findings of papilledema ble for a chiropractor to treat a patient with a history of
include indistinct optic disk borders, loss of the nor- cancer, and new onset headaches in known cancer pa-
mal yellow disk color, loss of the optic cup because tients should prompt a careful search for evidence of
metastasis that may include the neurologic and oph-

thalmoscopic examination. Various space-occupying
lesions create altered percussion notes (dullness or
difference in intensity) and may be confirmed by
neuroimaging.9
OTOSCOPY AND EAR INFECTIONS

The use of the otoscope and pneumatic otoscopy (in-
sufflation) is complementary to an excellent history
and a thorough understanding of how acute otitis me-
dia and otitis media with effusion may present. Typi-
cal symptoms of acute otitis media in children include
rhinitis, cough, irritability, fever, and earache, with
fever and earache appearing in approximately 50% of
patients.10 This is important to understand, because
some patients may have acute otitis media without
fever and/or earache. The best practice is to examine
the ears of children with symptoms of upper respira-
tory illness. Otoscopy can prove challenging in young
children and requires patience in the face of crying,
screaming, squirming, irritated parents, and a view
blocked by cerumen. Cerumen must be cleared for an
adequate view of the tympanic membrane. The use of
an ear curette is not recommended for chiropractors
and can lead to injury in squirming patients. Over-
the-counter softening agents and irrigation can clear FIGURE 31–2. Otoscope with tympanometry attachment.
cerumen. There is, however, variation in the scope of
practice of chiropractic in different states and coun-
tries, and each practitioner should check the scope of panies typically provide cuffed ear specula of various
practice in his or her local jurisdiction before the use sizes to accomplish the seal. The position, mobility,
of auricular irrigation. color, and translucency of the tympanic membrane are
It must be remembered to pull the pinna down and evaluated. If the position is bulging toward the exam-
back during otoscopy with infants and straight back iner with reduced mobility, the color is red, and the
with older children. The ear is pulled up and back with translucency is reduced, the diagnosis is more likely
adolescents and adults. Tympanic membrane signs of to be acute otitis media. If the membrane is neutral
acute otitis media include membrane bulging, injec- or retracted and mobility reduced with poor translu-
tion, cloudiness, and redness. There may also be a cency, the diagnosis is more likely to be otitis media
fluid level behind the membrane, as well as membrane with effusion. Again, redness alone has poor reliabil-
yellowing and opacities. Both the symptoms and ity for acute otitis media.10
the tympanic membrane findings lack reliability, and Tympanometry is a qualitative measurement of
the overdiagnosis of acute otitis media based on single membrane motility and pressure in the middle ear
findings such as a red tympanic membrane has been space and provides the benefit of a printed reading.
discussed.10 One type of device is portable, and when used in ad-
Otitis media with effusion is defined as a tympanic dition to the history and examination, is very help-
membrane with neutral position (neither retracted nor ful to diagnose the condition and monitor treatment
bulging) or a retracted membrane. There is fluid in progress.10–12 The hand-held probing instrument is
the middle ear space and no symptoms of acute in- similar to an otoscope and the probe is inserted in the
fection. The diagnosis of either condition is improved ear to form a seal (see Fig. 31–2). A known amount of
by the use of pneumatic otoscopy. The normal tym- sound energy is delivered to the tympanic membrane.
panic membrane is mobile in either direction under Some of the energy is transmitted through the mem-
the application of a small burst of air from a “squeeze brane and some returns as recorded by the device. The
bulb” that inserts into the head of the otoscope via a more sound energy that returns to the probe, the less
small rubber tube (Fig. 31–2). The ear speculum must compliant is the tympanic membrane, and vice versa.
create a seal with the ear canal, and this may be hard The device then applies a small amount of air pres-
to accomplish with disposable specula. Supply com- sure into the canal, forcing the tympanic membrane
inward, and the volume of air in the canal is mea- other devices that have been similarly used to agitate
sured. The pressure is then retracted negatively and a suspected fracture sites, but the tuning fork and thera-
peak negative pressure is obtained. A point of peak peutic ultrasound are the most available to chiroprac-
membrane compliance is graphically recorded and tors and are the only instruments discussed here.
compared with normal ranges.13 The tympanometer The 128-Hz tuning fork has been used to assess vi-
is a more advanced device and the practitioner may bration sense since the late nineteenth century.17 The
elect to refer a patient to an otolaryngologist for that vibrating fork is placed on a bony prominence be-
service. ginning from distal sites (such as the toes and fin-
gers) and is moved proximally as clinically indicated.
Vibration sense diminishes with a variety of neu-
TUNING FORKS, FRACTURES, AND
ropathies and may be the first sensation to be lost;
VIBRATION SENSE
its loss can be detected before loss of position sense
Common anecdotal opinion suggests that placing a and two-point discrimination.18 It must be remem-
vibrating 128-Hz tuning fork stem near or on a sus- bered that the length of time a patient feels the vibra-
pected fracture site can identify the fracture by exac- tion is as important as distinguishing when the vi-
erbation of pain. In a review article, Kazemi searched bration is present or absent. This requires the fork to
the major databases and found sparse reporting on be struck with similar force and placed on the bony
the use of the tuning fork for detection of fractures, prominence with similar pressure. This skill can be de-
and no reporting on its validity and reliability.14 The veloped with training, even though it is impossible to
type of work done centered on several techniques. perfect completely.17 As normal persons age, there is
One investigator reported on the use of 128-Hz tun- a slow loss of vibration sense that includes the length
ing forks compared to bone scans to detect tibial stress of time of perception, as well as whether vibration is
fractures in the military. The examiner systematically present or absent, so vibration must always be com-
placed the vibrating fork at a number of points from pared bilaterally and correlated with the history.
the tibial tuberosity to the ankle. In 52 patients, the The tuning fork is also used to assess hearing. Ac-
sensitivity and specificity of the fork to detect fracture cording to a review by Ng and Jackler, John Shore is
were 75% and 67%, respectively.15 The sensitivity was credited with the invention of the tuning fork in about
not deemed high enough to rule out a stress fracture 1771. In 1827, Tourtal described the occlusion phe-
with a negative test, but the test was thought useful nomenon by holding a ticking pocket watch between
if the history indicated a high pretest probability of his teeth and occluding an ear. He noted the tick-
stress fracture. Another investigator used the 128-Hz ing was better heard in the occluded ear. Sir Charles
fork and auscultation. The fork was placed distal Wheatstone is usually credited with the first use of the
to the suspected fracture site and the stethoscope tuning fork to assess hearing in 1827, noting that when
placed proximal to the site in 50 patients with lower- the vibrating fork was placed on the skull with both
extremity injuries. Reduced transmission of sound ears occluded, the sound was heard best in the ear
compared to the opposite limb was determined to closest to the source. In 1834, Ernst and Wilhelm We-
be evidence of fracture. This method identified 47 ber published the results of experiments conducted in
of 50 fractures, as compared to 44 correctly identi- 1825 based on the occlusion effect, noting the lateral-
fied using nonspecified clinical examination methods ization of the tuning fork sound into the worse hear-
alone.16 ing ear in some patients. It was Jean Pierre Bonnafont
Therapeutic ultrasound has also been used to de- and Eduard Schmalz who independently evaluated
tect fractures.14 The investigators found that applica- and clinically applied the Weber test. Schmalz made
tion of continuous therapeutic ultrasound with a 3-cm the observation that bone conducted sound lateral-
head at 0.75 MHz directly over the tibia, fibula, and ized to the better hearing ear in sensorineural loss
femur was 90.9% sensitive in the detection of stress and the poorer ear in conductive hearing loss. In 1855,
fractures, when compared to scintigraphy. A positive Heinrich Rinne performed experiments that com-
response was a sensation of intense pressure or pain as pared the length of time a person can hear a tuning
the sound intensity was increased to a maximum of fork through air as compared to bone, using the teeth
2.0 watts/cm2 . There are few reports on the use of instead of the mastoid process. Friedrich Bezold ap-
therapeutic ultrasound to detect fractures, but the plied the terms positive and negative to the Rinne test,
reported sensitivity is collectively high. The overall noting that if the air conduction time exceeded the
utility of using tuning forks or ultrasound to detect bone conduction time, the difference would be a pos-
stress or occult fractures has not been determined, itive number and vice versa.19
but appears useful in certain clinical situations, such There are many different forms of tuning fork tests
as suspicion of occult fracture when the history sug- for hearing, which use a variety of forks (both fre-
gests it and the radiograph is negative. There are quencies and construction of the fork). The Weber and
Rinne tests are the best known and most commonly cluding nasolacrimal duct obstruction (from scarring
used, although the Bing and Schwabach tests are over the duct in the nasal cavity), orbital cellulitis
mentioned in a variety of physical examination texts. (from destruction of the roof of the maxillary sinus
These tests and others have been supported and crit- and the bony nasal septum), and ocular motility re-
icized throughout their history and there is still no strictions from involvement of the extraocular mus-
agreement on their sensitivity and reliability, although cles. Because chiropractors promote healthy life habits
the Rinne test seems to enjoy the most assessment in addition to spinal care, it seems reasonable to screen
and support. A great deal depends on the manner patients who are known cocaine users for possible
in which the fork is struck and the experience of nasal complications.
the examiner.20,21 It is generally agreed that the fork
should be a 512-Hz frequency fork when performing
STETHOSCOPE AND THE HEART
simple screening, although some authors recommend
a 256-Hz fork.22 The fork should be struck at one-third Other than the ophthalmoscope, there may be no more
the distance from the free end of the tines (prongs) intimidating instrument to students and practitioners
against a firm but elastic surface, such as a block of than the stethoscope as it is applied for cardiac aus-
rubber or the thenar eminence of the hand.23 It may cultation. In one sense, it is a difficult skill and art to
seem redundant to use tuning fork testing for hearing develop, but in another sense there is a certain ease to
in the age of technology and audiometry, but it should it if the use of auscultation in put into context. There is
be remembered the chiropractor’s job is not to quan- an ongoing debate over the utility of cardiac ausculta-
titatively assess hearing like an audiologist. When a tion in light of the echocardiogram, the electrocardio-
patient has a head injury, a hearing loss complaint, or gram, and other technology.25,26 The American Board
tinnitus, it is reasonable to screen for hearing loss. It of Internal Medicine stopped testing physician auscul-
may be difficult to establish the type of loss, as hear- tatory skills as part of the final certifying examination,
ing losses can be mixed, but documenting a loss of and only one in four primary care residencies in the
some kind followed by referral is good practice. The US offers structured training in cardiac auscultation.26
methods of performing the various tests can be found Many physicians directly proceed to costly advanced
elsewhere in any standard physical examination work assessment such as the echocardiogram to investigate
and are not reviewed here. the heart, when careful auscultation and a detailed
history could help determine the need for techno-
logical examination.25 Several studies show that the
ANTERIOR RHINOSCOPY AND
auscultatory skills of physicians in training across sev-
COCAINE ABUSE
eral types of residencies are inadequate.27–29 The diag-
It is estimated that 28% of adults between the ages nostic accuracy was low (20–33%) and was not much
of 18 and 25 years have used cocaine at least once. better than medical students’ proficiency. However, it
Ongoing abuse can lead to cardiac, ophthalmologic, was also shown that skills improved when students
and nasal complications, depending on how the drug received structured training, and students also per-
is administered.24 In the case of intranasal (snorted) formed better when they used cardiac audiotapes for
cocaine, the nasal complications include mucosal is- self-training. This seems logical and also seems re-
chemia, necrosis, and septal perforation from the lated to the importance placed on auscultation as a
chronic vasoconstriction. The resultant rebound nasal necessary art, as well as a symbol of the doctor–patient
stuffiness leads to use of over-the-counter medicines relationship.
to control the stuffiness. These also contain vasocon- In light of this information, chiropractic students
strictors that contribute to the destructive cycle of the and educators might ask why chiropractors should be
nasal tissue. Repetition of this cycle eventually leads to expected to be as proficient at auscultation as medical
osteolytic sinusitis and destruction of bone and nasal students and residents, when those individuals appar-
cartilage. ently struggle, even though they have better access
Examination of the anterior nasal structures is sim- to patients more likely to have relevant findings. It
ple to perform with a rhinoscope or a nasal speculum might not be necessary for chiropractors to accurately
and a flashlight. The examiner must look carefully identify the types of murmurs present or the nature
along all the mucosal surfaces searching for white of extra sounds. Even experts such as cardiologists
curd-like patches, which is mucosal scarring from cannot expect 100% diagnostic accuracy because of
chemical irritation and vasoconstriction. The nasal the complexities of cardiac sounds. But it is possi-
septum may be perforated to absent and there may be ble for chiropractors to develop an understanding of
a saddle deformity from lost cartilaginous support. In normal findings and the basic premises of murmurs
addition to the nasal complications there are several and extra sounds. It may be enough to simply identify
ophthalmologic complications of cocaine abuse, in- whether there is a murmur or extra sound and make a
judicious referral in light of the history. For example, As with any other art and skill, proficiency comes
a doctor may identify the presence of a murmur. At from deliberate practice. Chiropractic educators may
that point, if the murmur is systolic in gross timing, not be able to provide extensive training for all
the history will help to determine whether referral is students. There are a number of available low-cost
necessary and how soon. If the murmur is diastolic, training tools, including audiotapes, CD-ROMs, and
it is an abnormal finding, even if the cause is not im- auscultation web sites, and small group training that
mediately threatening, and requires referral.30,31 Con- improve student skills.32,33 The presence or absence
sider the following illustrations. A 10-year-old boy is of murmurs regardless of patient age must always be
assessed at a sport physical for football. The examiner evaluated in light of the patient history. A common
hears a systolic murmur that is best heard at the third error among novice practitioners is to overestimate
intercostal space parasternally (Erb point.) For this il- or underestimate the meaning of murmurs without
lustration, murmur characteristics, such as pitch and attention to the past history. As patients reach the el-
loudness, are set aside for the moment. What should der years, murmurs may become more relevant be-
be done? The first step is to determine the previous cause of the presence of various heart conditions, but
history. If the child has an unremarkable cardiac his- the absence of a murmur does not guarantee health,
tory, does not appear undersize for age, is not cyanotic nor does the presence of a murmur guarantee disease
in the nail beds or lips/oral mucosa, has no palpable (or at least immediately threatening disease). The chi-
thrill upon palpation of the chest, and has appropri- ropractor should be alert to several conditions that
ately tolerated exercise for his age, then the murmur might reasonably be expected in the office based on
is most likely of no concern.30,31 The examiner knows the nature of chiropractic practice and the course of
that about half of all children have innocent murmurs the condition.
and the finding is benign. The examiner could also Consider rheumatoid arthritis and systemic lupus
make the assessment of the pitch and loudness of the erythematosus. Many rheumatoid arthritis patients
murmur. In innocent murmurs, the loudness is grade develop subclinical pericarditis that is discovered on
III/VI at most and is usually low- to medium-pitched. autopsy and clinical pericarditis is rare.34 Neverthe-
This information is not as relevant as the history and less, pericarditis is the most common cardiac com-
knowledge about innocent murmurs and the fact that plication of rheumatoid arthritis and the most likely
this murmur is systolic. If the examiner is uncomfort- finding is the pericardial friction rub. It is reasonable
able with the discovery, referral is always an appro- to think that a life-long rheumatoid arthritis patient in
priate choice. a chiropractic practice has a chance of developing the
Another illustration shows the opposite conclu- condition. The pericardial friction rub is typically easy
sion. A 21-year-old chiropractic student in physical to hear, and is usually described as a harsh, scratchy
exam skills class is found to have a murmur with both “leather rubbing against leather” type of sound. It
systolic and diastolic components. It has a machinery- is usually composed of systolic and diastolic compo-
like quality. There is a palpable thrill at the Erb point. nents. Even if the examiner is unsure of the sound’s
The student has no exercise limitations and she is source, the principle of “diastolic murmurs are abnor-
not cyanotic. She is bewildered but recalls that no mal” applies. The murmur is usually heard through-
one has performed a deliberate assessment of her out the pericardium and may be accentuated by sitting
heart, as far as she knows; her family brought her up and leaning forward. The patient may complain
from another country when she was young. It is sus- of chest discomfort, usually a sharp kind of pain, al-
pected she has previously undiscovered patent duc- though pressure or aching is a possibility. They may
tus arteriosus, which is later proven on echocardiog- also say the discomfort is lessened by sitting up and
raphy. The student has a diastolic component to the leaning forward and worsened by lying supine. De-
murmur complex (or possibly has two different mur- pending on the progression of the disease, the patient
murs), which requires further evaluation. What was may be in mild discomfort or may be in acute distress
the relevant information in the example? First, there with chest pain, dyspnea, and tachypnea. The likeli-
was a murmur, and in this case either two murmurs or hood of developing pericardial tamponade is low.34
a murmur complex of some kind. Second, there was a Clinical pericarditis in systemic lupus erythemato-
diastolic component to the findings. The result is re- sus patients is more common, estimated at 25% of
ferral whether the cause is known or not. In general patients.35 Lupus patients may seek chiropractic care
practice, this is often the case—an examiner discovers for their joint and spinal pains. Consider the follow-
the findings, hypothesizes about where the findings ing illustration. A 32-year-old woman with a 16-year
originate, and decides upon a referral for advanced history of systemic lupus erythematosus and a va-
investigation in certain cases. In the case of a chiro- riety of different disease complications complains
practor, the referral can be to the family physician or of chest pressure at her chiropractic visit. The pa-
cardiologist. tient had recently received parasternal injections of
corticosteroids to control costochondral pain. She had this problem. The first is any cardiovascular symptom
also been diagnosed with esophageal problems simi- or complaint. It is unusual for a competitive young
lar to those of scleroderma that also cause lower chest athlete to complain of exertional chest pain, dysp-
discomfort. She received ongoing chiropractic care for nea, light-headedness/syncope, or fatigue beyond the
her joint and back pains. She spent the previous night exertion of normal practices and games. These com-
with chest pressure and became short of breath to- plaints are often dismissed as traumatic, such as chest
ward morning. She had to sit up and lean forward pain with football, or are dismissed for reasons such
on a stack of pillows in order to sleep. As she put on as heat and humidity and dehydration. Parents and
her clothing in the morning she felt short of breath coaches with the “win-at-all-costs” attitude may as-
by simply raising her arms over her head to put on sume the athlete is avoiding working during practices.
a shirt. She was tachypneic at 30 breaths per minute For these reasons, the chiropractor should understand
and tachycardic at 110 beats per minute. Auscultation the work ethic of individual young athletes, and out-
revealed a grade III/VI pericardial friction rub with of-character complaints should never be minimized.
systolic and diastolic components. The finding con- It should also be noted that young athletes are un-
firmed the diagnosis of pericarditis most likely related likely to complain about the above symptoms unless
to systemic lupus erythematosus. She was assessed explicitly asked.39
in the emergency department. Myocardial infarction The second key is the presence of the dynamic out-
was excluded and echocardiography revealed a small flow murmur. The narrowing of the left ventricular
pericardial effusion. The patient was managed with outflow tract in hypertrophic cardiomyopathy may
observation and corticosteroids and the effusion re- create a systolic murmur that increases in intensity
solved over a few days without the need for pericar- with the Valsalva maneuver. The murmur also de-
diocentesis. This illustration shows the possibility of creases with squatting and increases with standing.
the pericarditis patient being seen in chiropractic prac- Although not present in all patients with hypertrophic
tice and the relative ease of diagnosis based on a clear cardiomyopathy, its presence is a definite cause for
understanding of the history and the physical finding. concern. Unfortunately, the majority of deaths from
Endocarditis is another problem that might ap- hypertrophic cardiomyopathy are in asymptomatic
pear in the chiropractic practice because of joint pains athletes with no known history of past cardiovascular
caused by the disease process. At times, arthralgias, complaints. One study showed only 21% of athletes
arthritis, myalgias, and low back pain may be the pri- who died from hypertrophic cardiomyopathy had rec-
mary and only complaint.36 Two populations among ognizable symptoms or signs of the disease.40
other traditional populations at risk for endocarditis The standard of diagnosis for pericarditis, endoca-
are injection-drug users and patients receiving pros- rditis, and hypertrophic cardiomyopathy is echocar-
thetic heart valves.37 The most common complaint in diography. This tool is invaluable for detecting small
endocarditis is fever, and when this symptom is ac- pericardial effusions, small valvular vegetations in en-
companied by joint pain in at-risk populations, the docarditis, and the various forms of hypertrophy in
presentation should be viewed with suspicion. Most hypertrophic cardiomyopathy. Other investigations,
patients have murmurs, some which might be pre- such as the electrocardiogram (ECG), stress testing of
existing. The task is to recognize the relationship be- various kinds, and radionuclide imaging may be used
tween endocarditis and musculoskeletal complaints as well, depending on the need. However, a chiroprac-
and use the stethoscope appropriately. In this case, the tor should expect that echocardiographic assessment
presence or absence of murmur is not as important as would be performed on most patients suspected of
the history. any of the above problems.
Of particular importance to chiropractors prac- The last heart-related consideration for chiroprac-
ticing with athletes and performing sport physicals tic practice is trauma. Blunt chest trauma from mo-
is hypertrophic cardiomyopathy. It is the most com- tor vehicle accidents or sports may cause a variety
mon cause of sudden nontraumatic death in otherwise of serious injuries that are usually managed in the
healthy young people and the most common cause of emergency department. However, less immediately
sudden cardiac death in athletes younger than age serious but significant injuries may also occur, notably
35 years. Hypertrophic cardiomyopathy is an auto- myocardial contusion. The forces sustained in acci-
somal dominant genetic disease. It occurs in 1 in 1000 dents may cause myocardial contusion with or with-
persons in the general population. It is possible to sur- out sternal fracture and at lesser speeds than might
vive young adulthood and be diagnosed with hyper- be expected. Usually the trauma results in no seri-
trophic cardiomyopathy later in life. Survival depends ous short- or long-term consequences, but within the
on the particular genetic expression of each case, as first 48–72 hours, dangerous arrhythmias may occur,
well as each patient’s level of physical activity.38 Chi- as well as the rare traumatic myocardial infarction.41
ropractors should be alert to a pair of key points with Patients with arrhythmias are often asymptomatic,
and it might be wondered why there is any concern if ing acute exacerbations. Asthma attacks are also no-
there are no symptoms or common significant conse- table as a cause of wheezing. Sports-oriented chi-
quences. The problem is the possibility that an asymp- ropractors who perform preparticipation physicals
tomatic arrhythmia may degenerate. In motor vehicle should be alert to previously unknown (or purposely
accidents where the patient has hit his or her chest on hidden) young asthma patients. Most asthma patients
the steering wheel or has been impacted by the infla- have no gross clinical evidence of disease between
tion of the air bag squarely in the chest, the chiroprac- acute episodes, and if the practitioner does not know
tor should consider referral for an ECG. The ECG is the the patient history, there is little evidence that a child
fundamental tool to use to assess for rhythm distur- could be asthmatic. Deliberate auscultation is key. In
bances as well as evidence of other cardiac problems. this author’s experience, auscultation throughout the
While the ECG alone has no definitive findings to respiratory cycle may reveal wheezes at the end of
prove myocardial contusion, the complications of my- the expiratory phase in some asthmatics. But if the
ocardial contusion, such as arrhythmia, can be identi- examiner pays attention only to inspiration, this clue
fied. Consider the following illustration. A 52-year-old will be missed; therefore, good technique is essential.
woman was driving at legal high speed on a Los Ange- Another sports-related concern is exercise-induced
les freeway in a sport utility vehicle. There was a rear bronchospasm (asthma), which tends to appear after
tire blowout and the vehicle careened head-on into a exertion. Hand-held spirometers can be employed to
restraining wall. The airbags deployed and hit the pa- detect airway resistance in suspected asthma patients
tient squarely in the chest. She declined transport to a in the office setting.
hospital and came to her chiropractor for assessment. In young children, or in adults with a history of al-
Her examination revealed extensive bruising over her lergy, unexplained cough, exercise-induced dyspnea,
chest and sternum, both breasts, and upper arms. She wheezes, and airway resistance, referral is indicated
had mild chest pain, but declined the chiropractor’s for advanced spirometry and other tests. The stetho-
insistence to obtain an ECG. In this case, there were, scope cannot be used to determine the efficacy of chi-
fortunately, no complications and no way to know if ropractic care in asthma patients. Indeed, the reduc-
there was evidence of myocardial contusion. The pation of wheezing during an acute attack may in fact
tient was treated for several months for a variety of indicate the condition is worsening as a consequence
complaints from the accident, and the external bruis- of increasing airway obstruction and decreasing abil-
ing took 3 months to resolve. Even though the patient ity of the patient to move air in either direction. All
declined an ECG, this is precisely the type of case and acute asthma attacks have the potential to rapidly de-
patient that needs one. generate, and in the author’s opinion chiropractic care
should be given to asthma patients only in the nona-
cute stage, or at least only if there is emergency trans-
STETHOSCOPE AND THE LUNG
port simultaneously on the way to the office.
Auscultation of the lung to diagnose specific pul-
monary disorders has limited value according to the
REFLEX HAMMERS AND NEUROLOGICAL
few studies performed to assess this skill.42 Neverthe-
ASSESSMENT
less, it must be remembered that physical examina-
tion is primarily performed to help develop hypothe- The history of the reflex hammer has been reported
ses and make management decisions as opposed to in several journal articles.43,44 Lanska is used as the
confirming or excluding diagnoses. The art of lung source for this brief introduction to the instrument
auscultation must be practiced just as auscultation and its effective use.43 The art of percussing the body
of the heart, and again focused study under supervi- to perform diagnostic assessment has been formally
sion is more likely to increase practitioner confidence. reported since 1761. Leopold Auenbrugger wrote a
Pneumonia, chronic obstructive pulmonary disease monograph on percussion of the chest, an idea he
(COPD), asthma, and acute bronchitis are common developed from percussing wine casks to determine
conditions seen in the general population. The pa- their fluid level. Percussion hammers were developed
tient history assists the clinician in focusing the ex- to perform the art of chest diagnosis. Hammers were
amination toward specific auscultatory findings. In used to percuss chests for lung disease and animal
illness with cough and sputum production with or skulls in search of brain cysts.
without fever, the examiner should search for rales Concerning the nervous system, Marshall Hall
(crackles) and bronchial breathing. These findings first discussed the reflex arc as a neurologic phe-
are most consistent in patients with pneumonia.42 A nomenon in the 1830s. In 1875, Erb and Westphal pub-
posterior-to-anterior and lateral chest x-ray is the stan- lished a paper on the utility of muscle stretch reflexes
dard in confirming the diagnosis. In patients with in the examination of the nervous system. They started
COPD, wheezes are a common finding especially dur- the notion of using a reflex (percussion) hammer to
FIGURE 31–3. Taylor reflex hammer.
elicit reflexes. However, for some time reflexes were

elicited not only by hammers, but also by the ulnar
FIGURE 31–5. Babinski reflex hammer, side position.
surface of the hand, the edge of the stethoscope, pa-
perweights, the foot of a laboratory stand, house keys,
and other objects. Berliner and Troemner were among
application. From the beginning, these neurologists
the investigators who believed a specialized hammer
recognized such things as patient discomfort if the
was the best way to elicit reflexes, and many such
tendon was struck too forcefully, as well as patient
hammers with a variety of names were developed.
distaste if the practitioner used other instruments, ob-
John Taylor was probably the first to make a reflex
jects, or the hand to elicit reflexes. They also recog-
hammer specifically for the purpose of eliciting deep
nized the role of distracting the patient to get the best
tendon reflexes in 1888. This triangular-headed model
results, à la Jendrassik.
is possibly the most familiar in the health professions
Every student and practitioner has experienced
(Fig. 31–3). Interest in muscle stretch reflexes was very
difficulty obtaining reflexes in certain individuals.
high, and notables such as Jendrassik (the Jendrassik
This is often blamed on poor technique, which might
maneuver) and others made important contributions
be the case. The key is to proceed along a system-
to examination of reflexes and its meaning. In addi-
atic plan, and in the end, if there is no discernible
tion to Troemner and Berliner, readers will recognize
reflex, the patient may be assigned a value of “0”
Babinski as the developer of his own style of hammer.
on the grading scale and the interpretation of that
It was Abraham Rabiner who took the gift of Babin-
finding will be done in light of the history. Sapira
ski’s own reflex hammer and modified it so that the
recommends that the initial tap should be light and
disc could be screwed on the end of the handle perpen-
then increased in force to the point that is minimally
dicular to the shaft or screwed into the side of the shaft
necessary to elicit a response. In this way, the exam-
and parallel to it (Figs. 31–4 and 31–5). Apparently the
iner has a better subjective assessment of the strength
disc applied to the side of the shaft was for the conve-
of the response.9 Another consideration, however, is
nience of placing the hammer in a pocket without the
the speed of the stretch of the tendon. The tap must
hammer getting caught in the clothing, as opposed to
be brisk in order to evoke a response in many pa-
the position of the disc having any special diagnostic
tients. Nolan suggests that if the tap is too light or
too forceful, there will be an altered response accord-
ing to the force.45 The patient should be relaxed, and
with patients in pain this might mean the examiner
will have to place the patient in a position to best
comfort them and still obtain the reflex. Tense pa-
tients tend to contract many of their muscle groups
simultaneously and unwittingly interfere with reflex
testing.9 The patient can be distracted by conversation
and/or asking the patient to look away from the stim-
ulus. The limb or part to be struck with the hammer
should be in between complete relaxation and com-
plete contraction, as some muscle tension is necessary
for a good response. Reflexes should not be graded as
0 (on a scale of 0–5 or 0–4) unless proper techniques
and some form of reinforcement are performed. The
FIGURE 31–4. Babinski reflex hammer, end position. Jendrassik maneuver is a method of reinforcement
that can be done several ways. These include clasp- tendon if there is no discernible response. Some nor-
ing the hands together in front of the chest and asking mal people have very weak or undetectable responses
the patient to pull them apart, clenching the teeth, and this is not rare, but examiners should not jump
clenching the fists, or squeezing the knees together. to this conclusion without a careful and deliberate as-
The patient should be instructed to tense only the sessment. It should also be noted that reflex responses
group indicated, however, as some patients will un- could vary between the upper and lower body in the
wittingly contract many muscle groups and “overdo” same patient. Adults frequently show more obvious
the facilitation.9 At the author’s institution, students responses in the lower extremities than in the upper
are taught to both contract a muscle group and count extremities. In addition, some examiners unwittingly
backward from some number in order to provide max- strike one tendon harder than its match on the oppo-
imum facilitation and distraction. The patient is also site side, giving the appearance of unequal responses.
asked to close the eyes or look away from the stimu- Although it is impossible to strike both sides with ex-
lus. The Jendrassik maneuver provides facilitation of actly equal force, focus and practice can develop rea-
a reflex for up to 6 seconds but the peak response is sonably consistent force.
within 300 msec of initiation, so the examiner should
be prepared to strike the tendon immediately after the
HAND GRIP STRENGTH AND THE
patient begins tensing.9
DYNAMOMETER
Another way to aid the process is for the exam-
iner to stretch the tendon to be struck with the thumb, Dynamometers have been used to measure grip
such as is done with the biceps reflex. The examiner strength since the 1950s.46 The Jamar Adjustable Hand
then strikes the thumb, which can be uncomfortable, Dynamometer (JA Preston, Grand Rapids, Michigan)
but is often productive in two ways. The elicitation of has been extensively researched for validity and relia-
the reflex is often more successful, and in many cases, bility and is considered the gold standard of this type
the reflex response is palpable under the thumb. This of instrument.46 Chiropractors are well acquainted
method often assists in reflexes such as the hamstring with this device and its application to measure
group or the triceps. As the tendon is struck, the ex- handgrip strength in a variety of clinical cases, in-
aminer should look for one or more of the three including worker’s compensation and personal injury
dications of the reflex response. The most familiar re- cases. The Jamar dynamometer is affordable and easy
sponse to both examiner and patient is visible motion to use, and is easy to recalibrate. Recently, the instru-
across a joint. The response may also be palpable con- ment has been modified for use with computer sys-
traction under the examiner’s thumb, and/or a visi- tems that give printed readouts of the results as well
ble contraction of the muscle belly in question. One of as measure the grip strength to the nearest hundredth
the errors novices make with reflexes is to leave the of a pound. The Dexter Hand Evaluation and Ther-
muscle belly of a particular group covered by clothing apy System is a computerized instrument that has
while hitting the tendon or thumb, such as leaving a been evaluated for validity and reliability, receiving
shirt sleeve covering the upper arm while perform- high marks for both.46 This system also automatically
ing the biceps reflex. This may cause the examiner to recalibrates.
miss evidence of a successful response. Another pit-
fall in examining reflexes is hitting the wrong place.
GONIOMETERS AND INCLINOMETERS
For example, when the triceps reflex is performed,
novices will often strike the arm on the lateral side There are a variety of goniometers and inclinometers
of the lower humerus once the patient places the arm discussed in the health literature. Figure 31–6 depicts
in the typical position, but the tendon insertion is more an example of an inclinometer in its nonelectronic,
medial. In other patients, a tendon group or single ten- simple form. These instruments have been assessed
don may not be exactly midline or might be smaller for validity and reliability for application to a vari-
than expected. This can be overcome by striking in ety of joints and have been found to be generally
slightly varied places around the expected tendon reasonable for both parameters, although specific de-
location. vices might vary.47–52 The different variations of the
The 0–5 (or 0–4) grading scale for reflexes and the instruments are not discussed here. However, based
interpretation of the results is treated extensively in on research and common experience, it is wise to ap-
standard texts and elsewhere in this volume and is not ply some peer-reviewed and recognized form of ei-
addressed here. The point is primarily that good tech- ther of these instruments for accurate measurement
nique leads to successful examination. After proper of joint motion. Instrumentation is superior to visual
technique is tried several times with the reinforcement estimation and provides evidence for improvement in
of the Jendrassik maneuver and the use of distraction, range of motion over time. This can be useful for doc-
a patient may be assigned a value of 0 for a particular umentation of functional improvement to third-party
The premise of the NCM and similar devices is the

thermocouple principle discovered by German scien-
tist T. J. Seebeck in 1829.55 Electric current flows in
a circuit made of two different metal conductors and
two junctions. The current occurs when there is a tem-
perature differential between the two junctions. A gal-
vanometer (millivoltmeter) shows a fluctuation of a
needle on a scale, which is called a “break.” When
the break occurs, the NCM was considered to pro-
vide evidence of a subluxation. This was based on the
premise that the subluxation caused “nerve interfer-
ence” that affected the vascular flow to the skin, al-
tering the skin temperature in affected areas. There is
little dispute that the nervous system affects vasomo-
tor tone via the sympathetic nervous system and as a
result local skin temperatures. There is also no doubt
that the NCM and other such devices measure what
they are purported to measure, that is, skin tempera-
ture differentials (validity), but the use of the thermo-
couple principle as a predictor of subluxation (pre-
dictive validity) requires that there is a spinal lesion
to be shown (construct validity). Clinicians who use
the NCM claim that they have shown before and after
FIGURE 31–6. Inclinometer. adjustment differences in the NCM findings but have
yet to show that this relates to the existence of sublux-
ations. There seems little doubt that some physiolog-
payers, as well as to provide concrete evidence to pa- ical event is happening as a result of the adjustment.
tients about their own function. It is also reasonable to think of “before and after” ad-
justment measurements as evidence for the clinical
efficacy of an instrument. But there continues to be a
lack of published clinical trials with solid experimen-
NEUROCALOMETER AND THERMOCOUPLE
tal and statistical design using the NCM and similar
DEVICES
instruments.56
The neurocalometer (NCM) has little mention in the There has been some published work on the reli-
peer-reviewed, indexed health literature, although it ability of thermocouple devices.57,58 In a review arti-
is frequently mentioned in non-peer-reviewed publi- cle, Plaugher notes the interexaminer and intraexam-
cations within the profession. There are currently 15 iner reliability of hand-held thermocouple devices as
citations concerning the neurocalometer in the MAN- generally good or moderate. Plaugher also notes that
TIS database. Several of these publications address the there were study design weaknesses in the publica-
history of the NCM and its effect on the chiroprac- tions. Finally, he notes there are no normative data
tic profession. Dossa D. Evans, DC, an engineer and for these instruments and calls for further research.59
Palmer graduate, invented the neurocalometer, prob- The NCM has several modern hand-held competitors
ably beginning his work on the instrument in 1920. that survived the patent infringement challenges of
B. J. Palmer formally introduced the device at the 1924 the earlier days, as well as challenges of perceived
Palmer Lyceum, although there is evidence that the merit. Two of these are the Nervoscope (Temposcope)
NCM was informally introduced in the prior year.53 and the Thermeter. Figure 31–7 depicts another vari-
The instrument was the center of great controversy, be- ation. Anrig discusses the use of the Temposcope in
cause Palmer restricted its availability to a segment of Pediatric Chiropractic.60 She notes factors that might in-
the profession.53,54 The instrument was only available terfere with the paraspinal scanning procedure, such
by lease through the Palmer School of Chiropractic. as air gapping between the skin and the instrument
Leasing was restricted to Palmer School of Chiroprac- interface, scanning areas that are too large at one time,
tic graduates and initially to members of the Universal scanning too fast with a nonamplified instrument, and
Chiropractic Association.53,55 Historical writers refer skin lesions. She notes that to avoid the air-gapping
to this event as the “neurocalometer debacle”53 that problem, the probes should be maintained perpen-
led to one of the many schisms in the profession (see dicular to the skin with sufficient pressure. In addition,
Chapter 1). she mentions that when a temperature differential
2. Some of the common conditions that may be as-

sessed through examination with diagnostic in-
struments include fever, hypertension, headache,
infection, fracture, drug abuse, and heart and lung
pathology, as well as neurological conditions or
disturbances.
3. Diagnostic decision making does not always
mean arriving at a final diagnosis. In chiroprac-
tic practice, it might be unrealistic to do so on
many occasions. Nevertheless, judicious manage-
ment decisions and, where necessary, referral for
further study depend on forming diagnostic hy-
potheses derived from the history and physical
examination.
4. Certain types of investigations, such as the
ECG and laboratory-based spirometry, do not fall
within typical chiropractic practice experience, yet
they are fundamental to the diagnosis of certain
conditions. Familiarity with the instruments and
when they are applied for conditions chiroprac-
tors might expect in the office setting is becom-
ing more important as chiropractors integrate into
FIGURE 31–7. Neurocalometer. mainstream health care. The chiropractor need not
know how to interpret an ECG, but knowledge
is found, the procedure should be repeated several of when referral for an ECG would be beneficial
times and that “accentuated differentials with a re- to the patient is commensurate with chiropractic
peated scanning procedure are more significant than licensure and autonomy.
those that diminish.”60 This observation raises two
questions: If there is direct pressure on the skin with
the instrument and the scan is repeated several times,
what effect, if any, does the inevitable skin friction QUESTIONS
have on the instrument reading, and how does this af- 1. A 64-year-old new patient desires treatment for
fect the clinical interpretation? These and other ques- low back pain. She is clinically obese and eats an
tions of validity and reliability need further study. unrestricted diet. She does not exercise and smokes
B. J. Palmer introduced the neurocalograph in two packs of cigarettes daily. Her initial blood pres-
1935–1936.54 This device was the NCM with a graphic sure measurement is 156/94 mmHg. How should
recording of “nerve interference.” The makers of the this patient be managed?
Nervoscope countered with their Analagraph, and in- 2. A 27-year-old patient complains of head pain that
creased the stakes with the introduction of the Anala- is new to him. It is 2 days old and he simply “woke
scope, which allowed the patient to see the readings as up with it.” There was no trauma. Although he
they were recorded.54 There are other similar devices, has been successfully treated for neck pain and
such as the Chirometer and the Synchrotherme, that headaches by chiropractors before, this pain is dif-
have followed similar principles. These instruments ferent in that it is persistent from morning until
were used to determine absolute temperature read- night, fluctuates in severity from moderate to se-
ings in order to know whether a paraspinal area was vere, seems to worsen when he bends forward,
bilaterally hot or cold. The reader is referred to the does not pulsate, and is accompanied by nau-
references for further information. sea. Occasionally, he has felt light-headed when
he bends forward. He has also felt unsteady on
his feet from time to time, although it is unclear
SUMMARY
what exactly he means. He feels muscle aches “all
1. Some of the commonly used diagnostic instru- over,” and is unsure whether he has had fever.
ments in chiropractic are the thermometer, List the examination procedures that should be
sphygmomanometer, ophthalmoscope, otoscope, performed for this patient and develop diagnostic
rhinoscope, tuning fork, stethoscope, reflex ham- hypotheses.
mer, dynamometer, goniometer, inclinometer, and 3. A 16-year-old high school football player who is
neurocalometer. an established chiropractic patient complains of
shortness of breath during the last two football The patient’s deep tendon reflexes should be eval-
games. It is early fall in a humid region, and tem- uated using a reflex hammer to look for signs of hy-
peratures are still high in the evening. The pa- perreflexia. The patient’s neck should be examined
tient is a running back and is a starter (first-string for rigidity especially if there is evidence of a low-
player). The coach insists that players remain well grade fever of 101o F (38.3o C). The history in this
hydrated and the patient states he has been com- case raises concern for a mass lesion in the brain.
pliant with drinking fluids during the game. What Mass lesions often, but not always, are preceded
should be done for this patient in the office and by longer histories of vague headaches that persis-
what follow-up should be considered? tently worsen over time and eventually cause gait
4. A 31-year-old patient who is a known intra- disturbances and nausea and vomiting. The fever
venous drug abuser presents to a chiropractor with suggests infection, and this presentation is typi-
complaints of diffuse joint pains and low back cal for a viral syndrome, possibly viral meningitis.
pain. The patient has been feeling vaguely ill over This patient should be referred to his private med-
the last several months, with general fatigue and ical practitioner for follow-up on an emergency
malaise. The patient has tried to stop using drugs basis.
by going in and out of insurance-funded rehabil- 3. This patient is at risk for hypertrophic cardiomy-
itation programs but has been unsuccessful and opathy. Although relatively uncommon, this his-
continues to use heroin on occasion. How should tory should raise suspicion of this potentially life-
the patient be managed? threatening disease. It is possible that humidity
5. A 37-year-old man was in a car accident. He was and lack of conditioning are the reasons for the
driving an older vehicle that had no air bags and perceived shortness of breath, but this should not
no shoulder harness, and he was not wearing his be assumed. The patient’s heart should be auscul-
seat belt. The collision was head-on but at a rela- tated in the supine, standing, and squatting po-
tively low speed. The patient struck his chest on sitions in a search for murmurs, particularly the
the steering wheel. He did not hit his head and dynamic murmur of left ventricular outflow ob-
did not lose consciousness. The chiropractor has struction. Regardless of the findings, the patient
known this patient for many years and knows the should be referred for echocardiographic assess-
patient has no remarkable history or physical find- ment. The presence of an abnormality on ausculta-
ings. It is now 5 days since the accident and the pation may convince the patient and coach that such
tient is complaining of neck and chest pain. What a referral is necessary before the patient continues
should be done for this patient? playing football.
4. The patient deserves an extensive examination for
evidence of subacute endocarditis. This patient can
be referred immediately to a medical physician
ANSWERS
or a preliminary examination can be conducted
1. Any measurement such as blood pressure that by the chiropractor to look for signs that may re-
falls outside the expected norms should first be quire referral to an emergency room. Inspection
repeated. Many patients are anxious during a first should be performed looking for the “peripheral
chiropractic visit and this can result in elevated stigmata” of subacute endocarditis, such as splin-
blood pressure. The blood pressure should be mea- ter hemorrhages in the nail beds. Roth spots on the
sured again after the patient relaxes. If the pres- retina may be seen during the ophthalmoscopic ex-
sure remains elevated, counsel the patient about amination. The heart can be auscultated for mur-
her lifestyle—that cessation of smoking, starting murs, although it may not be possible to deter-
exercise and weight loss, and proper diet all con- mine whether a murmur is new or preexistent.
tribute to reduction of blood pressure. Persistent Vital signs are performed to search for fever and
mild hypertension is a significant contributor to evidence of toxicity (racing pulse, reduced blood
cardiovascular and cerebrovascular disease. Refer pressure.) The patient will need follow-up with her
the patient to her medical practitioner to consider private medical practitioner for ECG and labora-
medical management of hypertension. tory testing, as well as echocardiography.
2. The patient should undergo both a neurological 5. After the physical examination and x-ray assess-
examination and ophthalmoscopic examination. ments are performed for neck, rib, and sternal frac-
The patient’s optic discs should be examined for tures, the question remains whether to refer the pa-
shape, color, and vascular morphology. The neuro- tient for an ECG to search for arrhythmias. Because
logical examination should include a search for ev- it has been 5 days since the accident, the likelihood
idence of ataxia during heel-to-toe walking or loss of serious complications from myocardial contu-
of balance when the Romberg test is performed. sion is statistically very low. If there is no evidence
of new heart sounds or rhythm disturbances by 9. Sapira JD. The art and science of bedside diagnosis, 1st ed.
pulse assessment, the chiropractor can reasonably Baltimore: Urban and Schwarzenberg, 1990.
treat the patient without an ECG, bearing in mind 10. Pichichero ME. Acute otitis media: Part I. Improving
that any change in the patient’s status should be diagnostic accuracy. Am Fam Physician 2000;61:2051–
addressed. 2056.
11. Lamm L, Ginter L. Otitis media: A conservative
chiropractic management protocol. Top Clin Chiropr
1998;5(1):18–28.
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A. A feasibility study of chiropractic spinal manipula-
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media with effusion in children. J Manipulative Physiol
Drezner JA. Sudden cardiac death in young athletes. Post-
Ther 1999;22:292–298.
grad Med 2000;108(5):37–50.
13. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s
Hunder GG. When musculoskeletal symptoms point to en-
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docarditis. J Musculoskel Med 1992;9(3):33–40.
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Kazemi M. Tuning fork test utilization in detection of frac-
14. Kazemi M. Tuning fork test utilization in detection
tures: A review of the literature. JCCA 1999;43(2):120–
of fractures: A review of the literature. JCCA 1999;
124.
43(2):120–124.
Keating JC. BJ of Davenport—The early years of chiropractic, 1st
15. Lesho EP. Can tuning forks replace bone scans
ed. Davenport, IA: Clinch Valley Printing Co., 1997.
for identification of tibial stress fractures? Mil Med
Lamm L, Ginter L. Otitis media: A conservative chiro-
1997;162:802–803.
practic management protocol. Top Clin Chiropr 1998;5(1):
16. Misurya RK, Khare A, Mallick A, Sural A, Vishwa-
18–28.
karma GK. Use of tuning fork in diagnostic auscul-
Moder KG, Miller TD, Tazelaar HD. Cardiac involvement
tation of fractures. Injury 1987;18:63–64.
in systemic lupus erythematosus. Mayo Clin Proc 1999;
17. De Michele G, Filla A, Nunziatina C, et al. Influence of
74:275–284.
age, gender, height and education on vibration sense.
Pichichero ME. Acute otitis media: Part I. Improving
A study by tuning fork in 192 normal subjects. J Neurol
diagnostic accuracy. Am Fam Physician 2000;61:2051–
Sci 1991;105:155–158.
2056.
18. Reggars JW. Vibratory sensation testing: Practice tip.
Sapira JD. The art and science of bedside diagnosis, 1st ed. Bal-
Comsig Rev 1995;4(1):14–15.
timore: Urban and Schwarzenberg, 1990.
19. Ng M, Jackler RK. Early history of tuning-fork tests.
Wells KA. Myocardial injury from blunt chest trauma—
Am J Otolaryngol 1993;14(1):100–105.
Implications for chiropractic practice. JNMS 2001;9:122–
20. Burkey JM, Lippy WH, Schuring AG, Rizer FM. Clin-
128.
ical utility of the 512-Hz Rinne tuning fork test. Am J
Otolaryngol 1998;19:59–62.
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1. Christensen MG, Kerkhoff D, Kollasch MW, Cohn L. 259.
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Chiropractic Examiners, 2000. informal tests of hearing. J Laryngol Otol 1989;103:
2. Dosh SA. The diagnosis of essential and secondary 7–11.
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3. Vasan RS, Larson MG, Leip EP, et al. Impact of high- 24. Alexandrakis G, Tse DT, Rosa RH, Johnson TE. Naso-
normal blood pressure on the risk of cardiovascular lacrimal duct obstruction and orbital cellulitis associ-
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4. Epperly TD, Moore KE, Harrover JD. Polymyalgia thalmol 1999;117:1617–1622.
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6. Pfund Z, Szapáry L, Jászberényi, Nagy F, Czopf J. 27. Mangione S, Nieman LZ. Cardiac auscultatory skills of
Headache in intracranial tumors. Cephalalgia 1999; internal medicine and family practice trainees. JAMA
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MR imaging in the evaluation of chronic headache in Clinical auscultation skills in pediatric residents. Pedi-
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31. Pelech AN. Evaluation of the pediatric patient with ogram and universal goniometers for measuring maxi-
a cardiac murmur. Pediatr Cardiol 1999;46(2):167– mum active knee flexion and extension of patients with
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34. Vollertsen RS, Miller FA. Recognizing and treat- Porter L. Interexaminer reliability and concurrent
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1992;9(4):87–102. cervical ranges of motion. J Manipulative Physiol Ther
35. Moder KG, Miller TD, Tazelaar HD. Cardiac involve- 1989;12:205–210.
ment in systemic lupus erythematosus. Mayo Clin Proc 51. Stude D, Goertz C, Gallinger M. Inter- and intraexam-
1999;74:275–284. iner reliability of a single digital inclinometric range
36. Hunder GG. When musculoskeletal symptoms point of motion measurement technique in the assessment
to endocarditis. J Musculoskel Med 1992;9(3):33–40. of lumbar range of motion. J Manipulative Physiol Ther
37. Mylonakis E, Calderwood SB. Infective endocarditis in 1994;17(2):83–87.
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38. Mohiddin S, Fananapazir L. Advances in under- STP electronic inclinometer, metrecom, and manual
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40. Drezner JA. Sudden cardiac death in young athletes. 54. Kyneur JS, Bolton SP. Lost technology: The rise
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1989;39:1542–1549. inter- and intraexaminer reliability of a paraspinal
44. Schiller F. The reflex hammer. In memoriam Robert skin temperature differential instrument. J Manipula-
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85. 58. Perdew W, Jenness ME, Daniels JS, Speijers FH,
45. Nolan MF. Introduction to the neurologic examination, 1st Fiorenzo JA, Cummins R. A determination of the reli-
ed. Philadelphia: FA Davis, 1996. ability and concurrent validity of certain body surface
46. Bellace JV, Healy D, Besser MP, Byron T, Hohman temperature measuring instruments. Dig Chiropr Econ
L. Validity of the Dexter evaluation system’s Jamar 1976;May/Jun:60–65.
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grip strength in a normal population. J Hand Ther musculoskeletal abnormalities of the spinal column.
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C H A P T E R
32
THE USE OF MEASUREMENT
INSTRUMENTS IN CHIROPRACTIC
PRACTICE
Christopher J. Colloca, Tony S. Keller, Gregory J. Lehman, and Donald D. Harrison
O U T L I N E
INTRODUCTION Dynamic
KEY TERMS Assessment of Muscle Strength
Clinical Utility Manual Testing
Qualitative versus Quantitative Measures Dynamometry
Reliability Isometric Testing
Validity Isokinetic Testing
Accuracy and Precision Isoinertial Testing
Sensitivity and Specificity PHYSIOLOGICAL MEASUREMENTS
Discriminability and Responsivity Electromyography
CLINICAL CONSIDERATIONS OF THE Measurement of Muscle Strength Using EMG
PAIN PATIENT Signal Amplitude
Perceptual Measurements Flexion-Relaxation Phenomenon
Outcomes Assessment and Disability Instruments Paraspinal Muscle Asymmetry
General Health Outcomes Assessment Instruments Neurodiagnostics
Pain Perception Outcomes Assessment Instruments Needle EMG
—Pain Intensity Nerve Conduction Velocity
—Pain Affect H-Reflex
—Pain Location F-Response
Condition-Specific Outcomes Assessment Instruments Evoked Potentials
Psychometric Outcomes Assessment Instruments CONCLUSIONS
Patient Satisfaction Outcomes Assessment Instruments SUMMARY
FUNCTIONAL MEASUREMENTS QUESTIONS
Spinal Stiffness Assessment ANSWERS
Static or Quasistatic KEY REFERENCES
Ultrasonic Indentation REFERENCES
2. To review methods of collecting perceptual out-

OBJECTIVES
come measures for pain, disability, satisfaction,
1. To review terminology important to measure- and general health.
ment of clinical outcomes, such as reliability, 3. To review functional spine measurements such as
validity, accuracy, precision, sensitivity, speci- spinal stiffness and muscle strength.
ficity, discriminability, responsivity, and clinical 4. To review physiological spine measurements such
utility. as electromyography and neurodiagnostics.
629
INTRODUCTION KEY TERMS

With the presentation of new patients, clinicians are Clinical Utility
faced with the challenge of diagnosing their condi- Prior to discussing spine instrument measures, it is
tion, assessing their clinical status, and monitoring necessary to present several important key terms that
their progress. Within this mix of patient manage- will be used throughout this chapter. Because mea-
ment, difficulty arises in objectively measuring pa- surements made during the patient encounter provide
tient clinical status. Aside from the primary objec- the clinician with information to describe the patient’s
tive of accurately understanding and describing a health, the usefulness of these measures must be clari-
patient’s clinical status, ever-increasing demands are fied in order to use these tests as a basis for meaningful
placed on clinicians from a state and national regu- clinical decisions. Usefulness is known as utility; thus,
latory standpoint, as well as from the medicolegal in the realm of clinical practice, the term clinical utility
arena and third-party reimbursement perspective. As- applies. Determining the clinical utility of a measure is
sessing and identifying dysfunction is necessary in perhaps the most important consideration in test se-
the development of objective outcome measures of lection. Clinicians must evaluate if a test is able to
spinal function. However, if an anatomical diagno- (a) provide an accurate diagnosis, (b) provide evi-
sis for low back conditions is impossible 80–90% of dence supporting the use of a specific treatment or
the time,1 being able to differentiate normal spinal treatment approach, or (c) enable the clinician to deter-
function from abnormal is fundamental to creating a mine the true outcome or effectiveness of the treat-
diagnosis based on spinal function rather than aber- ment or intervention.3 To choose the right test for the
rant anatomy. A diagnosis based on function and right patient at the right time is as much an art as it is a
tools and techniques to quantify dysfunction provide science. To assist the clinician in this decision-making
a means to assess a patient’s progress and current con- process, an introduction of key terms is presen-
dition separate from his or her subjective perception of ted within the context of spine instrument measures.
pain.
The chiropractic encounter has tended to be a high- Qualitative versus Quantitative Measures
touch, low-technology health care model with more Qualitative assessments determine the nature, as op-
concern for the person than the disease.2 Within this posed to the quantity, of the elements composing a
realm, qualitative assessments have been the predomi- test or measure. Inspection, palpation, and visual ob-
nant feature of clinical assessments in chiropractic, as servations of patient structure or function are all ex-
well as medical, practice. Technological advances over amples of qualitative assessments used by clinicians.
the past few decades, however, have made a num- Whether the clinician is judging muscle strength by
ber of devices available for clinicians to objectively the clinician’s kinesthetic sense, visually estimating
measure the spine and patient complaints. In addi- range or quality of spinal motion through observation,
tion, outcome assessment instruments have grown in or attempting to define tissue characteristics through
popularity to document the effect a condition has on palpation, such qualitative assessments can only esti-
the patient’s activities or quality of life. These ad- mate the clinician’s perceived judgment. Quantitative
vances have begun to bridge the gap between qual- assessments, in contrast, express a numerical amount
itative and quantitative assessments, serving to raise relative to the proportionate quantities of a test or mea-
the bar of objectivity in monitoring patient clinical sure. In the context of spine measurements, range of
status. motion can be described in units of degrees, spinal dis-
Building on the knowledge gained from pa- placements can be described in units of inches or cen-
tient history and physical examination, this chapter timeters, and physiological changes can be expressed,
presents the progression of spinal assessments used for instance, in units of temperature (degrees), electri-
in clinical practice. Through a review of the literature, cal signals (volts), or other relevant descriptors. Quan-
the benefits and shortcomings of popular spine mea- titative measures thus allow us to objectify clinical as-
surement devices are presented with specific empha- sessments in order to understand and communicate
sis upon usage and clinical utility. In this manner, information in absolute terms as opposed to those
perceptual, structural, functional, and physiological that are ambiguous. Table 32–1 provides a comparison
spine measurements are introduced and characterized of commonly used qualitative measures in chiroprac-
relevant to patient management. Herein, a rationale is tic practice and their quantitative counterparts using
presented for ordering and performing spinal assess- spine instrument measures.
ments within the context of clinical decision making.
As a result of this discussion, new insights will as- Reliability
sist the clinician in more effectively managing patients Because quantitative assessments use numbers to de-
with spinal complaints. scribe the entity being tested, they tend to be more
THE USE OF MEASUREMENT INSTRUMENTS IN CHIROPRACTIC PRACTICE 631
TABLE 32–1. Qualitative Clinical Assessments and Their Quantitative Counterparts
Test Qualitative (Findings) Quantitative (Units of Measurement)
Perceived pain, Patients’ subjective description (patient Outcomes assessment instruments

disability, and/or demeanor) (numerical score compared to normative
functional status values)
Pain threshold or pain Palpation for pain (tenderness, grading of Pressure algometry (psi, kg/cm2 , or Pa)
tolerance trigger points)
Posture Visual postural analysis (i.e., head tilt, high Postural grid photography; surface
shoulder, etc.) topographical measures;
computer-assisted digitization; diagnostic
imaging (x-ray, magnetic resonance
imaging, computed tomography)
(millimeters or degrees)
Range of motion Visual estimation (restricted mobility, pain Inclinometric measurement; goniometric
production or reproduction) measurement (degrees)
Intersegmental range Motion palpation (articular fixation, pain) Spinal stiffness assessments; static/
of motion quasistatic (N/m); dynamic (kg−1 , kg,
m/Ns, Ns/m, m/N); instantaneous axis
of rotation (degrees); instantaneous
helical axis (radians)
Muscle strength Muscle testing (grading 0–5) Dynamometric measurement (kg or lb)
Computerized and digital equipment
(kg or lb); load cell or strain gauge
types; B200 (kg or lb);
electromyelogram (mV)
Muscle endurance Muscle testing (grading 0–5) Biering-Sorensen test (time duration,
seconds, of task performance);
Electromyography (median frequency or
wavelet analysis) (Hz)
Muscle spasm Palpatory myospasm assessment Surface electromyography (mV)
Nerve function Orthopedic/neurologic exam (i.e., Nerve conduction velocity (ms); needle
mechanical tests, stretch tests, deep electromyography (mV); H-reflex (mV);
tendon reflex, dermatomal sensation) somatosensory evoked potentials (mV);
current perception thershold (mV);
thermography (degrees C or F)
Pathology History, inspection, palpation (mass, rubor, Diagnostic imaging; laboratory analysis;
calor, dolor) biopsy
reliable than qualitative measures. Reliability is the de- Validity

gree of stability exhibited when a measurement is re- Reliability, however, must not be confused with va-
peated under identical conditions. Interexaminer relia- lidity. Validity is the extent to which a test, measure-
bility, thus, refers to the agreement between clinicians ment, or study measures what it purports to measure.
performing identical tests. Along similar lines, intraex- Although a test or measure may be reliable, this does
aminer reliability concerns the ability of a single exam- not necessarily mean that it is valid. For example, it
iner to achieve the same results each time a test is per- would be invalid to use a measure of leg-length in-
formed. Consistencies of results are dependent upon equality to describe a patient’s pain because such an
a number of factors, including instrument error, the assessment isn’t intended to quantify pain. Reliability
skill and proficiency of the clinician, patient compli- is a necessary but not sufficient condition for valid-
ance, and the environment in which the test is per- ity. For instance, if the dial of the scale were 5 pounds
formed. These considerations are further discussed in away from zero, one would overreport their weight by
context with the spinal measurements presented in 5 pounds. Is the measurement consistent? Yes, but it is
this chapter. consistently wrong. The selection of the appropriate
TABLE 32–2. Types and Definitions of Validity Measurements
Term Definition
Content validity The extent to which the content of the test sufficiently covers the
area it purports to measure.
Construct validity The degree to which inferences can legitimately be made from
the measure or study.
Concurrent validity The ability of a measure to indicate an individual’s present
standing on the criterion variable.
Convergent validity The degree to which the validity of a measurement correlates to
another measurement that is different, but related, and
performed at the same time.
Discriminant validity The ability to correctly discriminate the findings into categories
such as positive or negative, normal or abnormal, etc.
External validity The extent to which the results of a test provide a basis for
generalizations to other circumstances.
Face validity The degree to which a measurement fits with accepted theory.
Internal validity The approximate truth about inferences regarding cause–effect
or causal relationships from the measure or study.
Predictive validity The extent to which the results of a test are predictive of the
future nature of events.
test is thus necessary for validity. The range of inter- Sensitivity and Specificity
pretations that can be put upon a test is another way Also important in understanding the meaningfulness
to describe validity. Subcategories of validity further of spine instrument measures are sensitivity and speci-
dissect the question of validity. Types of validity ap- ficity. Sensitivity represents the proportion of truly
pear in Table 32–2. afflicted persons in a screened population who are
identified as being afflicted by the test. In other words,
Accuracy and Precision sensitivity is a measure of the probability of cor-
Also important to consider in test selection are the ac- rectly diagnosing a condition, or the true positive rate
curacy and precision of a measurement device. Accuracy of a test. Consider, for instance, the sensitivity of a
is the degree to which a measurement represents magnetic resonance imaging (MRI)-documented disc
the true value of the attribute that is being mea- protrusion among back pain patients. Because disc
sured. The accuracy of a test is determined, when protrusion is a common finding among asymptomatic
possible, by comparing results from the test in ques- individuals,4 the sensitivity of disc protrusion in back
tion with results generated from an established ref- pain patients is low. Specificity, on the other hand, is the
erence method. Weighing an object with a known proportion of nonafflicted persons who are so identi-
mass, for example, can assess the accuracy of a weight fied by the screening test. It is a measure of the prob-
scale. Consequently, the ability to calibrate a de- ability of correctly identifying a nonafflicted person,
vice and regular calibration of equipment are re- or the true negative rate of a test. Laboratory evalu-
quired to maintain accuracy. The accuracy of an inations commonly have high specificity in ruling out a
strument, however, cannot be adjusted beyond its diseased state. Ideally, a test should have 100% sen-
precision. Precision is the reproducibility of a quan- sitivity and 100% specificity. In other words, the test
tifiable result or an indication of the random error. always correctly identifies the disease state in the pop-
To cite an example of the importance of precision, ulation tested. However, instruments used in physical
consider an inclinometry measure. If an inclinome- examinations are imperfect and subject to both inher-
ter system has a standard error of 5 degrees for mea- ent and human error. Interpretations from physical
suring range of motion, then differences significantly examination measures thus must be interpreted with
greater than 5 degree must exist to make any judgment caution and correlated with other significant findings.
about the significance of the results. Both the preci-
sion and accuracy of spine measurement instruments Discriminability and Responsivity
are important considerations when deciphering test Finally, clinicians must take into account whether
results. the information gained from an instrument allows
TABLE 32–3.Relationships Between Sensitivity ination may help to confirm the presence of nerve
and Specificity Among Tests for Disease States root involvement, the same examination is poor in
discriminating patients with somatic pain. Even more
Disease State complex are the uncertainties regarding psychosocial
factors and patient motivations to consider when eval-
Test Result Disease No Disease uating the pain patient. Within this context, this chap-
ter presents a number of spine instrument measures
Positive True positive False positive that are designed to assist the clinician in quantifying
(sensitivity) patient presentation and outcomes.
Negative False negative True negative In recent years, there have been significant ad-
(specificity) vances in the understanding of the physiologic and
biochemical processes that are involved in pain pro-
cessing at a spinal level. The elucidation of these mul-
tifaceted processes has meant a shift away from the
the clinician to distinguish between healthy and un- conceptualization of pain as a simple “hardwired”
healthy patients. This characteristic, discrimination, is system with a pure “stimulus–response” relationship.
determined by making comparisons to a normative In fact, many patients report pain in the absence of tis-
database. Further considerations, such as the number sue damage or any likely pathophysiological cause,
of healthy persons that test as diseased (false positive) which may be a result of psychosocial factors,5 or be
and the number of unhealthy persons who test as neg- related to plastic changes within the nervous system.6
ative (false negative), additionally assist in determining The International Association for the Study of Pain
a measure’s discriminability. Ideally, a highly discrimi- (IASP) defines pain as an unpleasant sensory and
nating test would have few false-positive and few false- emotional experience associated with actual or po-
negative results (Table 32–3). Another term, responsivity tential tissue damage or described in terms of such
or response stability, refers to the test’s ability to provide damage.5 Naturally, pain is subjective and highly in-
consistent measurements with repeated use over time. dividualistic. Theorists view pain as not simply a sen-
Without this attribute, it is difficult for a clinician to un- sation, but as a multidimensional phenomenon in-
derstand the value of a prescribed treatment regimen volving sensory, evaluative, emotional, and response
in pre- and postassessment. Important in assessment components.7 Each person learns the meaning of the
of responsivity is whether the observed change that oc- word pain through experiences related to injury in
curred is, in fact, reflective of the change that actually early life,5 and personal, social, and cultural influences
occurred. Along these lines, if a measure was found to all are thought to play important roles in the pain phe-
have a certain range of variability among days of the nomenon. Because pain, particularly persistent pain,
week, and a test was not performed on the same day, is not often directly tied to specific pathophysiology,
then the variability must be taken into consideration but rather is linked to integrated perceptions arising
when making any meaningful interpretation from the from neurochemical input, cognition, and emotion,
test comparisons. For the clinician, understanding the the mind greatly influences the intensity of the pain.8
benefits and limitations of the instrument measure is Moreover, there is a poor association between objec-
of most importance in both test selection and inter- tive measures of physical pathology and the amount
preting results in the realm of clinical practice. of pain and disability that a patient may express.9
These factors must be considered in the realm of pa-
tient management.
CLINICAL CONSIDERATIONS OF THE
Clinical decision making is based upon securing a
PAIN PATIENT
working diagnosis from a review of the patient his-
Observations made from the moment a patient en- tory, physical examination, standard tests, and imag-
ters the office can reveal much about his or her con- ing studies. In the center of this mix lies the patient
dition. Antalgic postures, altered gaits, and guarded and the patient’s complaints. While this chapter is
movements are examples of presentations that reveal not intended to provide a comprehensive review of
important information. After reviewing the patient the patient encounter, understanding the role that the
history, even more knowledge is gained. Does the pa- patient plays in arriving at a diagnosis is of prime
tient have pain or paresthesia in a dermatomal distri- importance. Patient evaluations are not as simple
bution suggesting possible nerve root involvement? as looking at test results. Comorbid factors such as
Conversely, does the patient have local or referred patient motivation can further influence patient re-
(scleratogenous) type pain possibly arising from so- sponses on a number of levels—from questionnaire
matic structures such as the disc, facet, ligament, mus- responses to actual test performance. Patients have
cle, or viscera? While a standard neurological exam- been known to amplify symptoms or functional status
for a variety of reasons based in the human nature.

Anxiety, stress, and emotional disturbances such as Strength
Functional
depression or hysteria may be responsible for elevated Posture Stiffness
pain scores.10 In addition, the effects of compensation, Endurance
Anomaly
litigation, and employment have been named as influ- Proprioception
ences in patient status and outcome.11 It is clear that
Pathology Range of Motion
comorbid factors exist in patient status and recovery;
thus, attentiveness in assessment of the big picture is
important for clinicians to consider. Structural Spine Physiological
A great deal can be learned about a patient through
observation. Triano et al. discussed issues surround-
ing patient motivation in the previous edition of this Pain Threshold
Neurological Testing
text.12 There, it was noted that test results should be
Perceptual
Thermography
Health Status
interpreted in conjunction with observations made
Outcomes Muscle
while the test is performed. Observing characteris-
Assessment Testing
tics such as quality of movements, facial expressions,
and performance efforts combined with some stan-
dardized approaches to patient evaluation will assist
in drawing meaningful conclusions from test results.
FIGURE 32–1. Categorization of spine instrument measures
A common misconception is the assumption that a
(perceptual, structural, functional, and physiological) and the
single measurement is reflective of the patient’s le-
associated tests in each category.
gitimate performance capacity. The use of repeated
measurements and the use of related tests serve to
validate whether test results are reflective of the or- The distinction between functional limitations and
ganic lesion, or are influenced by patient motivation. disability helps to explain why two patients with
Such procedures are reviewed in the framework of the similar impairments and functional limitations may
spine instrument measures presented in this chapter. have very different levels of disability.14 In common,
Recent models of spinal pain have been proposed however, is the fact that clinicians must make deci-
to assist clinicians and researchers in developing use- sions based on interpretation of a multitude of test
ful evaluation and management protocols. Waddell13 results.
conceptualized the back pain problem as possessing Four kinds of measurements provide relevant in-
three distinct elements: formation about patient clinical status and/or re-
sponse to treatment. In general, they are percep-
• Pain: An unpleasant sensory and emotional expe- tual measurements (i.e., reports of pain severity
rience associated with actual or potential tissue and pain tolerance), structural measurements (i.e.,
damage, or described in terms of such damage. anomalies, pathology, or posture), functional mea-
• Disability: Diminished capacity for everyday activ- surements (i.e., range of motion, strength, stiffness, ac-
ities and gainful employment. tivities of daily living), and physiologic measurements
• Impairment: An anatomical or physiological abnor- (i.e., neurologic assessment, laboratory examinations)
mality leading to loss of normal bodily ability. (Fig. 32–1). The most prevalent complaint among pa-
tients presenting to a chiropractic office is muscu-
While the three elements may be related, it is note- loskeletal pain.15 Thus, issues relevant to pain and
worthy that the strength of the relationship is not per- patient motivations are important in understanding
fect and disassociation of the elements can occur. the meaningfulness of spine instrument measures. Re-
Another model of disablement has been adapted search aimed at assessing the quality and effective-
to the physiotherapy management of low back pain.14 ness of health care as measured by the attainment of a
This model is slightly different than Waddell’s because specified end result, or outcome, is known as outcomes
it makes the distinction between a functional limita- assessment. Such measures include parameters such as
tion and a disability: improved health, lowered morbidity or mortality, and
improvement of abnormal states (perceptual, struc-
• Functional limitations: Restrictions in performance tural, functional, and/or physiological).
at the level of the individual (i.e., the ability to per-
form a task of daily living). Perceptual Measurements
• Disability: Restrictions in the ability to perform so- Patients’ perspectives are widely recognized as being
cially defined roles and tasks expected of an in- essential in making medical decisions and judging the
dividual (i.e., inability to work or participate in results of treatment.16 Acknowledging the multifac-
family social functions). torial facets of the pain phenomenon, a number of
instruments have been developed to assist the clini- Outcomes assessment instruments can be catego-
cian in better understanding patient presentation and rized into five classes: general health, pain percep-
monitoring response to treatment. Measurements can tion, condition-specific, psychometric, and patient
be further divided into those tests that are primarily satisfaction.19
patient-driven (perceptual measurements) and those
primarily clinician-driven (structural, functional, and General Health Outcomes Assessment Instruments Gen-
physiological measurements). In this section, two use- eral health status measures are designed to broadly
ful perceptual measurements are presented: outcomes assess the concepts of health, disability, and quality of
assessment and disability questionnaires and algom- life.20 One benefit of generic health status instruments
etry. Perceptual measures are based upon the conscious is their practicality in terms of use in all patients, re-
mental registration of a sensory stimulus. Thus, regardless of the illness or condition. Although generic
sults from perceptual measurements are highly de- health status measures are less responsive to changes
pendent on the patient’s conscious responses to the in specific conditions than are condition-specific mea-
question or stimulus. sures, they are important for expansive compar-
isons of the relative impact of different conditions
Outcomes Assessment and or treatments on the health of the population.20 De-
Disability Instruments veloped from the Medical Outcomes Study (MOS),
Outcomes assessment involves the collection and recor- the Health Status Questionnaire.21 also known as the
ding of information relative to health processes in an short form (SF-36 or SF-12, denoting its number of
effort to quantify patient status or a change in pa- questions), is a commonly used instrument in man-
tient status over time. A variety of questionnaires have aging patients with spinal complaints. A number of
been developed to take into account the patients’ self- other general health assessment instruments are avail-
report of their physical function and health. Important able to clinicians including the Sickness Impact Profile
properties of any outcomes assessment instrument (SIP),22 the Nottingham Health Profile (NHP),23 the Duke
include practicality (how long it takes to complete; Health Profile (DUKE),24 instruments developed out
how understandable it is to the patient; acceptabil- of the Dartmouth Primary Care Cooperative Information
ity to the population being tested), precision (cross- Project (COOP),25 and the Quality of Well-Being Scale.26
sectional and test–retest reliability), validity, and Table 32–4 describes these general health outcomes
responsiveness.17 Although the field of patient-based assessment instruments.
outcomes measures is relatively young, the number The SIP, NHP, DUKE, and COOP charts have been
and types of measures are growing exponentially.18 used to some extent in the study of patients with
TABLE 32–4. General Health Outcomes Assessment Instruments
Instrument Description
Health Status Questionnaire (HSQ) Multipurpose, short-form health survey with 36 questions (shortened version,
(SF-36, Rand-36, MOS-36) SF-12, has 12 questions); it yields an eight-scale profile of scores, as well as
physical and mental health summary measures
Sickness Index Profile (SIP) 136 items grouped into 12 categories: ambulation; mobility; body care and
movement; social interaction; alertness behavior; emotional behavior;
communication; sleep and rest; eating; work; home management;
and recreation
Nottingham Health Profile (NHP) 38-item questionnaire grouped into six dimensions: physical abilities; pain;
sleep; social isolation; emotional reaction; and energy
Duke Health Profile (DUKE) 17 questions grouped into 6 health and 4 dysfunction scores; the health
scores are physical health, mental health, social health, perceived health,
and self-esteem (physical, mental, and social health scores are further
aggregated into a general health summary score); the dysfunction scores
are anxiety, depression, pain, and disability.
Dartmouth COOP Chart (COOP) 6 single-item scales including physical fitness, feelings (mental well-being), daily
or usual activities, social activities, overall health, and change in health
Quality of Well-Being Scale Preference-weighted measures of symptoms and functioning to provide a
numerical point-in-time expression of well-being, ranging from 0 for death to
1.0 for asymptomatic optimum functioning
back pain and appear to measure similar concepts TABLE 32–5. Pain-Intensity Scales
of health. They have been reasonably well studied in
terms of their reliability and validity. Of the available Pain-Intensity
general health outcomes assessment instruments, the Instrument Description
Health Status Questionnaire (SF-36) appears to have
several advantages over the other generic measures Verbal rating Patients read a list of adjectives
due to its ease of use, acceptability to patients, and scale (VRS) describing levels of pain intensity and
its fulfillment of stringent criteria of reliability and choose the word or phrase that best
validity. McDowell and Newell27 describe the SF-36 describes their level of pain
as having a “meteoric rise to prominence.” Popula- (0–3 score; 3 = worst)
tion and large-group descriptive studies and clini- Visual analogue Patients place a mark on a 10-cm line
cal trials to date demonstrate that the SF-36 is very scale (VAS) (on paper or by using a mechanical
useful for descriptive purposes, such as document- device), with the ends labeled as the
ing differences between sick and well patients and extremes of pain (10 = worst), to
for estimating the relative burden of different medical denote their level of pain intensity; a
conditions. In fact, the SF-36 has been used in more quantifiable score is derived from
than 1000 publications.28 The usefulness of the SF-36 millimetric measurement (0–100)
is illustrated in articles describing more than 130 dis- Numerical rating Patients verbally (or by using a pencil)
eases and conditions. Among the most frequently scale (NRS) rate their pain from 0–10 (11-point
studied conditions are arthritis, back pain, depres- scale), 0–20 (21-point scale), or
sion, diabetes, and hypertension, with more than 20 0–100 (101-point scale) to rate their
SF-36 publications dedicated to each.28 The SF-36 ap- pain intensity (highest score = worst)
pears to strike the best balance between length, re-
liability, validity, responsiveness, and experience in
large populations of patients with back pain.29 Be-
cause it is short, the SF-36 leaves ample room for Pain Affect This is the degree of emotional arousal or
administration of more precise measures at the same change in action readiness caused by the sensory ex-
sitting. perience of pain. This dimension of pain relates to
the distress of an individual and can lead to fear-
Pain Perception Outcomes Assessment Instruments avoidance behaviors and interference with daily ac-
Pain IntensityThis is a quantitative estimate of the tivities. The most widely used measure of pain affect
severity or magnitude of perceived pain. The three is the affective subscale of the McGill Pain Question-
most commonly used methods to assess pain intensity naire (MPQ).34 The MPQ is a gold standard as a pain-
are the verbal rating scale (VRS); visual analogue scale assessment tool because of its established reliability
(VAS), and numerical rating scale (NRS).30 Table 32–5 and validity.30 The MPQ consists of 20 category scales
describes these pain-intensity scales. Positive and neg- of verbal descriptors of pain categorized in order of
ative attributes of the pain-intensity scales are dis- severity and grouped into 4 subscales: sensory dis-
cussed elsewhere.19,30 VAS and VRS instruments have crimination, affective, evaluative, and miscellaneous.
been found to correlate well, but have differences in In this manner, a total score or separate subscores for
the range of categories relative to the VRS.31 NRS each subscale can be calculated. A short form of the
instruments have been found to be easy to admin- MPQ has also been studied with positive results.35 As
ister and score, and thus can be used in a greater previously noted, pain is not an independent dimen-
variety of patients (e.g., geriatric patients, patients sion; rather, it is dependent upon the emotional, moti-
with marked motor difficulties) than is possible with vational, and somatosensory attributes of the patient.
the VAS. Additionally, the validity of the NRS has Thus, a score on a pain rating scale is not a pure mea-
been well documented in demonstrating positive and sure of the patient’s pain, but is heavily influenced in
significant correlations with other measures of pain unknown ways by the patient’s emotional and mo-
intensity.32 Comparing the VRS, VAS, and 11-point tivational state.36 Clinicians should take into account
NRS, Bolton et al.33 further recommended the 11-point the factors that influence pain scores to improve valid-
NRS for most types of outcomes studies, given the ity. Taking the average of several pain measures across
advantages of responsive evaluative measures. Also time or across measures can assist in the reduction of
noteworthy was their finding that asking patients erroneous reports of pain.
to report their usual pain levels, rather than current
levels, enhances the responsiveness of the measures This can give important clues of its etiol-
Pain Location
and is a more representative perspective of their pain ogy or source. The pain diagram allows the patient to
experience.33 visually communicate the perception of the location
1 2 to a specific disease or condition.40 Unlike items in a

23 24
generic measure, items in a disease-specific measure
assess only those aspects of health that tend to be
3 25 affected by the disease. The goal is to achieve high
4 5 26 27 relevance and responsiveness of the scales without
undue burden to the patient.
6 12 13 7 34 35 A number of instruments specific to the spine or to
28 29 spine-related complaints have evolved from the need
14 15 30 36 37 31 for reliable and valid measures of patient functional
8 9 status in clinical trials. What have developed are a
38 39 number of condition-specific instruments for spine-
16
10 11 32 33 related complaints that are suitable for use in every-
day clinical practice (Table 32–6). While it is not the
17 18 40 41
purpose of this chapter to provide a comprehensive re-
view of the numerous condition-specific outcomes as-
sessment questionnaires, some of the most commonly
used indices are presented.
20 42 43 Among the many reliable and valid instruments
19
presented in Table 32–6, the following questionnaires
are emphasized because of their ease of use and imple-
mentation in clinical practice. The Oswestry Disability
21 22
Index (ODI) was developed by Fairbank et al. and later
44 45 revised.41 It consists of 10 items assessing the level of
pain and interference with several physical activities,
FIGURE 32–2. Pain diagram depicting the body region method sleeping, self-care, sex life, social life, and traveling.
of scoring described by Margolis et al. (Reproduced with permis- The scale is one of the most widely used outcome
sion from Margolis RB, Tait RC, Krause SJ. A rating system for use with measures for patients with low back pain. Roland
patient pain drawings. Pain 1986;24:57–65.) and Morris44 created a back-specific scale, the Roland-
Morris Disability Questionnaire (RMDQ), by selecting
24 items from the SIP (e.g., “I avoid heavy jobs around
and distribution of his or her symptoms pictorially the house,” “I sleep less well,” “I stay at home”) and
(Fig. 32–2). The pain diagram consists of the front
and back outlines of a body on which the patient TABLE 32–6. Condition-Specific Outcomes
draws, using different symbols to indicate the qual- Assessment Questionnaires Pertaining
ity of pain he or she is experiencing. A score can be to the Spine
derived from points totaled from the number of body
regions marked as painful, and the number of dif-
Back
ferent pain qualities reported by the patient. In addi-
Oswestry Disability Index41,42
tion, the size of the painful areas can be quantified.
Million Visual Analogue Scale43
Ohnmeiss37 studied the repeatability of pain draw-
Roland-Morris Disability Questionnaire44
ings in a chronic low back pain population and found
Waddell Disability Index45
high intraobserver reliability and stability over time.
Low Back Outcome Score46
Pain diagrams have also been found to be related to
Clinical Back Pain Questionnaire (Aberdeen Low Back Pain
intervertebral disc pathology revealed on diagnostic
Scale)47,48 (applies to the neck also)
imaging studies.38 A number of other studies also
Low Back Pain Rating Scale49
demonstrate the reliability and clinical usefulness of
Quebec Back Pain Disability Scale50
the pain diagram in the evaluation and management
North American Spine Society Lumbar Spine Questionnaire51
of patients with musculoskeletal complaints.39
Resumption of Activities of Daily Living Scale52
Bournemouth Questionnaire53,54
Condition-Specific Outcomes Assessment Instruments Functional Rating Index55 (applies to the neck also)
While pain quality, intensity, timing, and distribution, Neck
reveal important qualities of the patient’s condition, Neck Disability Index56
the effect of a condition on function, or disability, Headache Disability Inventory57
and activities of daily living is of prime importance. Copenhagen Neck Functional Disability Scale58
The hallmark of a condition-specific measure is the Migraine-Specific Quality of Life Questionnaire59
attribution of symptoms and functional limitations
adding the phrase “because of my back.” The scale has tors of attitude and belief) also affects health-related
become popular among back pain researchers and has predicaments.
been translated into several languages.40 Depression, anxiety, and personality disorders
While the RMDQ can be used in chronic back have been identified as the most frequently occurring
pain patients, often it is the preferred measure for psychiatric conditions associated with persistent
administration to acute low back pain sufferers be- pain.19 Incorporation of psychometric outcomes
cause its questions appear to be more applicable to assessment tools may assist in understanding these
those with more recent pain. The RMDQ may be bet- comorbid factors. With such a variety of instruments
ter suited to settings in which patients have mild to available, it is confusing for chiropractors to deter-
moderate disability, and the ODI to situations in which mine which tool is best for use in their practice. As a
patients may have persistent severe disability.60 Both general recommendation, the Health Status Question-
the ODI and RMDQ instruments have been recom- naire and the patient history, when used together, may
mended by experts as a prime choice for clinicians serve as general screening tools for the presence of
managing patients with back pain.29 Similar to the significant psychosocial factors relating to a patient’s
ODI, The Neck Disability Index (NDI)56 consists of 10 condition. Once identified, further assessment of spe-
items assessing the level of neck pain and inference cific conditions or disorders can be conducted with
with activities of daily living. The NDI possesses sta- more sensitive indices. Table 32–7 lists several psycho-
ble psychometric properties and provides an objective metric outcomes assessment instruments available for
means of assessing the disability of patients suffer- use in clinical practice.
ing from neck pain.61 For general use, the Headache
Disability Inventory (HDI)57 is useful in assessing the Patient Satisfaction Outcomes Assessment Instruments
impact of headache and its treatment on daily living, The growing regulation of health care has created
although other specific headache questionnaires are ever-increasing requirements of accountability from
available.59 health care providers. Patient satisfaction measures
have been developed to assess the health care expe-
Psychometric Outcomes Assessment Instruments Health rience in the eyes of the patient. Common areas of
care providers and researchers alike attest to the im- inquiry include the patients’ satisfaction with their
portance of the role that psychosocial factors play in visit, satisfaction with their overall care, convenience,
influencing the effectiveness of treatment regimens. technical quality of care, and continuity of care, and
By definition, psychosocial influences are those issues satisfaction with the financial policies of the office.
involving both psychological and social aspects (i.e., Because these measures begin to distance themselves
age, education, work, marital, and related aspects of from the focus of this chapter, the reader is directed
a person’s history). Such influences can have an effect elsewhere for further discussion of patient satisfac-
upon pain perception, adaptation to pain, functional tion issues. Implementing outcomes assessment tools
status, and, ultimately, quality of life. In addition, into clinical practice is as easy as integrating any other
patient motivation (i.e., conscious or subliminal fac- procedure into the office environment. Many of the
TABLE 32–7.Selected Psychometric Outcomes Assessment

Instruments
Psychometric Instrument Evaluative Conditions
Beck Depression Inventory Depression

Modified Zung Depression Index Depression
Health Status Questionnaire Depression, health perception
Modified Somatic Perception Questionnaire Perceived depression
Waddell’s Nonorganic Low Back Pain Signs Nonorganic low back pain
Somatic Amplification Rating Scale Nonorganic low back pain
Fear Avoidance Beliefs Questionnaire Chronic pain/ fear avoidance
behavior
Anxiety Sensitivity Index Anxiety
Distress and Risk Assessment Method Depression, anxiety
Symptom Checklist-90 (SCL-90-R) Anxiety and depression
Adapted from Yeomans SG. The clinical application of outcomes assessment. Table 4–6. Stamford, CT:
Appleton & Lange, 2000:33.
questionnaires are easy to use, understand, and im- many studies have demonstrated that manual motion
plement without compromising valuable time and palpation techniques are not as reliable, specific, or
staffing resources. To gain information on treatment sensitive as previously believed.64,65 For this reason,
outcomes, it is necessary to administer outcomes as- mechanical devices have been developed in the hope
sessment instruments before, during, and after a treat- of improving the reliability and accuracy of spinal
ment plan. stiffness assessment. The quantitative equivalent of
motion palpation can be thought of as spinal stiffness
assessment.
FUNCTIONAL MEASUREMENTS
Assessment of spinal function across various dimen- Static or Quasistatic In the simplest sense, the me-
sions of mobility, strength, endurance, and coordina- chanical responses—force and displacement—are an-
tion provides a rational approach to clinical assess- alyzed at a given frequency by means of comput-
ment, rehabilitation strategies, and determination of erized data analysis interfacing a mechanical stylus
return-to-work potential for injured employees.62 Ob- containing a potentiometer or load cell that makes
jective, quantitative measurements of function pro- contact with the spine. In the evolution of quantita-
vide the clinician with a definition of the patient’s tive spinal stiffness assessment a number of devices
physical capacity, and succeeding tests document have been developed using a variety of methodolo-
changes in performance with treatment. Understand- gies. Researchers from Australia developed the Spinal
ing the benefits and limitations of the different func- Physiotherapy Simulator (SPS),66 a large table-mounted
tional measurements, their clinical utility, and their frame housing a testing head in which a load cell is
generalizability serves to assist the clinician in better encased. This device has been found to be reliable
managing patients. in measuring PA spinal displacements in a study of
asymptomatic subjects being tested at L3 (intraclass
Spinal Stiffness Assessment
correlation coefficient [ICC] = .88)66 and accurate in
Knowledge of spine segment motion patterns, forces, the measurement of a series of elastic beams. In the
and stiffness is of fundamental interest to under- latter, the system tended to underestimate beam stiff-
standing the postural, time-dependent, and dynamic ness by less than 1%.67 This device was found to be
response of the spine, the role of spinal implants in me- highly reliable in the measurement of relative dis-
chanical load sharing, and the response of the extrem- placement at L3 (ICC = .99) and at L5 (ICC = .95)
ities (appendicular skeleton) and spine (axial skele- when a PA force was applied to L4.68 The SPS has
ton) to externally applied forces, such as palpatory mostly been used in a research setting because of its
assessments and chiropractic spinal manipulation. In size. Latimer et al. described an enhancement of the
the course of physical examination, many practition- SPS to enable greater portability, thus making the tech-
ers assess mechanical responses, such as the amount nique more suitable for clinical practice, calling it the
of stiffness or movement that occurs at different ver- Stiffness Assessment Machine (SAM)67 (Fig. 32–3). Ed-
tebral levels, by palpating the spine. Reliable meth- mondston and colleagues also developed a variation
ods to obtain an adequate understanding of the force-
induced displacement response of the spine have long
been considered important. In principle, an unstable
segment should exhibit increased displacement or de-
creased stiffness, while a stiffened segment should
exhibit decreased displacement when compared to
adjacent segments.63 For assessment of intersegmen-
tal mobility, many techniques involve posteroante-
rior (PA) “springing” of the spine. In this manner,
clinicians use their fingers to contact on each side of
the spinous process or alternatively impart a force by
contacting the spinous process with the heel of their
hand and applying an oscillating motion. The exam-
iner thus relies on his or her kinesthetic sense to judge
the stiffness or mobility of the spine at the level be-
ing tested as compared to adjacent levels and uses
this information to formulate clinical diagnoses that FIGURE 32–3. The Stiffness Assessment Machine (SAM) be-
direct treatment. This technique is commonly known ing used to test posteroanterior stiffness at L3. (Reproduced with
in chiropractic circles as motion palpation and as PA permission from Squires MC, Latimer J, Adams RD, Maher CG. Indenter
mobilization in the physiotherapy arena. Because of head area and testing frequency effects on posteroanterior lumbar stiffness
the qualitative nature of such assessments, however, and subjects’ rated comfort. Manual Ther 2001;6:40–47.)
TABLE 32–8. Testing Conditions Found to Influence the Posteroanterior Stiffness of the Spine
% Change in PA
Study Testing Variables Stiffness*
Latimer et al.71 Force applied to L3: 80 N vs. 200 N 27% increase

Latimer et al.72 Plinth padding: rigid vs. padded at L3 19% decrease
Maher et al.73 Plinth padding: rigid vs. padded at L3 22% decrease
Lee and Liversidge74 Frequency of PA testing: 0.05 vs. 0.5 Hz 26% decrease
Lee and Svensson75 Frequency of PA testing: 0.01 vs. 0.5 Hz 16.5% increase
Squires et al.70 Frequency of PA testing: 0.25 vs. 2.0 Hz 9.2% decrease
Squires et al.70 Indenter head size: large vs. small 13% decrease
Squires et al.70 Indenter head size and PA frequency of PA testing: 21% decrease
Beaumont et al.76 Cycle of breathing: FRC vs. Max. Insp. 16% increase
Lee and Liversidge74 The vertebrae tested:
L4 vs. L5 11% increase
Viner et al.77 The vertebrae tested: L1 vs. L5 17% increase
Caling and Lee78 The angle of PA vector: neutral vs. 10 degrees cephalad neutral vs. 12% decrease
10 degrees caudad 11% decrease
Edmondston et al.69 Lumbar spine position: neutral vs. flexed 21% increase
Allison et al.79 The angle of force application to L5: perpendicular vs. vertical 9% decrease
Lee et al.80 Extensor muscle activation: relaxed vs. MVC 317% increase
Key: FRC = functional residual capacity; large indenter = 34 × 46 mm; Max. Insp. = maximum inspiration; MVC = maximal voluntary contraction;
small indenter = 12 × 25 mm.
* The results expressed as a percentage (%) change are based upon the variables being tested. The percentage changes were calculated in a standard
manner and are expressed as a change from the first to second variable.
Adapted from Squires MC, Latimer J, Adams RD, Maher CG, Indenter head area and testing frequency effects on posteroanterior lumbar stiffness
and subjects’ rated comfort. Manual Ther 2001;6:40–47.
of this device, labeling it the Spinal Postero Anterior from the distance found at preindentation, resulting
Mobiliser (SPAM).69 in a measure of displacement.
What these devices have in common is the desire Validation studies using UI have resulted in a
to minimize testing variables that may affect the mea- mean displacement error ranging from 14.37% to
sured stiffness values obtained from the spine in order 22.05%. Other research with the device has deter-
to develop a reliable and valid objective measure of PA mined its bench-top accuracy and reliability to range
spinal stiffness. From a number of published investi- between 0.99 and 1.00 (ICC) with error values in force,
gations several testing conditions have been found to displacement, and stiffness ranging from 0.81% to
influence or change the PA stiffness of the spine; they 13.62% over varying experimental conditions.81 Sev-
are presented in Table 32–8. eral sources of variation in spinal indentation have
also been identified,83 such as indentation site relo-
Ultrasonic Indentation Another method of spinal stiff- cation, intraabdominal pressure, subject movement,
ness assessment was developed at the University muscular response, and stiffness estimation. These
of Calgary by Kawchuk and colleagues; it uses variables, which have been unaccounted for in pre-
ultrasound imaging.81 This technique, referred to as vious indentation studies, might be responsible for
ultrasonic indentation (UI), advances a blunt probe the change or lack of change in force-displacement
housing an ultrasonic sensor mounted to a large properties between pre- and posttest trials. Ultra-
frame into the tissue surface and records the ensu- sonic indentation has also been put to use, with
ing deformation.82 By obtaining ultrasonic images of encouraging results, in investigating experimentally
a rigid, echogenic target (e.g., spinous or transverse induced degeneration in a porcine model.84 While
process) at the beginning and end of loading, soft- ultrasonic indentation appears to be promising in a
tissue compression can be quantified by measuring research setting, its large frame and high cost pro-
the distance to the target in each image and then sub- hibit its use in a clinical setting, and research has not
tracting the distance found at maximal indentation been done in clinically relevant human subjects. Its
developers are seeking to develop a hand-held device

to make the technology available to clinicians in the
future.
Dynamic As we have already discussed, the mechani-

cal and physiologic response of the spine to PA forces
is dependent upon many factors, including the in-
tensity, direction, duration, and frequency of the ap-
plied force. Of these factors, the frequency-response
and frequency-dependent stiffness characteristics of
the spine to PA dynamic loading are perhaps the least
well understood. Efforts to estimate the in vivo stiff-
ness behavior of the spine have mainly consisted of
static or quasistatic (low-frequency) mobilization us-
ing surface displacement transducers. The spine is
a viscoelastic structure that exhibits time-dependent
FIGURE 32–4. Dynamic spinal stiffness assessment is per-
behavior. The dynamic PA frequency-dependent
formed with a hand-held electromechanical device equipped
stiffness behavior of the human spine thus reflects
with an impedance head while simultaneous electromyographic
its viscoelastic structure, albeit generally more elas- (EMG) measurement is obtained from the adjacent erector
tic than viscous. spinae muscles. In this manner, the muscular contributions to
Different structures (ligaments, cartilage, bone, spinal stiffness can be considered during the neuromechanical
tendons, muscle) will exhibit varying degrees of assessment.
time-dependent and frequency-dependent viscoelas-
tic behavior. Consequently, the overall structural/
vibration response of the spine is modulated by the columbar spine.87 The authors found that the tho-
architecture or structural organization of component racolumbar spine typically exhibited an impedance
tissues, as well as load sharing provided by adjacent minimum at frequencies ranging between 30 and
structures (e.g., rib cage, sternum, pelvis). When such 50 Hz.87 Colloca and Keller88 were the first to si-
factors are combined with other considerations, such multaneously measure the dynamic stiffness and
as spinal curvature, the net effect is a complex struc- neuromuscular responses in low back pain patients
ture and frequency-dependent mechanical behavior. (Fig. 32–4). The authors observed significantly in-
As a result, quasistatic loading conditions tend to creased spinal stiffness in those patients with frequent
overestimate the displacement response (underesti- or constant low back pain (LBP) symptoms, in con-
mating the stiffness) as a consequence of creep de- trast to those patients with only occasional or no LBP
formation of the structure. Evidence of such behav- symptoms. Patients with increased spinal stiffness
ior has been observed in studies reporting the PA were also observed to have larger-magnitude neu-
motion response of the lumbar spine at different os- romuscular reflex responses corroborating the find-
cillation frequencies.74,75 In these studies, quasistatic ings of others who have observed the contributions of
or slow cycling (≤0.1 Hz) PA mobilization is associ- the musculature to spine stability.89 Noteworthy was
ated with an approximately 15–25% increase in de- Colloca and Keller’s suggestion that neuromuscular
formation (15–25% reduction in stiffness) in compari- responses be taken into account when assessing spinal
son to mobilization at 0.5–1.0 Hz. Another important stiffness.88
characteristic of the human lumbar spine is its non- To further validate dynamic spinal stiffness as-
linear, load-deformation behavior. Inherent nonlin- sessments, Keller, Colloca, and Gunzburg obtained
earities in the load-deformation characteristics of the intersegmental motion data in vivo by attach-
spine result in variations in the measured PA displace- ing accelerometers to rigidly affixed bone pins
ment and stiffness that are dependent on the magni- placed into the spinous processes and measur-
tude of the applied force. For example, previous PA ing the resultant motion characteristics to known
mobilization studies have reported a substantial in- forces.90 Fitting original data to a mathematical
crease in PA stiffness when the peak force applied is model, Keller et al. developed a 21-degrees-of-
increased.71,85 freedom model to describe the motion characteris-
Keller et al.86 validated a modified hand-held tics of the spine during mobilization assessment pro-
adjusting instrument to be used as a mechanical cedures and spinal manipulation.91 Dynamic spinal
impedance assessment device and later quantified stiffness assessments show promise in the compre-
the mobility characteristics (dynamic stiffness and hensive biomechanical analysis of the spine in clinical
mechanical impedance) of the normal human thora- practice.
Assessment of Muscle Strength TABLE 32–10. Factors Influencing Trunk Strength

Segmental instability, pathology, or dysfunction is be-
lieved to produce abnormal patterns of motion and Gender
forces that may play a role in the etiology of muscu- Age
loskeletal pain. Muscle tension is a function of muscle Body (or body segment) weight
length and its rate of change and thus can be altered Body position
by the level of neural excitation. These relationships Exercise and nutrition
are called the length–tension and velocity–tension re- Hormonal or genetic factors
lationships. The central nervous system excites the Motivation
muscle, and the generated tension is transferred to Motor learning and movement coordination
the skeletal system by the tendon to cause motion, Physiological factors (i.e., muscle fatigue and muscle
stabilize the joint, and/or resist the effect of externally co-contraction)
applied forces on the body.62 The ability to quantify Cross-sectional area of muscle
spine segment motion, or kinematics, together with the Type of contraction
concomitant forces, or kinetics, is therefore of clinical Speed of contraction
significance in terms of both diagnosis and treatment Duration of contraction
of spinal disorders and back pain. Before discussing Number of warm-up and learning trials
the use of spine instrument measures in evaluating Rest between trials
muscle strength, a review of some key terms provides Joint limitation (pathology, pain, or dysfunction)
a better understanding of some of the biomechanical
principles in this area.
limited as the ability of even skilled clinicians to de-
termine strength differences is rather restricted.12
Manual Testing Qualitative measures of muscle stren- In manual muscle testing performance, relative
gth include manual muscle testing techniques that muscle strength is judged more on the basis of the
rely on grading criteria to clinically assess patients total force and duration of effort that the examiner
(Table 32–9). Chiropractic clinicians commonly rely uses to overcome the patient than on the actual force
on manual muscle testing to evaluate extremity joint generated by the patient. Accuracy in such manual as-
injuries, and to grade the motor strength of potential sessment techniques requires differences in strength
spinal nerve root involvement in patients with radic- of 35% or more.92 Consequently, instruments have
ular symptomatology. Because of the qualitative na- been introduced to clinical practice to improve the
ture of these assessments, their clinical usefulness is objectivity of muscle-strength assessments. In general,
trunk strength and/or trunk muscle strength has been
shown to vary with many different factors as shown
TABLE 32–9.Qualitative Manual Muscle
in Table 32–10.
Strength Grading
Ultimately, the measured force is a function of
the individual’s motivation, environmental condi-
Grade Description % of Deficit tions (muscle length, rate of change of muscle length,
nature of the external load, metabolic conditions, pH
5: Normal Complete active range of 0 level, temperature, etc.), prior history of activation
motion against gravity with (fatigue), understanding instruction and description
full resistance of the tasks to be performed, control strategies and mo-
4: Good Complete active range of 1–25 tor programs employed to satisfy the demands of the
motion against gravity with task, and the biophysical state of the muscles and fit-
some resistance ness (fiber composition, physiological cross-sectional
3: Fair Complete active range of 26–50 area of the muscle, and cardiovascular capability).62
motion against gravity only, The complexity of these processes and their interre-
without resistance lationships cannot be overemphasized. Moreover, an
2: Poor Complete range of motion with 51–75 individual’s strength is reduced by 10–30% when ex-
gravity eliminated ertions are performed dynamically, as compared to
1: Trace Slight muscle contraction with 76–99 isometric strength.93
no joint motion
0: Zero No evidence of muscle 100
Dynamometry Researchers and clinicians use many
contraction
different methods to study trunk strength. No di-
Adapted from Guides to the evaluation of permanent impairment, 5th rect measures are available, but intradiscal pres-
ed. Chicago: American Medical Association, 2000. sure measurements and intraabdominal pressure
measurements are two in vivo methods of direct mea- Fatigue is another factor that may cause a reduction
surements used to estimate trunk strength.94 Two in strength upon multiple trials; consequently, varia-
ex vivo, or noninvasive, methods currently used tions in strength of up to 20% or more are necessary
to quantify strength changes are dynamometry and to determine a clinically relevant disparity in muscle
electromyography. strength.12 JTECH Medical (Salt Lake City, UT) has
Traditionally, dynamometers are tension- developed an easy to use hand-held dynamometry
measuring devices in which the stretching of a system that allows for quantitative manual muscle
spring or a strain gauge is used; today, a dynamome- strength assessment of the extremities (Fig. 32–6) and
ter can be defined as any instrument used to measure trunk (Fig. 32–7).
torque or force. As a whole, dynamometers are
clinically convenient and simple, with good reli- Isokinetic dynamometers measure
Isokinetic Testing
ability as long as positioning is consistent. There dynamic force or torque throughout a range of mo-
are many different kinds of dynamometers used tion at various constant, preset velocities. Isokinetic
to measure different types of muscle contractions tests thus require specialized instrumentation that
and muscle-induced motions. Some measure only contains either hydraulic or servomotor systems to
isometric force or torque production; others assess provide constant velocity. Specific examples of isoki-
dynamic (i.e., isokinetic or isoinertial) motion as netic dynamometers include Cybex II (Cybex Inc.,
well. Function is usually assessed in one or more of Ronkonkoma, NY), KIN/COM (Chattecx Corpora-
three planes: extension–flexion, rotation, and lateral tion, Chattanooga, TN), Biodex (Biodex Corporation,
flexion. Because trunk strength is different at different Shirley, NY), and LIDO (Loredan Biomedical Inc.,
joint angles, isometric strength test data is normally Davis, CA). Triano et al.12 note that the primary mea-
reported using a “strength curve,” a plot showing the surement obtained in isokinetic testing is the torque
force or torque generated by the trunk as a function generated during the controlled part of the motion
of the changing angle of the trunk (Fig. 32–5). and is only valid during the controlled part of the
Isometric Testing When performing isometric assess-

ments, a sustained effort of 2 seconds has been pro-
posed to meet standardized minimum criteria. Av-
eraging three consecutive tests can also be helpful
in identifying insincere efforts. Any variation greater
than 10–15% between trials may be suggestive of
voluntary holding back in performance. Computer
software has been developed to calculate consecutive
efforts and further determine a coefficient of varia-
tion to indicate whether the test performed was valid.
Torque
Angle FIGURE 32–6. Manual muscle testing of elbow flexion with

dynamometry. (Photograph courtesy of JTECH Medical, a division of
FIGURE 32–5. Strength curve. Zevex Inc., Salt Lake City, UT.)
FIGURE 32–7. Manual muscle testing of trunk extension with

a hand-held dynamometer. With this particular dynamometer
(PowerTrack [JTECH Medical]), maximum force is digitally dis-
played on a wrist-mounted LCD panel or, alternatively, strength
curves are plotted by computerized software. (Photograph cour-
tesy of JTECH Medical, a division of Zevex Inc., Salt Lake City, UT.)
motion. In principle, the resistance offered by the ma-

chine is equivalent to the applied muscle torque over
the entire range of movement. This represents the
patient’s muscular capacity.12 Sources of error that
should be taken into account with isokinetic testing
include inertial error, or the change in limb or trunk
orientation through the range of measurement. Iner- FIGURE 32–8. The B200 Triaxial Isoinertial Dynamometer
tial error can alter the amount of torque registered by (Isotechnologies, Inc., Hillsborough, NC) is used for isoinertial
the machine. Torque overshoot is another error that trunk muscle strength testing.
can occur with isokinetic testing, representing a ma-
chine artifact that arises from the inertial effect of mo- dimensional trunk velocity significantly increases low
tion as the preset velocity is achieved.12 To eliminate back pain risk.96
these errors, highly specialized machines have been The B-200 outputs each subject’s trunk position
developed. (three-dimensionally), angular velocity, and torque.
Position is measured from 0 degrees upright. Sign con-
Isoinertial TestingIsoinertial strength testing requires vention dictates forward flexion as positive (therefore,
the control of torque values that the patient will be per- backward extension is negative). Velocity output is the
mitted to use during movement. Isoinertial systems angular velocity of the upper body, with the axis of
can be made capable of monitoring position, veloc- rotation considered to be through the hips or L5-S1.
ity, and torque simultaneously while they indepen- Trunk moment (torque) output by the B-200 includes
dently vary. The B200 Triaxial Isoinertial Dynamome- the torque of the machine, and must be corrected for
ter (B-200) (Isotechnologies, Inc., Hillsborough, NC) the effects of gravity. The B-200 enables measurement
is a commercially available isoinertial dynamometer of isometric exertions at various trunk postures in ad-
(Fig. 32–8). It measures isoinertial strength against a dition to its dynamic testing capabilities. Isoinertial
preset resistance where the subject’s velocity varies trunk strength testing with the B-200 provides reliable
with the amount of force or torque the subject ap- measures of torque and velocity parameters, and ad-
plies. In other words, the subject’s movements (accel- ditional research has identified demographic param-
erations and decelerations) are made against a con- eters important to such testing in chronic low back
stant resistance. If the torque generated by the subject pain patients.97 In addition, a normative database has
is greater than the machine resistance, the surplus been developed to assist in the clinical utility of these
torque will determine acceleration.95 The B-200 is measures.98
also unique because movement about all three axes Although somewhat controversial, trunk weak-
(extension–flexion, rotation, and lateral flexion) can be ness has often been described as a contributor to low
measured simultaneously by a single machine. Quan- back pain. In fact, several investigations have revealed
tifying dynamic motions is important because three- stronger trunk muscles in asymptomatic subjects as
compared to patients with low back pain.99,100 In ad- radiating pain. Consequently, the increasing complex-
dition to weaker trunk muscles, there also appear ity of imaging studies has led to increased necessity
to be differences observed in the ratio of flexion-to- for more sophisticated functional tests to look for neu-
extension trunk strength.95 Other studies using isoin- rologic deficits.101
ertial techniques have reported that patients with low Physiological assessments allow the clinician to
back pain tend to have slower movements than do passively or actively measure resting or functional re-
normal subjects.93 Until more evidence is available, sponses of the body (i.e., electromyography), or evoke
however, correlation of trunk strength to other ob- responses through monitoring responses of various
jective measures of trunk function and perceptual nerves and muscles to electrical stimuli. Incorporation
measures is necessary to discriminate between symp- of specialized testing such as electrodiagnosis sub-
tomatic patients. stantially alters clinical impressions in a large percent-
age of patients.102 The complex relationship between
clinical information, the extent of testing, and final
PHYSIOLOGICAL MEASUREMENTS diagnostic certainty suggests that specialized medi-
In the presence of clinical findings suggestive of an cal knowledge is required for accurate physiological
underlying neurological condition, numerous tests assessments. Although this chapter is not intended
and measures are available to the clinician to fur- to provide a comprehensive review of the available
ther evaluate the patient. Clinicians have become in- spectrum of electrodiagnostic tests and their interpre-
creasingly dependent on neuroimaging studies such tations, this discussion does provide the clinician with
as MRI, computed tomography (CT), or bone scans, valuable information to assist in understanding the
but more reluctant to order specific physiological tests rationale behind some of the more commonly used
including electromyography (EMG), nerve conduc- physiological measurements in clinical practice.
tion velocity (NCV), and evoked potentials studies
(Fig. 32–9). The clinician may either not be aware of Electromyography
the precise applications and limitations of these stud- Electromyography (EMG) measures the electrical sig-
ies, or not be familiar with their use or interpreta- nals generated by muscle contraction, which are pro-
tions. While diagnostic imaging studies are valuable portional to the degree of neuromuscular activity and
in demonstrating pathology such as disc protrusion, therefore also to the strength of muscle contraction.
the clinical utility of such studies is limited without A brief overview of the properties of skeletal muscle
clinical correlation. For example, large disc hernia- will provide important background information of the
tion or other structural abnormality may exist without physiological properties for which electromyography
causing nerve compression, and many structural ab- is derived.
normalities are present in asymptomatic individuals.4 The structural unit of skeletal muscle is the muscle
Alternatively, in other situations, a relatively small cell, also referred to as a muscle fiber. Groups of mus-
disc protrusion may result in neurologic deficits and cle fibers are termed fasciculi and aggregate to form
a whole muscle. A fasciculus can include only a few
muscle fibers, as seen in smaller muscles such as the
Disorder Diagnostic Test lumbricales, or as many as 150 or more in larger mus-
Muscle Injury cles, such as the biceps brachii or gluteus maximus.
Muscle Spasm
Surface EMG
This unique arrangement of muscle fibers within the
Myofascial Syndrome fasciculus accommodates independent functioning of
Fibromyalgia
the muscle fibers from their respective activation. This
Postural Disorder
Gait Disorder
is important because the fibers belonging to a motor
Radiculopathy Needle EMG unit are spread throughout a muscle. A motor unit is
Plexus Disorder defined as a group of homogenous muscle fiber types
Myopathy innervated by a single axon. Activation of a motor
Neuropathy unit, therefore, results in the contraction of single mus-
Nerve Conduction
Local Nerve Injury cle fibers within many different fasciculi.
Studies
Entrapment Syndrome
Myofibrils are surrounded by a sarcoplasmic retic-
Central Pain
ulum that plays an essential role in both the stor-
Spinal Stenosis
Cord Compression Somatosensory age and release of ionic calcium to signal contractile
Syringomyelia
Evoked Potentials proteins. The contractile proteins of skeletal mus-
Multiple Sclerosis cle are organized into cylindrical organelles, termed
myofibrils, each organized into sarcomeres, its fun-
FIGURE 32–9. Neuromusculoskeletal disorders and com- damental contractile unit. Skeletal muscle is also
monly used corollary diagnostic tests. called striated muscle, resulting from its histological
FIGURE 32–10. Gross to molecular

skeletal muscle organization. Mus-
cle fasciculi contain muscle fibers
comprised of myofibrils, which con-
tain the contractile unit of the mus-
cle, the sarcomere. A = A band; I
= I band; Z = Z band. (Adapted from
Bloom W, Fawcett DW. Textbook of his-
tology, 10th ed, Fig. 11–19. Philadelphia:
WB Saunders, 1975:309. Skeletal muscle
photograph courtesy of Primal Pictures,
Ltd., Interactive spine—chiropractic edi-
tion, London.)
appearance from the repetitive series of transverse fast powerful movement is required. For each muscle
bands in each sarcomere, the most prominent be- contraction, motor units are recruited at the same
ing the Z, A, and I bands. The distance between force level. During high force demands, after all motor
two Z bands is defined as the sarcomere, which will units have been recruited, additional force is gen-
vary with the state of contraction or relaxation in erated by increasing the firing frequencies of the
the muscle. The dark A bands of the sarcomere are motor units. The tension created by a muscle also
formed by thick myofilaments, termed myosin fila- depends upon the geometric configuration of the mus-
ments, and interdigitated thin myofilaments called cle fibers, the length of the muscle, and the velocity
actin. During contraction the actin filament slides over of the contraction. The inside of a muscle fiber has a
the myosin. A second set of transverse bridges is the resting potential of about –80 mV, which remains in
M band, which serves to connect adjacent myofila- equilibrium until stimulated. A significant stimulus
ments. Huxley103 demonstrated that thick myofila- causes a rapid depolarization followed by repolariza-
ments are arranged in a hexagonal lattice and that tion, termed an action potential. The temporal and
thin filaments interdigitate with the thick filaments at spatial summation of action potentials are responsi-
each trigonal point, producing what is now termed the ble for the waveforms observed on oscilloscopes or
double hexagonal lattice of myofilaments. Figure 32– computers during EMG testing. There are several fac-
10 illustrates the structural organization of skeletal tors to consider when measuring muscle activity via
muscle. EMG (Table 32–11), which necessitates a basic under-
Motor units can also be classified.104 Slow-twitch standing of the components involved.105
motor units can fire continuously at low frequencies
for long periods of time. Fast-twitch fatigue-resistant Measurement of Muscle Strength Using EMG Signal Ampli-
units can produce greater forces than slow-twitch mo- tude The relationship between EMG and muscle force
tor units, but cannot fire continuously for long periods naturally arises when viewing an electromyogram.
of time. Fast-twitch fatigable fibers produce the great- It stands to reason that if there is little to no signal,
est force, but only are capable of doing so for short there will be no active muscle force and, alternatively,
periods. The force that a muscle produces and the the more muscle fibers that are active and the more
speed of movement are controlled by the type of motor frequently they fire, the higher the force responsible
unit found in the muscle, and the motor unit recruit- for the signal. The EMG can be quantified and used
ment. Slow-twitch motor unit recruitment is respon- to classify the electrical activity level that produces
sible for maintaining posture and slow movements. a certain muscular tension based upon changes in
Slow-twitch fibers are thus recruited first, and the amplitude and frequency. In other words, an EMG
fast-twitch fatigable units are only recruited when a force measurement seeks to quantify the average
TABLE 32–11.Factors that Influence the Signal Information Content

of Electromyography
Factor Influence
Neuroactivation The number of motor units recruited; the firing rate of

motor unit action potentials; the synchronization of firing
Muscle fiber physiology The conduction velocity of muscle fibers
Muscle anatomy The orientation and distribution of muscle fibers of motor
units; the total number of motor units; the diameter of
muscle fibers
Electrode size and The number of muscle fibers within the pickup area of the
orientation electrode; the number of motor units within the pickup
area of the electrode detection surface relative to the
muscle fibers
Electrode–electrolyte The material and preparation of electrode and electrode
interface site; the electrode impedance decrease with increasing
frequency (high-pass filter)
Electrode configuration The type of electrode used: needle or surface, monopolar
or bipolar; the effect of distance between electrodes
and bandwith (band-pass filter); the orientation of
electrodes relative to axis of muscle fibers
Adapted from Gerleman DG, Cook TM. Instrumentation. In: Marras WS, ed. Selected topics in sur-
face electromyography for use in the occupational setting: Expert perspectives. Washington, DC: US
Department of Health and Human Services, 1992:44–68.
number and firing rate of motor units contributing to as a biomechanical analysis has been found to reveal
an actual muscle contraction and to relate the quan- impairments that have not been routinely identified
tity to the actual force produced. The myoelectric sig- with standard clinical tests.108
nal represents the temporal and spatial summation Measuring the EMG activity of trunk musculature
of all active motor units within the recording area has been used in an attempt to assess dysfunction of
of the electrodes. EMG is thus not a direct assess- the lumbar spine. The majority of assessments have
ment of muscle force, but of muscle electrical activ- focused on quantifying the EMG amplitude differ-
ity, and other relationships need to be established ences between low back pain (LBP) patients and con-
(calibration of electrical output and force produced) trol subjects. The rationale behind these investigations
before reasonable muscle force estimates can be is to identify “spasm” or increased muscle activity in
made. LBP populations as a result of muscle splinting or
The change in the myoelectric signal is based on aberrant neural control. The research on this use of
the motor unit recruitment and firing rate within the EMG as a spinal assessment technique and outcome
muscle. In general, as more force is demanded, more measure is mixed. This chapter does not go into de-
motor units are recruited, and the motor units al- tail reviewing studies that assessed the discriminant
ready firing increase their frequency of firing. Elec- validity of trunk muscle EMG amplitude assessments
tromyographic measurements thus generally show a (see reference 109) but focuses instead on the newer
relatively monotonic (1:1) relationship between mus- EMG techniques and data collection protocols that
cle force and trunk muscle activity. However, this re- may provide a better assessment of spinal function.
lationship varies from muscle to muscle and is lin- The use of the erector spinae EMG signal has been re-
ear, curvilinear, or other based on the various roles searched in an attempt to discern differences between
or responsibilities of different muscles (i.e., posture those with low back injury and asymptomatic sub-
or locomotion). There is a monotonic relationship be- jects. Unfortunately, a general consensus on the use of
tween the EMG signal amplitude and muscle force.106 surface EMG in clinical practice is lacking. It is often
A quasilinear relationship between EMG and force has postulated that those with LBP have an increased level
been reported for smaller muscles, whereas a nonlin- of muscle activity relative to controls. Some studies
ear EMG–force relationship has been determined for show no difference between groups,110 while others
larger muscles where the increase in EMG signal is show an increase in EMG activity in those suffering
greater than the increase in force.107 The use of EMG LBP.111
Flexion-Relaxation Phenomenon There is some support healthy controls (n = 20) and a group of chronic
to suggest that differences exist between back pain LBP patients (n = 70). Repeated measurements over
patients and normal subjects during dynamic flexion 4 weeks demonstrated between-session reliability of
tasks at peak flexion112 and between the ratio of activ- 0.81–0.98 for the dynamic activity. The levels of surface
ity during forward flexion and reextension.113 Several electromyography (sEMG) activity in the fully flexed
studies have examined the apparent myoelectric si- position were significantly greater in the fully flexed
lence of the low back extensor musculature during position in the chronic LBP group than in the controls.
a standing to full flexion maneuver, or the flexion– The flexion:relaxation ratio (FRR), a comparison of the
relaxation phenomenon. The electrical silence that oc- maximal sEMG activity during 1 second of forward
curs in healthy subjects during lumbar spine flexion flexion with activity in full flexion, demonstrated sig-
has been hypothesized to represent the extensor mus- nificantly lower values in the chronic LBP group than
culature being relieved of its momentary supporting in the control group. The combined discriminant va-
role by the passive tissues, particularly the posterior lidity for the FRR for all four sites resulted in 93% sen-
ligaments.114 Likewise, a failure of the muscles to re- sitivity and 75% specificity. These results indicate that
lax is thought to be indicative of heightened erector dynamic sEMG activity of the paraspinal muscles can
spinae resting potentials or underlying back muscle be reliably measured and is useful in differentiating
spasticity (Fig. 32–11). chronic LBP patients from normal controls. The au-
Watson et al.115 assessed the test–retest reliabil- thors concluded that the FRR clearly discriminated
ity of the flexion–relaxation phenomenon measure in the patients from the healthy controls. Shirado et al.116
a group of chronic LBP patients (n = 11) and fur- also found that the flexion–relaxation phenomenon
ther compared the results between a group of normal could discriminate between chronic back pain patients
Normal Group Average Flexion ROM with Erector Spinae EMG

60
40
20
ROM (degrees)/EMG (%MVC)
0
1
16
31
46
61
76
91
106
121
136
151
166
181
196
211
226
241
256
271
286
−20 Lower ES EMG

Flexion ROM
−40
−60
−80
−100
−120
Time (20.5 Hz)
Lack of FRP in symptomatic low back pain patient
120
100 FIGURE 32–11. Top: Normal

erector spinae muscle activity dur-
80 ing flexion–extension. A silence in
ROM (degrees)/EMG (%SMVC)
60 muscular activity is noted at the

peak of flexion, which is indica-
40 Lower ES EMG tive of the flexion–relaxation phe-
Flexion ROM nomenon. Bottom: Lower erec-
20
tor spinae muscle activity during
0 flexion–extension in a patient with
1
10
19
28
37
46
55
64
73
82
91
100
109
118
127
136
145
154
163
172
181
chronic low back pain. Note the

−20 failure of the erector spinae to si-
−40 lence at the peak of flexion as seen
in asymptomatic groups. ROM =
−60 range of motion; SMVC = submax-
Time (20.5 Hz) imal voluntary contraction.
and normal subjects. In their study of 20 chronic LBP tor spinae bilateral asymmetry in a LBP population (n
patients, none exhibited the flexion–relaxation phe- = 6) than in a control group during an isometric ex-
nomenon, as compared to its clear demonstration in ertion. A similar difference between populations was
25 healthy subjects prior to maximum flexion. The found by Lehman124 during dynamic flexion tasks.
flexion–relaxation phenomenon has also been inves- Lehman’s study quantified the symmetry in the bi-
tigated in the cervical spine.117 However, no work has lateral erector spinae (upper T9 and lower L3) EMG
been performed relevant to its ability to discriminate linear envelope by using a cross-correlation function
between patients with cervicogenic disorders. Ahern that assesses the similarity between the left and right
et al. recommended that clinicians pay close attention EMG waveforms. They found that the left and right
to qualitative aspects of patient behavior to improve lower erector spinae linear envelopes (activation pro-
the sensitivity of the physical examination in detect- file) were less similar (correlated) in LBP sufferers than
ing bona fide impairment when assessing the flexion– in normals.
relaxation phenomenon.118
Neurodiagnostics
Paraspinal Muscle Asymmetry It has also been sug- Conventional electrodiagnostic evaluation, including
gested that a difference in the amplitude symmetry needle EMG and a variety of nerve stimulation tests,
between left and right trunk muscles may exist in the has a proven and long-established place in the evalua-
LBP population. Again, the research is mixed, with tion and diagnosis of disorders of muscle and nerve.125
the majority of studies finding no differences between Ongoing research into more standard electrodiagnos-
groups,119 and other studies finding a greater EMG tic tests has resulted in the ability to better define the
amplitude asymmetry in the LBP group.120 The in- sensitivity, specificity, and theoretical basis of these
consistent results reported by studies may be a result tests, leading to an improved understanding of how
of the many factors that modulate measured EMG ac- neurodiagnostic testing can influence diagnostic and
tivity levels that are not related to the level of neural treatment outcomes.126 As Table 32–12 shows, numer-
drive. Electrode placement, skin temperature, mois- ous neurophysiological tests are available to the clin-
ture, cutaneous fat distribution, as well as muscle fiber ician managing spinal disorders.
type and size can all influence measured EMG activ- Several questions can be answered by clinical neu-
ity level. Nonhomogeneity in these factors between rophysiologic examination such as whether a neuro-
sides of the body may relegate asymmetry in mea- logic deficit exists, and the extent of its nature, severity,
sured EMG activity to be the norm even though it is chronicity, and progression. Haldeman and Dvorak126
possible that bilateral muscles are contracting at equal have presented the natural progression of tests that
intensities. With so many factors modulating EMG ac- add information to the clinical examination (Fig. 32–
tivity, a large variation in EMG amplitude is seen121 12). The clinical examination is often capable of accu-
across subjects. A patient may have an elevated EMG rately defining both the presence and the nature of a
level relative to the patient’s normal activation level, neurologic deficit. If motor, sensory, and reflex abnor-
whereas the patient’s EMG activity level may still malities all follow well-defined, consistent patterns,
be within a range considered normal. Alternatively, the presence of a particular neurologic deficit can be
not all patients with back pain have a condition that assumed with a high degree of confidence. Unfortu-
presents with an elevated EMG trunk muscle activity. nately, however, in many patients with back pain such
One recent study122 compared the EMG activ- findings are not easily discernable. Moreover, no sin-
ity of the trunk muscles between normal subjects gle test has been developed to document all types of
and chronic LBP patients during standardized trunk neurologic deficit.
movements controlling for the many variables includ- Another consideration impacting test selection in-
ing age, sex, weight, and skin-fold thickness below volves the timing of the condition or injury. EMG
the attached electrodes. In this study, the EMG am- measures of denervation and reinnervation are slow,
plitude analysis revealed significant differences be- ongoing processes taking 3–4 weeks postinjury for
tween groups for some muscles (left lumbar and tho- the muscle membrane to react to denervation.126 Hy-
racic erector spinae). The authors further noted that persensitive responses in the form of spontaneous
the abnormal (asymmetric) EMG patterns detected electrical activity, as is seen in fibrillation potentials
among the chronic LBP patients were not explained by and positive sharp waves, thus are not observed with
postural asymmetries. Other EMG analyses compare needle EMG until nearly a month after injury. Direct
the changes in the muscle activation level over time, nerve conduction tests, however, become abnormal
making it possible to compare the shape of the EMG immediately after the onset of a neuronal injury.127
linear envelope (activation profile) across subjects, or
within a subject, to compare bilateral muscle group Needle EMG Needle EMG evaluation appears to be
symmetry. Grabiner123 found a greater degree of erec- the most useful electrophysiological technique in the
TABLE 32–12.Primary Clinical Neurophysiologic motor unit field.12 Needle EMG has proven useful
Tests and Their Utilization in distinguishing false-positive radiologic studies be-
cause normal persons have few, if any, electromyo-
Acute and Chronic graphic abnormalities in the paraspinal muscles.129
EMG Denervation Myopathies Needle EMG, in particular, can be a sensitive test for
radiculopathy and neuronal deficits.126 Such testing,
Motor nerve conduction Peripheral neuropathies however, requires a high level of technical experience
Entrapment neuropathies and expertise.
Sensory nerve Peripheral neuropathies
conduction Entrapment neuropathies
Nerve Conduction Velocity Nerve conduction velocity
Postganglionic nerve injuries
(NCV) testing provides information about the speed,
H-reflex S1 radiculopathies
or latency, of neural transmission along a known dis-
Cauda equina lesions
tance of a sensory or motor nerve fiber. By stimulating
Sciatic neuropathies
a nerve at two different points, two latencies can be
Peripheral neuropathies
obtained and a velocity calculated using the follow-
F-responses Motor neuropathies
ing equation: NCV = D/(Lproximal − Ldistal ). The dis-
Sciatic neuropathies
tance (D) in millimeters between the two electrodes
Peripheral neuropathies
divided by the difference in latency time (L) in mil-
Mixed nerve Peripheral and sciatic
liseconds equals the conduction velocity of the nerve
somatosensory evoked neuropathies
(NCV) in meters per second. Measurements may be
potentials (SEPs) Myelopathies
made at several points along the nerve to identify the
Brainstem and cortical lesions
location of a lesion. Nerve conduction velocities can
Small sensory nerve Sensory radiculopathies
be compared with known values for interpretation.
evoked responses Sensory peripheral neuropathies
In understanding nerve stimulation studies, one
Myelopathy
must remember that a nerve fiber is a cluster of
Dermatomal SEPs Root-specific sensory
variable-size nerves that will respond to different
radiculopathies
stimuli. The wave of propagation that results can be or-
Sensory peripheral neuropathies
thodromic (from proximal to distal) or antidromic (from
Myelopathies
distal to proximal). In this manner, the response of a
Cortical and nerve root Myelopathies
nerve can be identified using recording electrodes and
evoked potentials Radiculopathies
the relationship between stimulus and response can
Muscle evoked Myospasm
be displayed and recorded. The applied stimulus is
responses
graded as subthreshold, threshold, submaximal, max-
Thermography Reflex sympathetic dystrophy
imal, or supramaximal.
Adapted from Haldeman S, Dvorak J. Clinical neurophysiology and elec-
trodiagnostic testing in low back pain. In: Weisel SW, Weinstein JN,
Herkowitz HN, Dvorak J, Bell GR, eds. The lumbar spine. Philadelphia:
H-Reflex The Hoffman reflex, or H-reflex, is an elec-
WB Saunders, 1996:141–161. trical analogue of the sensory motor monosynaptic
stretch reflex that is elicited by selectively stimulating
Ia fibers of the posterior tibial or median nerve. Such
diagnosis of radiculopathy128 and is used to measure stimulation can be accomplished by using slow (less
single motor unit potentials. Spontaneous activity is than 1 pulse/second), long-duration (0.5–1 msec) sub-
measured during and after the insertion of the elec- maximal stimuli with gradually increasing stimula-
trodes into the muscle to be examined, and again once tion strength that bypass the muscle spindle and di-
activity has equilibrated. The patient is also requested rectly stimulate the afferent nerves. The H-reflex can
to perform varying degrees of muscular contraction be thought of as a controlled version of the clas-
intensities. The characteristics of the duration, am- sic deep tendon reflex where mechanical stimula-
plitude, and phases of the action potential are exam- tion to the tendon containing sensory receptors elic-
ined for abnormalities associated with disease. Some its a subsequent motor response. Studying H-reflex
phenomena associated with neurological disorders modulation may also provide insight into how the
include synchronization for motor unit potentials, fib- nervous system centrally modulates stretch reflex
rillation potentials, positive sharp waves, and fascic- responses.
ulations. Myopathies often demonstrate the common In the lower extremity, the H-reflex is traditionally
characteristic of a diminished mean duration of ac- performed by applying the electrical pulse over tibial
tion potentials. Other findings include spontaneous nerve at the popliteal fossa, which produces a burst
activity, increased polyphasic potentials, and reduced of action potentials traveling both orthodromically
Muscle
Evoked
Responses
Motor
Evoked
Potentials
Somatosensory
Evoked
Motor and Potentials
Sensory
Nerve
F-Responses Conduction
H-Reflexes
EMG
Clinical
Subjective
Symptomatic Hard Objective Proximal Nerve Peripheral Sensory Pathway Motor Pathway End Orange
Denervation
Presentation Findings Lesion Neuropathies Disturbances Disturbances Dysfunction
FIGURE 32–12. How each electrodiagnostic family of tests adds information to the clinical examination. (Adapted from Haldeman S,
Dvorak J. Clinical neurophysiology and electrodiagnostic testing in low back pain. In: Weisel SW, Weinstein JN, Herkowitz HN, Dvorak J, Bell GR, eds.
The lumbar spine. Philadelphia: WB Saunders, 1996:144.)
and adromically from the site of stimulation The use of a magnetic stimulator in conducting
(Fig. 32–13).130 The first impulses to reach the record- H-reflex tests allows for the recording from stimu-
ing electrodes are a direct motor response termed the lation of nerves at multiple levels from the popliteal
M-wave. The H-wave is delayed because of the re- fossa to the spine.133 Dishman et al. have used H-reflex
flex duration from the time it takes for the stimulus testing protocols in addition to transcranial magnetic
to travel along the Ia fibers, through the dorsal root stimulation in the investigation of the effects of lumbar
ganglion, across the spinal cord to the anterior horn spinal manipulation on the excitability of the motor
cell, which then propagates the impulse along the al- neuron pool134,135 with encouraging results and ap-
pha motor axon to the muscle. H-reflex latency can plicability to understanding the mechanisms of spinal
be determined easily from charts, according to height manipulative therapy.
and sex, or from published normal values.131 Alter-
natively, the patient’s asymptomatic limb can be used F-Response The F-response is a long-latency muscle
as the normal value because the difference in latency action potential seen after supramaximal stimulation
between both sides should not exceed 1 msec. to a nerve. The F-wave results from a centrifugal vol-
The H-reflex can be obtained at low stimulation ley in an alpha motor neuron, following antidromic
levels without any motor response (M-wave) preced- excitation of the nerve cell body in the ventral horn of
ing it. As the stimulation strength is increased, the the spinal cord. This test is performed by stimulating
M-wave appears. With further increases in stimula- a motor nerve in the leg or forearm, resulting in an im-
tion strengths, the M-response becomes larger and the pulse back to the anterior horn in an orthodromic re-
H-reflex decreases in amplitude. When the motor response in the same motor nerve, which, in turn, can be
sponse becomes maximal, the H-reflex disappears and recorded in the muscle to which the nerve travels.136
is replaced by a small late motor response, the F-wave. Unlike the H-reflex, the F-wave is always preceded
The H-reflex can normally be seen in many muscles, by a motor response and its amplitude is rather small,
but is easily obtained in the soleus muscle (with pos- usually in the range of 0.2–0.5 mV. Although it can be
terior tibial nerve stimulation at the popliteal fossa), elicited in a variety of muscles, it is best obtained in
the flexor carpi radialis muscle (with median nerve the small foot and hand muscles. The data obtained
stimulation at the elbow), and the quadriceps (with from the F-wave have been used in many different
femoral nerve stimulation). The H-reflex is useful in ways to determine proximal or distal pathology. The
the diagnosis of S1 and C7 root lesions, as well as the normal values can be determined from charts or pub-
study of proximal nerve segments in either periph- lished data and depend on the height of the patient,
eral or proximal neuropathies. The H-reflex has been the length of the arm or leg tested, and the presence of
shown to have a high correlation with the Achilles ten- any peripheral slowing of nerve conduction. In uni-
don reflex and measures the presence or absence of an lateral lesions, the best normal values remain those
S1 radiculopathy with a high degree of accuracy.132 of the patient’s asymptomatic limb. The difference
H- or F-wave latencies of the medial head of the gas-

trocnemius muscle in 97 patients with suspected S1
Cathode radiculopathy with or without additional L5 radicu-
S lopathy. Needle EMG of the medial gastrocnemius
muscle was supplemented by H- or F-wave latency
Anode measurement bilaterally by percutaneous stimulation
of the tibial nerve in the cubital fossa. EMG abnormal-
ities indicating S1 radiculopathy were followed by H-
1/4 or F-wave latency abnormality in 63% of patients. The
rest (37% of patients) showed mild EMG abnormali-
ties followed by a normal H- or F-wave. A normal
EMG finding was followed by a normal H- or F-wave.
Subsequently, a normal EMG finding was followed
by normal H- or F-wave in 64% of patients, whether
1/2 increased latency of the H- or F-wave without EMG
Active
abnormalities in gastrocnemius muscle was present in
36% of patients. The results of this study indicated that
measurements of H- or F-response latencies provide
the objective evidence of S1 radiculopathy, present-
ing with the unilateral increase of latency or the ab-
sence of response. The authors additionally noted that
abnormal H-response latencies without EMG abnor-
mality confirm the condition of sensory root affection
only.
R
Evoked Potentials Evoked potentials are electrical sig-
nals generated by the nervous system in response
to sensory stimuli. Auditory, visual, and somatosen-
sory stimuli are among those often used for clinical
evoked potential studies. Somatosensory evoked po-
tentials (SEPs) consist of a series of waves that reflect
FIGURE 32–13. Location of electrodes for obtaining tibial
sequential activation of neural structures along the
nerve H-reflex. The active (recording) electrode is placed half
somatosensory pathways following electrical stimu-
the distance between mid-popliteal fossa and apex of the medial
malleolus. R = reference electrode is applied over the triceps
lation of peripheral nerves. SEPs have been used to
surae tendon and the ground is placed between the active and complement the F-wave response in determining the
stimulating electrodes; S = stimulating electrodes are applied sensory component of a radiculopathy. The easiest
directly over the nerve on the popliteal fossa. (Drawing courtesy and most commonly used method of eliciting an SEP
of Dr. J. Donald Dishman and reproduced with permission from Dishman is by stimulating large mixed nerves, such as the me-
JD, Cunningham BM, Burke J. Comparison of tibial nerve H-reflex ex- dian nerve at the wrist, the common peroneal nerve at
citability after cervical and lumbar spine manipulation. J Manipulative the knee, or the posterior tibial nerve at the ankle.126
Physiol Ther 2002;25:318–325.) Upon stimulation of these nerves, it is possible to ob-
tain a well-defined and reproducible response over
between both sides’ shortest latencies should not ex- both the spinal cord and the scalp through the use of
ceed 2–3 msec, depending on the nerve being tested. computer averaging of the time-locked potentials. By
Clinical applications of the F-response include measuring the latency of these responses and relating
conditions such as entrapment neuropathies, root them to normative values that account for patient de-
compression syndrome, and estimation of motor mographics, it is possible to document disturbances
neuron excitability. Toyokura et al.137 evaluated in the primary sensory pathways from the point of
100 patients with lumbosacral radiculopathy and con- stimulation to the scalp.139 SEP abnormalities can re-
firmed disc herniation, and reported a 70% positive veal a reduced amplitude or impaired morphology of
response rate to F-response testing. It should be re- the signal.
membered, however, that because this response is SEPs are used for clinical diagnosis in patients with
independent of the sensory nerve root, F-responses neurologic disease and for intraoperative monitoring
are not sensitive for sensory radiculopathy or neu- during surgeries that potentially compromise the so-
ropathies. Bobinac-Georgijevski et al.138 performed matosensory pathways.140 Abnormal SEPs can result
from dysfunction at the level of the peripheral nerve, be evaluated to ascertain clinical utility and can be
plexus, spinal root, spinal cord, brainstem, thalamo- evaluated on the basis of discriminability and norma-
cortical projections, or primary somatosensory cortex, tive data.12 Claims of efficacy of any instrument or
and therefore are very nonspecific regarding the na- technology and clinical utility must be soundly based
ture of any pathology. Because individuals have mul- in the peer-reviewed indexed literature and be prop-
tiple parallel afferent somatosensory pathways (i.e., erly scrutinized to be worthy of use in chiropractic
anterior spinothalamic tract or dorsal columns), SEP practice to establish a diagnosis, monitor clinical out-
recordings can be normal even in patients with sig- comes, and be reimbursable from third-party payers.
nificant sensory deficits.139 SEPs are characteristic of
the functional integrity of the fast-conducting, large-
SUMMARY
diameter group Ia muscle afferent fibers and group II
cutaneous afferent fibers, which travel in the poste- 1. The clinical evaluation of a patient is depen-
rior column of the spinal cord. When a mixed pe- dent on both qualitative assessments, such as in-
ripheral nerve (containing both sensory and motor spection, palpation, and visual observation, and
fibers) is stimulated, both group Ia muscle afferents quantitative assessments that use tools to express
and group II cutaneous afferents contribute to the SEP a numerical value to describe a particular clinical
response. SEPs thus provide information concerning finding. The latter often require the use of com-
the integrity of the pathway through the brain, brain- plex diagnostic questionnaires or equipment. Any
stem, spinal cord, dorsal nerve roots, and peripheral objective test used to measure clinical outcomes
nerves. must be evaluated for such factors as reliability,
SEPs from physical stimuli administered in either validity, accuracy, precision, sensitivity, specificity,
the upper or lower extremity are detectable in the discriminability, responsiveness, and clinical util-
brain or the spine simply by placing electrodes over ity. These terms all have well-described definitions
the spinous processes at multiple levels and over the and scientific methods that are used to describe
scalp to evaluate the somatosensory pathway.126 In their value in the clinical encounter.
this manner, it is possible to determine the level within 2. Perceptual measures used to describe the clinical
the spinal cord at which a suspected lesion is interfer- condition of a patient are dependent upon the pa-
ing with the primary sensory pathways. SEPs may be tient’s conscious response to a question or verbal
useful in assessing suspected spinal stenosis or pathol- or visual stimulus. Outcomes assessment instru-
ogy proximal to the spinal nerve root,127 in addition to ments can be categorized into five classes: (a) gen-
being helpful with intraoperative monitoring during eral health status of a patient, (b) pain percep-
spinal surgery.141 tion including pain intensity, affect, and location,
(c) condition-specific instruments that evaluate the
effect of a condition such as back pain on a patient’s
CONCLUSIONS
functional capacity, (d) the influence of psychome-
A wide range of instruments have been developed tric or psychosocial factors such as depression and
through the years to assist the clinician in transform- anxiety on a patient’s outcome, and (e) patient sat-
ing a once qualitative-only practice to one that seeks isfaction with health care experience.
to obtain quantitative objective findings in patient 3. The assessment of spinal function includes the
management. Spine instrument measures include measurement of such factors as mobility, strength,
perceptual, structural, functional, and physiological endurance, and coordination. Spinal stiffness, de-
dimensions, with numerous instruments designed to fined as the mechanical responses to force and dis-
evaluate specific facets of each dimension. Varying placement of spinal tissues during movement can
degrees of reliability and validity, as well as sensitiv- be assessed qualitatively during the clinical exam-
ity and specificity, exist in many of the measures of ination through various palpation techniques or
each dimension. As noted in the prior edition of this quantitatively through the use of a number of mea-
textbook,12 some measures are generally accepted, surement devices. Spinal stiffness can be assessed
well established, and widely used, while others have as a quasistatic–static function or a dynamic func-
no proven value or are developmental in nature. The tion. Muscle strength can be evaluated either man-
chiropractic clinician should be able to discern which ually or through the use of various dynamometers
measures best serve the interests of patients from both and can be expressed as either isometric, isokinetic,
a utility and financial standpoint. As in many other or inertial strength.
health care professions, technological advances con- 4. Physiological measures of spinal function depend
tinue to bring new instruments to the marketplace in primarily on electrophysiological principles. Elec-
chiropractic. The main features of any instrument can tromyography can measure the electrical activity
of muscles using signal amplitude measured over anatomical or physiological abnormality leading
the skin during muscle contraction, changes in to loss of normal bodily ability.
muscle electrical activity during flexion and ex- 4. Five methods of assessing pain: (a) verbal rating scale,
tension of the spine, and asymmetry of paraspinal (b) Visual Analogue Scale, (c) numerical rating
electrical muscle activity. The research on these scale, (d) McGill Pain Questionnaire, and (e) pain
measures, however, has had mixed outcomes that diagram.
make it difficult to determine the clinical useful- Two methods of assessing disability caused by low
ness of these tests. Neurological deficits can be doc- back pain: (a) Roland-Morris Disability Question-
umented through the use of needle electromyo- naire and (b) Oswestry Disability Index.
graphy, peripheral nerve conduction, H-waves, Six methods of assessing muscle strength: (a) man-
F-responses, and a number of different meth- ual testing, (b) dynamometer, (c) isometric testing,
ods of recording cortical and spinal evoked po- (d) isokinetic testing, (e) isoinertial testing, and
tentials. Each of these tests has unique sen- (f) EMG.
sitivities and specificities that determine their 5. Needle EMG measures single motor unit poten-
clinical use. tials, and appears to be the most useful elec-
trophysiological technique in the diagnosis of
radiculopathy. Nerve conduction velocity (NCV)
ACKNOWLEDGMENTS measures speed, or latency, of neural transmis-
sion along a known distance of a sensory or
The authors would like to thank Dr. John J. Triano and his coau-
motor nerve fiber, and is best used to measure
thors, Dennis Skogsbergh, DC, and Matthew Kowalski, DC, for
neurologic deficit associated with peripheral nerve
allowing us to use and expand upon their thoughts and ideas pre-
entrapments.
viously presented in their respective chapters in the second edition
of this text.12
KEY REFERENCES
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2. What are the three aspects that a clinician must
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C H A P T E R
33
INDICATIONS FOR AND USE OF X-RAYS
Cynthia Peterson and William Hsu
O U T L I N E
INTRODUCTION Flexion–Extension Cervical Spine Views
HISTORY OF X-RAY USE IN Flexion–Extension Lumbar Spine Views
CHIROPRACTIC PRACTICE Using Plain Film Radiographs to Detect Malpositions
EVIDENCE-BASED GUIDELINES or Manipulable Lesions
To Expose or Not OVERVIEW OF THE CATEGORIES OF DISEASES
Lumbar Spine Radiographs AFFECTING THE MUSCULOSKELETAL
Indications SYSTEM
What Views to Take Congenital/Developmental Anomalies
Cervical and Thoracic Spine Radiographs Arthritides
Indications Tumors
What Views to Take Blood
Extremity Plain Film Radiographs Infection
Indications Trauma
What Views to Take Endocrine/Metabolic Disorders
Use of Radiographs for Structural Indications for Chest and Abdominal Radiographs in
and Biomechanical Analysis Chiropractic Practice
Scoliosis Evaluation Pitfalls in Radiographic Interpretation
Lordosis and Kyphosis Evaluation SUMMARY
Cervical Lordosis: Assessment and Clinical Relevance QUESTIONS
Lumbar Lordosis: Assessment and Clinical Relevance ANSWERS
Increased Thoracic Kyphosis KEY REFERENCES
Intersegmental Motion Analysis REFERENCES
1. To trace the evolution of the use of radiographs Radiography and radiology have been used in chi-
within the chiropractic profession. ropractic practice since the very early stages of the
2. To provide evidence-based guidelines for the cur- profession. Chiropractors graduating from accredited
rent use of x-ray in chiropractic practice. colleges have received extensive instruction in radia-
3. To identify areas of controversy in the use of x-ray tion physics and safety and radiographic positioning
within chiropractic practice. techniques, as well as plain film radiologic interpre-
4. To review the categories of bone diseases and their tation of the musculoskeletal system. The term “chi-
salient clinical and radiological features. ropractic radiology” is used to distinguish the field
5. To highlight the various pitfalls in radiographic from that of medical radiology. Historically, the main
interpretation in order to improve diagnostic difference was that chiropractors focused on postu-
accuracy. ral and biomechanical abnormalities observed on the
661
radiographs, in addition to evaluating for pathology. expose their patients to diagnostic radiography, pre-
This usually required spinal films to be taken in the ferring to limit its use to those with indicators of seri-
upright, weight-bearing position, as opposed to the ous pathological conditions. Other practitioners main-
recumbent radiographs routinely ordered in the med- tain the routine use of x-ray on virtually every pa-
ical field. To achieve their goals of assessing posture tient. These clinicians often use specific “systems” or
and bony position, many chiropractors also ordered named treatment approaches, focusing on subluxa-
radiographic views unique to their profession. tions and biomechanical aberrations visualized on ra-
As with all professions, chiropractic has evolved diographs. This approach has been the target of in-
and continues to change in response to new infor- creasing criticism.2,3
mation and research. This chapter briefly traces this Chiropractic roentgenometrics (the marking of ra-
evolution as it applies to radiography and discusses diographs for spinal malpositions, misalignments, or
the role that radiology plays within the profession to- “subluxations”) has always been controversial within
day. Evidence-based guidelines are offered to assist the profession, particularly because the impact of nat-
practitioners in their decision-making process as to ural and normal asymmetries within the body on
whether or not radiographs are indicated. Research in these measurements is not known.3,4 There are a num-
this area is ongoing and some areas remain controver- ber of techniques that rely on the routine use of such
sial within the profession. These areas of controversy radiographic measurements to determine the direc-
are identified, particularly in regard to the use of ration and force of the applied adjustment. The valid-
diography for specific biomechanical analysis. Brief ity (i.e., the ability to measure a clinically relevant
descriptions and typical clinical presentations of the entity) of these various marking procedures has not
various diseases affecting the musculoskeletal system been established, while attempts to evaluate the reli-
are outlined. Finally, common pitfalls in radiographic ability (ability to obtain the same measurements on
interpretation are addressed in order to improve di- more than one occasion or between different examin-
agnostic accuracy. ers) have given conflicting results.3,5,6 Although most
research in this area has focused on the reliability of
biomechanical and roentgenometric evaluations, re-
HISTORY OF X-RAY USE IN
search has also been undertaken to measure differ-
CHIROPRACTIC PRACTICE
ences in patient outcomes between those with high
Modern chiropractic was founded in 1895, the same and low x-ray use.7
year that Roentgen discovered ionizing radiation, and
radiology quickly became an integral part of the diag-
nostic workup for patients presenting to chiroprac- EVIDENCE-BASED GUIDELINES
tors. Chiropractors originally used x-ray to deter-
mine the location of vertebral “malpositions” they felt To Expose or Not
needed treatment. While some chiropractors still use For chiropractors to protect their right to use ion-
the radiograph in this manner, for many the emphasis izing radiation, request radiographs from imaging
has shifted to the diagnosis or exclusion of osseous centers, and obtain the right to do so in countries
or related soft-tissue pathology. Additionally, x-rays where it is currently illegal (e.g., Sweden, Germany,
are no longer considered a routine part of the diag- Belgium, Italy), it is necessary to demonstrate the
nostic workup of a chiropractic patient, and should safety and responsible use of this important diagnos-
be used only if clinically indicated based upon the tic tool. Much has been learned about the dangers of
history and physical examination findings. Indeed, ionizing radiation over the past century and govern-
a recent survey of members of the American Chiro- ments around the world are taking steps to control
practic Association found that the percentage of new the levels of exposure of their populations. Indeed,
patients receiving x-rays declined from 75% in 1995 government regulations now require that “[n]o inves-
to 60% by the year 2000.1 Another recent change is tigation should be requested unless it can be clinically
that an increasing number of chiropractors are send- justified, and its result, normal or abnormal, is likely
ing patients to local medical imaging centers rather to influence management of the patient.”8 To aid in
than taking the x-rays themselves. Part of this shift this goal, radiography in chiropractic practice should
is a result of improved interprofessional cooperation be restricted to cases where there are sound clini-
with medical physicians, which has resulted in im- cal justifications to use it, as documented in the pa-
proved and more consistent radiographic quality, as tient’s file.8–19 Using optimal radiographic techniques
well as a more judicious use of radiography by the may also reduce radiation exposure by decreasing the
clinician. number of repeated views. The use of follow-up ra-
However, there is still a wide variation in the diographs ordered after chiropractic treatment cannot
way radiography is used by practitioners. Some rarely be substantiated by evidence available at this time,
INDICATIONS FOR AND USE OF X-RAYS 663
especially when considering the existence of more

valid and reliable outcomes measures—which do not
use ionizing radiation—to assess a patient’s response
to treatment.20
The diagnostic yield of plain film radiographs, in
the absence of specific “red flags” in the patient his-
tory and physical examination, is very low. In other
words, the likelihood of finding a clinically relevant
abnormality on a radiograph in a patient with an un-
remarkable history and examination is very small,
and cannot justify the radiation dose or expense of
the procedure.9,11,13,15,16,21–23 Conversely, the failure
to x-ray a patient with “red flags” in the diagnostic
workup may lead to missed pathology that can be
very serious. Thus it is these “red flags” that serve as
the basis for imaging guidelines and help the clini-
cian determine the need for plain film radiographs.
However, given that chiropractic treatment often in- FIGURE 33–1. Spot-angled AP lumbosacral view demonstrat-
volves a high-velocity thrust into a joint, and thus a ing bilaterally symmetrical sacroiliitis as seen in ankylosing
potential for injury to a diseased area, it is understand- spondylitis or enteropathic spondylitis.
able for chiropractors to request radiographs more fre-
quently than their medical counterparts. Because the bar spine radiography on patients with low back pain
vast majority of research into cost-effectiveness and of less than 7 weeks’ duration, based on their his-
diagnostic yield of plain film radiographs has come tory and physical examination findings (Fig. 33–1 and
from traditional medicine, this perspective was most Table 33–1).
likely not considered.
What Views to Take Current research clearly states that
Lumbar Spine Radiographs only two views are necessary for plain film evaluation
Indications The greatest amount of research leading to of the lumbar spine, usually the AP or posteroante-
guidelines for the use of plain radiographs has oc- rior (PA) view, and the lateral view.8,24 Several insti-
curred in respect to radiography of the lumbar spine, tutions now use the PA view instead of the AP pro-
with the general consensus being that radiography is jection in many patients to obtain better visualization
not indicated in the majority of patients with back pain of the sacroiliac joints, vertebral endplates, and inter-
of less than 6 or 7 weeks’ duration in the absence of vertebral discs, as well as a significant reduction in
clinical indicators of serious disease.13 Deyo et al. were ovarian and breast radiation dose. In thin to average-
among the first to develop a list of clinical findings to size patients, the vertebral bodies themselves are no
help direct lumbar spine imaging decisions.22 Their further from the film in the PA projection than they
clinical “red flags” recognized that most “abnormali- are in the AP view.25–27 The routine inclusion of the
ties” found on lumbar spine radiographs, particularly spot-angled AP or PA lumbosacral view is not sup-
degenerative joint and disc disease, have a very poor ported by the literature.24 This view should only be
correlation to clinical symptoms.15 They also pointed included routinely in patients with signs or symp-
out that lumbar spine radiography adds substantially toms suggesting inflammatory spondyloarthropathy
to the costs of the diagnostic workup and delivers (Fig. 33–2). Similarly, lumbar oblique views are sel-
significant gonadal and breast irradiation if the an- dom needed, even in patients with defects in the pars
teroposterior (AP) view is used. Following imaging interarticularis. These defects should be clearly visual-
guidelines can reduce both costs and overall patient ized on the lateral view in most patients, and the addi-
exposure tenfold without any change in the number tional radiation dose delivered with the oblique views
of days of pain suffered by the patient.15 In fact, the is dificult to justify because they rarely change patient
likelihood of finding a serious disease such as a ma- management.
lignancy is less than 1% in primary care.23 Clues in the
patient history and physical examination should alert Cervical and Thoracic Spine Radiographs
the clinician in most of these cases. This same concept Indications Guidelines for plain film radiography of
applies to patients with a high risk of fracture, infec- the cervical spine are not as clearly delineated in
tion, and inflammatory arthropathy. Thus Simmons the literature as they are for the lumbar spine,
et al.18 expanded on the original list created by Deyo and specific information targeting the thoracic spine
et al.22 to offer specific “red flag” indicators for lum- was not found. However, many of the indications
Indicators for Lumbar Spine

TABLE 33–1.
Radiography
History red flags

1. Age older than 65 years
2. History suggesting high risk for osteoporosis
(corticosteroids; Dilantin, high alcohol intake; early
menopause and no hormone replacement therapy
3. Symptoms of urinary tract dysfunction
4. Symptoms of persisting sensory deficit
5. Pain worsening despite adequate treatment
6. Intense pain at rest
7. Pain worse at night
8. Fever, chills
9. Unexplained weight loss
10. History of repetitive stress of sufficient severity to
cause stress fracture
11. Recurrent back pain with no radiographs in the past
2 years
12. Previous lumbar surgery or fracture
13. History of radiographic abnormality elsewhere
reported to patient but with no films or reliable
report reasonably available
14. History of finding from other study (e.g., bone scan
or gastrointestinal series) that requires spine
radiograph for correlation
15. Anticipation of need for another study or treatment
that would be facilitated by preliminary radiographs
(e.g., epidural injection) FIGURE 33–2. Infection involving the L4-L5 level. Note the nar-
16. Patient unable to give a reliable history rowed disc space with destruction of the adjacent endplates.
Physical examination red flags
1. Significant motor deficit these cases may still be low. In many cases, the risk of
2. Unexplained deformity missing a significant fracture, dislocation, or instabil-
ity justifies a more liberal approach in the application
of plain film radiography to this group of patients.29
outlined for low back pain can also be applied to A few studies have attempted to link clinical
neck and mid-back pain. Most of the literature fo- findings to radiographic findings in trauma patients,
cusing on cervical spine plain film radiography has and reported that asymptomatic patients with some
concentrated on trauma patients and those with form of neck trauma will not typically demonstrate
inflammatory arthropathy, particularly rheumatoid a fracture,11,14,29,34 whereas patients with respiratory
arthritis.12,14,17,28–35 compromise, motor dysfunction, and altered con-
Cervical spine trauma is a potentially devastating sciousness are more likely to demonstrate cervical
injury for the patient because of the risk of spinal spine fractures.14 Although all patients with serious
cord damage. The fear of missing significant injury cervical spine injuries report neck pain or demonstrate
has lead to the practice of ordering x-rays for nearly tenderness on palpation, these two clinical findings
all patients with cervical spine trauma.12,14,17,29,32,34,35 are typical of a myriad of cervical spine conditions and
However, it is the degree of trauma, and not its mere are not specific to fracture or dislocation. Paresthesia
presence, that is significant. For example, two studies may or may not be associated with cervical spine frac-
of patients brought to an emergency room after neck ture, with mixed findings in the literature.17 However,
trauma found that only 2.4–2.8% had radiographically any sign or symptom of neurological compromise jus-
detectable injuries.14,29 This figure is most likely much tifies exposure to plain film radiographs, and often
lower in chiropractic practice, because patients with advanced imaging procedures.34 Furthermore, frac-
severe neck trauma are often first taken to hospital by tures and gross dislocations are usually painful imme-
ambulance. This is not to suggest that chiropractic pa- diately after trauma, whereas the soft-tissue injuries
tients with a history of cervical spine trauma should associated with whiplash-type trauma often have a
not receive radiographs, only that the absolute yield in delayed presentation of symptoms. Thus the clinician
must link the clinical findings with the severity of the usually aware of the diagnosis before chiropractic con-
injury to determine the need for radiographs. sultation. Although instability of C1-C2 may occur
Inflammatory arthropathies include rheumatoid ar- in the rare patient with congenital dens anomalies
thritis, which targets the cervical spine in many pa- such as agenesis, hypoplasia, and os odontoideum,
tients with long-standing disease and some with less there are usually no clinical features suggesting these
advanced arthropathy. The upper cervical spine is anomalies and thus no red flags in the history. These
the favored target site, with the potential of seri- anomalies are usually discovered when the patient re-
ous consequences such as instability and brainstem ceives a radiographic evaluation for another reason,
compression.30 However, while rheumatoid arthritis such as trauma. Clinical signs indicating upper cervi-
is the most common arthropathy to cause erosion cal instability, including intractable pain and signs of
and instability of the cervical spine, ankylosing cervical myelopathy, can also be applied to these pa-
spondylitis, Reiter syndrome, psoriatic arthritis, lu- tients, thereby justifying the need for x-ray exposure.30
pus, and scleroderma may have similar findings on oc-
casion. Therefore, patients with known inflammatory What Views to Take The minimal diagnostic series for
arthropathies should receive plain film radiographs of the thoracic spine includes AP and lateral views
their cervical spine prior to spinal manipulation. Ad- (Table 33–2). Traditionally, three views were consid-
ditionally, a spot flexion lateral view, focusing on the ered minimal to evaluate the cervical spine. These
atlantodens interval (ADI), must be included to assess included neutral lateral, AP lower cervical, and AP
the integrity of the transverse ligament of the atlas. In- odontoid projections.34 However, the routine use of
stability of this region is an absolute contraindication the open-mouth odontoid projection has been ques-
to spinal manipulation and these patients should be tioned. Research into the diagnostic usefulness of this
referred for surgical fusion.30 view concluded that “odontoid view radiography is
C1-C2 instability may also be caused by Down syn- warranted in patients with conditions with increased
drome, where patients have a high incidence of ab- risk for disease in C1 to C2, but for the vast majority
sence of the transverse ligament of C1 with resultant of outpatients it is not worth the technical difficulty,
C1-C2 instability.33 They, too, must be evaluated ra- radiation exposure, or expense.”33 Candidates for the
diographically prior to cervical spine manipulation. open-mouth projection include those with a history of
A flexion lateral view is imperative in this patient trauma, inflammatory arthropathy, Down syndrome,
population. The rare mucopolysaccharide disorders malignancy, known congenital defects of the area, and
called Morquio and Hurler syndromes may also have mucopolysaccharidoses.33
C1-C2 instability as the result of a hypoplastic or ab- Supplementary views often include flexion and ex-
sent dens,33 but these patients, or their parents, are tension radiographs in trauma patients.28 However,
TABLE 33–2. Spinal Radiographic Views and Rationale
Area Minimal Series Supplementary Views Rationale for Supplementary Views
Cervical spine AP lower cervical AP open mouth Trauma, inflammatory arthropathy, Down
Neutral lateral Flexion/extension syndrome malignancy, known congenital
Obliques pillar anomaly
Trauma, inflammatory arthropathy
(degenerative disc disease)
Malignancy, trauma (radiculopathy)
Trauma
Thoracic spine AP, lateral Swimmer’s lateral Symptoms located in cervicothoracic junction
Lumbar spine PA (or AP), lateral Spot-angled lumbosacral Symptoms of inflammatory spondylarthropathy
Spot-lateral lumbosacral Poorly visualized on lateral view
Obliques Malignancy, trauma (spondylolysis)
Flexion/extension Clinical signs suggesting instability
Pelvis AP
Full spine PA (or AP) for Right and left lateral To assess primary from secondary scoliotic
scoliosis bending curves, determine fusion levels
Sectional laterals If not done for scoliosis evaluation
Key: AP = anterior posterior; PA = posterior anterior.

these should not be performed in acute trauma pa- radiographs are essential in these conditions, with the
tients without first thoroughly evaluating the AP exception of early LCPD, and bilateral views may be
lower cervical, AP odontoid, and neutral lateral radio- indicated. Clinicians must be cognizant of the clin-
graphs for evidence of fracture, dislocation, or poten- ical features suggesting these conditions so that ra-
tial instability.32 Flexion/extension views are poten- diographs are taken when indicated and unnecessary
tially dangerous in that they may induce spinal cord exposures are avoided.
injury in an initially neurologically intact patient. Ad-
ditionally, the muscle spasms that accompany cervical What Views to Take The minimal diagnostic series for
spine trauma restrict the evaluation of latent instabil- extremity radiographs varies, depending on the spe-
ity in patients with no evidence of fracture or dislo- cific joint or area examined. In general, at least two
cation on the initial radiographs. Thus flexion and ex- views at 90 degrees to each other are required, except
tension radiographs should be performed when the for the hand, wrist, foot, and ankle, where three views
clinical examination demonstrates improved global are considered to be minimal. Additionally, modifica-
functioning in these patients and the three-view series tions to the routine series must be made for trauma
is normal.34 However, computed tomography (CT) patients. Additional projections may be required and
and magnetic resonance imaging (MRI) are better for views are taken without moving the injured part
detecting potential instability than flexion/extension (Table 33–3).
plain films. Flexion and extension cervical views are
occasionally indicated in patients with degenerative Use of Radiographs for Structural
disc and joint disease to detect hypermobility or in- and Biomechanical Analysis
stability. The use of the flexion lateral cervical view As mentioned earlier, biomechanical analysis was one
has already been discussed in patients with inflamma- of the main distinguishing features between med-
tory arthropathy and Down syndrome. Historically, ical and chiropractic use of radiography. Research
oblique cervical radiographs were done on most pa- has failed to substantiate these various systems of
tients with evidence of degenerative disc disease, par- analysis, other than to verify that most have at least
ticularly in the presence of radiculopathy, to assess the reasonable intraexaminer reliability. Furthermore, re-
patency of the intervertebral foramina. However, the search has confirmed that exposure to ionizing ra-
correlation between foraminal stenosis and symptoms diation has inherent risk and must thus be used
of radiculopathy is very poor. Current opinion holds judiciously.11,36,37 With more valid and reliable out-
that oblique views add little useful additional infor- come measures available to assess the effects of chi-
mation beyond that available on the two- or three- ropractic treatment, reliance on the radiograph for
view series in patients with degenerative disc and joint biomechanical information has come under increas-
disease; they may be very useful, however, in trauma ing criticism.2–6,38 However, there are circumstances
patients or in those with a history of malignancy and in which radiographic structural and biomechanical
neck pain.34 Pillar views may be indicated in patients information is not only useful, but is absolutely crucial
with a hyperextension injury and normal plain films to patient diagnosis and treatment. Scoliosis is a clas-
of the cervical spine. Impaction or compression frac- sic example where the spinal radiograph is necessary.
tures of the articular pillars of the cervical spine are Intersegmental hypermobility or instability, whether
often missed because the pillar view is not considered. as a consequence of trauma, arthropathy, or congenital
anomaly, is most often assessed with plain film radio-
Extremity Plain Film Radiographs graphy. Spondylolytic spondylolistheses are also de-
Indications The two most common reasons to x-ray tected using spinal radiographs, as are the etiologies
the extremities are to evaluate trauma and the symp- of the excessive thoracic kyphosis.
toms of arthritis. Less common indicators for x-ray
exposure to the extremities include symptoms of in- Full-spine radiographs remain the
Scoliosis Evaluation
fection, history, or clinical findings of tumor, and to diagnostic imaging modality of choice for the eval-
evaluate gross deformities. Special attention needs to uation of scoliotic curves. Idiopathic scoliosis is the
be directed to the hip in pediatric patients. Although most common orthopedic disorder of the adolescent
exposure to ionizing radiation in the pediatric pop- age group,36 being much more common in females
ulation should be the exception rather than the rule, and resulting in a significant number of spinal ra-
there are several conditions targeting the pediatric hip diographs over the course of curve monitoring and
that are of concern to the chiropractor. These include treatment. Patients are often exposed to full-spine ra-
developmental dysplasia of the hip formerly called diographs every 3–6 months until skeletal maturity.
“congenital hip dysplasia,” Legg-Calvé-Perthes dis- Additionally, lateral bending radiographs are usually
ease (LCPD; avascular necrosis of the femoral head), taken upon first diagnosis to assess primary from sec-
and slipped capital femoral epiphysis. Plain film ondary curves and to determine fusion levels.39 This
TABLE 33–3. Extremity Radiographic Views and Rationale
Area Minimal Series Supplementary Views Rationale for Supplementary Views
Shoulder AP internal and external AP neutral and Trauma series

(nontrauma) rotation (baby arm) transthoracic lateral or Y Visualize lung apex for abnormality
view of scapula (baby
arm, axillary view)
A/C joints AP weight-bearing and Bilateral comparison Determine normal variation in movement from
non-weight-bearing injury
Elbow AP and lateral Oblique (medial or lateral) Possible radial head fracture
AP with hand pronation Possible radial head fracture
Wrist PA, medial oblique, PA with ulnar deviation Trauma wrist to assess scaphoid
lateral Lateral oblique Trauma wrist to assess pisiform, hook of hamate
Norgaard (ballcatcher’s) Early RA to visualize erosions
projection
Hand PA, medial oblique, Single finger views, PA and Trauma fingers
lateral lateral
Hip (nontrauma) AP or AP pelvis and frog True lateral hip Trauma hip patient as substitute for frog-leg
leg projection.
Knee AP and lateral Tunnel To visualize intracondylar notch
Sunrise To visualize patellofemoral joint
Ankle AP, medial oblique, Always include the base of the fifth metatarsal on
lateral the ankle series
Foot Dorsoplantar, medial For toes, use a sponge to Toes often are curled and joints are not
oblique, lateral straighten out the toes adequately visualized without sponge
Axial view calcaneus Trauma calcaneus; tarsal coalition
Key: A/C = acromioclavicular; AP = anterior posterior; PA = posterior anterior; RA = rheumatoid arthritis.
results in a substantial radiation dose to the young pain all patients of small to medium habitus, or at least in
tient and may have long-term consequences. A con- those with scoliosis. The PA projection also provides
servative estimate of the number of full-spine radio- substantial reduction in ovarian radiation dose.
graphs given to the scoliotic adolescent is at least 12.36
It has been documented that females with scolio- Lordosis and Kyphosis Evaluation Chiropractors have
sis have a higher incidence of breast cancer than do traditionally been very interested in evaluating spinal
females without scoliosis and this has been directly curves, using alterations in the lumbar and cervical
linked to differences in x-ray exposure between these lordoses and the thoracic kyphosis as indicators of in-
two groups.36,37 Reducing radiation dose to sensitive jury or dysfunction, as well as aiming treatment at
organs such as the breast, gonads, and thyroid gland is restoration of “abnormal” curves. However, a wide
crucial for these adolescents.25–27,37 Although current range of normal exists within spinal curves, just as
imaging techniques deliver far less ionizing radiation it does with the rest of the human body.4 Further-
than a few decades ago, more needs to be done. Since more, there are numerous different ways to assess
1982 physicians have been calling for the replacement these curves radiographically, with only fair agree-
of the AP full-spine radiograph with the PA projec- ment between various methods.5 Patient positioning
tion (Fig. 33–3). 26,27,39–41 It has been calculated that also impacts on spinal curve analysis, particularly in
the PA radiograph reduces sternal exposure by 98.9% the cervical spine where slight alterations in flexion
and breast skin exposure by 92%. Furthermore, replac- or extension of the head can significantly change the
ing the AP view with the PA view results in a three- cervical curve.4,5 Unfortunately, many clinicians make
to sevenfold reduction in cumulative doses to the thy- their judgments on the status of spinal curves simply
roid gland and female breast, thus reducing the breast from their visual impressions of the radiographs with-
cancer risk by three- to fourfold and the thyroid cancer out any radiographic measurements. Studies have
risk by half.38 Thus it would seem desirable for chiro- shown not only that visual estimation is extremely
practic physicians to consider replacing the AP full- inaccurate when compared to x-ray measurements,
spine radiograph with the PA full-spine radiograph, but that chiropractors are not consistent in their visual
Studies comparing cervical lordosis to patient symp-

toms have been frequently performed in the past four
decades.31,42 A review of the literature on this topic up
until 1993 concluded “[t]here is little evidence to sup-
port the contention that altered cervical curvatures are
of prognostic significance.”42 Both medical and chiro-
practic studies were included in this review, as well
as several different ways of measuring cervical lordo-
sis. Thus, a straight, or even kyphotic, cervical curve
may be within normal limits for particular patients,
has no link to long-term pain or dysfunction, and is
not necessarily the result of trauma. Consequently, the
flattening of this curve cannot be used as evidence for
the necessity of treatment, with the goal of creating
a “normal” cervical lordosis. More valid and reliable
outcome measures are available to document the ef-
fects of treatment.20
Lumbar Lordosis: Assessment and Clinical Relevance As

in the neck, a variety of radiographic methods are
used to assess lumbar lordosis, each choosing differ-
ent anatomical landmarks.38 Concurrent validity of
three methods for measuring lumbar lordosis has also
been studied, with results similar to those found in
the cervical spine. All methods had excellent reliabil-
ity but only fair agreement with each other. Taking
the factors of reliability, concurrent validity, ease of
use, and low risk of measurement error into consid-
eration, the acute rotation angle method appears to
be the preferred measurement technique.43 The clin-
ical relevance of lumbar lordosis is difficult to estab-
lish because of the wide variety of techniques used
to evaluate it in the various studies. Because the con-
current validity between measurement methods is not
consistent, studies commenting on the significance of
an increased or decreased lumbar lordosis must be
FIGURE 33–3. New compression fracture L1 with a step de- viewed with some skepticism. Furthermore, because
fect and zone of sclerosis along the superior endplate. of the radiation dose delivered in lumbopelvic films,
the evaluation of lumbar lordosis alone is insufficient
estimation from one time to the next on the same set clinical justification for the use of ionizing radiation.
of patients.6 Thus this method of spinal curve analysis Recent investigations comparing the degree of lum-
should not be used for more than broad estimates of bar lordosis in back pain patients found conflicting
spinal curvature. results.44,45 Because of such controversies in the liter-
ature, more quality studies need to be conducted be-
Cervical Lordosis: Assessment and Clinical Relevance fore the clinical relevance of lumbar lordosis is truly
There are at least nine different ways to measure cervi- known.
cal lordosis radiographically.5 Studies on most of the
techniques demonstrate that they have strong inter- Increased Thoracic KyphosisPostural analysis often re-
and intraexaminer reliability (measurements are reveals an accentuated or exaggerated thoracic kypho-
producible). Studies examining the validity (i.e., do sis. However, the specific cause is usually only
they actually measure what they claim to measure?) detectable by exposing this region of the spine to ion-
of these techniques, however, are sparse. A recent izing radiation. Although age-related normal thoracic
study comparing three of these measurement meth- kyphosis measurements are listed in various radi-
ods found only fair concurrent validity.5 The ideal ology books, applying the Cobb method of kypho-
radiographic method to determine cervical lordosis evaluation in practice is challenging. All of the
sis, if in fact there is one, is yet to be established. “normal” measurements use T1 and T12 vertebrae as
the appropriate landmarks for determination of the Flexion–Extension Lumbar Spine ViewsThis spinal series,
kyphotic angle. However, T1 is rarely visualized on which is used to detect intersegmental hypermobil-
the lateral thoracic or chest film because of the overly- ity and instability, can be performed in the upright
ing thick tissues of the shoulder girdles. Additionally, weight-bearing position, but film quality often suf-
accurate identification of T12 is challenging and relies fers because of patient motion artifacts. Several au-
on the posterior aspects of the hemidiaphragms cross- thors recommend the recumbent position for these
ing the T12 vertebral body. Thus, the strict application views to maximize patient comfort, as well as to in-
of ranges of normal to an actual patient may not be crease the range of lumbar motion, facilitating the
possible, necessitating clinical judgment. Pathological detection of occult instability. Lumbar intersegmen-
processes resulting in an increased thoracic kyphosis tal instability may rarely be caused by acute trauma.
include compression fractures, Scheuermann disease, More common causes include degenerative disc dis-
senile kyphosis, ankylosing spondylitis, tuberculo- ease, adjacent fused spinal segments, hormonal influ-
sis (or pyogenic spinal infection), neurofibromatosis ences, and spondylolytic spondylolisthesis. Because
(combined with scoliosis), idiopathic scoliosis, and of the substantial radiation dose delivered with these
rare congenital anomalies. Patient age, gender, and two extra lateral radiographs, clinicians are increas-
history usually make one of these conditions much ingly offering their patients conservative treatment
more likely than the others and the radiograph sim- if they suspect intersegmental instability, relying on
ply confirms or rules out the clinical suspicion. flexion/extension views for those patients with poor
response.
Intersegmental Motion Analysis In general, plain film ra- Using Plain Film Radiographs to Detect
diography is still used for flexion–extension studies Malpositions or Manipulable Lesions
of both the cervical and lumbar spinal regions. Lat-
As mentioned earlier, using plain film radiographs
eral bending studies flourished in popularity during
simply to detect spinal “subluxations,” or to deter-
the 1980s, but because the findings on these proce-
mine the specifics of the spinal adjustment, is con-
dures were not found to be clinically relevant or pre-
troversial. The validity of the various systems of
dictive of future pathology when subjected to the rig-
roentgenometric analysis has not been proven and
ors of scientific research, lateral bending studies have
their underlying premise of bilateral symmetry within
largely been abandoned. There is also concern for the
the body does not take into account natural struc-
substantial radiation doses incurred for these addi-
tural anomalies. Additionally, the reliability of de-
tional views in the lumbar spine. Because a few prac-
termining lateral flexion and rotation malposition is
titioners remain convinced of the validity of informa-
questionable.3 There are numerous diverse and elab-
tion gleaned from lateral bending radiographs, future
orate systems developed by chiropractors over the
studies could use open-access MRI units as a research
years to analyze the spine and to determine particular
tool to avoid the risks of ionizing radiation.
adjustments. Because patients tend to improve with
time and/or treatment, clinicians using the various
Flexion–Extension Cervical Spine Views The indications mensuration methods have assumed that this proves
and contraindications for flexion–extension views the theory behind their particular system of analysis.
have been discussed previously and include a his- One of the challenges of chiropractic practice in the
tory of trauma, degenerative disc and facet disease, in- twenty-first century is to determine reliable and valid
flammatory arthropathies, or Down syndrome. Usu- nonradiological methods to identify the manipulable
ally this series is performed with the patient in the lesion. Chiropractors in some European countries no
weight-bearing position, but passive radiographs or longer use the radiograph to determine the specifics
recumbent films to detect latent or occult instability of their adjustments and look to other methods of de-
have also been suggested. Once flexion/extension cer- termining the manipulable lesion.
vical radiographs are obtained, careful analysis of in-
tersegmental motion needs to be performed. This can
OVERVIEW OF THE CATEGORIES OF DISEASES
be done by hand using a variety of techniques, or
AFFECTING THE MUSCULOSKELETAL SYSTEM
with the aid of computer digitization. Both transla-
tion in the sagittal plane and angular rotation should Radiographic abnormalities affecting bone, joint,
be evaluated. In general, more than 3.5 mm of excur- and related soft tissue can be classified into seven
sion of one vertebra upon another as measured from categories, easily remembered by the mnemonic
flexion to extension indicates instability. Additionally, CATBITES:
the atlantodental interval must always be evaluated
and should not exceed 3 mm in adults or 5 mm in • Congenital/developmental anomalies
children. • Arthritides
• Trauma
• Blood disorders/bone infarct Signs and Symptoms of Craniocervical
• Infection Junction Abnormalities
• Tumors Motor myelopathy
• Endocrine/metabolic abnormalities
• Soft-tissue diseases • May be quite subtle and nonspecific
• May be manifest only by lack of endurance
With a few exceptions, most categories of radio- • May be quadriparesis, triparesis, paraparesis, hemi-
graphic abnormalities are associated with a related paresis, or monoparesis
significant clinical history and clinical presentation.
Fractures and dislocations are associated with se- Sensory abnormalities
vere trauma and clinical symptoms are often obvious.
Arthritides, infection, and tumors are typically asso- • Posterior column dysfunction
ciated with pain, swelling, and deformity. Patients • Hypalgesia (spinothalamic tract dysfunction)
with blood disorders such as sickle cell anemia and • Bladder dysfunction (urgency or hesitation)
hemophilia are usually aware of their condition prior
to seeing a chiropractor. Patients with endocrine and Brainstem dysfunction
metabolic disorders usually have characteristic phys-
ical features, such as exophthalmos with hyperthy- • Nystagmus (horizontal or downbeat)
roidism, truncal obesity and moon-face with Cushing • Apnea
syndrome, and bronze complexion with Wilson dis- • Ataxia
ease. Most congenital anomalies offer few physical • Dysmetria
hints to their presence. Skin dimples, abnormal spinal • Internuclear ophthalmoplegia
curvature, elevated shoulder, and hairy patches are a • Facial diplegia
few of the external manifestations of underlying bony
abnormalities in the spine. Rarely, congenital anoma- Lower cranial nerve dysfunction
lies, such as os odontoideum, present with neurolog-
ical symptoms. • Decreased hearing
• Dysphagia
Congenital/Developmental Anomalies
• Soft-palate paralysis
Most congenital/developmental anomalies are dis- • Trapezius muscle weakness
covered incidentally on radiographs taken for other • Tongue atrophy
reasons. Thus most are asymptomatic, with a few
exceptions.46 The dilemma to the clinician is whether Vascular compromise
the patient’s presenting symptoms can be attributed
to the anomalies. Understanding the neurovascular • Syncope
anatomy adjacent to the osseous anomalies and the • Vertigo
associated visceral abnormalities would help the clin- • Intermittent paresis
ician to determine if the patient’s symptoms are associ-
ated with the osseous anomalies (see sidebar Signs and
Symptoms of Craniocervical Junction Abnormalities). Oc-
cipitalization of atlas (C1) is either an isolated anomaly Agenesis of the C1 posterior arch, either partial or
or a composite of syndromes such as Arnold-Chiari complete, is itself not associated with any symptom.
malformation (type I), Sturge-Weber syndrome, and However, because of the proximity of the transverse
Klippel-Feil syndrome. It may produce symptoms ligament and possible associated laxity, a flexion study
such as headache, reduced range of motion, visual and to assess for atlantoaxial instability may be warranted.
auditory disturbances, and neurological symptoms of Pons posticus (posterior ponticulus) is an arcuate
the extremities because of compression of the spinal foramen above the posterior arch of the atlas as a result
cord/brainstem. of ossification of the oblique portion of the atlanto-
Primary basilar impression is a congenital anomaly occipital ligament. It is either unilateral or bilateral
with elevation of the posterior cranial fossa resulting and found in approximately 14% of anatomical speci-
in the odontoid process projecting above the plane of mens. Symptoms of vertebral artery compression are
the foramen magnum. Possible symptoms may result postulated at extreme rotation of craniocervical junc-
from compression of the pyramidal tracts or posterior tion with pons posticus; however, this is not a univer-
columns of the spinal cord, as well as from develop- sal finding. Wight et al. have documented an associa-
ment of syringomyelia. tion of pons posticus with common migraines.47
Odontoid anomalies such as os odontoideum, hy- vertebrae, typically seen at C7. The size and shape of
poplasia of the odontoid process, and agenesis of the the cervical ribs do not correspond to the presence of
odontoid are likely to develop multidirectional at- symptoms.
lantoaxial instability and may develop symptoms of Butterfly vertebrae affect the thoracic and lumbar
cord compression or vertebral artery injury. Although spine and are usually an isolated anomaly with no
the true incidence of odontoid anomalies is unknown, clinical significance. However, multiple butterfly ver-
they are thought to be rare. Clinical suspicion should tebrae are seen in spinal dysraphisms associated with
be raised in patients with transient cord compression meningocele or diastematomyelia. Vertebral anoma-
symptoms with neck motion, hypalgesia at the C2 lies associated with related visceral anomalies have
dermatome, and occipitalgia. A study of 12 patients often been reported.49
with various types of os odontoideum showed onset Hemivertebrae result from failure of one of the lat-
of symptoms usually in adulthood, and in a few cases, eral ossification centers of the vertebra to form. It is
symptoms occurred after trauma.48 commonly associated with scoliosis. Rarely, ventral
Down syndrome, or trisomy 21, is a common genetic or dorsal hemivertebrae are found resulting in accen-
defect caused by three copies of the twenty-first chro- tuated sagittal curvatures.
mosome and results in mental retardation, character- VATER syndrome is an aggregate of bony and
istic facial features, and ligamentous laxity, especially visceral anomalies. These include vertebral anoma-
the transverse ligament of the atlas. A flexion study of lies, anal atresia, tracheoesophageal fistula with
the cervical spine should be incorporated as a part esophageal atresia, and renal and radial dysplasia.
of the cervical radiographic study in patients with Spina bifida occulta is a bony defect of the poste-
Down syndrome. rior arch. It is usually an incidental finding on radio-
Congenital block vertebrae result from segmentation graphic study and does not predispose to low back
failure of the embryonal somites during the third to pain. A larger bony defect of the posterior arch at
eighth fetal weeks. An isolated congenital block ver- multiple levels is spina bifida vera. It may be asso-
tebra is clinically insignificant. However, an increased ciated with a large soft-tissue mass that is clinically
risk of early degenerative changes occurs above and detectable.
below the fused segment as a consequence of hyper- Other congenital anomalies, such as physical find-
mobility. ings of anal dimple, hairy lumbar patch, asymmetrical
Klippel-Feil syndrome results from defective embry- size of the lower extremities, and lipoma, should raise
ological development of the closely approximated cer- the suspicion of a rare entity called diastematomyelia.
vical vertebrae, scapulae, and genitourinary system, This is a rare form of spinal dysraphism where the
with manifestation of multiple congenital block ver- spinal cord is divided by an osseous, cartilaginous,
tebrae, elevated scapulae, and associated anomalies or fibrous structure separating the spinal canal into
of the genitourinary system. Clinical presentation of a two lateral halves. Widening of the interpediculate
short, webbed neck, low hairline, and decreased cer- distance, usually present at the site of abnormality,
vical range of motion should raise one’s suspicion of with or without visualization of the osseous septum,
Klippel-Feil syndrome. is the radiographic finding.
Cervical spondylolisthesis is a rare congenital Various rib cage osseous anomalies are asymp-
anomaly typically found at C6 with spina bifida tomatic and are found incidentally. These include
occulta and defective articular pillars. Anterolisthesis congenital pseudoarthrosis of the first rib, the Srb
is occasionally found and is typically asymptomatic; anomaly (incomplete segmentation of the first and
however, there are reported cases of headache, torti- second rib without intercostal space), bifurcated rib,
collis, and radicular arm pain. rib foramen, and intrathoracic rib. Deformities of the
Agenesis of a cervical pedicle results from defective chest wall, such as pectus excavatum and pectus car-
growth of the ossification center of the neural arch. It inatum, are obvious on physical examination and do
is most likely asymptomatic and only discovered inci- not require radiographs to confirm the diagnosis.
dentally when oblique cervical radiographs are taken As with other disorders, detection of osseous
for a patient with cervical and/or arm pain. It is read- anomalies is driven by the patient’s presenting symp-
ily differentiated from lytic metastatic destruction of toms and the clinician’s findings on physical examina-
the pedicle by the compensatory sclerosis of the con- tion. Radicular pain, neurological deficits, and phys-
tralateral pedicle/pillar. ical deformity are the indications for radiographic
Cervical ribs are found in 0.5% of the population study.
and may produce neurovascular compressive symp- Genetic diseases, such as achondroplasia and clei-
toms of the upper extremities after middle age when docranial dysplasia, are usually obvious on physical
the shoulders begin to droop. They are the cervi- examination. Therefore, radiographic study is usually
cal equivalent of the costal elements of the thoracic not necessary. However, an increased risk of spinal
stenosis and foraminal encroachment is seen in achon- manifested radiographically may not correlate with
droplasia, and radiographic study is warranted if the the severity of symptoms present in the patient. Thus
affected patients present with compressive neurolog- in order to enhance the predictive value of plain film
ical symptoms. imaging, the rationale for imaging must be based on a
Developmental dysplasia of the hip (DDH) was high index of suspicion following a thorough history
formerly known as congenital hip dysplasia. It is char- and physical examination.
acterized by lateral displacement of the hip secondary Osteoarthritis is the most common arthritis affect-
to abnormality of the acetabulum/labrum complex ing mainly the weight-bearing joints such as the hip,
during infancy. Asymmetry of the gluteal folds, re- knee, and spine and the interphalangeal joints of the
duced range of motion of the hips, or audible click on hands and feet. It is a polyarticular arthritis that affects
Ortolani and Barlow maneuvers in an infant should primarily middle-aged and elderly women. Unfortu-
raise the suspicion of DDH. Plain films are insensitive nately, a disparity exists between the severity of ra-
in the early detection of DDH because of the lack of os- diographic changes of osteoarthritis and clinical signs
sification of the femoral head until 5–6 months of age. and symptoms. This is particularly true with forami-
Despite this, there are several radiographic clues, in- nal encroachment due to osteophytosis of the degen-
cluding lateral displacement of the proximal femoral erative uncovertebral joints. The severity of the un-
metaphysis, asymmetrical sclerosis of the acetabulum, covertebral arthrosis can be readily appreciated on
and asymmetrical ossification of the proximal femoral the anteroposterior lower cervical radiograph, and
epiphyses. Skeletal ultrasonography is the imaging the oblique views are unnecessary for assessment of
modality for DDH. foraminal encroachment. Crepitus, loss of motion, and
bony prominence are typical physical findings. Pain
Arthritides and stiffness that reduce with activity are common
Each individual arthritic condition has unique physi- symptoms suffered by patients with osteoarthritis.
cal features, a characteristic patient predilection, and Repetitive movements or recurrent chronic injury may
preferred target sites. Knowing these, the clinician predispose to the early development of osteoarthri-
is able to narrow the diagnosis and confirm it with tis. With degenerative processes of the spine, signs of
radiographic imaging. Age is a great discriminat- spinal stenosis and lateral nerve root entrapment may
ing factor in the diagnosis of arthritic conditions. occur.
Juvenile chronic arthritis affects young children, anky- Erosive osteoarthritis is a variant of osteoarthri-
losing spondylitis affects young adults, and primary tis with episodic symmetrical inflammatory involve-
osteoarthritis affects the elderly. Gender is another ment of the distal and proximal interphalangeal joints
discriminating factor. Rheumatoid arthritis, osteitis of both hands. It typically affects middle-aged females
condensans ilii, systemic lupus erythematosus, and with pain, edema, redness, and loss of motion of the
scleroderma have a high predilection for adult fe- involved digits. Laboratory tests are noncontributory.
males, whereas gouty arthritis, Reiter syndrome, and It is differentiated from rheumatoid arthritis by the
hemophilia tend to affect males. Certain diseases normal bone density, presence of osteophytosis, and
show a predilection to specific ethnic groups: sickle the absence of rheumatoid factor. It lacks the discrete
cell anemia, sarcoidosis, and tumoral calcinosis favor marginal erosions with fluffy, periostitial tissues asso-
those of African descent; ossification of the posterior ciated with psoriatic arthritis at the joint margin.
longitudinal ligament is more common in patients Diffuse idiopathic skeletal hyperostosis (DISH) is char-
with an Asian heritage; and systemic lupus erythe- acterized by excessive bone formation at the liga-
matosus targets patients with a white heritage. mentous and tendinous attachments, and typically
Early detection and treatment of rheumatic dis- affects the same age group as those patients with
eases is crucial in the prevention of associated morbid- osteoarthritis. It also shares a similar clinical presenta-
ity. Most diagnoses can be made with a careful history tion as osteoarthritis—stiffness and achy pain. Calci-
and physical examination without further diagnostic fication/ossification of the anterior longitudinal lig-
testing. Although specific radiographic findings are ament of the spine over four contiguous vertebral
associated with certain arthritic conditions, most find- segments without osseous fusion of zygapophyseal
ings are late manifestations, for example, marginal and sacroiliac joints is the criterion for the diagnosis
erosions and overhanging edge sign with gouty arthri- of DISH in the axial skeleton. Exuberant bony forma-
tis, soft-tissue calcification with scleroderma or der- tion in the cervical spine may result in dysphagia and
matomyositis, and chondrocalcinosis with calcium hoarseness. It has been linked to adult-onset diabetes
pyrophosphate dihydrate depositional disease. The mellitus in up to 32% of patients.
earliest radiographic findings of most arthritic con- Ossification of the posterior longitudinal ligament, oc-
ditions are nonspecific. Furthermore, particularly in casionally found concurrently with DISH, may pro-
osteoarthritis, the extent of the arthritic condition duce insidious onset of myelopathy with loss of
proprioception, which manifests as difficulty walking of the high incidence of osteonecrosis and fracture in
with a wide-based gait. this group, either as a sequel of steroid medication or
Neurotrophic arthropathy results from a defect in the as a complication of the condition.
protective mechanism of the joint, with loss of pro- Ankylosing spondylitis, psoriatic arthritis, entero-
prioception and pain perception. The end result is a pathic spondyloarthropathy, and Reiter syndrome
painless, destructive arthritis with repetitive injuries. belong to a group of arthritides that favor axial joints,
Conditions resulting in peripheral nerve neuropathy especially sacroiliac joints. In addition, they are differ-
or spinal cord degeneration may produce neurotro- entiated from other inflammatory arthritides by the
phic arthropathy. Clinically, the patients may present absence of rheumatoid factor in the patient’s serum.
with wide-based gait, loss of pain sensation and Ankylosing spondylitis is a chronic inflammatory
deep tendon reflexes, and painless joint swelling and disease involving the synovial joints of the axial skele-
deformity. ton and ligamentous attachment sites. It affects young
Rheumatoid arthritis, scleroderma, dermatomyo- adults with equal sex ratio. Bony fusion of the axial
sitis, and systemic lupus erythematosus belong to a synovial joints is the sequela starting at the sacroil-
group of connective-tissue disorders with the pres- iac joints and ascending the spine (see Fig. 33–1).
ence of rheumatoid factor in the serum, hence called Postinflammatory changes of the outer anulus fibro-
seropositive arthropathies. sus of the discs lead to formation of characteristic
Rheumatoid arthritis is a synovial inflammatory syndesmophytes—thin linear vertical calcifications
arthritis affecting both extremities and the axial skele- bridging the edges of vertebral bodies. Atlantoaxial
ton. Clinical symptoms include pain, periarticular instability is one of the associated complications. En-
soft-tissue swelling, reduced range of motion, and teropathic spondyloarthropathy mimics ankylosing
stiffness. It is characterized by bilateral symmetri- spondylitis in radiographic manifestation and is as-
cal distribution in the extremities with uniform joint sociated with ulcerative colitis and Crohn disease.
space loss, periarticular osteopenia, and marginal ero- Psoriatic arthritis is a destructive arthritis associ-
sion. Predilection for the atlantoaxial joint with resul- ated with psoriasis. Approximately 15% of patients
tant instability is seen. with psoriasis develop psoriatic arthritis. The arthritic
Scleroderma, also known as progressive systemic condition may predate the skin lesions. Predilection
sclerosis, is characterized by atrophy of the smooth sites for arthritic involvement are the digits of the
muscle, which manifests clinically as atrophy of skin hands and feet, knees, sacroiliac joints, and lumbar
and musculature, dysphagia, and decrease in pul- spine.
monary function. It is a generalized systemic inflam- Reiter syndrome is a triad of arthritis, uveitis, and
matory connective-tissue disease. It typically affects urethritis. It is a reactive arthritis secondary to vene-
women of childbearing age, with a predilection for real or dysenteric disease. History of sexual disease
the extremities. or diarrhea usually precedes the onset of urethritis,
Dermatomyositis is characterized by inflammation uveitis, and arthritis. Presence of the clinical triad may
of striated muscle with potential pulmonary compli- not be simultaneous or coexisting. Predilection for ar-
cations. Clinically, it presents as skin rash and muscle ticulations of the lower extremities is common. Ax-
weakness. It has a bimodal age distribution involv- ial involvement is limited to the sacroiliac joints and
ing young children and elderly in their fifties and six- thoracolumbar spine. In some patients, skin lesions
ties. Because of the esophageal muscle involvement, of the soles and palms are characteristic. Arthritic
aspiration pneumonia is common. It may also produce involvement of the lower extremities tends to demon-
chronic interstitial pneumonia and/or fibrosis.50 strate large painful joint effusions and swelling of the
Systemic lupus erythematosus (SLE) is a common, heel pad (lover’s heel).
generalized, connective-tissue disorder with inflam- Gouty arthritis is characterized by recurrent acute
mation, involving multiple organs mediated through arthritis resulting from deposition of monosodium
inflammatory changes in vascular, dermal, serous, urate in synovial joints. The delicate balance of uric
and synovial membranes. Clinical presentation is typ- acid metabolism is easily upset by excessive purine
ically constitutional with malaise, fever, and weight catabolism or reduced excretion as a result of renal dis-
loss caused by changes to the blood cells and kid- ease. The prevalence of gouty arthritis increases with
ney. Facial “butterfly rash,” photosensitivity, alope- increasing serum uric acid levels. Males are affected
cia, and polyarthralgia are common manifestations of 20 times more often than females. Onset is usually
SLE. Women of childbearing age are the most affected abrupt with exquisitely painful monoarticular arthri-
group. Skeletal changes concentrate at the hands with tis, usually in the great toe, foot, or ankle. This is
reversible deformity with no erosive changes, os- followed by a variable asymptomatic period rang-
teopenia, soft-tissue atrophy/calcification, and a mild ing from months to years. Recurrent attacks usually
degree of tuftal resorption. Clinicians should be aware last longer and become frequent and polyarticular.
Radiographic findings of the initial attack are nonspe- drosarcoma, and Ewing sarcoma, in that order. Fi-
cific and may appear normal. Specific radiographic brosarcoma, chordoma, non-Hodgkin lymphoma and
findings may not be present for many years af- Hodgkin lymphoma, synovioma, and adamantinoma
ter the initial attack. These may include eccentric account for the remainder of primary malignant bone
soft-tissue tophi, erosions with well-defined margins, tumors. Not all bone tumors present with symptoms;
overhanging margins, intraosseous calcification, rel- in fact, most benign tumors are asymptomatic un-
ative preservation of joint space, and normal bone less pathological fracture occurs. Malignant tumors
density. invariably produce symptoms. Table 33–4 delineates
Various metabolic disorders result in deposition of painful and nonpainful bone tumors/lesions accord-
excessive cations and catabolic products in soft tissue ing to age of onset.
and joints, which results in arthritic conditions. These Clinical indications suggesting bone tumor in-
include hemochromatosis (Fe), alkaptonuria (homo- clude enlarging mass, soft-tissue swelling, and pain.
genetic acid), hyperparathyroidism (Ca), and Wilson Bone tumors growing near nerve structures may
disease (Cu). Because these products are deleterious present with radiculopathy or myelopathy.
to the articular cartilage, secondary degenerative dis- An overview of the features differentiating ma-
orders of the involved joints occur in various degrees. lignant and benign tumors is crucial for appropriate
management of the afflicted patient. Malignant tu-
Tumors mors are radiographically aggressive with the follow-
Bone tumors, like many other disorders, exhibit peak ing features:
ages or age ranges of occurrence. For example, Ewing
sarcoma, osteoblastoma, chondroblastoma, osteosar- • Moth-eaten or permeative pattern of bone destruc-
coma, and aneurysmal bone cyst are most common tion
in patients younger than 20 years of age, whereas • Wide zone of transition
metastasis and multiple myeloma are more common • Cortical disruption
in patients older than 50 years of age.51,52 Bone tu- • Various patterns of periosteal reactions (lami-
mors can be classified into primary and secondary nated, spiculated, Codman triangle)
tumors based on their origin. Primary tumors are fur- • Soft-tissue mass
ther divided into malignant and benign, while sec-
ondary tumors are always malignant because they Benign tumors rarely exhibit the radiographic features
are the result of metastases. Metastases account for of malignant tumors with the exception of giant cell
70% of all malignant bone tumors. Malignancies of tumor and aneurysmal bone cyst, both of which show
the breast, prostate, lung, and kidney are responsible an expansile, lytic lesion that may appear aggressive.
for 80% of all bony metastases; thyroid and gastroin- Most benign tumors
testinal malignancies may also metastasize to bone.
Metastatic bone tumors may be lytic (destroy bone), • Have a well-corticated sclerotic margin.
blastic (build bone), or mixed. Lytic metastasis ac- • Have a geographic pattern of bone destruction.
counts for 75% of all metastases, with blastic metas- • Rarely cause cortical disruption without trauma.
tases seen in 15% and mixed metastasis in 10% of cases.
Plain film is insensitive in detecting early lytic metas- Blood
tasis because 30% bone destruction must be present Avascular necrosis (AVN) results from an interruption
to be detectable. Suspicion of metastatic bone disease of blood to osseous structures, which already have a
should be raised in a patient with a history of pre- tenuous blood supply. Sites prone to avascular necro-
vious cancer along with weight loss, cachexia, and sis include the femoral head, talus, scaphoid, and
night pain. Most metastases are found in the axial humeral head. Risk factors are pregnancy, lupus, alco-
skeleton and proximal portions of the humeri and fe- holism, sickle cell anemia, trauma, infection, caisson
murs where bone marrow is abundant. Moth-eaten disease, radiation therapy, rheumatoid arthritis, amy-
and permeative bony destruction are the manifesta- loidosis, and steroid use. Plain film radiography has
tions of lytic metastases, and most metastases involve low sensitivity for early detection of AVN, but high
multiple sites concurrently. The solitary sclerotic bone specificity for the late stage of AVN; bone scans or
lesion is a diagnostic dilemma and challenge. Previ- MRI are recommended for early detection.
ous films and bone scan studies are invaluable tools in Legg-Calvé-Perthes disease is an idiopathic os-
delineating malignant bone metastasis from a benign teonecrosis of the proximal femoral epiphysis in a
entity such as a bone island.51 young child between the ages of 4 and 8 years. Painful
Primary malignant bone tumors account for only limp with referral pain to the anterior thigh or knee
30% of all malignant bone tumors. The most com- is the common clinical presentation. Reduced hip
mon are multiple myeloma, osteosarcoma, chon- range of motion, especially in abduction and internal
TABLE 33–4. Tumors and Tumor-Like Lesions Classified According to Symptoms and Age
Age Painful Nonpainful
Any age Infection (acute or chronic) Fibrous dysplasia (pelvis, ribs)

Bone island (pelvis, femur)
Enchondroma (MC: hands and feet)
Simple bone cyst
Children ABC (metaphysis/diaphysis, neural arch) Fibrous cortical defect (metadiaphysis)
Brodie abscess (infection) Osteochondroma/HME (anywhere)
Simple bone cyst (metaphysis)
10–25 Osteosarcoma∗ (metaphysis) Osteochondroma (anywhere)
Ewing sarcoma∗ (diaphysis) Nonossifying fibroma (metaphysis)
Osteoblastoma∗ (neural arch) Simple bone cyst (metaphysis/diaphysis)
Chondroblastoma∗ (epiphysis)
ABC (metaphysis/diaphysis, neural arch)
20–40 Fibrosarcoma∗ (knee, femur, tibia, humerus)
Reticulum cell sarcoma∗ (diaphysis/metaphysis)
Giant cell tumor∗ (metaphysis/epiphysis)
Osteoid osteoma∗ (femur, tibia, neural arch)
40–70 Metastases∗ (spine [pedicle], pelvis, etc.) Hemangioma (vertebral body and skull)
Multiple myeloma∗ (spine, pelvis, etc.)
Chondrosarcoma∗ (metaphysis/diaphysis)
Chordoma∗ (sacrum, sphenoid, clivus)
Osteosarcoma (Paget disease)∗
Key: ABC = aneurysmal bone cyst; HME = hereditary multiple exostosis; MC = medullary cavity.
∗
Malignant tumors.
rotation, is usually present. Collapse of the proximal mycobacterial, and fungal infections can affect the
femoral epiphysis along with fragmentation, sclero- bone and joint. Patients with immunocompetency
sis, and joint effusion are the radiographic changes weakened by chronic illness such as diabetes, alco-
associated with this disease. holism, renal disease, malignancy, intravenous drug
Spontaneous osteonecrosis of the knee should be sus- abuse, and immunosuppressive therapy are prone to
pected in the elderly patient with sudden onset of knee infection. Pain, swelling, fever, and inability to move
pain, which gradually increases and may become dis- the affected joint are the clinical presentations of joint
abling or remain chronic. The initial plain film simply infection. Joint distension is the earliest radiographic
shows age-related degenerative changes, only to show finding in septic arthritis. A single level of discal nar-
collapse of the weight-bearing portion of the medial rowing with focal endplate erosion is highly sugges-
femoral condyle on a later study. Patients with sponta- tive of infectious spondylodiscitis. Brodie abscess is
neous osteonecrosis of the knee cannot associate their a chronic infection of the medullary cavity of a long
symptoms with any significant trauma. bone. On x-ray, pathology from infections will usually
Bone pain associated with sickle cell anemia is typ- cross joints, which distinguishes them from tumors,
ically caused by an ischemic event or osteomyelitis. which tend to spare joints (see Fig. 33–2).
Hemophilia is an X-linked deficiency or defect of
coagulation factor VIII resulting in uncontrolled hem- Trauma
orrhage in all tissues. Hemarthrosis typically occurs
Numerous intrinsic and extrinsic factors influence the
with development of secondary osteoarthritis. Be-
severity of injuries to soft tissue, articulations, and the
cause of the X-linked recessive nature, it only affects
bony structure. Age, disease processes, nutrition, and
males, with symptoms developing in childhood. Os-
physical fitness play important roles in the health of
seous growth disturbance is common.
the body and therefore influence the resistance of the
body to injury. Extrinsic factors such as the severity of
Infection forces and mechanism, repetitiveness, and duration
Various infectious agents are responsible for infec- of injury determine which type of injury is likely to
tion of musculoskeletal structures. Bacterial, viral, occur (Table 33–5). A thorough history and physical
TABLE 33–5. Mechanisms of Injury and Specific Fracture/Dislocations
Location Mechanism of Injury Type of Injury
C/S, T/S, L/S Flexion Compression fracture, dislocation,

flexion teardrop fracture
Extension ALL/discal injury, pars fracture,
dislocation, teardrop fracture
Shearing/distraction Chance fracture/dislocation
Rotational Facet fracture/dislocation/subluxation
Axial compression Jefferson fracture, burst fracture
Extremities Tensile force Transverse fracture
Compressive force Oblique fracture
Rotational force Spiral fracture
Repetitive subthreshold forces Stress fracture (fatigue or insufficiency fracture)
Open epiphysis Shearing/avulsive/compressive Salter-Harris fractures
Bony prominence Tensile force Avulsion fracture
Articular surface Shearing force Osteochondral fracture
Compressive force Depression or impaction fracture
Key: ALL = anterior longitudinal ligament; C/S = cerried spinel; L/S = lumbar spine; T/S = thoracic spine.
examination are helpful to determine what type of is any pain in the midfoot zone and tenderness at the
injury is likely to be present and hence the necessity base of the fifth metatarsal or navicular or an inability
of radiographic study (see Fig. 33–3). to bear weight. Similarly, specific symptoms and signs
Severity of trauma, high intensity of pain, physical de- associated with knee injuries increase the likelihood of
formity, loss of motion, discoloration, and swelling are use- positive radiographic findings. These include age, in-
ful indications for plain film radiographic study.
Several unique anatomical regions present with
unusual fractures/dislocations, which necessitate
careful scrutiny. The radioulnar and tibiofibular syn-
desmotic joints are prone to concurrent injury. The
pelvis consists of the two innominates and the sacrum.
Fracture of one bone is likely to be associated with frac-
ture/dislocation of another bone or joint in the pelvis.
Complex joints such as the wrist and ankle are likely
to present with unique fracture/dislocations.
Transverse fractures deserve special attention, es-
pecially in the absence of significant trauma. They are
found typically with pathologically weakened bone
and thus should be considered as pathological un-
til proven otherwise. A suspicion of stress fracture
should be raised in the scenario of elite athletes and
osteoporotic elderly when musculoskeletal pain is ag-
gravated with activity initially, but later even occurs at
rest, if the aggravating activity continues (Fig. 33–4).
Specific physical findings of acute ankle and foot in-
juries have been delineated to determine the need for
radiographic study.53 An ankle x-ray series is only re-
quired if there is pain in the malleolar zone and tender-
ness in either the posterior aspect of the distal fibula
or the posterior aspect of the distal tibia, or inability to FIGURE 33–4. Stress fracture of the proximal tibia. A trans-
bear weight immediately after the injury or during ex- verse sclerotic band is present with callus formation at the
amination. A foot x-ray series is only required if there metadiaphyseal region of the proximal tibia.
ability to bear weight, hemarthrosis, point tenderness clinical features include prominence of the frontal si-
over the bone, and effusion.54 nus, a widened mandibular angle, and large hands
and feet.
Endocrine/Metabolic Disorders Ochronosis is a metabolic disorder that stems from
The following diseases fall into the category of meta- defective homogentisic acid oxidase. Excessive accu-
bolic/endocrine disorders: rickets, scurvy, hyper- mulation of homogentisic acid in connective tissues
parathyroidism, hyperthyroidism, Cushing disease, results in tissue death and severe premature degener-
Wilson disease, ochronosis, hematochromatosis, ative changes. Severe disc narrowing and calcification
acromegaly, osteoporosis, and osteomalacia. typifies the axial changes associated with adult pa-
Rickets and scurvy are two metabolic disorders of tients with ochronosis. Suspicion of ochronosis should
the bone associated with deficiency or defective probe made in patients with black pigmentation in the soft
cessing of vitamin D and C, respectively. Both typ- tissues, bluish tinge of the ears and nose cartilages, and
ically affect infants and toddlers. Suspicion of ei- black urine.
ther condition should be raised in a toddler who Osteoporosis is the most common metabolic disease
presents with irritability, weakness, delayed matu- of bone affecting the elderly, and thus is called se-
rity, skin fragility, and growth plate swellings. These nile osteoporosis or senescent osteoporosis. Women
two disorders are rare in developed countries be- are four times more likely to be affected than men;
cause of improved nutrition. Rare instances of vitamin however, the difference diminishes after 80 years of
D–resistant rickets may be undetected and present to age. It is characterized by the loss of bone quantity,
a clinic as failure to grow with bowing deformity of not quality. An increased risk of fractures in the tho-
the lower extremities. racolumbar spine, femoral neck, distal radius, and
Hyperparathyroidism results from overproduction proximal humerus, and the associated morbidity in
of parathormone as a result of parathyroid adenoma, this group of patients, necessitates prompt diagno-
chronic renal disease, and long-term dialysis. The sis and appropriate management by the health care
end result is overstimulated osteoclasts, which re- provider. Knowledge of conditions predisposing a pa-
move the bony matrix, resulting in diffuse osteopenia. tient to osteoporosis is helpful in categorizing patients
Patients with hyperparathyroidism typically present in this high-risk group. Gastrointestinal malabsorp-
with bone tenderness, weakness, lethargy, polydipsia, tion, ulcerative colitis, Crohn disease, hemolytic ane-
and polyuria. mia, steroid or heparin therapy, alcoholism, hyper-
Hyperthyroidism and hypothyroidism are disorders parathyroidism, hyperthyroidism, Cushing disease,
of the thyroid gland with over- and underproduc- and long-term immobilization are some of the disor-
tion of thyroxin, which regulates the metabolic rate ders that deleteriously affect the bone density. Unfor-
of body cells, including bone cells. Hyperthyroidism tunately, plain films are insensitive in the detection of
results in osteopenia in addition to the characteris- osteoporosis because at least 30–50% loss of bone must
tic goiter, exophthalmos, and pretibial myxedema. occur prior to a detectable change on the radiographs.
Hypothyroidism results in retardation of growth in Alternative imaging modalities, such as DEXA (dual-
the newborn—delayed bone growth, persistent sec- energy x-ray absorptiometry) scans with low radia-
ondary growth centers, short stature, and mental re- tion dose, are more sensitive in detecting the severity
tardation. of bone loss. Despite the low sensitivity of plain film in
Cushing disease is characterized by truncal obesity, the diagnosis of osteoporosis, there are a few helpful
“buffalo hump,” “moon face,” hirsutism, and hyper- radiographic signs of osteoporosis, including cortical
tension secondary to an overproduction of glucocor- thinning, accentuated weight-bearing trabeculae, and
ticoid steroid from the adrenal cortex. A neoplasm of loss of vertebral body height. Clinical findings sug-
either the adrenal cortex or anterior pituitary gland gesting osteoporotic fracture are acute thoracolumbar
is the usual etiology. Musculoskeletal manifestations or pelvic pain and deformity with insignificant trauma
of Cushing disease mirror those of long-term steroid in patients with underlying risk factors that affect their
therapy: osteopenia, compression fractures, avascu- bone integrity.
lar necrosis, destructive arthropathy, and soft-tissue Osteomalacia, in contrast to osteoporosis, is a
atrophy. metabolic defect in the quality of the bone. The defi-
Acromegaly results from an overproduction of ciency of the inorganic substance, calcium salts, leads
growth hormone from a pituitary eosinophilic ade- to softening of the affected bone in osteomalacia. This
noma in a skeletally mature individual. With the stim- is either through inadequate intake or excessive excre-
ulation of growth hormone, bone formation occurs tion of calcium and/or phosphate. Chronic gastroin-
at subperiosteal locations and entheses, and a prolif- testinal malabsorption, renal diseases, defective vita-
eration of cartilage cells at articular regions. Classic min D processing, and anticonvulsant drug therapy
can lead to osteomalacia. Similar to osteoporosis, de-

tection of osteomalacia by plain film is difficult with-
out further laboratory tests. However, osteomalacia
manifests with the following radiographic signs: de-
creased bone density, loss of cortical and trabecular
definition, and pseudofractures. Clinical findings sug-
gestive of a patient with osteomalacia are generalized
muscle weakness and bone pain with bony deformi-
ties of the lower extremities.
Indications for Chest and Abdominal

Radiographs in Chiropractic Practice
Plain abdominal radiographs are rarely indicated in
chiropractic practice and are usually performed prior
to a contrast-enhanced examination such as an intra-
venous pyelogram or barium study. They may also be
used to detect abnormal calcifications and air patterns
within the abdomen or to assess the patient with an
“acute abdomen” in a hospital setting. However, soft-
tissue abnormalities are commonly noted on lumbar
spine radiographs and the clinician is responsible for
the accurate diagnosis of these findings. The guide-
lines for chest radiography published in the litera-
ture target the medical profession exclusively,7,8 and
often include acute, potentially life-threatening con-
ditions in patients who initially present to an emer-
FIGURE 33–5. Large mass in the right upper lobe of the lung,
gency room. Thus, guidelines relevant to chiropractic
including the apex and extending well below the clavicle. This
practice must be modified to reflect patients present-
was originally detected on the shoulder radiographs. The diag-
ing to this setting and may simply reflect the neces- nosis was bronchogenic carcinoma.
sity for a referral to an appropriate medical special-
ist. Chest radiographs should be obtained whenever
a lung or mediastinal abnormality is detected on cer- • Patient with signs or symptoms of congestive heart
vical spine, thoracic spine, full spine, or shoulder ra- failure
diographs (Fig. 33–5). Significant chest lesions are not • Inflammatory arthropathy (rheumatoid arthritis,
unusual on skeletal radiographs and the chiropractor ankylosing spondylitis, SLE, scleroderma) in a pa-
is responsible for the detection and follow-up of these tient with chest symptoms
abnormalities. Additional clinical criteria for request- • Patient with a history of significant asbestos expo-
ing chest radiographs are the following: sure at least 10 years previously
• Coal miner with chest symptoms
• Heavy smoker older than age 50 • HIV-positive patient with chest symptoms
• History of malignancy with chest symptoms • Patient with signs and symptoms of lymphoma
• Trauma to thoracic cage (diagnose rib fractures/ • Patient with sudden dyspnea and chest pain (send
pneumothorax) to hospital emergency room)
• Febrile patient with cough or other chest signs/
symptoms Pitfalls in Radiographic Interpretation
• Cervicothoracic pain or shoulder pain, not repro- Clinicians who choose to interpret their own radio-
ducible with neck or shoulder exam in chronic graphs are, as a rule, held responsible for all abnor-
smoker malities visualized. Clinicians who take an appropri-
• Patient with abnormal physical examination find- ate diagnostic series, perform a complete search pat-
ings (rales, rhonchi, wheezes, absent breath sou- tern of every view, are able to distinguish significant
nds), cyanosis, recent onset of dyspnea from insignificant abnormal radiographic findings,
• Patient with Marfan syndrome who has not been and can link the patient’s clinical information with
examined for thoracic aortic aneurysm the patient’s radiographs will improve their diagnos-
• Patient with a history of sternal fracture who has tic accuracy.55 Pitfalls in radiographic diagnosis can
not been evaluated for posttraumatic thoracic aor- come from several sources, but are primarily linked
tic aneurysm to weaknesses in knowledge of the variety of normal
radiographic appearances, failing to scrutinize the en- radiographic appearances, failing to scrutinize the
tire radiograph, accepting less than optimal radio- entire radiograph, accepting less than optimal
graphs, and the fact that it takes between 30% and 50% radiographs, and the fact that it takes between
bone destruction to be detectable on plain films.55 30% and 50% bone destruction to be detectable on
plain films.
SUMMARY
1. Chiropractic was founded in the same year as the QUESTIONS
discovery of ionizing radiation (1895), and the two
1. Why has the PA full-spine radiograph replaced the
fields quickly grew together. Chiropractors origi-
AP projection for the evaluation of scoliosis?
nally used x-ray to determine the location of ver-
2. What are the clinical indicators supporting the use
tebral “malpositions” they felt needed treatment.
of plain lumbar spine radiographs in patients with
While some chiropractors still use the radiograph
low back pain of less than 7 weeks’ duration?
in this manner, many now use radiography to di-
3. In which specific conditions are flexion lateral
agnose, screen, or exclude bone pathology.
cervical spine radiographs indicated to assess
2. Evidence-based guidelines for radiography are
the atlantodentol interval prior to chiropractic
based on the principle that diagnostic testing
treatment?
should only be performed when its result is likely
4. What are the specific clinical indications for an an-
to alter treatment. Use of these guidelines reduces
kle series in a patient with trauma to this region?
unnecessary radiography, thereby reducing both
5. What is the relevance of a straight cervical curve?
exposure to radiation and cost, and improves the
diagnostic yield of plain film radiographs, which
is quite low in the absence of red flags. In the
ANSWERS
lumbar spine, for example, red flags include age
older than 65, osteoporosis, persisting neurologi- 1. The PA full-spine radiograph delivers substan-
cal deficit, night pain, and unexplained weight loss tially lower radiation doses to sensitive organs
(see Table 33–1). and tissues such as the breast, thyroid gland, and
3. A few chiropractors continue to order radiographs ovaries than does the AP full-spine radiograph.
for uses other than ruling out red flags. Certain The protection is superior to that provided with
treatment systems are based on obtaining pre- and shielding and there is no risk of obscuring the
posttreatment measurements of minute changes in apices of the curves.
vertebral positioning, and relate such changes to 2. Plain film radiographs are not indicated in the vast
clinical presentation. This use of radiography has majority of low back pain patients with symptoms
not been adequately studied and remains an area of less than 7 weeks in duration in the absence of
of controversy within the profession. “red flag” indicators. These indicators are listed in
4. The main categories of bone disease are congen- Table 33–1.
ital, arthritides, tumors, blood, infection, trauma, 3. A flexion lateral cervical radiograph must al-
endocrine, and soft tissue (forming the mnemonic ways be done in patients with rheumatoid arthri-
CATBITES). Although each category encompasses tis, particularly with neck symptoms. The other
a variety of conditions with many clinical presen- inflammatory arthropathies such as ankylosing
tations, a few generalizations may be applied. Con- spondylitis, psoriatic arthritis, Reiter syndrome,
genital anomalies often look very unusual or cause and, rarely, scleroderma and SLE, may rupture the
variations in normal anatomy. Arthritides are of- transverse ligament of the atlas, thus requiring a
ten accompanied by joint erosion and decreased flexion lateral view. Down syndrome and the rare
bone density. Tumors may cause extensive growth mucopolysaccharidoses may have an absent trans-
or destruction in an area. Blood disorders may af- verse ligament. It is rare to rupture the transverse
fect bone density and appearance. Infections often ligament with trauma because the dens is more
destroy the joints and blur the usual bone–soft- likely to fracture. However, trauma may also be
tissue demarcation. Trauma tends to cause disloca- an indicator for a flexion lateral view.
tion and fractures. Endocrine disorders often affect 4. If there is pain in the malleolar zone and tenderness
bone density and appearance. Soft-tissue disor- in either the posterior aspect of the distal fibula or
ders may change the density and appearance of posterior aspect of the distal tibia, or an inability to
soft tissues. bear weight immediately after the injury or during
5. Pitfalls in radiographic diagnosis can come from examination.
several sources, but are primarily linked to weak- 5. Many studies have failed to find any clinical rele-
nesses in knowledge of the variety of normal vance to loss of the cervical lordosis.
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C H A P T E R
34
INDICATIONS FOR AND USE
OF ADVANCED IMAGING STUDIES
Dennis R. Skogsbergh
O U T L I N E
INTRODUCTION Infection
COMPUTED TOMOGRAPHY Cystic Lesions
MAGNETIC RESONANCE IMAGING Tumors and Marrow-Infiltrating
Low-Field Strength versus High-Field Strength Disorders
Spine Dynamic MRI
Thoracic Spine Magnetic Resonance Angiography
Anomalous Development NUCLEAR IMAGING
Intervertebral Disc Degeneration BONE DENSITOMETRY
Disc Derangement SUMMARY
Stenosis QUESTIONS
Spine Trauma ANSWERS
Intrinsic Change within the Spinal Cord KEY REFERENCES
Postoperative Spine REFERENCES
OBJECTIVES remains the initial imaging tool for defining gross

osseous morphology, vertebral alignment, interver-
1. To review the use and limitations of plain film tebral spacing, and intersegmental stability. In most
radiography. cases, gross patterns of fractures and bone disease are
2. To review the use of computed tomography (CT). also readily assessed with plain film. However, plain
3. To review the use of magnetic resonance imaging film routine radiography has many limitations and
(MRI). may not be appropriate for the early detection of some
4. To review the use of nuclear imaging studies. conditions. For example, it is well known that 30–50%
5. To review the use of bone densitometry testing. bone destruction may be necessary in some areas be-
fore a solitary lesion becomes visible on plain film ra-
diography. Central spinal stenosis is often underesti-
mated because the critical landmark determinations
INTRODUCTION
for the calculation of canal diameters are inaccurate,
The fundamental importance of diagnostic imaging and guidelines cannot be strictly applied. Lateral re-
in spinal pain syndromes is clear. Not only is the di- cess changes are often missed completely on plain
rection of patient management facilitated thereby, but films. Furthermore, soft-tissue abnormalities can be
it also provides an understanding of any unique at- virtually “invisible” on plain film. Today, these types
tribute that may limit or require treatment modifica- of uncertainties and ambiguities may be clarified by
tion. For many years diagnostic imaging in chiroprac- various advanced imaging studies. Spinal diagnos-
tic was limited to conventional radiography, which tic imaging has evolved to its present state with the
683
interim development of conventional tomography,

arteriography and epidural venography, skeletal ra-
dionuclide scanning, ultrasonography, and computed
tomography (CT).
More recently, there have been monumental
changes in the field of radiology. Magnetic resonance
imaging (MRI) has perhaps had more impact on the
diagnosis of spinal diseases than on any other region
of the musculoskeletal system. It has become widely
accepted in clinical practice and the use of other types
of imaging studies (often more invasive) has propor-
tionally decreased. Although the addition of new tech-
niques has made the detection of earlier and subtler
pathology almost routine, it also has led to uncertainty
as to which is the most effective imaging strategy for
a given clinical situation. Choosing the optimal ex-
amination with cost-effectiveness is important in the
initial stages of diagnosis and treatment planning,
but also later with follow-up. The various diagnostic FIGURE 34–1. CT myelogram at the level of L3. There is
imaging techniques can work together in suggesting some beam-hardening artifact because of the bilateral pedicle
key diagnostic considerations and in following re- screws. Nevertheless, visualization of the spinal canal and ver-
sponse to management. They help to determine the tebral arch components is not impaired. Assessment of hard-
extent of injury or pathologic abnormality, and of- ware placement and its integrity, and any degree of spatial in-
ten its clinical significance. The use and sequencing trusion of intervertebral disc or osteophyte into the confines of
the neural canals, can be accomplished with confidence.
of diagnostic examinations are rapidly changing, and
all of the modalities have some practical applicability.
Today, in spine practices, the heaviest emphasis is on screws, but the environs of the spinal canal are nev-
CT and MRI. Ongoing advances with these modalities ertheless imaged well. Obese patients may image less
continue to restructure approaches to spinal imaging. well.
CT produces images of superior contrast reso-
lution, but less spatial resolution than conventional
COMPUTED TOMOGRAPHY
radiographs. This provides greater depiction of soft
During the 1980s, CT was the study of choice for tissue than plain film radiography. Computed to-
spinal investigations beyond conventional radiogra- mography produces an image based on mathematical
phy. With the introduction of MRI later in the 1980s, measurements of the attenuation of a well-collimated
CT now plays a secondary role to MRI. However, x-ray beam passing through a section of anatomy.
CT has evolved with technological advances that Contrast in the image derives from the differences in
have caused its clinical usefulness to be reevaluated. attenuation based on electron density and the effective
With spiral CT, single breath-hold acquisition in a anatomic number of the tissue components. The high
typical study is 25–30 seconds, and multidetector contrast between low-density fat and higher-density
scanners have scan times two to eight times faster. intervertebral disc and nerve roots allows for a highly
Furthermore, image-processing techniques, includ- accurate depiction of nerve root impingement. In-
ing multiplanar reconstruction (MPR) and volumet- deed, CT became increasingly important because of
ric three-dimensional imaging, provide new capabil- its high-resolution cross-sectional depiction of the soft
ities that may be critical in musculoskeletal imaging. tissues and bony components of the spine. Reformat-
CT with MPR allows for superior delineation of facet ted data produces images of somewhat lesser res-
joints, their orientation, and the associated patholog- olution in other planes. Three-dimensional images
ical changes of degenerative joint disease, including often provide unique visual perspectives versus tra-
erosions, cystic change, marginal proliferation, cap- ditional planes of imaging. These three-dimensional
sular calcification, and synovial cysts. Its widespread techniques are most useful in complex spine fractures
availability, speed, and versatility have made CT a and fracture-dislocations. General indications for CT
mainstay in evaluating acute trauma. Patient move- are listed in Table 34–1.
ment remains a problem with the CT examination, High-resolution CT allows for excellent noninva-
as are some metallic objects (dental fillings, shrap- sive evaluation of osseous detail and adjacent soft tis-
nel, surgical hardware, etc.). In Figure 34–1, a beam- sues of the spine, particularly the complex anatomy
hardening artifact is created by the presence of pedicle in areas that do not image well with conventional
INDICATIONS FOR AND USE OF ADVANCED IMAGING STUDIES 685
Indications for Computed

TABLE 34–1. would provide significant additional information rel-
Tomography ative to the contents of the spinal canal and foramina.
CT has the added benefit of accurately detecting con-
Degenerative changes comitant thoracic cage and abdominal abnormalities
Uncinate processes, zygapophyseal joints, facet cysts including vascular injuries with minimal respiratory
Stenosis and related stenotic features misregistration.
Vacuum facet, vacuum sacroiliac, vacuum disc Nonenhanced CT of the cervical spine using thin
Disc herniation, particularly far lateral herniation (when MRI is (1.5-mm) slices may be the preferred imaging proce-
inappropriate) dure for the evaluation of monoradiculopathy. Not
Ligamentous ossification: ossification of posterior longitudinal only is CT less expensive than MRI, but high-
ligament, ligamentum flavum, annulus fibrosus resolution techniques accurately differentiate be-
Trauma tween disc herniation and posterior spurring of the
Spondylolysis/spondylolisthesis uncinate processes. With thicker-slice MRI there is
Primary bone neoplasm partial averaging of the signal superimposed on the
Infection and Inflammatory process signal similarity, making differentiation between disc
Complex congenital bony anomalies and bone virtually impossible. CT images do not allow
Dysraphism, diastematomyelia, meningocele, lipomeningocele for the differentiation between annulus fibrosus and
Postoperative: fusion, grafts, hardware nucleus pulposus, or contained versus noncontained
disc herniations. In this regard, MRI is superior and
it has expanded our understanding of intervertebral
radiographs. A prime example is occult or poorly disc pathology. While the calculation of CT attenua-
visualized fractures of the spine. CT is the examination tion values (Hounsfield units) is helpful in the differ-
method of choice in evaluation of spinal trauma. Also, entiation between certain tissues, it has not been help-
uncooperative patients and those in pain may limit ful for the disc proper. Another example is conjoined
certain conventional examinations. Often there is in- nerve root differentiation, which remains difficult be-
ability to adequately visualize the C1-C2 region. In the cause of similarity in the density of the disc and nerve
thoracic spine the T1-T4 region is notoriously difficult root.
to image with plain film radiography and swimmer’s MRI has largely replaced CT in the workup of de-
lateral views provide only limited information. While generative disease of the thoracic spine. CT is, how-
the routine use of CT for screening purposes is not ever, useful in showing disc calcifications, and both
advocated, it is appropriate for that group of patients costovertebral and facet disease. There is ongoing con-
who are not otherwise reliably examinable. troversy as to the use of CT alone or in conjunction
Spiral CT is significantly more sensitive than plain with myelography (CT myelography) for the diagno-
film radiography for the detection of cervical spine sis of degenerative disease including stenosis. In many
fractures. Nunez et al. reviewed 88 patients with cer- spine specialty centers today CT myelography and
vical spine trauma and 32 evidenced injury inade- CT discography are extensively used to sort through
quately portrayed on plain film.1 Sagittal and coro- the pathoanatomy and better understand pain
nal multiplanar reconstructed images also help in the generators.
diagnosis of alignment and rotational abnormalities.2 The overlying bowel pattern often obscures visu-
CT is very useful for compression and burst in- alization of the sacrum and sacroiliac joints on con-
juries to provide additional information with respect ventional studies. Not only does CT provide superior
to retropulsed fragments, and spatial intrusion of in- anatomic detail for the detection of sacral fracture,
tervertebral disc material into the spinal canal and in- stress fractures, sacroiliitis, infection, and tumor, but
tervertebral foramina. The posterior vertebral arches it is also sensitive to pelvic bleeding in cases of pelvic
are seen in great detail with CT. This is in contrast to trauma or aneurysm. MRI has also largely replaced
a somewhat limited evaluation of the posterior ele- CT for the study of spinal neoplasms, except for the
ments with MRI. Figure 34–2 exemplifies such a case. visualization of cortical erosions and calcified tumor
The plain film lateral view shows subtle abnormal- matrices. With prominent and annoying metallic arti-
ity at C2, but the remaining views failed to elucidate fact in the postsurgical setting, CT with MPR allows
the injury at the cervicothoracic junction seen on the the questions of fusion status and stability, graft incor-
CT examination. The advanced imaging provides im- poration, graft migration, and hardware integrity to be
proved visualization of the crush pattern and vital in- settled when unanswered by MRI. Figure 34–3 shows
formation with respect to the integrity of the spinal the usefulness of CT in a case of persistent neck pain
canal and arch elements. after a two-level interbody fusion. Before manipula-
With trauma, CT can usually discern bone, blood, tion or other management proceeds, a critical deter-
disc, and foreign bodies, but in cases like these, MRI mination is whether there has been adequate healing
A
D FIGURE 34–2. A young male patient with cervical and thoracic in-
juries, including rib fracture. A. Anteroposterior and lateral conven-
tional radiographs. The anteroposterior dimension of the C2 body is
increased. A line of lucency extends vertically and somewhat obliquely
from the inferior endplate (which is interrupted) through the poste-
rior body region. Fracture is suspected anteroinferiorly at C2. Only
the superior aspect of the C7 vertebra is visualized laterally. The
open-mouth view appeared normal. The swimmer’s lateral projection
was not revealing. B. Axial CT and sagittal MPR reveal the peculiar
C2 fracture pattern through the posterior body and right transverse
process extending to the base of the odontoid process. The poste-
rior neural arch is intact. C. Axial CT at T1 showing a complex burst
pattern with some posterior fragment migration into the canal. D.
Sagittal and coronal MPR further characterizes the burst fracture
pattern at T1.
especially in discerning complex spatial relationships.

CT is frequently performed at the conclusion of stan-
dard myelography as a supplementary procedure.
There is increased sensitivity to contrast differences
with additional information evident in up to 40%
of cases.3 Despite the strong use of MRI, CT myel-
ography is still considered by some to be the gold
standard for demonstrating the soft-tissue and bony
changes that result in nerve root and spinal cord
compression.4 Furthermore, metallic artifact may pre-
clude the effective use of MRI. In Figure 34–5, there
is clear depiction of right paracentral and forami-
nal disc herniation just below the level of a previous
fusion.
CT may also be coupled with a discographic exam-
ination. Discography has been used for many years
and remains somewhat controversial in some circles.
It provides a physiological test of an interverte-
bral disc with a volumetric, manometric, and pain-
provocative challenge followed by a morphologic ra-
diographic portrayal. It is accurate and reproducible.5
After instillation of dye within the nuclear sector of
the intervertebral disc (Fig. 34–6), CT images with
or without MPR are obtained. Figure 34–7 is illus-
trative of complementary imaging procedures of CT
myelography, MRI, and CT discography. MRI and CT
both demonstrate the disc protrusion. The discogram
demonstrates a radial tear with posterior tracking of
the herniation material and, in this case, reproduction
of the patient’s pain. CT is also used for guidance dur-
ing interventional procedures.
MAGNETIC RESONANCE IMAGING

MRI became clinically available in 1981. There have
FIGURE 34–3. Axial CT of the cervical spine (top) with sagittal been few controlled studies comparing and contrast-
MPR (bottom) in a patient with significant neck pain persisting ing MRI with other imaging modalities, but MRI has
6 months after a two-level anterior interbody fusion. Note the been enthusiastically supported and has rapidly be-
failure of trabeculation across the lower fusion site. On con- come the primary diagnostic imaging technique for
ventional flexion and extension views there was no abnormal the spine. It has not, however, lived up to initial expec-
motion and the fusion appeared solid.
tations that it would fully elucidate all facets of patho-
morphology and obviate the need for other imaging
at the fusion site. Flexion and extension stress views techniques. The detailed physical principles related
are used routinely in the search for excessive interseg- to the production of the MRI image are quite com-
mental movement, but they often fail to demonstrate plex and beyond the scope of this chapter. As it turns
subtle abnormal movement, and evidence for vertical out, MRI is sensitive to an entire spectrum of phenom-
trabeculation traversing the interface is often unclear. ena to which radiography is totally insensitive. There
In this case, CT allowed visualization of graft incor- is little similarity with the physics of ultrasonogra-
poration at the upper interface but not at the lower. phy or conventional radiography. CT and x-ray atten-
The patient imaged in Figure 34–4 had a lumbar fu- uation are based on the various types and amounts
sion procedure without instrumentation. The patient of chemical elements, and not on nuclear motion or
had persistent pain without fever. Despite the obvious free flow of fluid. MRI uses magnetic fields and radio
nature of the graft localization on CT, actually extru- frequency (RF) waves instead of ionizing radiation.
sion, this was not clear on the plain film examination. The MR image is created from an RF signal derived
Overall, CT is a powerful and versatile tool in the from protons soon after they absorb energy from an
adjunctive diagnosis of musculoskeletal pathology, electromagnetic pulse.
A
B
FIGURE 34–4. A patient with persistent lower back pain for 5

months after an anterior lumbar fusion procedure. A. Axial CT
through the L4-L5 disc interspace. Note the poor localization of
the bone graft with partial extrusion. B. Sagittal MPR. C. Coronal
C
MPR.
The image character, or signal, produced by MRI is or time of echo (TE). By changing the TR and TE at
dependent largely upon the tissue T1 and T2 proper- the time of image acquisition, the relative contribu-
ties, and the number of mobile hydrogen ions (proton tions of T1, T2, and proton density (image contrast) are
density). T1 and T2 relaxation are physical properties varied.
intrinsic to a tissue. Specific techniques for obtain- T1-weighted pulse sequences are obtained with
ing the MRI are called pulse sequences. Commonly short TR (about 400–600 msec) and short TE (5–
used sequences include spin-echo (SE), gradient-echo 30 msec). T1-weighted images (also called fat images)
(GRE), and short T1 inversion recovery (STIR). Many have high signal-to-noise ratio (SNR) and produce
new techniques have been developed, but the most excellent anatomical representation. On the other
frequently used is the SE pulse sequence. The param- hand, T2-weighted sequences require a long TR (1500–
eters used to define a particular sequence are repeti- 3000 msec) and a long TE (60–120 msec). T2-weighted
tion time (TR), and a pulse and the echo time (time sequences (also called water images) emphasize the T2
between the application of a pulse and its recording, properties of a tissue, especially its state of hydration,
FIGURE 34–6. Anteroposterior and lateral lumbar visualiza-

tion of discographic dye localization.
is often possible. Much like conventional photography

or radiography, a variety of factors influence the ap-
pearance and usefulness of the final image. Spatial res-
olution, for instance, is determined by the size of the
acquisition, field of view, and slice thickness chosen.
The type of receiver coil is likewise important in this
regard. Also, the number of excitations or averages im-
proves quality, but always at the expense of the time
required to complete the examination. Unfortunately,
there is no one best pulse sequence, or set of sequences.
Rather, an examination is best when specifically tai-
lored to the patient and the diagnostic information
desired. However, examinations have been standard-
ized for general information purposes. These standard
sequences are often performed initially and then sup-
plemented with others when the need arises as the ex-
amination continues. Spine protocols have been stan-
dardized to region with variations adapted to clin-
ically suspected or discovered abnormalities. Wide
variation is seen in clinical practice and between imag-
FIGURE 34–5. Recurrent right-sided radiculopathy in a patient ing centers. It behooves the practitioner to become ac-
with prior anterior cervical interbody fusion. Axial CT myelogra- quainted with the various imaging techniques, advan-
phy (top) and sagittal MPR (bottom) showing right paracentral tages and disadvantages, and the availability at one’s
and foraminal disc extrusion at the level immediately below the local MRI facility. Furthermore, the quality of the scan
level of a solid fusion. proper and quality of interpretation vary widely.6,7
Table 34–2 characterizes and compares differences
particularly free extracellular fluid. Those sequences of signal intensity on T1-weighted and T2-weighted
with long TR and short TE reflect the number of mo- images.
bile hydrogen nuclei, or spin-density (proton den- As might be expected, there are potential prob-
sity). Figure 34–8 illustrates signal differences be- lems that may prevent scanning or that might pro-
tween T1-weighted, proton-density weighted, and duce an inadequate or inferior study. Artifacts may
T2-weighted images in the sagittal plane. Note the significantly degrade image quality. Any number of
myelographic effect in Figure 34–8A (left to right) system-produced artifacts are possible. The most com-
created by the sharp contrast between the high- mon artifact confronted is caused by patient motion.
signal cerebrospinal fluid and the dark posterior When this occurs, the sequence must be repeated.
vertebral bodies and ligamentous tissue and spinal The length of a sequence is directly proportional to
cord. motion degradation, and newer and shorter pulse se-
By using various sequences in different planes, quences have been developed with only minor quality
anatomical depiction as well as tissue characterization trade-off. Today, fast spin-echo techniques are widely
A B
FIGURE 34–7. Comparative axial views of a thoracic disc lesion. A. CT myelography (top) and noncontrast MRI (bottom). B.
CT discogram. Focal appearance of the protrusion is seen equally well with CT and MRI. Discography demonstrates the internal
morphology of the radial tear and posterior tracking of the dye. The patient experienced concordant pain during injection at this
level.
used with excellent images in a fraction of the time. veloped to help patients cope with this problem. When
Metallic particles and surgical instrumentation pro- these fail, sedation is often used. Open systems may
duce varying degrees of artifact, degraded images, or be helpful in this regard, but most open MRI systems
signal void. The degree to which this occurs is dif- have mid- or low-field-strength magnets and there-
ficult to predict. Often the MR examination provides fore, poorer image quality than high-field-strength
important diagnostic information despite local artifact magnets.
(Fig. 34–9).
Not all patients can undergo an MR examination. Low-Field Strength versus High-Field Strength
Contraindications to MRI have been widely stud- Magnet strength varies widely and is ranked from
ied. Most relate to the presence of ferromagnetic ob- low-field strength to high-field strength: ultralow-
jects (Table 34–3). Claustrophobia remains a signifi- field (<0.1 tesla [T]); low-field (0.1–0.3 T); mid-field
cant problem, occurring in 2–5% of patients. Today (0.3–0.6) high-field (>0.6 T). The advantage of high-
there are a plethora of schemes to assist the space- field magnet strength is a higher signal-to-noise ra-
challenged patient including mirrors, music, shorter- tio and improved image resolution (both spatial
bore magnets, and scenic art painted on the magnet and temporal). Imaging time is significantly short-
wall. In some cases, a prone position may be helpful. ened with higher field strength. Advanced MRI tech-
A variety of anxiety-reducing strategies have been de- niques such as magnetic resonance angiography are
FIGURE 34–8. A. Midsagittal cervical MRI (1.5 T) demonstrat-

ing signal differences between three commonly used sequences:
(left) T1-weighted (TR 504, TE 11.5, 3.0 mm); (middle) proton-
density weighted (TR 1250, TE 30, 3.0 mm); (right) T2-weighted
(TR 3000, TE 120, 3.0 mm). B. Axial cervical GRE sequence (TR
1057, TE 17.9, FA 400, 3.0 mm) showing high contrast between
the high-signal cerebrospinal fluid, and low-signal spinal cord and
B
canal components, creating a “myelographic” effect.
clearly better at high-field strength. The selection of provides faster, higher resolution, and thinner-slice
lower-field-strength equipment is often based on images than low-field strength.8 Indeed, even further
cost, maintenance, and local reimbursement policies, increase in signal-to-noise ratio is possible as strength
rather than clinical efficacy and the radiologist’s pref- increases beyond 1.5 T.9
erences. To others, the most cost-effective system is In some clinical situations, the diagnostic accuracy
one that provides the highest-quality images and the between low- and high-field strength is comparable,
largest number of applications. High-field strength for example, anterior cruciate and meniscal lesions.10
TABLE 34–2.Differences in Signal Intensity on T1-weighted

and T2-weighted Images
Tissue T1 T2
Cortical bone Low Low

Tendons and ligaments Low Low
Fibrocartilage Low Low
Muscle Intermediate Intermediate
Nonneoplastic tumor Low-intermediate Low/intermediate/possible high
Neoplastic tumor Low-intermediate Intermediate-high/possible low
Water, cerebrospinal fluid Low High
Proteinaceous fluid, abscess Intermediate High
Fat High Intermediate-high
Hemorrhage, acute High High
Hemorrhage, chronic Low High
TABLE 34–3.Contraindications (Relative

or Absolute) for MRI*
The following may be contraindicated unless tested and

known safe at various magnetic strength levels. Surgical
documentation of an implanted device is necessary, but not
often known or available.
Intracranial aneurysm clips
Cardiac pacemakers
Some prosthetic heart valves
Implanted cardiac defibrillators
Carotid artery vascular clamp
Spinal cord stimulators (neurostimulators)
A
Insulin infusion pump (implanted drug infusion device)
Bone growth stimulator
Metallic hardware, † devices, ‡ fragments
Hearing aids and dentures (remove)
Cochlear implants, ocular implants, penile implants
Some shrapnel and bullets
Intraocular foreign bodies
Tattooed eyeliner
Some types of makeup
∗
May not apply to low-field imaging systems, e.g., Toshiba Access
0.064T
†
Postoperative MRI: In general, if the metallic object is a “passive im-
plant” (i.e.,) there is no power in operation of the object) and made from
nonferromagnetic material (titanium, tantalum, Elgiloy, MP35N, etc.),
the patient may undergo 1.5-T examination immediately after surgery.
‡
Weakly ferromagnetic devices (intravascular coils, filters, and stents.)
become firmly fixed in 6–8 weeks following placement and are unlikely
to be dislodged in a 1.5-T magnetic field.
in decision making is significantly better with high-

field-strength MRI.12 In the same region (knee), how-
ever, high-field systems are expected to offer a signif-
icantly better diagnostic performance than low-field
systems in the detection of grade 2 and grade 3 ar-
ticular cartilage lesions.13 In the cervical spine, the
ability to obtain high-quality, thin sections is impor-
tant in evaluating the intervertebral canals in patients
with monoradiculopathy. In such cases, unenhanced
B CT with a 1.5-mm slice thickness may be the optimal
study because of its ability to differentiate disc her-
FIGURE 34–9. Axial (A) and sagittal (B) MRI demonstrating niation from uncinate process or posterior vertebral
signal void created by titanium fusion cages placed at L4-L5 body spurring.
and L5-S1. Nevertheless, there is clear visualization of en-
croachment of the right intervertebral foramen by the cage. Spine
The patient developed foot drop after surgery that was relieved
The clinical strength of MRI is its excellent soft-tissue
by extracting the right cage by one-quarter turn.
contrast resolution, direct multiplanar imaging, lack
of ionizing radiation, and the potential to character-
In another study, the positive predictive value for ize pathologic tissue. While CT remains the proce-
anterior cruciate ligament lesions demonstrating dif- dure of choice for imaging the fine detail of cortical
fuse increase in signal on T2-weighted images with bone, fracture (especially small avulsions), and steno-
ligament enlargement was 90% for high-field strength sis of the neuroforamina, MRI is superior for almost
and 79% for low-field strength, but for other tear pat- all other affections of the spine. Vertebra, interverte-
terns there was no difference.11 On the other hand, bral disc, spinal canal, ligament restraints, and the
some studies suggest that although low-field-strength neuroforamina are all visualized well with current
MRI offers diagnostic potential, the level of confidence MRI techniques. The use of paramagnetic contrast
Indications for Magnetic

TABLE 34–4. is helpful when a malformation is extensive over mul-
Resonance Imaging tiple segments (Fig. 34–11).
Degenerative disc disease and herniation Intervertebral Disc Degeneration

Conjoined nerve roots Aging and degeneration produce classical MRI ap-
Stenosis and facet disease pearances in signal intensity and morphological
Spondyloarthropathies character. The hallmark finding is decreased signal
Trauma intensity of the intrinsic aspect of the disc on T2-
Epidural hematoma weighted images. Thinning of the disc interspace,
Postoperative evaluation of the spine, differential deagrosis of disc bulging, and marginal hypertrophic change
recurrent herniation and postoperative scar are visualized on all sequences. The conspicuity of
Infection the disc–cerebrospinal fluid (CSF) interface is much
Muscle damage greater on T2-weighted, GRE, and STIR images. Gas
Tumor: bone and spinal cord present in the nucleus or at the discovertebral attach-
Marrow disorder ments is better imaged with CT and conventional
Bony anomalies radiographs.
Tethered cord, syrinx, Chiari malformation The vertebral endplate reaction to disc degener-
Dynamic studies ation takes several forms. Type I change consists of
Simultaneously delineate multiple soft-tissue and osseous vascular-reactive marrow and edema (low signal on
abnormalities T1-weighted and high signal on T2-weighted). Type II
Angiographic screening endplate change with progressive fatty marrow re-
placement demonstrates a zone of high signal on
both T1-weighted and T2-weighted images. Type III
augments the evaluation of tumor and infection, and change, representing bony accretion and sclerosis, ap-
helps to differentiate between recurrent disc hernia- pears as a low signal on both T1-weighted and T2-
tion and postsurgical scarring. Indications for MRI are weighted images. The type III pattern may appear
listed in Table 34–4. on conventional radiographs when sufficiently ad-
The purpose of any imaging study is to delineate vanced. Type I and type II changes may enhance with
and characterize normal and abnormal tissue. It is im- contrast and must be differentiated from discitis and
portant to try to answer specific questions identified at endplate infection. A recent study reported pain dur-
the time of clinical examination. Spine techniques vary ing discography, disc narrowing, and type I endplate
depending on the region of interest and the patho- changes as the best predictors of a painful disc. Chem-
logic process being studied. Spin-echo sequences re- ically sensitive discs are best predicted by type II end-
main the best techniques for detecting disease of the plate changes, bright high-intensity zones posteriorly,
spine and remain the standard by which others are and concentric high-intensity zones. Type I Modic
compared. Fat saturation and inversion recovery se- changes may relate to discogenic pain and perhaps
quences also have important uses in selected cases. instability.14,15 Annular tears with associated granu-
In the cervical spine, GRE images allow for thin sec- lation tissue may be seen peripherally in any sector
tions and provide excellent differentiation between as a high-intensity zone on T2-weighted and STIR im-
hypointense bone and hyperdense disc. ages. These same areas may enhance after administra-
tion of contrast on T1-weighted sequences. Granula-
Thoracic Spine tion tissue has been reported in these same areas via
Large-field-of-view techniques allow imaging of the biopsy.16,17
entire thoracic spine in the sagittal plane. This is espe-
cially useful when searching for multilevel degenera- Disc Derangement
tive change, metastatic disease, or bony or soft-tissue The terminology chosen to describe herniation has
abnormality. Demonstration of a lesion on sagittal im- been varied and confusing. Most “herniations” are
ages then prompts more specific axial techniques. In seen in degenerated discs. T1-weighted axial images
Figure 34–10A, note the coverage from C6 through L2. show the midline herniations well because of epidu-
The extent of a large intraspinal soft-tissue mass is de- ral fat displacement. Focal abnormal annular contours
picted well in Figure 34–10B. Bony involvement may measuring 3 mm assuredly have nuclear material be-
be further evaluated by CT. neath. Annular bulge means disc desiccation and loss
of height with concentric extension of the disc beyond
Anomalous Development the vertebral margin in a broad-based manner. The
MRI is useful in the assessment of complex anomalies, term protrusion is used when there is focal or broad-
particularly where there are spinal cord, nerve root, or based extension of the annulus and either the outer
cranial associations. The large-field-of-view capability annulus/posterior longitudinal ligament complex is
A B
FIGURE 34–10. A. Sagittal T1-weighted image with field of view from C6 thru L2. The large field of view is useful when searching
for multilevel bony or soft-tissue abnormalities. Note the abnormal vertebral morphology and signal at T7-T9 in this osteoporotic
patient with wedge compressions. B. Midsagittal T2-weighted thoracic spine showing a large fusiform intraspinal soft-tissue mass
expanding from the posterior elements that severely encroaches the spinal cord. No bony abnormalities were evident on conventional
imaging. Diagnosis: multiple myeloma.
intact or the base of the annular morphology is of the involved nerve root may be apparent. The
broader than the apex. Disc extrusion, on the other mass effect of disc protrusion is virtually always
hand, represents a clear disruption of the annu- greater in appearance than actual dimension. A
lus/posterior longitudinal ligament complex and/or cap of inflammatory reaction/granulation tissue con-
the base of the abnormality is narrower than its apex. tributes to the appearance of mass effect. This tis-
Any degree of extension beyond the disc space repre- sue enhances with the administration of intravenous
sents migration. For a disc to be sequestered requires gadolinium. There may be some prognostic signif-
a separated fragment from the parent disc isolated in icance in such cases because they are more likely
the epidural space. In such cases, there may be adja- to exhibit resorption.18 Tear patterns include trans-
cent hematoma or granulation tissue. verse tears at the discovertebral interface, concentric
Mass appearance should also be correlated with tears between lamellae of the outer annular bundles,
the cross-sectional mensuration of the canal and re- and radial tears extending from the nucleus to the
lationship to descending and exiting nerve roots. outer annulus. Yu et al. described disc tear patterns in
In some instances, pre- or postcompressive swelling detail.19–21
Differentiation between spinal cord hematoma ver-

sus edema, acute intervertebral disc injury, ligament
rupture, subtle fracture or contusion, posttraumatic
syrinx, cyst, and chronic cord abnormalities may
be possible. MRI also may be helpful in differen-
tiating between benign and malignant compression
fractures.22,23
Intrinsic Change within the Spinal Cord

The intrinsic aspect of the spinal cord is not visualized
with any other imaging modality. In cases of multiple
sclerosis, syrinx, myelomalacia, and myelopathy, sig-
nal that is isointense with CSF may be seen within the
cord proper. In a similar manner, MRI adds additional
information about intrinsic changes within the nerve
rootlets and related soft tissues, including infection
and tumors.
Postoperative Spine
Examination of the spine in the early postoperative pe-
riod is difficult. Anatomy has been altered and local
inflammation, hematoma, and gas change the antic-
ipated signal intensities. Often CT and MRI with-
out contrast fail to differentiate between rehernia-
tion and scar. Most postoperative disc herniations
do not enhance with contrast. On the other hand,
scar tissue within the epidural space commonly en-
hances homogeneously, but less consistent patterns
of enhancement are seen adjacent to a laminec-
tomy defect. MRI following fusion with instrumen-
tation may be hampered by ferromagnetic artifact.
In these cases, despite some beam-hardening artifact,
CT may provide additional important information.
In Figure 34–12, note the MRI appearances pre- and
postkyphoplasty.
FIGURE 34–11. Sagittal thoracolumbar and lumbosacral Infection

spine with multilevel anomalous development including nonseg- Most infections of the intervertebral disc occur as an
mentation, diastematomyelia, and an abnormal conus. extension of osteomyelitis, or direct inoculation dur-
ing invasive diagnostic or surgical procedures. Infec-
Stenosis tion rates as high as 15% are possible. Spinal infection
The various elements of stenosis are nicely portrayed is common in those practices where the case mix is
with MRI. Bony hypertrophy and ligament intrusion strongly postoperative. By the time the diagnosis is
into the confines of the spinal canal and foramina made, the disc and both endplates are often involved.
are well depicted. Calcification within the disc or its Conventional radiographs are usually normal in early
periphery is not specifically evident, however. This, infections. It may take as long as 8 weeks for defini-
along with gas in discs or facets, is seen best on CT. tive changes to become evident. Signs of irregularity
Accurate measurements of canal dimensions can be of the endplates, displacement of the paravertebral
made by computer. lines, or visible sclerosis may develop by 5–12 weeks.
Scintigraphy is highly sensitive but nonspecific and
Spine Trauma there is poor visualization of abscesses. MRI is the
While the first imaging modality is conventional ra- gold standard for discitis and osteomyelitis. Early
diography and CT, MRI offers significant additional findings are a result of edema and inflammatory cell
information that may not be evident on those studies. infiltration.
A B
FIGURE 34–12. A. Acute vertebral compression, prekyphoplasty. B. Postkyphoplasty appearance. Note the signal void within the
vertebral body that has been filled with methylmethacrylate.
Cystic Lesions
Unsuspected cystic and other soft-tissue masses are
readily imaged with MRI. These are often discovered
fortuitously (Fig. 34–13).
Tumors and Marrow-Infiltrating Disorders

In the early stages, destructive changes in the spon-
giosa often go undetected with CT and conventional
radiographs. They are insensitive for the early detec-
tion of infiltrating neoplasms such as metastatic ade-
nocarcinoma, myeloma, leukemia, lymphoma, and
other infiltrating processes that affect the bone mar-
row. As it turns out, MRI is more sensitive than bone
scanning for detecting marrow tumor located in the
axial skeleton. MRI plays a major role in demonstra-
tion of marrow abnormalities, but abnormal signal
intensities are nonspecific, even in the face of known
disease. T1-weighted images provide good con-
trast between the normal fatty marrow and low-
signal tumor. Contrast may be less apparent on
T2-weighted images. Fat-suppressed techniques and
STIR sequences provide greater conspicuity. Gadolin- FIGURE 34–13. A pilot with lower back pain after prolonged
ium enhancement is often used, but enhancement sitting during transcontinental flights. This unsuspected large
is nonspecific and occurs with infection and trau- mass was discovered during conventional lumbar MR imaging.
matic or osteoporotic compression fractures. Contrast Diagnosis: sacrococcygeal teratoma.
enhancement is important when spinal cord tumor is up to 16% can be expected, along with a reduction in
suspected (Fig. 34–14). the midsagittal canal diameter of 2 mm.26 The clinical
significance of these findings remains unclear.
Dynamic MRI In the past, positional MRI had to be variously ob-
Although CT and MRI are presently the most fre- tained with limited motion range and without weight-
quently used noninvasive imaging methods for steno- bearing effects. Weishaupt et al. recently documented
sis, imaging of a supine patient may not demon- positional changes in the intervertebral canal mea-
strate the degree of change in canal dimension that surements and nerve root compression not visible at
has been shown by upright flexion–extension myel- conventional recumbent MRI. This study was per-
ography. Marked variation in the severity of lum- formed on a mid-field strength scanner with the pa-
bar dural sac stenosis during flexion and extension tients seated.27 There is now an MRI system available
in some patients has been shown. The symptoms of with capabilities to image in the upright, recumbent,
lumbar spinal stenosis and intervertebral disc dis- and other nontraditional positions (Fonar, 0.6 T). This
ease are often posture-dependent, and it is gener- opens investigation for patient scanning in positions
ally assumed, without adequate research support, that of relevant clinical symptoms. Such studies may un-
flexion–extension motions of the lumbar spine affect mask and offer elucidation of dynamic-kinetic depen-
the capacity of the spinal canal and the mechanics of dent anatomicopathological problems.
the intervertebral disc.
Currently, there is much interest in dynamic load- Magnetic Resonance Angiography
ing of the lumbar spine, as well as weight-bearing and Evaluation of the vascular system with MRI has devel-
dynamic flexion/extension imaging. Axial-loaded CT oped rapidly in the last few years. Improved nonin-
myelography and MRI imaging have been accom- vasive three-dimensional time-of-flight magnetic res-
plished with the patient recumbent and loaded in a onance angiography (MRA) techniques have become
portable device.24 In 66 of 84 (78.6%) patients inves- a useful and accurate method of obtaining cerebrovas-
tigated in another study, there was a statistically sig- cular evaluations in clinical practice, with excellent
nificant reduction of the dural sac cross-sectional area correlation.28 Their usefulness includes imaging of
in at least one site during axial compression in slight vertebrobasilar insufficiency29 and craniocervical ar-
extension.25 With change from flexion to extension terial dissection30 and identification of underdevel-
and distraction to compression, an area reduction of oped axial arterial loops in the upper cervical spine,31
A B
FIGURE 34–14. A. T1-weighted sagittal lumbar Spine MRI precontrast. B. Postcontrast enhancement. Note the increased con-
spicuity of the lesion (neurofibroma) after contrast administration.
FIGURE 34–15. Noncontrast MRA, transverse plane at skull

base. Vascular depiction is excellent. These studies are use-
ful for noninvasive screening of vessels larger than 3 mm in
diameter.
B
anomalous origins of vertebral arteries and exten-
sive vertebral arterial tortuosity, and vertebrobasilar FIGURE 34–16. A patient with dizziness, headache, and neck
thrombosis related to blunt cervical spine trauma.32 pain following lower cervical spine trauma. A. Axial CT demon-
There are, however, some problems with the non- strating fracture of a right cervical transverse process. Con-
invasive technique, and vessel depiction smaller than tiguous slices showed facet fracture on the same side. B. Non-
contrast MRA showing nonvisualization of an occluded right
3 mm is not possible, making intraarterial digital-
vertebral artery.
subtraction angiography a superior procedure.33
Nevertheless, MRA is considered an excellent screen-
ing tool, especially when combinations of different nance venography has been employed in the evalu-
MRA techniques are used. For instance, sensitivity ation of cerebral venous thrombosis.38 Recent studies
for aneurysms greater than 5 mm is 100%,34 and le- have used contrast-enhanced MRA in the evaluation
sions of 3–4 mm are routinely detected.35 Figure 34– of spinal vessels. Such techniques may help to narrow
15 is an example of noncontrast MRA of the brain. diagnostic possibilities and guide further treatment
The case illustrated in Figure 34–16 demonstrates the in patients with radiculopathy or myelopathy, and to
importance of the proper combinations of imaging detect spinal dural fistulae.39
modalities. The patient was involved in a motor vehi-
cle accident and experienced vertiginous complaints.
NUCLEAR IMAGING
Conventional imaging was not helpful. CT reveals
fracture of a right transverse process. The correspond- The development of bone-localizing diphosphonate
ing MRA reveals associated injury to the vertebral occurred in 1972, and the techniques of nuclear bone
artery. imaging have become a common, safe, and indis-
Very recent MRA techniques employ contrast en- pensable diagnostic procedure. While there is a neg-
hancement with injection of contrast medium, pro- ligible risk for reaction, it is contraindicated during
viding images that rival those obtained with con- pregnancy and while breast-feeding. Bone scanning
ventional catheter angiography,36 but with fewer (scintigraphy) detects changes in bone physiology on
artifacts. Higher-quality images of the supraaortic the basis of high sensitivity to alteration in vascular-
vessels with shorter acquisition times allow assess- ity or osteogenesis. In other words, a lesion must be
ment of the carotid and vertebral arteries with even metabolically active to be detected. In those instances
greater accuracy.37 These procedures improve detec- of purely destructive processes (without pathological
tion of aneurysms, arteriovenous malformations, and fracture) such as myeloma, the resulting scan may be
intracranial atherosclerotic disease. Magnetic reso- normal. While it is extremely sensitive to changes in
A B
FIGURE 34–17. Bone scintigraphy. A. Posterior and anterior planar images, 2 hours postinjection. There is widespread multifocal
uptake in a patient with metastatic disease. B. Collimated lateral lumbopelvic image (Paget disease). C. Lumbar SPECT study
demonstrating increased uptake in the right neural arch of L5 in a 13-year-old male with unilateral spondylolysis.
bone metabolism, the specificity is low and patterns ings. Once located, CT, MRI, or biopsy can clar-
of abnormal uptake may be produced by a number of ify the true pathology. These techniques tend to be
different disorders. most valuable when the conventional radiograph is
As with other imaging modalities, scintigraphy negative or questionable. Conversely, scintigraphy is
may identify a focal location of abnormality but often unnecessary when other imaging is positive.
provide only a differential diagnosis as to etiology. Its application in oncology is well known and im-
Interpretation of the images must be placed in the portant because early detection markedly influences
proper complementary framework of clinical find- patient management and outcome. In such cases,
multiple body areas are evaluated without additional TABLE 34–5.Common Indications for
exposure. Bone Scintigraphy
The principle of nuclear imaging depends on the
selective uptake of the chosen radiopharmaceutical Unexplained (nonspecific) bone pain
(compounds called tracers, labeled with a radioactive Neoplastic disease and response to treatment
substance with a sufficient energy level to be detected Suspected (occult) fracture, including stress fracture
outside the body) by different body tissues. They are Osteomyelitis versus cellulitis
administered by means of an IV injection. The tracers Avascular necrosis
produce gamma- or x-radiation, and radiation dosage Arthritis
is about 0.7 rads to bone and 0.12 rads to the whole Reflex sympathetic dystrophy syndrome
body per millicurie (mCi) of tracer. Positron emission Bone graft viability
tomography (PET), on the other hand, uses cyclotron-
produced isotopes that emit positrons. PET is useful
in evaluating physiological function of organs on a tle stress fractures of the pars interarticularis. Active
dynamic basis. pars stress and recent fracture or remodeling is usu-
Bone scintigraphy records the distribution ally clearly detected with bone scanning. Scintigraphy
of a radioactive tracer (usually Tc-99 methylene may also aid in estimating the age of a fracture. SPECT
diphosphonate [Tc-99 MDP]) in the skeletal system more accurately localizes the location of the lesion
in planar (two-dimensional) or tomographic (three- in the transverse plane. MRI may demonstrate sim-
dimensional) images. This may be performed in a ilar changes, but often only with STIR sequences. Ta-
whole-body or limited mode. Anterior and posterior ble 34–5 lists common indications for bone scintig-
views are obtained with additional views as needed raphy. Rapid-sequence pinhole collimation produces
(Fig. 34–17). Bone single-photon emission computed very high resolution of a specific area. Zoom mag-
tomography (SPECT) produces a tomographic image nification also improves resolution.40–42 Other radio-
portrayal of tracer uptake. pharmaceuticals may be used in suspected infection
Multiphasic bone scintigraphy consists of blood- and malignancy. Usefulness of gallium-67 scanning
flow images, intermediate and delayed. The initial includes the detection and follow-up of infection and
blood pool phase is a dynamic sequence obtained as the detection and localization of tumors. Its greatest
the tracer is injected. Intermediate static images usu- utility lies with lymphoma.43 Tc-99m-labeled colloid
ally follow within 15 minutes. Delayed images, planar (albumin or sulfur) is used for regional bone marrow
or tomographic, are obtained in 2–5 hours. Occasion- abnormalities. Indium-111 Tc-99m-labeled leukocytes
ally, even 24-hour delayed imaging is necessary. The are most sensitive for acute infections of less than
triple-phase scan helps differentiate soft-tissue abnor- 4–6 weeks’ duration. Their sensitivity declines with
mality from bone pathology and is useful in assessing antibiotic therapy.44
the approximate age of fractures.
The use of bone scintigraphy is very important
BONE DENSITOMETRY
in orthopedic practice. For instance, in a young low-
back-pain patient with extension provocation but Spinal osteoporosis is an orthopedic problem of epi-
normal-appearing conventional radiographs, scintig- demic proportions that carries significant morbidity.
raphy may be used to rule out stress reactions and sub- In the United States alone, approximately 1.5 million
FIGURE 34–18. DEXA bone den-

sity determination with normal T-
values at the femur.
fractures are attributable to osteoporosis each year.45 the hip, each SD loss increases the fracture risk rate
Reduced bone mineral density (BMD) correlates well 2.4-fold.
with the osteoporotic fracture, as well as risk for fu-
ture fracture. Conventional radiographic evaluation
SUMMARY
is not sensitive for subtle fracture, and certainly not
for risk for fracture in those patients without proven 1. Standard plain film radiographic techniques are
osteoporosis. It is well known that bone density loss baseline for all clinical presentations. They are
of up to 50% often goes unrecognized on plain film especially useful in trauma and degenerative
x-rays. disease, and for functional determinations. Plain
Our understanding of the magnitude of the prob- film examination is of limited use for visual-
lem and awareness of preventative strategies have izing soft tissue, detecting small fractures, or
heightened, medical treatment and kyphoplasty have detecting small bone loss caused by cancer or
developed, and technology for BMD determination metabolic disorders; bone destruction must ap-
is now available. In the last decade, bone den- proach 30–50% prior to detection on plain film
sity determination has become an important as- x-rays.
pect of management of patients at risk for osteo- 2. Conventional tomography has been mostly re-
porosis. Several techniques have been used. These placed by CT, but it is useful in the study of the
include single-photon absorptiometry, dual-photon atlantooccipital, atlantoaxial, and cervicothoracic
absorptiometry, dual-energy x-ray absorptiometry regions, and in the exploration for occult injury
(DEXA), quantitative computed tomography, and ul- in the posterior arches. CT is appropriate for sus-
trasound transmission velocity and broadcast ul- pected trauma not apparent or incompletely de-
trasound attenuation. DEXA is presently the tech- fined on plain film x-rays. CT also provides accu-
nique most used in this determination. Advanced rate mensuration of canal dimensions and degen-
fan-beam DEXA systems allow for practical, low- erative disease of the posterior joints and uncinate
radiation dose scanning. When possible, follow-up processes.
examinations should be performed on the same 3. MRI is the preferred technique for the evaluation of
equipment. the spinal cord (e.g., posttraumatic myelomalacia,
Patients with multiple risk factors who are syringomyelia, multiple sclerosis).
younger than 65 years of age benefit from scanning, 4. Nuclear imaging studies are indicated when oc-
but those with previous fracture and no risk factors cult injury or lesion is suspected but not otherwise
should also be scanned. Risk factors include early defined, or when dating of a suspected injury is
menopause; no estrogen replacement; low calcium necessary.
intake; family history of osteoporosis; small frame; 5. Plain film radiography cannot detect subtle frac-
white derivation; athletes with amenorrhea; and use ture, nor should it be used to screen for os-
of certain medications, including diuretics, steroids, teoporosis because bone density loss of up to
and anticonvulsants. 50% often goes unrecognized on plain film
Measurements at the femoral neck and the Ward radiography. Bone densitometry techniques in-
triangle are more sensitive than at other peripheral clude single-photon absorptiometry, dual-photon
areas.46 The lumbar spine is commonly scanned along absorptiometry, DEXA, quantitative computed
with the hip. Sensitivity is greater with lateral imag- tomography, ultrasound transmission velocity,
ing versus anteroposterior imaging (Fig. 34–18).47 It and broadcast ultrasound attenuation. DEXA is
is important to relate the patient’s bone mineral den- presently the technique most used in this determi-
sity (BMD) to the mean peak bone mass of healthy nation, because it allows practical, low-radiation
25–30-year-old patients (T-score), rather than age- dose scanning. Risk factors for osteoporosis in-
matched reference ranges (Z-scores), because the Z- clude early menopause, no estrogen replacement,
scores may underestimate the degree of loss and give low calcium intake, family history of osteoporo-
a false sense of security.48 Osteoporosis is diagnosed sis, small frame, white derivation, athletes with
with BMD is less than or equal to –2.5 standard de- amenorrhea, and use of diuretics, steroids, and
viations (SD) below peak bone mass (T-score). Os- anticonvulsants.
teopenia occurs when BMD falls between –1.0 SD
and –2.5 SD below peak bone mass (T-score). Nor-
mal bone mineral density is no more than 1 SD below
QUESTIONS
the young adult mean value (T-score). The relation-
ship between low bone mass and risk for fracture 1. Which is the imaging modality of choice for visu-
is strong. For every SD below peak bone mass in alization of the spinal cord proper?
the spine, the fracture rate is increased 1.9-fold. In 2. What are the clinical strengths of MRI?
3. What are the clinical indications for use of contrast 2. Cowan IA, Inglis GS. Atlantoaxial rotatory fixation: Im-
with MRI? proved demonstration using spiral CT. Australas Radiol
4. When is CT preferred over MRI? 1996;40(2):119–124.
5. What are the principal uses for MRA? 3. Dublin AB, McGahan JP, Reid MH. The value of com-
puted tomographic metrizamide myelography in the
neuroradiological evaluation of the spine. Radiology
ANSWERS 1983;146(1):79–86.
4. Russell EJ. Computed tomography and myelography
1. MRI is the only imaging modality that allows in the evaluation of cervical degenerative disease. Neu-
for the characterization of the spinal cord with roimaging Clin N Am 1995;5(3):329–348.
recognition of abnormalities such as multiple scle- 5. Anderson SR, Flanagan B. Discography. Curr Rev Pain
rosis, myelopathy, and myelomalacia. 2000;4(5):345–352.
2. MRI allows for excellent soft-tissue contrast res- 6. Friedman DP, Rosetti GF, Flanders AE, et al. MR imag-
ing: Quality assessment method and ratings at 33 cen-
olution, direct multiplanar imaging without ion-
ters. Radiology 1995;196(1):219–226.
izing radiation, and the potential to characterize 7. Jarvik JG, Robertson WD, Wessbecher F, et al. Vari-
pathological tissue. ation in the quality of lumbar spine MR images
3. The primary use is in the differentiation of recur- in Washington State. Radiology 2000;215(2):483–490.
rent intervertebral disc herniation from postsurgi- 8. Bradley WG. Future cost-effective MRI will be at high
cal scarring. Contrast may increase the conspicu- field. J Magn Reson Imaging 1996;6(1):63–66.
ity of pathological lesions, for example, infection, 9. Campeau NG, Huston J III, Bernstein MA, et al. Mag-
tumor, and multiple sclerosis. netic resonance angiography at 3.0 tesla: Initial clin-
4. In patients unable to complete an MRI scan; when ical experience. Top Magn Reson Imaging 2001;12(3):
artifact on MR is excessive; when neuroforaminal 183–204.
encroachment on MRI is unclear; occult vertebral 10. Cotten A, Delfaut E, Demondion X, et al. MR imaging
of the knee at 0.2 and 1.5 T: Correlation with surgery.
fractures; for a less expensive examination when
AJR Am J Roentgenol 2000;174(4):1093–1097.
the object of the study is equally well answered 11. Barry KP, Mesgarzadeh M, Triolo J, et al. Accuracy of
by CT and MRI; in conjunction with myelography MRI patterns in evaluating anterior cruciate ligament
and discography; and to detect subtle cortical ero- tears. Skeletal Radiol 1996;25(4):365–370.
sions (destruction). 12. Rand T, Imhof H, Breitenseher M, et al. Comparison of
5. Vertebrobasilar insufficiency, craniocervical dis- diagnostic sensitivity in meniscus diagnosis of MRI ex-
section, anomalous upper cervical vascularity, ver- aminations with a 0.2 T low-field and a 1.5 T high field
tebrobasilar thrombosis, aneurysm, and arteriove- system [in German]. Radiologe 1997;37(10):802–806.
nous malformation. 13. Woertler K, Strothmann M, Tombach B, et al. Detection
of articular cartilage lesions: Experimental evaluation
of low- and high-field-strength MR imaging at 0.18 and
1.0 T. J Magn Reson Imaging 2000;11(6):678–685.
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Philadelphia: WB Saunders, 2002. flammation associated with annular tears: Demonstra-
Ross JS. MRI of the spine, 2nd ed. Baltimore: Lippincott, tion with gadolinium-enhanced lumbar spine MRI. Eur
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18. Komori H, Okawa A, Haro H, et al. Contrast-enhanced
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20. Yu SW, Haughton VM, Sether LA, et al. Anulus nial aneurysms: A comparative study. AJNR Am J Neu-
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21. Yu SW, Sether LA, Ho PS, et al. Tears of the anulus fibro- tracranial aneurysms: Evaluation with high-resolution
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22. Cuenod CA, Laredo JD, Chevret S, et al. Acute vertebral (TONE) [in Japanese]. Nippon Igaku Hoshasen Gakkai
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ance on unenhanced and gadolinium-enhanced MR 35. Ross JS, Masaryk TJ, Modic MT, et al. Intracranial
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23. Yuh WT, Zachar CK, Barloon TJ, et al. Vertebral J Roentgenol 1990;155(1):159–165.
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C H A P T E R
35
INDICATIONS FOR AND USE OF
LABORATORY TESTS
Robert W. Ward
O U T L I N E
INTRODUCTION —HLA-B27 (Human Leukocyte Antigen-B27)
USES OF DIAGNOSTIC LABORATORY TESTS —Erythrocyte Sedimentation Rate (ESR)
Diagnosis of Presenting Complaints —C-Reactive Protein (CRP)
Screening for Underlying Occult Pathology Serum Glucose
Assessment of Risk Factors Serum Lipids
Monitoring Treatment Progress Guaiac (Hemoccult Test)
PRINCIPLES OF DIAGNOSTIC TESTING Allergens
Test Characteristics Nutritional Anemia
Accuracy Uncommon Tests
Precision Function Tests
Reference Range —Neurological
Sensitivity and Specificity —Endocrine
Interfering Factors and Physiologic Influences Pathogen Culturing
Test Selection HIV
Purpose of Testing Prostate Cancer
Cost/Risk/Benefit Assessment Papanicolaou (Pap) Smear
Probability of Affecting Course of Therapy Sexually Transmitted Diseases
Tests Commonly Used in the Chiropractic Setting Tests Rarely or Never Encountered
Chemistry Panels Serum Electrolytes
Complete Blood Count Electrocardiography
Urinalysis Enzyme Markers of Organ Damage
—Specific Gravity Functional Tests
—Protein —Hepatic
—Glucose —Urinary
—Ketones Tumor Markers
—Blood Tests without Established Clinical Utility
—Bilirubin Hair Analysis
—Leukocyte Esterase Manual “Nutritional” Challenge
—Nitrite Guidelines for Use of Tests for Screening
—Urobilinogen Asymptomatic Patient Populations
—Microscopic Examination Diabetes
Inflammatory Diseases Heart Disease and Stroke
—Rheumatoid Factor (RA Latex, RF) Cancer
—Serum Urate —Prostate
—ANA (Antinuclear Antibody) —Cervical
—DsDNA Ab (Double-Stranded DNA Antibody) —Colon
705
—Breast QUESTIONS
—Testicular ANSWERS
—Tuberculosis KEY REFERENCES
SUMMARY REFERENCES
more common among rural practitioners than urban

OBJECTIVES
practitioners.2 Approximately 90% of legal jurisdic-
1. To familiarize readers with the reasons for obtain- tions within the United States permit chiropractors to
ing diagnostic testing. order laboratory testing without referral to a medical
2. To understand the concepts describing principal practitioner.3
performance characteristics of diagnostic tests. Clinical information is usually collected from such
3. To understand the factors influencing selection of patients in a fairly sequential manner, beginning with
diagnostic procedures. the presenting history, progressing to physical exami-
4. To review some of the diagnostic tests that are most nation procedures, and culminating in diagnostic test-
commonly used or encountered in the chiropractic ing. Generally, as the clinician progresses through this
setting. sequence, an initial (and often broad) list of poten-
5. To review guidelines for laboratory testing of com- tial health problems that may be causing the patient’s
mon conditions. complaints is formulated, and is progressively nar-
rowed as additional data is collected. This list of po-
tential causes (differential diagnosis) is generally for-
INTRODUCTION mulated from the patient history. This list dictates the
choice of physical examination procedures and tests
Laboratory tests are encountered in several different
that are capable of detecting each of the differential
ways in the chiropractic setting. The chiropractor may
diagnoses. The clinical findings from the physical ex-
have performed or ordered the tests directly to assess
amination allow the differential list to be refined and
some aspect of the health status of a patient. Tests may
narrowed. It is not until after such refinement has oc-
have been ordered by other health care professionals,
curred that diagnostic tests should be considered, be-
and the results of these tests may become known to
cause testing always involves a financial cost and may
the chiropractor and have the potential to impact the
even pose some health risk to the patient. This neces-
care the patient receives from the chiropractor. Test
sitates an evaluation of the potential costs, risks, and
results often appear in a patient’s health care records,
benefits prior to ordering diagnostic tests. As a re-
and knowledge of these tests and their indications can
sult of these considerations, as well as imperfections
provide insight into potential relevant health issues
inherent in the tests themselves, absolute diagnostic
that the patient may not even be aware of. Some ap-
certainty is a rarity in clinical practice.
parently healthy patients may benefit from use of di-
agnostic tests to search for hidden illness, especially
if they are at increased risk for a particular illness by USES OF DIAGNOSTIC LABORATORY TESTS
virtue of personal history, family history, or popula-
tion demographics. It is important for the chiroprac- Diagnosis of Presenting Complaints
tor to have a basic understanding of the concepts of The most common use of diagnostic testing arises
diagnostic testing, knowledge of commonly encoun- from the need to collect information that may be im-
tered testing procedures, and an awareness of infor- portant in the management of symptomatic patients.
mation resources that can be used to acquire addi- Diagnostic testing is neither necessary nor used with
tional knowledge as the need arises. Such knowledge every patient. Testing is usually required when there
is essential for meaningful holistic patient care and for are several likely diagnoses that have widely diver-
communicating and collaborating with other health gent treatment strategies, or when there is a reason-
care providers. able possibility of an illness that is potentially life-
A comprehensive survey study of work performed threatening or requires immediate referral to another
by chiropractors1 reported that chiropractors rou- type of health care practitioner. Often, patients pre-
tinely (>75% of patients) determine the need for di- senting in the chiropractic setting are judged to meet
agnostic testing, sometimes (26–50%) use laboratory neither of these criteria, and a trial of care is be-
data to confirm a diagnosis, but virtually never collect gun without performing any testing. In these cases,
samples and perform lab tests themselves. Use and testing may be performed for diagnostic purposes if
in-office performance of laboratory procedures are the patient’s response to care is significantly below
INDICATIONS FOR AND USE OF LABORATORY TESTS 707
expectations. In addition to testing for the causes of the ing to determine whether the therapy provided has
patient’s complaints, chiropractors often encounter been successful in reducing the blood glucose level.
subtle clinical findings unrelated to the presenting Some of these patients will even be required to have
complaint that may represent the early manifestations assessments on a daily basis. Another example often
of illness. encountered is with forms of cancer for which there
are tests that can provide information about the level
Screening for Underlying Occult Pathology of tumor activity in the body. In these cases, moni-
Diagnostic testing is sometimes obtained for patients toring tests are used by the oncologist to assess the
who have no outward manifestation of the disease success or failure of chemotherapy agents, and to de-
process under consideration. This should be for per- termine whether surgical removal has been complete
sons who are at significantly greater risk for that ill- and/or whether malignant tissue has regenerated fol-
ness. Previous incidence of an illness that is known lowing treatment previously believed to be successful.
to be recurrent or to cause serious latent complica-
tions may create a requirement for screening tests. PRINCIPLES OF DIAGNOSTIC TESTING
Some illnesses are known to have strong genetic or
familial tendencies, and the presence of these illnesses Test Characteristics
in the patient’s family may warrant screening. There Accuracy An accurate test is one with a result that re-
are also illnesses that develop predominately in vari- flects reality. In other words, the measurement (test re-
ous populations (defined by factors such as age, gen- sult) for your patient is actually what is going on with
der, or ethnicity) that are well managed only if de- your patient. Accuracy is most important for diagno-
tected early. As the practice of screening exposes the sis because the result will be compared to a reference
asymptomatic patient to costs and risks associated range that has already been established. Inaccurate
with the testing, the most common screening proce- test results usually arise from procedural error (poor
dures are performed in accordance with established technique, defective laboratory reagents, defective or
guidelines. These guidelines often undergo periodic uncalibrated equipment).
revision, as the accumulation of newer or better clini-
cal research data mandates change. Practicing health Precision A precise test is one that yields the same
care providers should endeavor to maintain an aware- measurement repeatedly with the same sample. This
ness of such changes as a routine component of their concept of reproducible measurement is most impor-
continuing education. tant when tests are being used to monitor changes in
a patient. If changes seen from one test to the next are
Assessment of Risk Factors not significantly greater than the error typically
Testing may be ordered to assess a patient’s risk seen between consecutive measurements, then such
for developing particular health problems later in changes cannot be relied upon as an indication of
life. A common example of this is the assessment change in patient status.
of serum levels of cholesterol and triglycerides,
which do not themselves verify the presence of Reference Range The reference range for a diagnostic
atherosclerosis. However, excessive concentrations in test is determined by selecting a representative sam-
the blood do have predictive value for the develop- ple of apparently healthy individuals from a popu-
ment of atherosclerosis in subsequent years. Assess- lation and subjecting them to the test. The data col-
ment prior to manifestation of disease therefore allows lected from this process is used to establish normal
for implementation and monitoring of preventative values for that population. As with any other human
intervention. trait, there is variation in the test values obtained from
the normal population, and the normal results for any
Monitoring Treatment Progress given test are therefore described by a range of val-
Just as the onset of symptoms associated with illness ues rather than a single value. In general, the normal
may lag behind the physiologic or biochemical ab- range is defined statistically (±2 standard deviations
normalities that indicate the presence of disease, so from the mean value for the normal population). For
too the symptomatic response of the patient to treat- some tests, the normal values are set so as to provide a
ment may not accurately reflect the results of therapy. particular level of sensitivity or specificity (see Sensi-
A common example of this is adult-onset diabetes, a tivity and Specificity below). There will be a small pro-
disease process that may take years or even decades portion of the healthy population that have test val-
to create noticeable (and usually irreversible) damage ues outside the normal range. Generally, when test
and symptoms. Once this disease has been detected results for a particular procedure fall within the es-
and diagnosed by assessing the patient’s fasting blood tablished normal range, the test is said to be negative,
glucose level, it is necessary to conduct additional test- and when the results are outside the normal range, the
C A B A
C
A B
Number of people
Number of people
Measurement on test
B
Measurement on test C
Number of people
FIGURE 35–1. Typical distribution of diagnostic test measure- A B
ments in a healthy population. Vertical line A represents the
median value for the healthy population, and vertical lines B
and C designate boundaries of “normal range” for diagnostic
test.
test is said to be positive. When the statistical method

of determining normal values is used, approximately Measurement on test
5% of the healthy population will have test results
outside the range of normal values (2.5% too low, FIGURE 35–3. Graphic representation of specificity and sen-
2.5% too high). This is referred to as a “false positive” sitivity. A. Specificity is measured by dividing the shaded area
(Fig. 35–1). Similarly, for most diagnostic tests, there (healthy population with negative test) by the total area beneath
the curve for the healthy population. B. Sensitivity is measured
will also be a proportion of the diseased population
by dividing the shaded area (diseased population with positive
that fall within the normal ranges, and this is referred
test) by the total area beneath the curve for the diseased pop-
to as a “false negative” (Fig. 35–2). ulation.
Specificity and sensitivity are

Sensitivity and Specificity
mathematically determined characteristics of a test clinical certainty that can be reasonably applied to the
that are useful prior to testing in determining which results.
tests should be used for a particular patient. These Specificity is calculated by the following for-
values are also useful after test results have been ob- mula: (number of healthy patients with negative
tained, because they are an indicator of the level of test)/(number of healthy patients). This is a measure-
ment of the proportion of test results in the healthy
population that are negative. Conceptually, it is an
C
assessment of how likely a patient with an abnormal
test result is to actually have the illness being tested
Number of people
A B
for. In simplest terms, a positive result on a test with
high specificity is more likely to truly be positive
(Fig. 35–3A).
Sensitivity is calculated by the following formula:
(number of diseased patients with positive test)/
(number of diseased patients). This is a measurement
of the proportion of test results on the diseased pop-
Measurement on test
ulation that are positive. Conceptually, it is an assess-
ment of how likely a patient with a normal test result
FIGURE 35–2. Hypothetical distribution of test measurements
is to not have the illness being tested for. In simplest
in a healthy population (left curve; A) and a diseased population
(right curve; B). Note the overlap of populations. The vertical
terms, a negative result on a test with high sensitivity
line C represents the upper limit of the “normal” value for the is more likely to truly be negative (Fig. 35–3B).
test. The shaded area to the right of line C represents the Specificity and sensitivity can play an important
proportion of the healthy population with an abnormal test, and role in the selection of diagnostic tests. If the doctor
the shaded area to the left of line C represents the proportion desires to establish that a particular disease process is
of the diseased population with a normal test. not present, then a useful test will have a high level
of sensitivity (negatives that are truly negative). This the population with a particular disease, and that the
situation is generally encountered when the doctor values measured by the test increase when the disease
would like to “rule out” a possible but unlikely dis- is present. If the normal ranges are defined statisti-
ease process that poses serious risk to the patient if cally from the entire range of the “well” population,
present. A good example in the chiropractic setting then there will be some members of the “well” popu-
is an older male patient with back pain. The doctor lation who have false positives on the test. By arbitrar-
believes from the information available that the pain ily setting the upper limit of the normal range to the
is probably from a musculoskeletal disorder, but it is highest value obtained from the “well” population,
possible that the pain may represent skeletal metasta- all members of the “well” population will fall within
sis of undiagnosed prostate cancer. In this instance, a our new normal range, and there will be no false pos-
low-cost, low-risk test with high sensitivity (such as itives (specificity of 100%). However, expanding the
the prostatic specific antigen test) is ideal. If the test normal range in this fashion dramatically increases
result is negative, the chiropractor can proceed with the number of people with the disease who will fall
treatment, confident that he has not ignored a poten- within the normal range (falsely negative), resulting
tially fatal condition. in a decrease in test sensitivity. Similarly, the upper
On other occasions, the doctor may wish to esta- range of the normal values could be decreased to im-
blish that a particular disease process is actually prove sensitivity, but at the cost of a loss of specificity
present. This situation is generally encountered when (Fig. 35–4).
the application of therapy for the suspected illness
entails significant cost or risk to the patient. In the ex- The useful-
Interfering Factors and Physiologic Influences
ample above of the older male with back pain, suppose ness of some diagnostic tests can be compromised
that the highly sensitive test for prostate cancer was by a number of interfering factors, including diet,
positive, but that the test was of low specificity (an un-
acceptably high rate of false positives). There is now a
much higher suspicion that serious illness is present, A
C
but additional tests will be required to firmly establish
the presence of the disease prior to therapy, because
Number of people
A B
the treatments are expensive, pose significant health
risks (including death), and have a fairly high rate
of posttherapeutic complication (mainly sexual impo-
tence). In this situation, more specific testing (such as
a biopsy or bone scan) will be desired.
To calculate the specificity and sensitivity, it is nec-
essary to have an accurate assessment of how many
persons in a particular population actually have the Measurement on test
illness in question. In practice, a test that is deemed B
C
by consensus to have the highest predictive value for
the illness is considered to be the gold standard, and
Number of people
A B
other tests for that illness are compared against the
gold standard. For many illnesses, the gold standard
does not have sufficient predictive value to allow for
an accurate assessment of sensitivity or specificity of
other tests.
There are a number of diagnostic tests that mea-
sure phenomena that are influenced by age, race, or
gender. For such tests, the sensitivity, specificity, and Measurement on test
even the normal values may be different for these de-
mographic subsets than they would be for the en- FIGURE 35–4. Changes in sensitivity and specificity with
tire population. Sensitivity and specificity may also changes in normal range. Same test and populations as in Fig-
ures 35–2 and 35–3. A. The upper end of the normal range
change based on the disease status of the patient
has been reduced so that the entire diseased population has
(mild/early vs. severe/late, treated vs. untreated).
a positive test (sensitivity of 100%). Note the dramatic reduc-
Sensitivity and specificity can also be changed to a tion in specificity as compared to Figure 35–3A. B. The upper
desired value by altering the defined “normal” range end of the normal range has been increased so that the entire
for the test. For example, suppose that for a particu- healthy population has a negative test (specificity of 100%).
lar test the entire range of values obtained from the Note the dramatic reduction in sensitivity as compared to
“well” population overlaps the range obtained from Figure 35–3B.
behaviors immediately prior to testing, medications, certainty will have any meaningful effect on treatment
and the presence of illnesses other than those the test outcomes. Similarly, when dealing with conditions
was intended to detect. Physician awareness of these that are self-limiting, diagnostic testing to demon-
factors is important both for posttest interpretation strate the presence of such conditions will generally
and for providing patients with proper pretest in- not be of benefit.
structions. Specific examples of important interfering
factors can be found below in the section on tests com- Tests Commonly Used in the
monly used in the chiropractic setting (see Tests Com- Chiropractic Setting
monly Used in the Chiropractic Setting below). The tests described in this section are those most likely
to be used by chiropractors. In some jurisdictions col-
Test Selection lection of samples, even the testing itself, may be done
Purpose of Testing The reasons why diagnostic testing entirely within the chiropractor’s office. In other juris-
is being considered for a particular patient may signif- dictions, such testing may require sending the patient
icantly impact the choice of tests. As discussed above, to the laboratory for sample collection or even referral
issues of sensitivity and specificity come to bear on the to a medical practitioner. If you are in doubt about the
choice of tests, particularly with regard to whether allowable practices in your area, ask your licensing
the doctor is interested in establishing that a partic- authority.
ular illness is absent (sensitive test) or present (spe-
cific test). The ideal screening tests for use on asymp- Chemistry Panels Most diagnostic laboratories provide
tomatic populations to assess for occult disease should a selection of chemistry panels. These are an assort-
be sensitive, low-risk, and low-cost. When using tests ment of diagnostic tests that are offered as a package,
to monitor therapy, the choice is restricted to tests that generally at a price that is significantly lower than
have already been demonstrated to be abnormal for the cost would be if each of the tests were to be or-
that patient and that can reasonably be expected to dered individually. These can be very useful for inves-
show appreciable changes concurrent with changes tigating particular organ systems (e.g., a thyroid panel
in the patient’s health status. would contain several tests for thyroid function, as
well as an assessment of the pituitary secretion of thy-
Cost/Risk/Benefit Assessment When undertaking any rotropic hormones). However, indiscriminate use of
diagnostic procedure, there needs to be a reasoned testing panels can lead to additional and often unnec-
assessment of the direct and indirect economic costs essary tests. This occurs frequently with panels con-
to the patient (and/or payor); the risk of harm to taining multiple tests (e.g. chem-20, SMAC-18) that
the patient from the procedure; the potential benefit cover a wide range of organ systems and which many
from the procedure; and, finally, whether the antici- physicians order to screen apparently healthy patients
pated benefit is sufficient to warrant the cost and/or for occult disease. As discussed earlier with regard to
risk. While this is an essential part of the decision- normal reference ranges, a healthy patient has a 95%
making process, it is multifactorial and often involves chance of testing within the reference range on any
highly subjective considerations, and is often more given diagnostic test. If each test on a panel of 23 tests
of an art than a science. Often the costs and bene- is viewed as a separate event at this same 95% chance
fits involve factors that are unique to the patient and level, then a healthy patient has only a 29% proba-
unknown to the doctor. For this reason, for proce- bility of testing within the normal ranges on all 23
dures that entail significant cost or risk, it is highly tests. Conversely, 71% of healthy patients will have at
desirable to make the patient aware of the costs, least one test result outside the normal ranges, and
risks, and benefits and to involve him or her in the some of them will receive unnecessary (and some-
decision-making process. It is very common to pro- times risky or expensive) follow-up procedures for
ceed with therapy even in the face of diagnostic un- confirmation.
certainty when the cost or risk of the appropriate di-
agnostic procedure is greater than the cost and risk Complete Blood Count The basic complete blood count
of instituting a trial of therapy for the most probable includes a red blood cell count (RBC), a white blood
diagnosis. cell count (WBC), and a platelet count. Additional
measurements may be obtained in conjunction with
In clinical prac-
Probability of Affecting Course of Therapy these basic values. These include the erythrocyte in-
tice, it is common to have narrowed the list of probable dices (discussed below), reticulocyte count, and differ-
diagnoses without having a high level of certainty as ential white cell count. Some diagnostic laboratories
to which is correct. In such cases, when appropriate automatically include some of these measurements,
therapy is sufficiently similar for the conditions in while others require that they be ordered separately.
question, it is questionable whether testing for greater Which is required for a particular patient depends
entirely on the differential diagnoses being consid- flammatory substances, and increases dramatically
ered, so the physician must take into account the in- in cases of primary malignancy of hematopoietic tis-
dications for each of these measurements prior to or- sues (resulting in leukemia). The total count of white
dering testing. cells may be decreased in aplastic anemia. There are
Normal values for the RBC vary with age and also several subpopulations within the sample of
gender, because females of reproductive age have white cells, and a differential white cell count is of-
decreased erythrocyte counts secondary to menstru- ten useful in determining the cause of a change in
ation. The RBC is decreased with anemia, the pri- the white cell count. A very simplistic interpretation
mary clinical use of this test. The RBC is increased of the differential count for an increased white cell
with polycythemia, although this condition is un- count is as follows: Increased neutrophils indicate
common. A related measurement with similar indi- bacterial infection; increased lymphocytes indicate vi-
cations is the hematocrit, which is a measurement of ral infection; increased eosinophils indicate a chronic
the percentage of blood volume that is occupied by allergy; and increased basophils indicate a hyper-
blood cells. sensitivity reaction. This interpretation of the dif-
The erythrocyte indices and reticulocyte count are ferential count is both simplistic and incomplete,
useful in determining the probable cause of an ane- and the reader is urged to refer to a more com-
mia. This is clinically important, as patient manage- prehensive reference on the differential count (see
ment is highly dependent on causative factors. The Key References below) prior to formulating diagnostic
mean corpuscular volume (MCV) is a measurement impressions.
of the average size of the red blood cell. This vol-
ume tends to increase with anemia as a consequence Urinalysis Urinalysis has been on the chiropractic
of vitamin B9 (folate) and/or B12 (cobalamin) defi- consciousness for some time, as evidenced by B. J.
ciency, and to decrease with anemia because of iron Palmer’s utterance, “My analysis is better than uri-
deficiency. While useful, the MCV is not very sen- nalysis.” Urinalysis can give significant information
sitive, as it is often normal in patients with iron or about the health and function of the urinary tract, as
B12 deficiency, and is often normal in patients with well as indications about other body systems. Ideally,
dual deficiencies. Another useful index is mean cor- the sample should be collected from the first urina-
puscular hemoglobin (MCH), a measurement of the tion of the day, should not include the initial stream
total amount of hemoglobin in each erythrocyte. A of urine voided, and should be tested immediately.
low MCH can indicate anemia caused by deficiency This is often impractical in the outpatient setting typ-
of iron and/or B6 , and a high MCH can indicate ane- ical of the chiropractic practice. After the sample has
mia because of B9 and/or B12 deficiency. Also use- been collected, it is inspected for color and clarity. Or-
ful is the mean corpuscular hemoglobin concentration ange to red coloration may indicate the presence of
(MCHC), which is also decreased with iron and/or B6 blood, brown coloration indicates the presence of ex-
deficiency. cess bilirubin, and cloudy urine indicates the presence
Anemia is often caused by blood loss in the form of insoluble materials such as bacteria, white cells, or
of internal or occult bleeding or hemolysis. More un- crystals. Chemical testing, described below in more
common is anemia from failure of the bone marrow to detail, is then performed either with a chemical dip-
produce sufficient new blood cells (aplastic anemia). stick or by a diagnostic laboratory. Lastly, a sample of
In such cases, the MCV, MCH, and MCHC tend to be the urine is spun in a centrifuge to concentrate any
normal. However, the reticulocyte count may be use- solids present, and these are examined under a micro-
ful. Reticulocytes are premature red cells that have scope.
left the bone marrow prior to achieving full develop- The chemical tests are usually performed in the
ment, and small numbers of them are normally found chiropractic setting with the dipstick. The dipstick is
in the blood. The reticulocyte count is decreased or a plastic strip with numerous patches of test reagent
within normal reference range when the marrow is affixed to it. The dipstick is briefly immersed into the
not producing enough blood cells. The reticulocyte urine, and the excess fluid is shaken off to prevent
count will increase if the marrow is increasing red reagents from adjacent patches from mixing. A short
cell production in response to chronic blood loss. In time interval (usually a minute) is allowed to pass for
the cases of anemia caused by recent loss of signif- reactions to occur, and the color of each reagent patch
icant amounts of blood, the reticulocyte count will is compared to a reference chart to yield categorical
be normal, as the marrow has not yet had time to (e.g., positive/negative) results for the chemical tests
respond. (Fig. 35–5). The same chemical tests are included in
The white cell count is a reflection of the status of the laboratory urinalysis, but the methodology differs
the body’s immune system. The total white cell count significantly, and the results are quantitative rather
increases when the body responds to infection or in- than categorical.
FIGURE 35–5. Urinalysis dipstick

bottle with color reference chart
for interpretation of results.
Specific Gravity This is a measurement of the amount concentration of glucose exceeds the capacity of the
of dissolved material within the urine. An excessively convoluted tubules of the nephron to reclaim glu-
low specific gravity in the first urination of the day cose from the urine filtrate. Typically, this does not
indicates that the kidneys are not properly concentrat- occur until the serum glucose concentration exceeds
ing urine; samples collected at other times are highly 350 mg/dL, which is well beyond the levels seen with
influenced by the patient’s fluid intake. High spe- many diabetics. While this is a very specific test for el-
cific gravity may be seen with proteinuria. The pH evated serum glucose, it is fairly insensitive and there-
of the urine is also measured, and in most patients fore a very poor test for screening the asymptomatic
is somewhat acidic. Bacterial urinary tract infections population for diabetes. Additionally, the chemical
tend to make the urine less acidic. However, the pH reagent for this test is neutralized by the presence of
of the urine is highly dependent on diet and may also ascorbic acid above 50 mg/dL in the urine, resulting
be influenced by changes in blood pH as a result of in false negatives in patients taking large doses of vi-
respiratory conditions. tamin C.
Protein The dipstick urinalysis is fairly sensitive to Ketones This test detects only acetoacetate, one of the
serum albumin. Mild elevations of this protein may metabolic by-products of fatty acid catabolism. Trace
be seen with hypertension or after intense exercise. amounts of this substance are normal in the urine, with
Significant elevations indicate leakage of serum pro- the levels increasing as the catabolism of fat increases.
teins through the nephron, as from glomerulonephri- Significant increases in ketone levels can be seen with
tis or renal infarct. There are numerous other proteins diabetic ketosis and with chronic alcoholism. False
that may be present in the urine, such as bacterial pro- positives may be seen with patients who are taking
teins from infection, hemoglobin, and the Bence-Jones levodopa for Parkinson disease.
immunoglobins characteristic of multiple myeloma.
These proteins could be present in significant concen- Blood The reagent is sensitive to both hemoglobin and
tration, yet not be detected by the dipstick reagent. The myoglobin, and will even react with whole blood
laboratory urinalysis for protein uses a completely dif- cells. The intent of the test is to detect occult bleed-
ferent chemical process, and it detects all proteins in ing from within the urinary tract (from infection,
the urine. However, it provides no direct information stones, infarct, tumor, etc.), and the test is quite sen-
as to which proteins are present. sitive for this. However, false positives may be seen
from myoglobin following vigorous exercise and from
Glucose Normally, there should be no glucose in the hemoglobin fragments secondary to hemolytic con-
urine. Glucose appears in the urine when the blood ditions. As with the dipstick test for glucose, false
negatives can occur in patients taking large doses of may be seen with infection or inflammation of the uri-
vitamin C. nary tract. Small amounts of epithelial tissue may be
seen normally. Bacteria indicate either infection or an
BilirubinBilirubin in the urine generally indicates pri- old sample. Crystals indicate either a tendency to form
mary hepatic disease, such as hepatitis. False positives stones or an old sample. Casts are three-dimensional
can be seen in patients taking etodolac, a type of non- protein forms in the shape of the nephron, and a small
steroidal antiinflammatory drug. The reagent is neu- number of casts without cells in them (hyaline casts)
tralized by urine concentrations of ascorbic acid of 25 might be normal. Larger numbers of hyaline casts are
mg/dL, resulting in false negatives in patients taking seen in renal failure. Casts containing erythrocytes
large doses of vitamin C. (red cell casts) are seen in glomerulonephritis, and
casts containing leukocytes (white cell casts) are seen
Leukocyte Esterase This enzyme is produced by gran- in pyelonephritis.
ular leukocytes, and is a very sensitive marker for in-
fection in the urinary tract. However, it is not highly Inflammatory Diseases There are numerous tests for
specific because this marker may also be present in the factors that are associated with different forms of
urine in cases of aseptic inflammation of the urinary inflammatory joint disease. While clinically useful,
tract, and sometimes even in cases of infection or in- these tests are, in general, not specific, and the high
flammation outside the urinary tract but adjacent to it rate of false positives presents a risk of diagnostic
(e.g., vaginal infections). Test sensitivity is reduced in confusion for the doctor and unnecessary anxiety for
patients taking tetracycline and cephalosporins. the patient. These tests are not warranted unless there
is reasonable clinical suspicion of connective-tissue
Nitrite Nitrite in the urine is formed by bacterial con- disease; fatigue and diffuse musculoskeletal pain are
version of nitrate, and requires three factors to be not indicative of such disease in the absence of other
present: (a) nitrate in the patient’s diet (usually red features such as joint swelling, associated dermatitis,
meat), (b) nitrate-converting bacteria in the urinary or organ involvement.4
tract, and (c) time for the conversion to occur. Nitrites
may be seen with bacterial urinary tract infection on Rheumatoid Factor (RA Latex, RF) Rheumatoid arthritis
the first urination of the day, but if urination is occur- (RA) is an autoimmune disease characterized by de-
ring frequently during the day, subsequent samples struction of the joint synovium. This test is designed
might not contain nitrite because there has not been to detect and measure the concentration of the autoan-
adequate time for conversion to occur. As with sev- tibodies that cause the disease process. However, the
eral of the other tests mentioned above, high levels of test is not satisfactorily sensitive or specific, and di-
urine ascorbic acid will neutralize the reagent. agnosis of RA depends on multiple clinical criteria.
The test is positive in only 26–60% of persons meeting
Urobilinogen This test is not part of the urine dipstick, the criteria for definite RA,5 80–90% of persons with
but is regularly included in the laboratory urinalysis. Sjögren syndrome, and approximately 30% of patients
Urobilinogen is formed from bilirubin in the intestinal with scleroderma or lupus. This test is also positive in
tract. Some of it is absorbed through the intestinal mu- approximately 5% of the healthy population.6
cosa and subsequently filtered from the blood by the
kidney. Therefore, trace amounts are normally found Serum Urate Hyperuricemia is a risk factor for gout
in the urine. Urobilinogen may increase during in- (deposition of urate crystals in synovial joints), and
creased bilirubin production, as in hemolytic disease. in the chiropractic setting is most often used with pa-
However, it is probably more useful as a check on the tients suspected of having gout. However, this test
laboratory performing the urinalysis. Urobilinogen is not diagnostic for gout, and some rheumatologists
will spontaneously oxidize; thus, detection requires have even called for removal of this test from the
that testing be done within approximately 30 minutes. diagnostic criteria.7 A person without gout may have
If the lab report states that there is no urobilinogen had high urate levels at the time blood was drawn,
present, it is likely that the sample aged prior to test- and a person with gout may have low urate levels
ing. Such aging allows for the growth of bacteria, and at the moment blood was drawn. The gold standard
the subsequent presence of nitrites, high pH, protein, test for gout is arthrocentesis (aspiration of synovial
and crystals in such samples may be an artifact. fluid through a hypodermic needle, which is then ex-
amined under a microscope for the presence of urate
Microscopic Examination Examination of the solids in the crystals). Uric acid is a by-product of nucleic acid syn-
urine may reveal cells, bacteria, casts, and/or crystals. thesis and levels will be elevated with increased nu-
Red blood cells may be seen with infection, trauma, cleic acid synthesis or with impaired renal excretion
stones, renal infarct, and tumors. White blood cells of urate. Causes of increased urate include a diet high
in nucleic acids, a genetic tendency toward overpro- acute and chronic disease.14 However, the CRP test
duction of nucleic acids, renal failure, leukemia, lym- provides no information on the site or nature of
phoma, myeloma, and psoriasis. Urate levels may also the inflammation. CRP is now also attracting great
be increased in persons using diuretics, alcohol, sali- interest as a risk factor for atherosclerosis,15 and
cylates (aspirin), or niacin supplements. is believed to be an indicator of plaque-forming
activity rather than an indicator of the extent of
ANA (Antinuclear Antibody)This test detects autoantibod- vascular disease.16
ies against components of the cell nucleus. These an-
tibodies are present in 93% of persons with systemic Serum Glucose Tests to measure glucose levels in the
lupus erythematosus (SLE),8 and it is for persons sus- blood are useful in the diagnosis and monitoring of di-
pected of having this disease that the test is most com- abetes mellitus. According to current guidelines from
monly used. It is also frequently positive with a num- the American Diabetic Association, diagnosis of dia-
ber of other autoimmune connective-tissue diseases betes mellitus can be based solely on a fasting plasma
(such as RA and scleroderma). It is also often positive glucose level of >125 mg/dL on more than one oc-
in persons without disease (35–75% in persons older casion. The World Health Organization (WHO) has
than age 65 years), and 45% of those with high titers adopted this standard, and also includes in its defini-
have no connective-tissue disease of any kind at the tion of diabetics those who have normal fasting serum
time of testing.9 Consequently, antinuclear antibody glucose but have increased serum glucose 2 hours af-
is not useful as a screening test in the asymptomatic ter feeding.17 The WHO guidelines have been shown
population. to be effective at identifying persons requiring in-
tervention because of risk of future microvascular
DsDNA Ab (Double-Stranded DNA Antibody) This test mea- disease.18 The patient must not have eaten for at least 8
sures autoantibodies against double-stranded DNA. hours prior to the drawing of blood for this diagnostic
High levels of these antibodies are seen only in per- criterion to be meaningful. It has been this author’s ex-
sons with SLE, and the levels seen correlate well with perience that some physicians ignore this requirement
the relative activity of the disease. With appropriately for fasting and, consequently, render diagnoses of di-
set levels, the test has 66–95% sensitivity and 75–100% abetes mellitus to nondiabetic patients. Serum glu-
specificity for SLE.10 cose levels are also often used to monitor the status
HLA-B27 (Human Leukocyte Antigen-B27) This test detects of persons previously diagnosed with diabetes mel-
the presence of a lymphocyte surface antigen associ- litus, although this is not entirely satisfactory, as the
ated with ankylosing spondylitis (AS). While it is true “snapshot” value obtained with this test may not be
that there is an increased incidence of spinal arthritis reflective of the typical serum glucose levels for the
in persons with this antigen and that 88% of persons patient. The monitoring test of choice for diabetics
with AS have a positive HLA-B27, it is also positive is the glycosylated hemoglobin test (HbA1c ), which
with 8% of the white population in the United States, measures the amount of glucose covalently bound to
only a small fraction of whom will ever develop in- hemoglobin. This measurement is a reflection of the
flammatory spinal arthritis.11 The test is expensive, average serum glucose level during the previous sev-
and of little clinical use because of very low specificity. eral months, and gives a better indication of the effec-
HLA-B27 may have limited value in the assessment tiveness of patient management over time. The glyco-
of patients with highly atypical AS.12 The diagnostic sylated hemoglobin test is not generally useful for the
procedure of choice for AS is plain film radiography. diagnosis of diabetes.19 In the past, many physicians
used the glucose tolerance test (also oral glucose tol-
Erythrocyte Sedimentation Rate (ESR) This test measures erance test [OGTT]) for the diagnosis of diabetes mel-
the rate at which red cells settle and sink to the bot- litus. However, this test is highly inconvenient and
tom of a sample of blood. This rate of settling will unpleasant for the patient, is not recommended in the
increase with almost any type of inflammation, and is American Diabetes Association guidelines for diag-
affected by a wide variety of factors unrelated to dis- nosis of diabetes mellitus, and is becoming increas-
ease, including even the amount of hemoglobin in the ingly uncommon. However, there is a small but signif-
blood.13 While this test is commonly and widely used, icant population of persons who have normal fasting
as a result of low specificity and sensitivity for most glucose levels but significantly elevated postprandial
conditions it has clinical utility only in the diagnosis levels (impaired glucose tolerance). Several studies
and monitoring of temporal arteritis and polymyalgia have stated a need to retain the OGTT for detection
rheumatica. of these at-risk persons.17,20–23 However, a more re-
cent comparison of diagnostic criteria for diabetes and
C-Reactive Protein (CRP) This test is a better indicator cardiovascular disease concluded that persons with
of active inflammation, and may be seen in both impaired glucose tolerance who had increased risk of
developing cardiovascular disease also had impaired and risk through a dramatic increase in unnecessary
fasting glucose,24 implying that the fasting glucose colonoscopy and biopsy.29 Causes of false-positive
is probably sufficient for reducing future morbidity tests include occult gastrointestinal bleeding unre-
from undiagnosed diabetes. lated to cancer and eating meat that has not been thor-
oughly cooked (as in rare beef). The reagent on some
Serum Lipids Lipid levels are often tested in asymp- test strips is very similar to that used on the urine
tomatic adults as an assessment of risk for atheroscle- dipstick for blood, and the test may be similarly neu-
rosis and cardiovascular disease, although lipid levels tralized by the presence of ascorbic acid in the stools.
are only part of a complex continuum of factors used False negatives from vitamin C supplementation are
to calculate risk of future morbidity.25 Lipid levels pro- likely to occur only at very high doses (i.e., to bowel
vide no information whatsoever as to the presence or tolerance).
absence of vascular disease, but do have predictive
value in the development of such diseases. Lifestyle, Allergens The physician may come to suspect that
genetics, the endocrine system, and the liver influence a patient’s complaints are in part a result of irrita-
serum lipid levels. Testing of lipid levels requires that tion from an allergen. While a classic low-technology
the patient fast prior to collection of blood; otherwise, method for evaluating for such irritation is a trial of
the test may be more reflective of the composition withdrawal from suspected allergens, this is usually
of the meal prior to testing than of the patient’s lipid more practical with food materials than with environ-
metabolism. Attempts have been made to derive sat- mental allergens, such as pollens, spores, or animal
isfactory “normal” values for nonfasting convenience materials. There are several forms of testing available
sampling as well.26 Serum triglycerides and choles- for determining substances to which a patient is al-
terol may be elevated with diabetes mellitus, hypothy- lergic. Perhaps the most common methods are the
roidism, obesity, and familial hyperlipidemia. When skin sensitivity test and the radioallergosorbent test
assessing risk of vascular disease, it is useful to ob- (RAST). In the skin sensitivity test, exposure to small
tain not only the total cholesterol level, but also the amounts of potential allergens of known composition
proportion of serum cholesterol that is in the form of is achieved by subcutaneous injection, with the injec-
low-density lipoprotein (LDL) and high-density tion sites marked and labeled. A few days later the in-
lipoprotein (HDL). The ratio of LDL to HDL is a bet- jection sites are inspected, and sites corresponding to
ter predictor of vascular health than is the total choles- allergens for that patient will demonstrate erythema,
terol level. Many elements of lifestyle influence serum sometimes accompanied by induration. In the RAST, a
lipid levels, and conservative management of risk blood sample is sent to the laboratory, and the plasma
through lifestyle modification should be pursued dili- is tested for antibodies against various allergens. Sen-
gently prior to resorting to chemical intervention.27 sitivity for this procedure is 62–90%, and specificity is
87–99%.31
Guaiac (Hemoccult Test) This test is for the detection of
occult blood in the stools. A small amount of fecal ma- Nutritional Anemia There are several nutritional defi-
terial, often collected from the glove following a dig- ciencies that may result in anemia, and testing may
ital rectal examination, is applied to a plastic strip to be necessary to determine the appropriate course of
which the test reagent has been attached. A blue color therapy. Iron deficiency is a common cause of mi-
will be seen on the test area within a minute if the crocytic anemia, especially in women of reproductive
test is positive. This test may be necessary for patients age. However, it is not advisable to supplement with
who have a normocytic, normochromic anemia con- iron before determining the need for it, as excessive
sistent with blood loss, but no known bleeding. Daily levels are toxic. Measurement of the total iron in the
gastrointestinal bleeding, even in amounts too small blood is not very useful. The test of choice is serum
to be visualized, may over time outpace the ability of ferritin, which measures the level of the body’s iron
the bone marrow to replace the erythrocytes, resulting storage protein. Serum ferritin will increase with a
in anemia. This test is also used regularly as a screen- number of different conditions, but is only known
ing test in asymptomatic adults older than age 50 years to decrease with iron deficiency. Liver disease in-
for the early detection of colon cancer. The guaiac test creases ferritin, and will mask iron deficiency if both
has 57% sensitivity for colorectal cancer,28 but 90–95% are present at the same time. Another useful test
of positive tests in this age group are false positives is total iron-binding capacity (TIBC), which mea-
for cancer.29 Appropriate frequency for screening is a sures levels of transferrin, an iron transport pro-
subject of debate. Testing every 2 years reduces mor- tein. TIBC increases with iron deficiency and acute
tality by 14–25%, and these figures would probably liver disease, and decreases with starvation and
double with annual screening.28,30 However, the high chronic liver disease. The TIBC test is not reli-
rate of false positives would result in significant cost able if the patient recently had a blood transfusion.
Macrocytic anemia may be associated with deficiency TMS study is new and not yet in widespread use, it is
of vitamin B12 and/or folate. Red cell folate may be likely to become more popular in the future, because
measured directly. If folate levels are low, this may the test can differentiate between pathologies of the
actually be a result of B12 deficiency, because B12 is re- muscle, peripheral nervous system, and central ner-
quired for folate uptake. Serum B12 may also be mea- vous system.40–43
sured directly, and will be decreased in cases of dietary
insufficiency of B12 or B12 malabsorption (pernicious Endocrine Endocrine tests may be used by a variety of
anemia). In dietary deficiency, oral supplementation physicians to assess for the presence of hypofunction
is sufficient. If malabsorption is the cause, injections or hyperfunction of a particular endocrine gland. In
will be required. The presence of B12 malabsorption is cases where there is a reasonable suspicion of such
determined by using the Schilling test.32 However, it disease prior to testing, it is customary to test for both
may be preferable to avoid the Schilling test, which is the level of the hormone(s) from the gland under in-
expensive, requires that the patient to orally ingest ra- vestigation and the level of the trophic hormones from
dioactive materials twice, and requires the patient to the pituitary that stimulate the gland. This is because
collect all urine excreted during two separate 24-hour glandular dysfunction may be a primary disorder of
periods. A promising alternative to the Schilling test the gland, or may be secondary to dysfunction of the
is the intrinsic factor antibody test (IF Ab), which has pituitary. This distinction is important not only be-
similar performance characteristics, and is safer and cause of the dramatic influences on the therapeutic
less expensive.33 course, but because there is a high incidence of pi-
tuitary tumor associated with pituitary dysfunction.
Uncommon Tests For example, suppose that a particular patient has hy-
The tests in this section are less commonly used di- persecretion of cortisol from the adrenal gland (Cush-
rectly by chiropractors, but are often encountered in ing syndrome). Serum levels of cortisol would be ele-
chiropractic practice. Medical practitioners most often vated when tested. The physician would also require
order these tests, but some may be recommended to the level of adrenocorticotropic hormone (ACTH) to
the patient by the chiropractor as routine screening for determine if the problem is primary or secondary. If
occult pathology. Chiropractors also need to be aware the problem were a primary adrenal disease, then we
of the uses of these procedures for collaborative care. would expect to find decreased levels of ACTH, as the
healthy pituitary responds to the increased levels of
Function Tests cortisol. If the problem is in the pituitary, we would
Neurological Typically, neurological function tests are expect increased levels of ACTH from the diseased
obtained by chiropractors to rule out significant neu- pituitary, and the increased cortisol levels would rep-
rological pathology when a trial of therapy for a resent a normal response from healthy adrenals. One
musculoskeletal diagnosis has not produced the an- potential confounding factor for the example given
ticipated recovery, or to objectively demonstrate the here is that there are some uncommon nonglandular
presence of a neurological deficit for the purposes tumors (such as oat cell carcinoma of the lung) that se-
of medical-legal documentation. The need for such crete cortisol without stimulation from the pituitary.
testing is rare.34 A neurologist usually performs these This uncommon condition can mimic primary cortisol
tests. Electromyography (EMG) is a recording of the hypersecretion.
electrical signals produced by a muscle, and there are
characteristic findings that differentiate pathology of Pathogen Culturing In theory, when a patient is believed
the muscle from pathology of the peripheral nerve or to have an infection, it is desirable to identify the
nerve roots.35–37 Nerve conduction velocity (NCV) is causative organism in order to choose the most ap-
a measurement of the speed at which nerve impulses propriate therapy. Material from the affected body
travel along a peripheral nerve, and can provide system is collected (blood, lung sputum, or stool sam-
evidence of damage to a peripheral nerve or nerve ple). Care is taken to prevent contamination from the
root. Somatosensory evoked potentials are performed environment, and culture media are chosen that will
by recording an averaged cortical electrical response allow pathogens to grow but will suppress the growth
on a patient while applying sensory stimuli to the of normal bacterial fauna. However, this is usually
extremities. Significant asymmetry from one side of not done for pragmatic reasons. In most cases, appli-
the brain to the other indicates a disturbance some- cation of a broad-spectrum antimicrobial agent is ef-
where in the sensory pathways for one side of the fective in controlling the organism and is less expen-
body.38 Transcranial magnetic stimulation (TMS) is sive than culturing. Typically, the course of such a trial
performed by recording the electrical response of par- of therapy is over by the time results from culturing
ticular muscles while using a magnetic field to depo- would have become available, and this delay in
larize the motor cortex of the brain.39 Although the treatment presents significant risk for some patients.
Culturing is most often obtained for infections that pain is suspected of having spinal or pelvic metas-
prove resistant to the initial trial of therapy, because tasis of prostate cancer (primary prostatic carcinoma
the procedure also allows for in vitro trials of numer- in situ is rarely symptomatic). The PSA with a cut-
ous antimicrobial agents to determine which is most off of 4 ng/dL is a highly sensitive test for prostate
likely to be effective (antibiotic sensitivity testing). cancer (88%), but is not sufficiently specific (50%).48
Culturing may also be done when the physician needs Elevations above the normal reference range can be
to rule out infection as a differential diagnosis, as in caused by prostatitis, benign prostatic hypertrophy, a
culturing for stool pathogens in patients suspected of digital rectal examination prior to sample collection,
having inflammatory bowel disorders. and sexual activity (including masturbation) within
48 hours preceding sample collection. Patients should
HIV It is not uncommon for chiropractors in the be instructed to avoid sexual activity for the 48 hours
United States to have patients who are infected with prior to sample collection. A PSA result showing mild
HIV but who have not yet been diagnosed. For some elevation should be followed with a second PSA test
victims of HIV, the first manifestation of the illness for confirmation prior to initiating more invasive pro-
may be vague and poorly characterized complaints cedures for confirmation. New forms of this test that
that appear to be musculoskeletal in origin, and these are likely to be more specific are currently under de-
patients may see a chiropractor as the primary con- velopment. Another test for prostate cancer is the
tact. It is important that the chiropractor be aware acid phosphatase, a blood test for detection of an en-
of the testing procedures currently available for this zyme produced by the tumor. While fairly specific,
disease, even if only for the purposes of counseling the acid phosphatase test is unsuitable for screening
the patient.34 The first test to be used is the enzyme- for prostate cancer because it is rarely positive un-
linked immunosorbent assay (ELISA). This test is a til the tumor has spread beyond the confines of the
highly sensitive (96–100%) for antibodies against HIV, gland capsule to other body areas, and is gradually
but is not satisfactorily specific (76–100%).44 Because disappearing from clinical use. Positive blood work
of the serious impact to the patient of HIV diagno- for prostate cancer is usually followed by transrectal
sis, it is standard practice to retest in the event of any ultrasonography and biopsy for confirmation prior to
positive result. For patients with two positive ELISA therapy. Choice of therapy is a very challenging and
tests, the diagnosis is still tentative. Diagnosis is con- complex decision because of the wide variability of
firmed by the Western blot, a more specific (87–100%) rate of disease progression and the high rate of seri-
immunosorbent assay.44 This sequence of testing was ous side effects from therapy.
originally developed for testing of donor blood,45 and
quickly found its way into clinical practice. It is impor- Papanicolaou (Pap) Smear The Papanicolaou test (Pap
tant to note that the antibodies detected by these tests smear) is a screening test for cancer of the uterine
are typically not present until 2–4 months after the ac- cervix. This particular type of cancer is easily treated if
tual onset of infection. As the infection progresses, T detected early, but has a poor prognosis following de-
lymphocytes (which have a surface receptor known velopment of symptomatic metastasis. For this reason,
as CD4) are selectively destroyed, leaving other lym- all females of reproductive age and intact reproduc-
phocytes with the CD8 receptor intact. Progress of the tive tract should have this test for screening purposes
infection and/or efficacy of therapy can be monitored annually. A specially shaped wooden spatula is gently
either by direct CD4 cell count or by assessing the ratio scraped against the uterine cervix, and some surface
of CD4 cells to CD8 cells. epithelial cells adhere to the stick. These are smeared
onto a glass slide, chemically fixed, and mailed to the
Prostate Cancer Prostate cancer is very common in laboratory. Cytological assessment of the cells can de-
older men, and treatment outcomes are generally tect malignancy, and can also detect dysplastic precan-
favorable if the cancer is detected prior to metastasis. cerous cells, actually identifying patients at risk prior
Current clinical practice for screening the asymp- to the development of disease. Although the sensitiv-
tomatic population for prostate cancer calls for a ity is only 30–87% and specificity is 86–100%,49 repet-
digital rectal examination and a prostate-specific anti- itive annual screening can detect more than 90% of
gen (PSA) test every 2 years in men age 50 years and cervical cancers in early stages. Additionally, screen-
older, or age 40 years and older if there is a family ing accuracy may be improved in the future through
history of prostate cancer. However, such guidelines concurrent use of cervicography and a detection test
are not universally accepted.46 Additionally, recent re- for DNA of the human papilloma virus (HPV DNA).50
search suggests that the PSA test without a digital These tests are performed as an outpatient procedure.
rectal examination is sufficient for detection of
prostate carcinoma.47 Testing may also be necessary Sexually Transmitted Diseases Sexually transmitted, or
in cases where a chiropractic patient with low back venereal, diseases are quite common, and several have
significant health consequences if left untreated. In myocardium, as well as distinguish between simple is-
some jurisdictions, detection of sexually transmitted chemia and ischemic necrosis, between new ischemic
disease requires reporting to public health officials. damage and healed damage, and determine the site
Syphilis is fairly common, with an estimated annual and extent of the lesion. The ECG is also an element
incidence of 40,000 in the United States. Two tests in of the treadmill stress test for angina pectoris. The pa-
common usage for this disease are the Venereal Dis- tient suspected of having angina is asked to perform
ease Research Laboratories (VDRL) test and the flu- increasingly strenuous exercise on a treadmill while
orescent treponemal antibody absorption (FTA-ABS) ECG recordings are being collected, with the positive
test. The VDRL is used for screening and for mon- finding being appearance of ECG evidence of cardiac
itoring treatment. It is a quantitative test, and is re- ischemia coincident with onset of symptoms. A cardi-
sponsive to changes in disease status. The test has a ologist typically performs these evaluations.
sensitivity of 96.6% and a specificity of >99%.51 The
FTA-ABS is more specific than the VDRL, and is usu- Enzyme Markers of Organ Damage There are numerous
ally used for confirmation of a positive VDRL.52 The tests designed to detect metabolic enzymes in the
FTA-ABS has 91% sensitivity in primary syphilis and blood. Normally, these enzymes are compartmental-
100% sensitivity in secondary syphilis. The FTA-ABS ized in the cells where they are found, and only get
remains positive for life in most persons who have into the blood when these cells are lysed, either from
been infected with syphilis, even when the disease senescence or through injury from trauma or disease.
is no longer present. False negatives may be seen in There are normally background levels of these mark-
patients who are also infected with HIV, with false ers present as a consequence of natural cell death and
negatives more likely in those who have already pro- tissue remodeling. Whenever a particular organ or tis-
gressed to AIDS.53,54 Diagnostic testing for bacterial sue type is subject to unnatural damage, the serum
and protozoal sexually transmitted disease (gonor- level of enzymes found there will temporarily increase
rhea, Trichomonas, Chlamydia, etc.) typically consists of to abnormal levels. There are many such tests, and
microscopic examination and/or selective culturing. those described here are only the most commonly
used.
Tests Rarely or Never Encountered Alanine aminotransferase (ALT) is sometimes re-
The tests in this section are rarely used in the chiro- ferred to as serum glutamic-pyruvic transaminase
practic setting, but may be necessary for the diagnosis (SGPT) in older literature. This enzyme is part of the
of serious organic pathology. For each of these proce- Cori cycle (the process that allows for transport of am-
dures, basic information is provided about indications monia from muscle tissue to the liver), and is there-
and appropriate referral. fore present in significant amounts in the liver, kid-
ney, and muscle tissue. A similar enzyme, aspartate
Serum Electrolytes This series of tests can be used to as- aminotransferase (AST; serum glutamic-oxaloacetic
sess the current status of the patient with regard to the transferase [SGOT] in older literature) is also found in
ions essential for maintaining cellular electrochemical liver and muscle, and also the brain. Although these
gradients. Skilled interpretation of these values can enzymes elevate with myocardial infarction, they
yield information about which body system(s) may are not used to diagnose this condition because the
be causing unexplained illness, including the respi- time delay between heart damage and appearance in
ratory, renal, and endocrine systems. These tests are the blood is too long to wait for results. The primary
routinely ordered for all seriously ill patients at hos- use of these tests is in determining whether there has
pital admission. been recent hepatic damage (i.e., hepatitis, biliary ob-
struction, cirrhosis).55 In cases of hepatitis A, these en-
Electrocardiography Electrocardiography (ECG) is a zymes elevate in the blood 2–3 weeks after infection,
technique for measuring the electrical activity of the and usually return to normal values 8–9 weeks after
heart. Much diagnostic information can be obtained infection. Gamma-glutamyl transpeptidase (GGTP),
from this simple procedure, which involves placing found in liver and pancreas, also elevates when there
surface electrodes at various standardized positions is liver damage, but elevates and disappears much
on the chest wall and recording the potentials gener- faster (over the course of several days). GGTP ele-
ated between the electrodes by the heart. This proce- vates with even modest alcohol consumption and is
dure is routinely used to evaluate the heart in cases elevated in 90% of patients with active liver disease.
of suspected pathology of the myocardium or cardiac The test has acquired an undeserved reputation as be-
conductive system. Several variations of the proce- ing diagnostic for alcohol abuse, but it is not partic-
dure are common, and are described by the number ularly useful for this purpose (sensitivity of 69% and
of electrodes used. Skilled interpretation of a 12-lead specificity of 65%).56 One of the uses of the GGTP test
(12-electrode) ECG can often detect pathology of the is in determining whether liver damage is resolving
(elevated ALT and AST, normal GGTP) or ongoing (all Lactate dehydrogenase (LDH) is found in almost ev-
three markers elevated). ery tissue, and can be elevated in the blood after dam-
Alkaline phosphatase (ALP) is found in the liver, age to the heart, liver, skeletal muscle, kidney, red
bone, and intestine. It is most often used to detect blood cells, and skin. LDH has been used in the di-
damage to the liver or bone. To determine whether an agnosis of myocardial infarction because it remains
elevation of ALP is from liver or from bone, testing for elevated in the blood longer than CK and cTnI after
one or more different liver markers (ALT, GGTP, etc.) such events, but is now rarely used for this purpose
will be done at the same time. Elevation of ALP from because it is only useful for late detection.63 Many di-
bone pathology occurs in disease processes where agnostic laboratories still include this enzyme in their
there is significant ongoing destruction and reactive “liver panel,” but internists currently favor the other
remodeling of bone (i.e., Paget disease, osteomalacia, liver enzyme markers discussed above. Comparative
cancers of bone). Consequently, ALP is not elevated in assay of LDH isozymes used to be undertaken to de-
less metabolically active conditions of the bone, such termine the organ of origin (site of damage), but this
as osteoporosis or simple fracture. ALP levels are af- practice has been rendered completely unnecessary
fected by a wide range of physiologic factors, includ- by newer testing methods.63
ing height, weight, age, gender, blood pressure, and
tobacco use.57 Functional Tests
Amylase is found in the pancreas and salivary Hepatic When disease of the liver is sufficient to nega-
glands, and may be elevated in conditions that inflame tively impact its ability to perform its metabolic func-
or obstruct these glands (i.e., pancreatitis, Sjögren syn- tions, liver secretions will be found in reduced levels in
drome). Usually the test is done when there is sus- the blood. Serum albumin is a multifunctional globu-
picion of acute pancreatitis, and is clinically useful lar protein that is produced by the liver; consequently,
for both diagnosis and prognosis.58 Lipase, found albumin levels will be reduced with hepatic disease.64
in the pancreas, liver, intestines, and other tissues, Albumin levels are also reduced by conditions that re-
also elevates during episodes of pancreatitis. Typi- strict the availability of precursor amino acids, such
cally, both tests will be done when pancreatitis is sus- as fasting, malnutrition, or Cushing syndrome. Blood
pected because neither test is satisfactorily sensitive urea nitrogen (BUN) is a measurement of the solu-
or specific by itself. Lipase remains elevated for a ble urea in the plasma, an end product of amino acid
longer time after damage has occurred. In cases of catabolism that is produced only in the liver. BUN lev-
chronic pancreatitis, amylase and lipase are typically els will also be decreased by hepatic disease, and by
normal because the damage to the pancreas has oc- low levels of amino acid catabolism, as seen in fast-
curred over many years and there is insufficient re- ing or malnutrition. Indirect bilirubin, a waste prod-
cent damage to result in a positive test. These tests uct of the degradation of hemoglobin from lysed red
are not useful in the evaluation of chronic pancreatic blood cells, is conjugated in the liver to form direct
damage.59 bilirubin. In cases of significantly increased bilirubin
Creatine kinase (CK) is found in muscle tissue and levels, a yellow coloration is imparted to the body tis-
brain, and elevates quickly after damage to these tissues (most easily noted at the ocular sclera). This is
sues. It is used primarily in assessment of suspected referred to as jaundice (or icterus) and may have nu-
myocardial infarction (MI), as the serum level of CK merous causes. Measurements of these two different
rises rapidly within a few hours, and stays elevated forms of bilirubin can be made, and the results of the
for several days, following myocardial infarction. The two measurements compared to yield information as
CK test is not specific enough for diagnosis of MI by to the probable cause of the jaundice. An increase in
itself, but in conjunction with ECG is considered to both forms indicates excessive hemolysis with normal
have sufficient negative predictive value for ruling liver function. An increase in indirect bilirubin with
out such events.60 While it is possible to perform more decreased direct bilirubin indicates impaired hepatic
advanced testing that can determine whether the CK function. An increase in direct bilirubin with normal
in the blood comes from the heart, brain, or skeletal indirect bilirubin is consistent with posthepatic biliary
muscle (creatine kinase myocardial band), this testing obstruction. Evaluation of hepatic function is gener-
is sometimes no longer necessary because a better test ally done by an internist.
is available. Cardiac troponin I (cTnI) is a contractile
protein found only in heart muscle. The sensitivity of Urinary Specific gravity of the urine indicates the abil-
cTnI for acute myocardial infarction is much higher ity of the kidney to concentrate urine. This basic func-
than that of CK 6–8 hours after the event, but CK is tional assessment of the urinary tract was previously
more sensitive in shorter time frames.61,62 These tests discussed in the section on urinalysis. Two other com-
are generally ordered in the emergency room after sus- mon functional tests that assess the ability of the
pected myocardial infarction. kidney to filter wastes are the BUN (see Hepatic above)
and serum creatinine (a waste product from skeletal interpreted to indicate a need for supplementation,
muscle metabolism). Should the kidney fail to prop- and high levels are said to indicate potential mineral
erly filter waste metabolites from the blood, levels toxicity. The correlation between nutrient intake and
of both of these waste products will increase. Nei- mineral content in the hair is controversial, and prob-
ther an increased BUN nor an increased serum cre- ably poor.67 Some laboratories that market this type of
atinine is sufficiently specific to allow for conclusions analysis do not simply provide the analysis, however.
about the function of the kidney, as each has mul- The laboratory typically asks for a very detailed sur-
tiple possible causes for an increase. However, only vey of patient complaints, and then provides a written
two things significantly increase both markers: se- report along with the measurements describing how
vere dehydration and renal dysfunction. Therefore, the measurements correlate with the patient’s com-
interpretation of these two laboratory tests lies not plaints and recommending a specific course of nu-
in the actual measurements so much as in the ratio tritional therapy involving proprietary supplements
of the measurements. In cases of renal dysfunction, that can only be purchased through the laboratory.
the BUN:creatinine ratio is normal (about 10:1), but This author inquired with one such laboratory as to
both values have increased significantly. Renal func- how the normal reference ranges for this type of anal-
tion tests are usually performed by a urologist or an ysis had been determined, and was informed that
internist. there was no reference “range.” The healthy finding
was said to be a single fixed value (rather than a
Tumor Markers Some types of cancer produce char- range), with any deviation from that value indicat-
acteristic chemical markers that can be tested in the ing a need for therapy. No sensible explanation for
blood and quantified to allow for monitoring progres- the basis of this statement or the means by which the
sion of disease and/or efficacy of treatment, and to de- normal value was determined was provided. There
tect recurrence after therapy. These tests are not rou- is no established benefit from this type of evaluation.
tinely used for screening purposes, either because a Potential risks include economic costs associated with
significant proportion of tumors do not produce the unnecessary dietary supplements and delay of appro-
markers (resulting in low sensitivity) or because there priate therapy secondary to misdiagnosis of organic
is a high rate of false positives and secondary testing illness.
is of high risk.64–66 Typically, an initial test to see if a
tumor marker is present will be done after the diag- Manual “Nutritional” Challenge Various forms of a man-
nosis has already been made. Included here are a few ual muscle resistance test have been proposed for a
of the most common tumor markers. Cancer antigen wide range of diagnostic purposes. There are systems
125 (CA125) is most often seen with ovarian cancer. of interpretation that express belief in an association
Carcinoembryonic antigen (CEA) is a marker that is of various patterns of “weakness” of particular mus-
seen with various tumors arising from epithelial tis- cle groups with dysfunction of particular organs. It
sues, such as colon and lung cancer. Human chorionic has also been proposed that changes in the “strength”
gonadotropin (HCG), a hormone that is the basis for of an indicator muscle in response to stimulation with
pregnancy tests, is also a tumor marker that may be a food substance (either through oral stimulation or
seen in malignancies of the testes, ovaries, or uterus. contact with the exterior of the patient’s body) can pro-
Alpha-fetoprotein, a normal protein in the fetus, can vide reliable indications of the patient’s need to either
be a marker for hepatic carcinoma or reproductive supplement or avoid that substance. There is no ex-
cancers in the adult. planation for this diagnostic method that is consistent
with sound physiological or neurological science. Ad-
Tests without Established Clinical Utility ditionally, there is no credible evidence of reliability
The tests in this section are sometimes used for diag- or validity in the peer-reviewed literature available as
nostic purposes, but have no established clinical util- of this writing. A review of the body of peer-reviewed
ity. For each of these procedures, information is pro- literature supportive of this methodology concluded
vided about the current status of the procedure and that all such works were sufficiently flawed as to pre-
the procedure’s potential risks and benefits. clude drawing any valid conclusions from reported
data.68 A review of data from a reliability study of
Hair Analysis This has been used to evaluate the nu- this method reveals a very strong correlation between
tritional status of patients, particularly with regard to test outcome and examiner expectation.69 While this
minerals. A sample of hair from the nape of the neck method clearly has no utility as a diagnostic tool for
(where growth is most rapid) is sent to the labora- nutritional status70 or organic diagnosis, it may still be
tory, and the mineral content of the hair is analyzed. clinically useful as a strong potentiator of the placebo
Low levels of mineral micronutrients in the hair are effect. Practitioners who rely on this method of patient
assessment risk harming patients by delaying needed Tuberculosis Routine tuberculin skin tests are not rec-
treatment through misdiagnosis.1 ommended for the general population, only for those
who are at risk of contracting and/or spreading the
Guidelines for Use of Tests for Screening disease. Health care workers (such as chiropractors)
Asymptomatic Patient Populations are a population that poses significant risk of spread-
Unattributed guidelines in this section represent the ing the infection, and the American Lung Association
author’s interpretation of the current state of consen- recommends periodic screening for both health care
sus in the health care provider community. Guidelines providers and teachers. There are no guidelines for the
originating from government agencies or nongovern- frequency of such testing. Testing annually is probably
mental organizations of authority are attributed to too frequent, as frequent testing has the potential to
their source. These guidelines refer to patients with- induce an immune response to the test itself, resulting
out identifiable risk factors. Alteration of screening in a false positive.
frequency or timetable may be advisable in those with
significant risk factors.
SUMMARY
Diabetes Fasting serum glucose every 3 years starting
1. Laboratory tests may be ordered to reach or con-
at age 45 years in the general population, earlier and
firm a diagnosis, to screen asymptomatic pa-
more often in persons with identifiable risk factors
tients for occult disease, to assess risk factors to
(American Diabetes Association).
help prevent future disease, to monitor the ef-
fectiveness of therapy, or to provide medicolegal
Heart Disease and Stroke There are no formal recom- documentation.
mendations for type, timing, or frequency of screen- 2. Every test, including laboratory tests, has inher-
ing tests for vascular disease in populations without ent weaknesses that must be understood before
risk factors. Serum lipid tests are the most frequently results may be interpreted. The important charac-
employed screening tests for these conditions. teristics of a test are its accuracy (how close to re-
ality its results are), precision (how close repeated
Cancer measurements are), reference range (which values
Prostate PSA every year beginning at age 50 years, were used to determine what a normal or abnor-
and at age 45 years for males of African ancestry or mal result is), sensitivity (ability to obtain a pos-
who have a father or brother who was diagnosed with itive result in those with a condition), and speci-
prostate cancer at an early age (American Cancer So- ficity (ability to obtain a negative result in those
ciety). without a condition).
3. When several tests are available to screen for a
CervicalPap smear and visual inspection of uterine condition, factors such as cost, invasiveness, risk,
cervix annually, beginning at age 18 years or onset of convenience, patient preference, and the inherent
sexual activity, whichever is earlier (American Cancer characteristics of the tests may influence test selec-
Society). tion.
4. Some of the laboratory tests commonly used by
chiropractors include chemistry panels, complete
Colon Hemoccult test every year and sigmoidoscopy
blood count, urinalysis, arthritide tests, tests for
every 5 years beginning at age 50 years (American
active inflammation, serum glucose tests, serum
Cancer Society).
lipids, guaiac test, allergen testing, and tests for
nutritional anemia.
Breast Monthly self-examination of breasts and breast 5. There are many guidelines established for labora-
examination by health care provider every 3 years tory screening of common conditions, including
from ages 20 through 40 years. After age 40 years, fasting serum glucose every 3 years starting at age
monthly self-exam, annual professional exam, and 45 years or earlier in those with risk factors for dia-
annual mammogram are recommended (American betes, serum lipid tests for heart disease and stroke,
Cancer Society). The clinical utility of mammog- yearly PSA beginning at age 50 years or at age
raphy in asymptomatic patients recently became 45 years for males of African ancestry or who have
controversial. relatives with prostate cancer, yearly pap smears
for cervical cancer beginning at age 18 years or on-
Monthly self-examination of testicles and in-
Testicular set of sexual activity, and yearly hemoccult test for
guinal lymph nodes from puberty to age 40 years. colon cancer.
not very important in this situation, because the

QUESTIONS
diagnosis has already been reached.
1. When selecting tests for monitoring the progress 2. C. Ordering procedures that are not needed by the
of treatment, the most desirable test characteristic patient solely for the purpose of increasing practice
is revenue is a violation of professional ethics. Test-
A. Sensitivity. ing all patients for all possible illnesses exposes the
B. Specificity. patient to unnecessary risk and costs.
C. Precision. 3. A. Test selection should be based primarily on the
D. Accuracy. health needs of the patient.
2. It is often appropriate to order diagnostic tests 4. B. Anemia is by definition a low red blood cell
for count. Infection often results in a moderate in-
A. Improving the earnings of the practice. crease in the white cell count, and leukemia results
B. Enhancing the process of educating patients in a dramatic increase in white cell count. Late-
about public health issues. stage cancer may result in changes in the complete
C. Assessing risk for future disease. blood count, but such changes are a reflection of
D. Routine screening of new patients for any pos- the physiologic stress of the disease and are not
sible organic disease. diagnostically useful.
3. A primary factor influencing the doctor’s choice 5. Choices A and B represent appropriate screen-
of diagnostic tests is ing in adults older than age 50 years, but not
A. The purpose for which the test is intended. in younger adults, because the conditions be-
B. The doctor’s personal preference. ing screened for are quite uncommon in younger
C. The patient’s personal preference. populations. Choice D is a recommendation for
D. The insurer’s preference. diabetes screening that is too early and too
4. The complete blood count (CBC) can be useful often.
in diagnosis of a number of different conditions.
However, the CBC is not useful at all in the diag-
nosis of KEY REFERENCES
A. Anemia.
B. Metastatic cancer. Fischbach F. A manual of laboratory and diagnostic tests, 6th ed.
C. Infection. Baltimore: Lippincott, Williams and Wilkins, 1999.
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following is a recommended screening for asymp-
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A. Annual digital rectal examination and PSA test REFERENCES
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C H A P T E R
36
DOCUMENTATION AND RECORD
KEEPING
Louis Sportelli and Gary Tarola
O U T L I N E
INTRODUCTION EXTERNAL DOCUMENTATION
INTERNAL DOCUMENTATION Health Records
Contemporaneous Recording Diagnostic Imaging
Patient Care Records Reports
Medicare Requirements PATIENT CONSENTS
Medicare X-Ray Documentation Informed Consent/Consent to Treatment—General
Medicare Physical Examination Documentation Consent to Treatment—Competence
State Regulations and Contractual Agreements Authorization to Release Patient Information
Preprinted Clinical Record-Keeping Forms Financial Assignments
Illiterate or Physically Handicapped Patients Publication/Photo/Video Consent
Patient Compliance Issues Authority to Admit Observers
Records Retention CHART/FILE ORGANIZATION
Documentation General Considerations
Doctor/Clinic Identification Use of Preprinted Forms
Patient Identification Legibility and Clarity
Patient Demographics Use of Abbreviations/Symbols
Health Care Coverage RECORDS MAINTENANCE
Patient History Confidentiality
Examination Findings Records Retention and Retrieval
Findings of Special Studies Administrative Records
Miscellaneous Assessment and Outcomes Instruments Records Transfer
Available Sources Clinic Staff Responsibilities
Clinical Impression RECOMMENDATIONS ON RECORD
Treatment Plan KEEPING
Chart/Progress Notes SUMMARY
Reexamination/Reassessment QUESTIONS
Financial Records ANSWERS
Internal Memoranda Recording Patient Visits KEY REFERENCES
4. To review the required components of external

OBJECTIVES
documentation.
1. To review the function of patient records. 5. To suggest methods of organizing patient
2. To review the regulations affecting patient records. records.
3. To review the required components of internal 6. To review the required components of patient con-
documentation. sent.
725
7. To review the requirements for record mainte-

INTERNAL DOCUMENTATION
nance.
8. To offer suggestions to facilitate and improve the Contemporaneous Recording
record-keeping process. It is helpful for chart notes to be produced as soon
after the patient encounter as possible, for all hand-
writing to be legible, for providers to review all en-
INTRODUCTION tries made by staff members or transcribed from dicta-
tion, and for records obtained from outside sources to
When a new patient enters the office, a file is created be reviewed at the earliest possible time. Moreover, a
that becomes the foundation of the patient’s perma- record review conducted while the patient is still fresh
nent record. This file should include, for example, per- in the doctor’s mind also enables the doctor to better
sonal patient data (e.g., name, address, phone num- consider the patient’s condition, treatment plan, and
bers, age, birth date, sex, occupation), insurance and response to therapeutic intervention. This informa-
billing information, appropriate assignments and con- tion should be appropriately reflected in the records.
sent forms, case history, examination findings, imag- The record containing this data will enable the cur-
ing and laboratory findings, diagnosis, work chart for rent treating provider and any subsequent providers
recording ongoing patient data obtained on each visit, to recommend appropriate follow-up care and avoid
the service rendered, health care plan, copies of the duplication of tests and services.
insurance billings, reports, correspondence, and case
identification (e.g., by number) for easy storage and Patient Care Records
retrieval of patient’s documents. An appropriately While there is no universal standard for record keep-
prepared patient file should also include all infor- ing, groups such as managed care organizations, the
mation obtained from the patient’s history, examina- National Council for Quality Assurance (NCQA),
tion, special studies, records from previous providers, state boards of examiners, and federal programs such
and any questionnaires or forms collected from the as Medicare and Medicaid have all developed guide-
patient. This information should be gathered with lines or specific requirements for record keeping.
legible, clear notations and handwriting, and assem- While this chapter cannot provide information on all
bled in a logical way that maximizes efficiency when such guidelines, it is recommended that caregivers be
it becomes necessary to review the records. Com- familiar with the requirements of each contract they
pleteness of records should be a top priority to en- enter into when developing patient records. There is
sure that an accurate record of all pertinent events is a general trend from regulatory agencies toward de-
maintained. manding a higher level of compliance on the part of
A patient file is an integral component of health every practitioner when dealing with issues of patient
care and serves many important functions. First, it care. As such, patient records should reflect the pa-
provides a documented record of the immediate care tient’s current status, what was done, the reasons for
and treatment of the patient. This gives the current performing specific procedures or tests, and all results
provider and any subsequent providers access to im- obtained from such testing. It may be useful, for exam-
portant information on the patient’s clinical status at ple, to note which spinal segments were manipulated,
the time the record was made, as well as the effect(s) of the type of adjusting technique used, and the location
any therapy that has been applied. This information and method of therapeutic modalities so that success-
helps to direct future treatment, and ensures proper ful treatment approaches may be repeated at future
continuity of care if several providers are involved. visits and unsuccessful approaches discarded.
Second, appropriate charting provides a foundation
for producing accurate reports to other health care Medicare Requirements
providers, insurance companies, attorneys, and other Regardless of a clinician’s personal opinion of the
interested parties. Third, the patient record is helpful term subluxation, documentation of a subluxation
for public health purposes, teaching, and clinical re- remains an important part of the information required
search. This chapter offers suggestions on prepar- by Medicare. Under Medicare rules the subluxation
ing the various forms and documents, both internal may be demonstrated by an x-ray or physical exam-
and external, that may be used to compile informa- ination. All levels of subluxation identified must be
tion to formulate a diagnosis and treatment plan and documented in the patient’s medical record, regard-
to determine “necessity” of care. This chapter also less of the current treatment plan.
addresses the important issues of patient confiden-
tiality, professional records, and patient consent to Medicare X-Ray DocumentationAccording to Medicare,
care. an x-ray may be used to document a subluxation. The
DOCUMENTATION AND RECORD KEEPING 727
x-ray must have been taken at a time reasonably prox- To demonstrate a subluxation based on physical ex-
imate to the initiation of a course of treatment. Unless amination, two of these four criteria are required, one
more specific x-ray evidence is warranted, an x-ray of which must be asymmetry/misalignment or range-
is considered reasonably proximate if it was taken no of-motion abnormality.
more than 12 months prior to or 3 months following The following documentation requirements apply
the initiation of a course of chiropractic treatment. In whether the subluxation is demonstrated by x-ray or
certain cases of chronic subluxation (e.g., scoliosis), by physical examination:
an older x-ray may be accepted provided the benefi-
ciary’s health record indicates the condition has ex- Initial visit:
isted longer than 12 months and there is a reasonable
basis for concluding that the condition is permanent. 1. History as stated by the patient.
For specific information on the coverage guidelines 2. Description of the present illness including
of chronic conditions and maintenance therapy, see • Quality and character of symptoms/
the “Indications and Limitations of Coverage” section problem.
of the policy. A previous computed tomography (CT) • Onset, duration, intensity, frequency, loca-
scan and/or magnetic resonance image (MRI) of the tion, and radiation of symptoms.
spine may be used in lieu of an x-ray. The time frames • Aggravating or relieving factors.
specified for x-rays are also applicable for MRIs and • Prior interventions, treatments, medica-
CT scans. Effective for Medicare claims with dates of tions, and secondary complaints.
service on or after January 1, 2000, an x-ray is not re- • Symptoms causing the patient to seek treat-
quired to demonstrate the subluxation. However, an ment. These symptoms must bear a direct
x-ray may be used for this purpose if the chiropractor relationship to the level of subluxation. The
so chooses. An x-ray is always required for dates of symptoms should refer to the spine, muscle,
services prior to January 1, 2000. bone, rib, and joint and be reported as pain,
inflammation, or signs such as swelling
According
Medicare Physical Examination Documentation and spasticity. Vertebral impingement or ir-
to Medicare, a physical examination may be used to ritation of spinal nerves is recognized as
describe a subluxation by evaluation of the muscu- a cause of headaches, arm, shoulder, and
loskeletal/nervous system to identify and document hand problems, as well as leg and foot pains
the subluxation. The PART process has been adopted and numbness. Rib and rib/chest pains are
by the Health Care Financing Administration (HCFA): also recognized symptoms of a vertebral
disease, but in general, other symptoms
(P) Pain/tenderness: evaluated in terms of must be related to the level of the abnor-
location, quality, and intensity. Pain is identified mality that has been cited. A statement on
through one of the following: observation, percus- a claim that there is “pain” is insufficient.
sion, palpation, and provocation, visual analog- The location of pain must be described and
type scale, verbal confirmation, and/or pain ques- whether the particular vertebra listed is ca-
tionnaires. pable of producing pain in the area deter-
(A) Asymmetry/misalignment: identified on mined.
a sectional or segmental level. Asymmetry can be 3. Evaluation of musculoskeletal/nervous sys-
observed with posture and gait analysis, static and tem through physical examination.
dynamic palpation for misalignments of vertebral 4. Diagnosis: The primary diagnosis for Medi-
segments, and imaging techniques. care must be subluxation/segmental dysfunc-
(R) Range of motion abnormality: changes in tion, including the level of subluxation, either
active, passive, and accessory joint movements reso stated or identified by a term descrip-
sulting in an increase or decrease of sectional or seg- tive of subluxation. When a practitioner does
mental mobility. Range of motion is determined by not routinely use the term subluxation, the
observation, motion palpation, testing, and stress characteristics of the segmental dysfunction or
diagnostic imaging. manipulable lesion must contain the same de-
(T) Tissue tone: changes in the characteristics scriptive terms listed for a subluxation. Such
of contiguous, or associated soft tissues, including terms may refer either to the condition of the
skin, fascia, muscle, and ligament. Tissue tone can spinal joint involved or to the direction of po-
be identified through observation, palpation, instru- sition assumed by the particular bone named.
mentation, strength testing, strength evaluation, 5. Treatment plan: The treatment plan should in-
etc. clude the following:
• Recommended level of care (duration and sic this advice seems, it remains important. Doctors
frequency of visits). should not allow forms to master them and their prac-
• Specific treatment goals. tices by using the forms without any review, modifi-
• Objective measures to evaluate treatment cation, or critical evaluation. Moreover, the review of
effectiveness. office forms should embrace several different perspec-
6. Date of the initial treatment. tives. The doctor should evaluate the forms keeping
in mind the viewpoint of the following people who
A sample medical history checklist form (Fig. 36–1) may at some point have access to part of or the entire
and sample case history form (Fig. 36–2) are included chart:
for reference purposes.
• Patient
Subsequent visits:
• Insurance claims adjuster
• Fraud investigator
1. History
• Attorney
• Review of chief complaint
• Judge or juror
• Changes since last visit
• Peer review panel
• Systems review if relevant
• Compliance officer
2. Physical exam
• Board of examiners
• Examination of area of spine involved in
• Legislators
diagnosis
• Managed care organizations
• Assessment of change in patient condition
since last visit
• Evaluation of treatment effectiveness Having an independent audit of your office records
3. Documentation of treatment given on day of by a qualified individual may help to provide keen
visit. insight into the issue of compliance requirements of
office records. It is important that each health care fa-
A sample daily Subjective Objective Assessment cility in the United States regularly update their in-
Plan (SOAP) notes form (Fig. 36–3) is included for formation relative to HIPAA (Health Insurance Porta-
reference purposes. bility and Accountability Act) regulations and HCFA
compliance requirements. Web sites are available for
State Regulations and Contractual Agreements updating information, and programs are available to
All providers should review their state statutes to help provide education for the doctor and staff to pre-
determine whether there are any specific reporting pare for HIPAA compliance. Most state and national
or documentation requirements or state-mandated associations, as well as other organizations, will have
guidelines in order to be in full compliance with the programs and data to provide up-to-date information
regulations. Also, contractual agreements with, for for the field practitioner. As in all instances, reliance
example, managed care entities, third-party payors, on a trusted source for this information is important,
and insurance companies must also be carefully re- and the doctor is urged to seek out those groups in
viewed to determine the requirements and mandates which the doctor has confidence.
for reporting when treating patients under these con- Doctors should tailor their forms to their practices.
tracts. If a portion is not needed, never used, or represents
information the doctor has never found helpful, that
Preprinted Clinical Record-Keeping Forms portion of the form should be removed. Although
Preprinted forms can prove helpful and improve office some sections of various forms may not apply to the
efficiency by reminding both the doctor and patient of patient’s current condition, allowing any portion of a
pertinent facts and occurrences that might otherwise form to remain blank or unanswered leaves the doctor
be forgotten. The doctor should address each condi- open to speculation as to why entire areas of an intake
tion that a patient indicates on a history or intake form. form contained no entries and whether or not the doc-
Reviewing all records that are brought by the patient, tor addressed subjects on those areas of the forms at
as well as all records completed by the patient, will all.
provide an important overview from which a deter- It is reassuring to the patient if the patient’s first
mination of the underlying cause of the presenting visit begins with identification and discussion of the
symptoms can be made and a treatment plan or refer- patient’s complaint(s). Only after the clinical infor-
ral plan can be developed. mation has been obtained should the record move to
Doctors should be aware of the content of every financial information, a secondary concern. A nega-
form they use in their offices. No matter how ba- tive impression can easily be created if the first and
A B
C FIGURE 36–1. Sample medical history checklist.
foremost concern represented on the intake forms ap- prior to patient acceptance and/or treatment. Condi-
pears to be reimbursement or financial issues. tions such as cataracts, Parkinson disease and other
neurological deficits, extreme pain, literacy, educa-
Illiterate or Physically Handicapped Patients tional level, general intelligence, language barriers,
Doctors sometimes forget that not all patients are able and cultural differences may materially impair the pa-
to understand, read, or even see the questionnaires, tient’s ability to provide meaningful information. It
forms, case histories, and other paperwork required may therefore be necessary for a staff member to read
A B
C D
FIGURE 36–2. Sample case history form.
aloud the forms and record the patients’ answers on cooperating, not following instructions, or not per-
their behalf. forming self-help activities. Every doctor has encoun-
tered patients who do not keep appointments, fail to
Patient Compliance Issues comply with the doctor’s instructions, and do not co-
Records should reveal not only what happened, but operate in their treatment. Failure of patients to fol-
also what did not happen, such as if a patient is not low recommendations can and often does result in an
work, driving, and sexual or other physical activ-

ities that might aggravate the patient’s condition
during rehabilitation.
When a doctor does not point out such shortcom-

ings and insist on compliance, the doctor does a
disservice to the patient and reduces the effectiveness
of a treatment plan. Failure to document noncompli-
ance and record that the patient has been warned
about its possible deleterious effects can be a dis-
service to the patient. If the noncompliance reaches
the point of jeopardizing good-quality care, the doc-
tor should inquire as to the reason for the difficulty
and, under certain conditions, consider formally dis-
charging the patient with an appropriate letter of with-
drawal. Physician records that do not note such diffi-
culties in patient compliance may obscure the reason
for a poor treatment outcome or discharge of the pa-
tient to anyone reviewing the records at a future date.
Records Retention
The question, “When can I safely discard my records?”
is one that lacks a simple answer and probably has
FIGURE 36–3. Sample daily SOAP notes form. none that is accurate under all circumstances. Records
can be destroyed after the statutory limitation (the law
exacerbation of the current condition or the onset of establishing the time beyond which a suit cannot be
new conditions. There may never be a satisfactory so- brought) of each state. However, other factors should
lution to the problem of patient noncompliance, but be considered. The impact of the statute also varies
from a patient-centered perspective, the only course of considerably depending on statutory exceptions and
action is to attempt to encourage patient compliance. If judicial interpretation. Sometimes short periods are
unsuccessful, it is important to document the patient’s extended almost indefinitely by various exceptions
behavior regarding the patient’s failure to comply, and and special rules. The time may not start “running”
ultimately undertake appropriate steps to assist the until the injury is discovered, for example, or, in the
patient in seeking more satisfactory, appropriate, and case of an infant, until the infant reaches the age of
effective care. majority. With so many variables in statutes of limi-
Notations such as DNKA (did not keep ap- tations and the unpredictability of statutory changes,
pointment) and FAWAN (failed appointment without providers might consider storing records for as long
adequate notice) can be used in the doctor’s records to as space permits, or, alternately, microfilming or dig-
document any patient failure to keep an appointment. itally scanning them. The incorporation of electronic
DKNA and FAWAN should not be considered a con- charts and files will one day become commonplace
demnation of the patient, but missed appointments and the issue of storage will not be a problem. Un-
can have a profound effect on patient response and til then, however, judgment regarding the keeping of
should be recorded and, where possible, acted upon. records beyond statute or mandated time frames is a
These acronyms could be followed with appropri- decision for each practitioner to make.
ate explanation, for example, “sick child,” “resched-
uled for tomorrow,” or “refused reevaluation or MRI Documentation
examination.” Documentation may be composed of portions or all of
A patient’s failure to fully participate in the pa- the following information, depending on clinical need
tient’s own well-being should be fully charted. Issues and circumstances (Table 36–1).
warranting notation include A carefully written employee handbook can im-
prove morale, prevent disagreements, and help to pro-
• Failure to keep scheduled appointments. vide a sound risk management process to the office
• Failure to perform at-home therapy or exercise. function. Included in this handbook should be poli-
• Refusal to adopt weight-reduction or other recom- cies on patient confidentiality and office policy regard-
mended lifestyle changes. ing violation of the policies regarding patient privacy;
• Resistance to advice, including taking time off these policies should attempt to be HIPAA-compliant
from work, avoiding lifting, and foregoing house- and meet the latest mandated requirements.
TABLE 36–1. The Composition of Documentation
Internal Documentation External Documentation Patient Consents
Doctor/clinic identification Direct correspondence Informed consent

Patient identification Health records Consent to treat minors
Patient demographics Diagnostic imaging reports Authorization to release patient information
Patient history External reports Financial assignments
Examination findings Consent to participate in research
Special studies Publication and video consent
Treatment plan Authorization to admit observers
Chart/progress notes
Reexamination/reassessment
Financial records
Health care coverage
information
Doctor/Clinic IdentificationBasic information identify- • Marital status

ing the practitioner or facility should appear on the • Race
documents used to establish the doctor–patient rela- • Number of dependents
tionship. This can be preprinted on forms, affixed by • Employer, address, phone number
rubber stamp or adhesive labels, or typed or hand- • Spouse’s occupation
written in ink. Basic information should include:
• Practitioner’s name Health Care Coverage Health care coverage informa-

• Specialty designation (if applicable) tion is important for the business function of a health
• Facility name (if different) care facility, and such records are a part of the health
• Legal trade name (if applicable) care record. However, the information obtained and
• Street address and mailing address (if different) the format used are at the discretion of the practitioner.
• Telephone number(s) (may also include fax num-
bers and e-mail address) • Current incident report of accident or injury
• Insurance company or responsible party (auto/
Clear identification of the patient
Patient Identification
worker’s compensation/health/other)
with relevant demographic information (see Patient • Group and policy numbers, effective date
Demographics below) is a necessary component of the • Spouse’s insurance company and policy informa-
chart. This information can be obtained with ease by tion (if applicable)
using preprinted forms for completion by the patient.
Identifying information might include:
Patient History This is the foundation of the clinical
• Case/file number (if applicable) database for each patient. The practitioner may choose
• Name (prior/other names) to enter this data on a formatted or unformatted page.
• Birth date, age There should be an adequate picture of the patient’s
• Name of consenting parent or guardian (if patient subjective perception of the history. Important ele-
is a minor or incapacitated) ments of the history might include:
• Copy of letter of guardianship (where appropriate)
• Address(es) • Date history taken
• Telephone number(s) (home and/or business) • Present complaint/chief complaint
• Social security number (if applicable) • Description of accident/injurious event or other
• Radiograph/lab identification (if applicable) etiology
• Contact in case of emergency (closest relationship • Past history, family history, social history (work
name/phone number) history and recreational interests, hobbies as
appropriate)
Patient Demographics
• Review of systems (as appropriate)
• Gender (M or F) • Past and present medical/chiropractic treatment
• Occupation (special skills) and attempts at self-care
• Any clinical considerations which may pose con- be considered experimental or investigational be-
traindications to treatment cause they are new and unproven. The routine use
• Signature or initials of person eliciting history of technological procedures is inappropriate and
may make their utility suspect. There are excellent
articles and texts available for clinicians to review
Examination Findings Objective information relative to
in order to provide proper criteria for diagnostic
the patient’s history is obtained by physical as-
testing.
sessment/examination of the area of complaint and
• Other chiropractic examination procedures: The
related areas and/or systems. Gathering and record-
uniqueness of the chiropractic evaluation relative
ing this information may be facilitated by use of
to obtaining baseline information is important to
preprinted and formatted examination forms. The ini-
determine and document for specific chiropractic
tial examination, at minimum, will be focused on
relevance. These include, but are not limited to,
the area of chief complaint. The initial examination
static and motion palpation, posture analysis, and
provides an excellent opportunity to begin the im-
dynamic function analysis.
portant process of patient education, which enhances
the doctor–patient relationship. Such documentation
should include the date of the examination and name A sample physical examination form (Fig. 36–4) is
or initials of the examining practitioner. It is also rec- included for reference purposes.
ommended that if persons other than the primary ex-
amining practitioner perform and/or record elements Reports and results of special
Findings of Special Studies
of the objective examination, their names and/or ini- studies become a component part of the contempora-
tials should appear on the examination/data form. neous file. This documentation should include date
Depending on clinical circumstances, such evalua- of study, facility where performed, name of techni-
tions might include: cian, name of interpreting practitioner, and relevant
findings. Special studies ordered by the practitioner
• Vital signs such as height, weight, temperature, might include:
pulse, respiration, and blood pressure. Vital signs
provide the doctor of chiropractic an opportunity • Diagnostic imaging (e.g., plain film radiography,
to discuss the autonomic nervous system and its CT scan, magnetic resonance imaging, diagnostic
role in the health of the individual. ultrasound, radionuclide bone scan)
• Physical examination: The extent of physical exam- • Neurophysiologic/electrodiagnostic testing (e.g.,
ination is usually dependent upon the informa- nerve conduction velocities, electromyography,
tion gleaned from the case history. If the patient somatosensory evoked responses)
presents with a focused complaint with no signif- • Other laboratory tests (e.g., blood analysis, urinal-
icant other current or past history of illness or in- ysis, cultures)
jury, the examination may be limited to evaluation
of the current complaint. If the history includes
Miscellaneous Assessment and Outcomes Instruments
information on other related or distinct health is-
sues, the examination may need to be expanded to Various assessment and outcomes instruments can
include evaluation of these other health issues, or contribute to clinical management and become part of
referral to another specialist may be considered. the case record. These outcomes measures are impor-
• Neuromusculoskeletal examination: The neuromus- tant tools in patient care, and provide objective mea-
culoskeletal examination may be conducted in sures of patient status. These may be completed on the
stages, depending on clinical need and may well initial examination and many of these instruments are
involve the central, peripheral, and/or autonomic used in a repeated or serial fashion, which provides
nervous system. the doctor with objective documentation regarding
• Instrumentation: When using instrumentation, it is patient progress. It is for this reason that it is essential
important to determine the medical necessity and for the record to identify the date(s) of completion and
clinical utility of any test or instrumentation. Tests name(s) of the scoring practitioner/technician. Mea-
and instrumentation should be used only when surement instruments currently in use include:
additional information is needed to guide the doc-
tor to a treatment plan. In many cases, there is a • Visual analogue scale
limitation to the available technology. Some tech- • Pain diagrams
nological procedures have a high rate of false neg- • Pain questionnaires (e.g., McGill)
atives or false positives, some have little proven • Pain disability instruments (e.g., Oswestry, neck
validity for certain conditions, and others may disability index)
A B
C D
FIGURE 36–4. Sample physical examination form.
• Health status indices (e.g., SF-36, sickness impact The Outcome Assessment Program including Out-
profile) comes Assessment 2002 CD-ROM and the book, The
• Patient satisfaction indices Clinical Application of Outcomes Assessment, by Kim
• Other outcomes measures Christensen and Steven Yoemans, can be ordered from
FCER, 704 E. 4th Street, Des Moines, IA 50309 (web
Available SourcesA complete package of materials on site: www.outcomesassessment.org).
survey forms/instruments can be obtained by writ- Clinical Impression Upon completion of the subjective
ing The Chiropractic Report, 3080 Yonge Street, Suite and objective database, the practitioner formulates a
5065, Toronto, Ontario M4N 3N1 Canada (web site: clinical impression or working diagnosis. It is impor-
www.chiropracticreport.com). tant to note that following the initial case history and
examination, a definitive diagnosis may not be possi- ciently complete to provide reasonable information if
ble with the information available. It may be equally as requested by a subsequent health care provider, insur-
significant to note that preliminary consideration has ance company, and/or attorney (e.g., progress notes,
been given by the provider to “red flags” for poten- SOAP [subjective (data), objective (data), assessment,
tially serious conditions, for example, neurologic in- and plan (problem-oriented record)] notes). A dated
volvement, vascular compromise, and infection. The record of what occurred on each visit and any signif-
initial clinical impression should be recorded within icant changes in the clinical picture or assessment or
the file or in the contemporaneous visit record. Be- treatment plan should be noted. The method in which
cause the clinical impression may change with new chart notes are recorded is a matter of preference for
clinical information or in response to treatment, it is each practitioner (see Fig. 36–3).
important that each clinical impression be dated. The
record might include: Reexamination/Reassessment All relevant information
from the assessment and reexamination should be
• Primary, secondary, and/or tertiary elements of di- recorded in the patient file. Negative findings are of-
agnosis ten as relevant as positive findings. For example, if a
• Appropriate diagnostic coding (e.g., International patient presents with low back pain and associated
Classification of Diseases–Clinical Modification leg pain, a negative straight-leg raise test is as rele-
[ICD-CM]) vant as a positive test, signifying referred pain versus
Treatment Plan This management plan will outline the radicular pain.
short- and long-term treatment goals and provide a
Financial Records Financial records are important for
framework from which patient care will be rendered.
the business function of a health care facility, and such
This arises from the accumulation of clinical data and
data is part of the health care record. It is often help-
the formulation of the initial clinical impression. The
ful to keep financial records and clinical records sep-
plan may include further diagnostic testing to mon-
arate to facilitate simplicity of chart review. This pro-
itor progress, or a therapeutic trial to test clinical
vides ease of reviewing relevant patient-centered care,
impressions and assess the appropriateness of
and also separates the financial issues from the clinical
treatment procedures selected. The treatment plan
issues within the chart. Financial records include:
documents the approach to management by the
practitioner and staff (e.g., spinal adjusting, therapy • Billing statements
modalities, recommended exercise regime, lifestyle • Explanation of benefits from payors
and dietary modifications). Any plan for referral to • Proof of payment
or consultation with other health care providers is ap-
propriately listed in the record. The written treatment Internal Memoranda Recording Patient Visits
plan may appear on a form dedicated to the clinical
workup or in the contemporaneous visit record, and • Patient sign-in sheets: Patient sign-in sheets should
might include: be reviewed when the new HIPAA compliance
regulations become effective. Creative ways to
• Diagnostic/reassessment plan: It is helpful to iden-
obtain sign-in by the patient are available if it is
tify a time frame for reassessment after initiating
determined that sign-in sheets are a necessary and
a clinical trial, or to consider a plan of action if
desired record to obtain.
unexpected circumstances arise.
• Staff messages (intraoffice): Care must be exercised
• Practitioner’s treatment plan (modes and frequency of
and staff should be made aware of the sensitive
care): In addition to the adjusting procedures to
nature of any and all records that are permanently
be used the plan might also include nutritional
part of the patient’s file.
recommendations, a therapeutic exercise program,
• Phone messages and summaries/transcription of
adjunctive modalities, orthotic/bracing care, and
patient conversations: Maintaining a record of mes-
other care considered appropriate.
sages often helps to document patient compliance
• Patient education and self-care plan: It is helpful to
or discussions relative to additional testing or
have some mechanism to monitor the compliance
referral.
with the self-care plan in order to accurately deter-
mine the effectiveness.
• Intra- or interdisciplinary referral or consultation. EXTERNAL DOCUMENTATION
Chart/Progress Notes Once the initial patient workup External documentation includes all records arising
is complete, all record entries should be made in a sys- from outside the practitioner’s office, but also includes
tematic manner. The patient’s records should be suffi- any communication with third parties.
Correspondence in the form of letters or mem- of consent is one that is objectively documented (e.g.,
oranda to leave the office should have information a witnessed written consent or videotape).
identifying the practitioner and/or clinic, address,
and telephone number, and be contemporaneously Consent to Treatment—Competence
dated. A copy must always be kept on file, including: A patient must be competent to give consent to treat-
ment. The treatment of minors (the age of majority at
• Introductory letter(s) to or from referring practi- which a young adult can give consent varies from 14
tioner (DC, MD, etc.) to 21 years depending on the jurisdiction) and men-
• General correspondence to or from other practi- tally impaired adults requires the prior consent of a
tioners parent or guardian in most circumstances.
• General correspondence to or from attorney(s)
Authorization to Release Patient Information
• General correspondence to or from patient
• General correspondence to or from various payor With the consent of a competent patient or guardian,
groups records may, and in most situations must, be provided
to third parties with a legitimate need for access. The
patient consent should not be more than 90 days old,
Health Records
or within the time period provided by law. Whenever
In addition to correspondence, copies of the following health care information is released pursuant to autho-
should be kept in the patient’s file: rization from a patient, documentation of the autho-
rization should be requested and retained (except in
• Pertinent copies of health records from previous some emergencies). If the request is for all or part of the
or concurrent health care providers health care record, the original record should never be
• Special consultative reports released, unless required by law. In most cases, copies
• Reports of special diagnostic studies are acceptable for submission. Before any records are
sent out, they should be reviewed to make certain they
Diagnostic Imaging comply with the original request for records and have
current patient authorization.
When indicated, a reasonable attempt should be made
to obtain recent imaging studies (or copies) that are Financial Assignments
relevant to the presenting problem of the patient and
While financial data is important for the business func-
that summarize and record pertinent information. If
tion of a health care facility, and such records are in-
the practitioner does not have expertise in interpreting
deed part of the health care record, the information ob-
certain studies, then a copy of the study report should
tained and the method of acquiring such information
be obtained.
is at the discretion of the practitioner. Any alteration
of standard fees charged necessitates documentation
Reports
(e.g., in cases of financial hardship, by contract).
Frequently, a practitioner is required to write a formal
report. The information for such a report comes from Publication/Photo/Video Consent
patient records. Adequate reporting usually requires All records from which a patient may be identified
the practitioner to review the patient’s history, ex- (e.g., photographs, videotapes, audiotapes) should
amination findings, diagnoses, treatment procedures, only be created once consent has been obtained. Such
progress notes/work chart, and other reports that may consents should identify the purpose of the record and
have been written, together with records from other the circumstances under which it will be released.
health care providers who have treated or evaluated
the patient. Authority to Admit Observers
Persons not participating in the treatment of the pa-
tient should not be permitted to watch examinations
PATIENT CONSENTS
or procedures without authorization from the patient.
Informed Consent/Consent to This principle is subject some exceptions where the
Treatment—General patient is a minor.
Patient consent or approval to treatment in some man-
ner is necessary. It is, for the most part, implied rather CHART/FILE ORGANIZATION
than expressed. However, where there is a higher per-
ceived risk of harm (“material risk”) from a recom- General Considerations
mended treatment, this risk should be disclosed, un- Records should be kept in chronological order and en-
derstood, and accepted by the patient. The best record tered as contemporaneously as possible. They should
not be backdated or altered. Corrections or additions well as a legal one. Assurance of confidentiality is nec-
should be dated and initialed. The card or file should essary if individuals are to be open and forthright with
be fully documented and contain all relevant, objec- the practitioner. Patients rightly expect that such in-
tive information; extraneous information should not formation about their health will remain private and
be included. The record should be complete enough to secure from public scrutiny, thus the principle that
provide the practitioner with information required for all doctor–patient communications are privileged and
subsequent patient care or reporting to outside par- confidential.
ties. The information should accurately reflect each
patient encounter. The data should be patient-specific. Records Retention and Retrieval
Boilerplate charting systems or software programs de- Health records should be retained and in a way that
signed to expedite chart notes can be problematic be- facilitates retrieval. To the extent possible, they should
cause the treating provider or subsequent providers be kept in a centralized location. In most circum-
must rely on potentially nondescript data. This stances, recent records are maintained on premises
type of reporting often becomes difficult to support either as hard copy or electronically, and after a pe-
medical/chiropractic necessity for reimbursement riod of time can be archived or microfilmed, or put on
purposes. When information is not patient-specific or microfiche and placed in storage. The length of time
creates duplicative phrases that create the impression that records, in whatever form, must be kept varies.
of “routine rubber stamp” chart notes, credibility is Many states/provinces have legislated minimum pe-
often lost. riods of time for retention of health records, usually
between 5 and 15 years. When the decision is made
Use of Preprinted Forms to dispose of health records, the manner of disposal
The use of preprinted forms can assist in tasks such must protect patient confidentiality. If a chiropractic
as obtaining a case history, noting examination find- office closes or changes ownership, secure retention
ings, and charting case progress. Use of forms is at the of the health care record should be ensured.
discretion of the individual practitioner, but should fa-
vor comprehensiveness and completeness rather than Administrative Records
brevity. Administrative records are primarily those relating to
the nonclinical side of practice, but there is some over-
Legibility and Clarity lap into the doctor–patient relationship. Examples of
Health records must be legible and should be neat, administrative records include telephone logs, sched-
organized, and complete. Entries in charts should be ule and record of appointments, patient personal data
written in ink. Entries should not be erased or altered information, insurance forms and billing, collection
with correction fluid (whiteout), tape, or adhesive la- and patient billing, routine correspondence, and a
bels. If the contents of any document are changed, the record filing system that makes for accurate retrieval
practitioner should initial and date such changes in of patient data. These records must be maintained in
the corresponding margin. a legible and retrievable format.
Records Transfer
Use of Abbreviations/Symbols
It is mandatory that health care data (excluding data
The use of abbreviations or coding can save record
and reports from outside sources) requested by an-
space and time. A legend of the codes or abbreviations
other provider currently treating a patient or former
should appear on the form or be available in the office
patient be forwarded upon receipt of an appropriate
in order that another practitioner or interested person
request and patient consent. In some jurisdictions, this
can interpret and use the information. The legend can
duty to forward information to another treating health
also be used for intraoffice communications and as a
professional is imposed by statute. However, even in
dictation aid.
the absence of a statutory requirement, a practitioner
has a responsibility to comply with such a request,
and as expeditiously as possible.
RECORDS MAINTENANCE
Confidentiality Clinic Staff Responsibilities
The rule of confidentiality requires that all informa- The practitioner is responsible for staff actions regard-
tion about a patient gathered by a practitioner be kept ing record keeping and consent forms, and for en-
confidential unless its release is authorized by the pa- suring that administrative tasks are handled correctly
tient or the patient’s guardian in case of a minor, or is and promptly. Any employee involved in the prepa-
required by law. The rule is an ethical responsibility as ration, organization, or filing of records should fully
understand professional and legal requirements, in- 5. Do not indent. It is better to leave no blank space
cluding the rules of confidentiality. A more thorough within the record. However, if indenting is used,
review of this subject may be found in Professional it should be consistent throughout all records.
Chiropractic Practice: Ethics, Business, Jurisprudence and 6. Line through blank spaces. See recommendation 7.
Risk Management, listed in the Key References below. 7. Properly identify the record. Each record should
include the date and some practitioners are also
including the time the entry was made. Each suc-
cessive page or card should record the patient’s
RECOMMENDATIONS ON RECORD KEEPING
name and the date. That step affords protection in
1. Do not erase. Whether an erasure results from im- two ways. First, it minimizes the risk of misplacing
mediate recognition of an error or is made later a page. Second, it also reduces the risk that a sheet
for the sake of accuracy, it can adversely affect the or card from one patient’s file could get mixed in
credibility of the record. The recommended way with another’s, or accidentally copied and passed
to make a change is to cross through the erro- along to outsiders.
neous information (without obliterating it), insert 8. Fill in all blanks. It is recommended that all sections,
the correction, initial it, and date it. Another pro- especially on preprinted forms, be completed if
cedure that can be used after an inaccurate entry clinically relevant, or crossed through, marked
has been lined-through is to note “error: see be- with N/A (not applicable), or some other notation
low (date)” and then move to the first available used where not clinically relevant.
lines to record the entry properly, stating that it is 9. Don’t say or write anything disparaging about the pa-
a correction. The doctor should date and initial the tient. It is a practice that the doctor and staff should
information. This method of correcting entries has be cautioned against simply because any comment
the benefit of added credibility as a result of entry becomes part of the patient’s permanent record
sequence. Subsequent entries will follow it in due and an insensitive comment can easily be miscon-
order. There is no reason to infer that the record strued.
was improperly altered at some later, more criti- 10. Avoid judgmental words. Words that judge or criti-
cal, date. Revisions or additions to data should not cize a patient should be avoided.
be entered after receipt of a records subpoena or 11. Identify the record keeper. Each entry should be fol-
once it becomes probable that there will be litiga- lowed by the signature or initials of its author. This
tion in which records will be relevant. Alteration of is important in order to identify who authored
records in some jurisdictions carries very specific each entry in the record, particularly if staff mem-
penalties (e.g., Texas, Ohio) and any implication bers enter data and new staff are added or former
may impugn the reputation of the practitioner. staff replaced.
2. Maintain records in ink. Making notes in pencil 12. Don’t enter data prematurely. No entry should ever
invites suspicion that records could be altered eas- be made before the procedure is actually per-
ily. “Penciled” notes are scrutinized more carefully formed. Standard procedures encourage the fill-
than those entered with ink, and an expert can eas- ing out of insurance forms, for example, before an
ily detect the best-concealed erasure. The use of x-ray series is actually performed. Filling them out
ink helps to avoid even the possible appearance of in advance, however, can create confusion, and if
impropriety. for some reason the tests are not performed, the
3. Do not skip lines or leave spaces. The importance of form can be inadvertently sent in to an insurance
not allowing space in the records will greatly re- company.
duce any suggestion of records alteration. 13. Maintain legibility. The usefulness of records is vir-
4. Do not “squeeze in” notes. The caveat that doctors tually negated if they must be interpreted. Print-
not “squeeze” notations within records is a corol- ing, with capitals at the beginning of sentences
lary to recommendation 3. If no lines are skipped and standard punctuation, is best. While person-
and no blanks are left (other than reasonable and alized “short-hand” is permissible, a legend must
uniform margins), there will be no room for sub- be available and provided to those with a legal
sequent or additional entries. If entries are rou- right to the records.
tinely scribbled in margins, inserted with arrows 14. Be consistent. Whatever system is used should
and wedges, written between existing lines, and be consistent throughout the records. Variance in
the like, it is frequently impossible to tell what was spacing, for example, gives rise to questions re-
original and contemporaneous or at what time var- garding the lack of consistency.
ious changes were made. When an entry is unusual 15. Avoid or explain contradictions. If information on
and made to conform with recommendation 7, a different forms appears contradictory, an expla-
“squeezed-in” note is acceptable. nation should be provided.
16. Document unusual events. All unusual events such so as long as someone else reviewing the records
as patient disorientation, falls, or equipment fail- can decipher them.
ures should be recorded. 26. Any release of records authorization should be current
17. Avoid ambiguous words. Entries such as “better to- and valid. Beware of authorizations that purport to
day” may convey very different impressions de- revoke prior authorizations. If a doctor released
pending upon the reader. The doctor should add information after receiving such notice to anyone
some description of what was observed, what the other than the recipient named in that release, the
patient said, and what prompted the conclusion doctor has violated the patient’s right to confiden-
that the patient was “better.” tiality. Some authorities suggest the authorization
18. Record all patient contact. Each patient contact with should not be more than 90 days old. It is best to
doctor or staff should be recorded. Conversa- check with your state board, and if appropriate,
tions, whether personal or by telephone, should the patient, when a request for release of records
be logged if it pertains to clinical matters. The en- is obtained.
try should identify the means of communication, 27. Keep financial and clinical information separated. The
the date and time, who initiated the contact, the appearance that a doctor is primarily interested
details of the conversation, and particularly any in the doctor’s own remuneration can be created
instructions given the patient. when many forms have questions about insur-
19. Don’t criticize other providers. If a patient criti- ance, liens, assignment, and other compensation
cizes the care of another provider, document the details. The doctor must be aware, however, that
patient’s account of the events (i.e., outcome of financial records are part of the health care record,
prior treatment). Personal commentary of other including:
providers’ activities should be avoided. • Patient account ledgers
20. Exclude frivolous remarks. Attempts at humor or • Billing statements
other entries that do not bear upon patient care • Explanation of benefits
should be avoided. Frivolous comments suggest a • Proof of payment
lack of professionalism. They can prove extremely 28. Individualize the forms used. The best form for any
embarrassing and upsetting to a patient who gains doctor is one that fits a personal practice style. The
access to his or her records. doctor using forms is encouraged to take them and
21. Don’t use two different pens on the same day’s en- tailor them to meet the individual needs, practice
try. Even if the ink color is the same, two pens style, office efficiency, and clinical procedures of
will likely have inks which have radically dif- the doctor’s office.
ferent components. Experts are very much at- 29. Review and archive files. Upon periodic file review,
tuned to the ink markers on documents examined outdated portions may be removed and stored in
for alteration. Different pens, particularly if the an archive file. A permanent note should be kept
inks were manufactured a long time apart, can in the active file indicating that the patient has
make it appear that the records may have been additional records.
altered. 30. Document patient noncompliance. No doctor is re-
22. Don’t alter records. If additions or clarification need quired to condone missed appointments or other
to be made to a record, use the recommendation instances of patient noncompliance that can hin-
listed above. It is an important rule to never im- der treatment. If the noncompliance reaches the
properly alter records. point of jeopardizing good-quality care, the doc-
23. Initial reports (x-ray, lab, consultant’s) before filing. tor should consider formally discharging the pa-
This simple expedient will ensure that important tient with an appropriate documented and formal
information is not overlooked and filed away pre- letter of withdrawal.
maturely. It will also allow the doctor to corrobo- 31. Proofread correspondence and reports. The now com-
rate, if necessary, that a particular report was, in mon practice of sending professional correspon-
fact, reviewed. dence bearing the notation “dictated but not read”
24. Computer-generated notes should be individualized. is unseemly.
Often, computer-generated notes are boilerplate
in nature and do not contain clinically relevant,
patient-specific information. These types of “scan-
SUMMARY
ning” systems should be avoided, or methods to
personalize the data should be implemented. 1. Complete and accurate patient records are es-
25. Maintain a legend for any codes used. Many doctors sential to ensure the highest quality of care.
use various codes and symbols in maintaining They provide documentation of the immediate
their records. There is nothing wrong with doing care and treatment of the patient, enabling the
current provider, and any subsequent providers, be kept. If storage facilities are available, records
access to important information about the patient’s should be kept as long as possible. Requests for
clinical status and effects of therapies to date. This records should be handled as efficiently as possi-
helps direct future treatment and ensures proper ble and documented in writing.
continuity of care if several providers are involved. 8. There are many suggestions one may find helpful
Records also form the basis for producing accurate to improve the record-keeping process. For exam-
reports to other health care providers, insurance ple, do not erase; use ink only; do not leave empty
companies, attorneys, and other interested parties. spaces; avoid judgmental, criticizing, or disparag-
Patient records may also be used for public health ing remarks; do not enter data prematurely; initial
purposes, teaching, and clinical research purposes. and date all entries; be legible; record all encoun-
2. While there is no universal standard for record ters; keep a legend of abbreviations used; and do
keeping, groups such as managed care organi- not alter records.
zations, the National Council for Quality Assur-
ance, state boards of examiners, and federal pro-
grams such as Medicare and Medicaid have all QUESTIONS
developed guidelines or specific requirements for
1. What are the two ways that a subluxation may be
record keeping. Practitioners must also be aware
documented based on federal Medicare require-
of record-keeping requirements from contractual
ments?
agreements with managed care entities, third-
2. When a patient is noncompliant with recommen-
party payors, and insurance companies.
dations regarding his or her treatment and other
3. Patient records should include contact informa-
health issues, what is a reasonable course of action
tion on the treating doctor(s) or clinic, patient con-
for the provider to take?
tact and demographic information (gender, date
3. How long should a provider retain patient files?
of birth, occupation, social security number, emer-
4. What is the general rule of patient confidentiality?
gency contact, etc.), health care coverage or finan-
5. What is the recommended method of making cor-
cial information, patient history, examination find-
rections or additions to a patient record?
ings, special studies results, outcomes measures to
document progress, clinical impression, treatment
plan, chart notes, and reexaminations,
ANSWERS
4. External documentation includes correspondence
from other practitioners, attorneys, patients, and 1. Subluxation may be demonstrated by x-ray taken
payor groups, health records from other practi- reasonably proximate to the initiation of treatment,
tioners, results of outside diagnostic testing, and or by physical examination using the PART for-
any reports prepared by other providers related to mula.
the patient. 2. Make notations in the record of the nature of the
5. Patient consent to treatment is necessary and patient’s noncompliance, warn the patient of the
should be documented, where relevant, in writing. potential effects of the noncompliance, and if the
Minors and mentally incompetent adults cannot provider feels that the noncompliance is a potential
give consent, which must be obtained from a par- health risk, formally discharge the patient.
ent or legal guardian. Consent to disclose or release 3. Files must be retained at least as long as state
confidential records should also be documented in statutes of limitation require. However, consider-
writing. A consent to office financial policies can ation should be given to retaining records longer
also be obtained, but is not required. based on practicality, economics, and available
6. Entries should be recorded as soon as possible fol- space.
lowing an event and dated to ensure chronolog- 4. The general rule of patient confidentiality is that
ical order. Only relevant information should be all information about a patient gathered by a prac-
recorded; extraneous information should not be titioner be kept confidential unless its release is au-
included. Records should be specific to each pa- thorized by the patient, the patient’s legal guardian
tient and care must be taken to avoid generic or in case of a minor, or is required by law.
meaningless entries. Preprinted forms may save 5. Corrections and additions to a patient’s record
time and improve legibility and clarity. should be made in a manner that does not delete
7. As the custodian of patient records, practition- or otherwise obscure previously recorded infor-
ers must ensure complete confidentiality of such mation. Do not white out or cross out, only cross
records for the entire time of their possession. State through. Any added information should be dated
laws differ as to the length of time records must and signed by the person making the notation.
and sample letter book. Palmerton, PA: PracticeMakers

KEY REFERENCES
Products, 2000 (web site: www.practicemakers.com).
Chapman-Smith D. The chiropractic profession. NCMIC Ladenheim C, Sherman RP, Sportelli L. Professional chiroprac-
Group, West Des Moines, IA, 2000. tic practice: Ethics, business, jurisprudence and risk man-
Current procedural terminology (CPT) 2000. Chicago: Ameri- agement. Palmerton, PA: PracticeMakers Products, 2001
can Medical Association, 1999. (web site: www.practicemakers.com).
Fuller Delong M. Medical acronyms and abbreviations, 2nd Medicare’s national level II codes, HCPCS, 2000, 12th ed.
ed. Practice Management Information Corporation, Chicago: American Medical Association, 1998, (web site:
Oradell, NJ, 1989. www.hgsa.com/professionals/policy/z6g.html).
Haldeman S, Chapman-Smith D, Petersen DM Jr. Guidelines Miller KJ. Practical assessment of the chiropractic patient. MPA
for chiropractic quality assurance and practice parameters. Media, Huntington Beach, CA, 2002.
Gaithersburg, MD: Aspen, 1993. US Department of Health and Human Services. Acute low
Haldeman S. Principles and practice of chiropractic, 2nd ed. back problems in adults, clinical practice guideline, number
East Norwalk, CT: Appleton and Lange, 1992. 14, Publication No. 95–0642. Rockville, MD: AHCPR,
Ladenheim C, Sherman RP, Sportelli L. The chiropractic form 1994 (web site: http://www.ahcpr.gov/data/).
S E C T I O N
INTRODUCTION TO SPECIFIC
IV
TREATMENT METHODS
Spinal manipulation has been the predominant form and mechanically assisted manipulation, are described
of treatment used by chiropractors during the profes- as illustrations of the diversity of this treatment ap-
sion’s existence. The evidence supporting the efficacy of proach. The chapter concludes with a presentation of
manipulation, particularly spinal manipulation, was dis- clinical models that have been used to explain the role
cussed in earlier chapters and continues to grow. There of spinal manipulation and direct treatment.
are now a number of conditions for which manipulation In Chapter 38, Tom Bergmann describes the use
performs favorably when compared to other commonly of the high-velocity low-amplitude (HVLA) thrust tech-
used treatments. Along with the growing number of clin- niques that are the most common and oldest form of
ical trials, research in the basic sciences continues to manipulation or adjustment offered by the chiroprac-
provide us with a better understanding of the mecha- tic profession. He distinguishes between the use of
nism through which manipulation may bring about these short and long levers, and differentiates between spe-
clinical changes. Cost-effectiveness and patient satisfac- cific and general hand contacts on spinal tissues or
tion studies also tend to favor manipulation and chiro- structures that define the subtypes of HVLA manipula-
practic care over other forms of treatment, particularly tion. Dr. Bergmann briefly discusses the forces involved
in the management of back and neck pain. in thrust techniques, and the theoretical effects of these
While the chiropractic profession and spinal manip- forces on the spinal tissues, including the joint cavitation
ulation are closely linked, manipulation is not the only that is one of the distinguishing features of the HVLA
tool used by chiropractors. Nor is manipulation limited thrust. The chapter concludes with a discussion of some
to the spine. Chiropractors have used various forms of of the principles and methods of applying these adjust-
physical modalities through most of the profession’s ex- ment techniques.
istence, and have long espoused the value of good nutri- In Chapter 39, John Scaringe and Craig Kawaoka
tion, exercise, and a positive outlook on life. This section describe a variety of nonthrust and mobilization tech-
looks at the predominant forms of treatment that are niques. The authors provide an overview and histori-
used by chiropractors in their efforts to relieve pain, im- cal context for the use of the mobilization techniques,
prove function, and enhance the quality of their patients’ define and describe the categories of mobilization pro-
lives. cedures, and discuss the use of the different methods
To begin this section, Chapter 37 focuses on the ba- or techniques. Drs. Scaringe and Kawaoka review the
sic principles of the chiropractic adjustment, or spinal rationale, indications, and contraindications for these
manipulation. This chapter briefly reviews the history techniques and outline treatment protocols for some of
of manipulation within the practice of chiropractic and these procedures. The authors discuss the more com-
documents a few of the significant contributions to the mon theories used to explain the effects of mobilization
evolution of the chiropractic adjustment, including the on spinal tissues and conclude with a discussion of ex-
meric system, the concept of major and minor sublux- amples of some of the more popular mobilization proce-
ations, and the recoil adjustment. This is followed by dures applied to the spine and extremities.
a brief review of the classification systems that have While the chiropractic adjustment is usually asso-
been developed to describe the chiropractic adjustment ciated with the application of higher-amplitude forces
and other spinal manipulation techniques. A few of the to the spine by manual methods, a number of low-
more common chiropractic techniques, including high- force adjusting techniques that use instruments to ap-
velocity, low-amplitude thrusts, toggle recoil, joint play, ply the force have been developed over the years. In
743
744 SPECIFIC TREATMENT METHODS
Chapter 40, Arlan Fuhr discusses the history and de- Many chiropractors use the multiple physical modal-
velopment of the use of adjusting instruments in the ities available either as independent therapy or in con-
chiropractic profession. He describes the development junction with manipulation. In Chapter 44, I look at the
of the so-called Activator adjusting instrument (AAI), one use of the various forms of physical modalities and
of the more widely used alternatives to manual adjust- the role they play in the treatment of spinal prob-
ments. Fuhr describes the use of specific methods of lems. The use of these so-called passive modalities is
examining patients to determine the necessity for this generally considered important as part of a cohesive
treatment approach and concludes with a discussion of treatment plan. The many forms of applying thermal
the rationale and theoretical models, as well as the lit- agents and electrical currents are then reviewed, as
erature supporting this method of adjusting. well as the use of more standard traction devices,
Many, if not most, practicing chiropractors use a va- supports, and orthotics. The chapter includes a dis-
riety of soft-tissue, nonmanipulative, manual treatment cussion of the indications, contraindications, and treat-
techniques in their approach to patients with spinal ment protocols for the use of these various physical
problems. In Chapter 41, Stephen Perle discusses modalities.
such concepts as muscle shortening, myofascial trigger Acupuncture, acupressure, and trigger point tech-
points, muscle injuries and strains, and tendon injuries, niques have become more popular treatment ap-
as well as soft-tissue barriers, and reviews how these proaches in the past decade. In Chapter 45, John
soft-tissue injuries may be amenable to soft-tissue man- Amaro provides an interesting overview of the use of
ual treatment methods. He then describes a number acupuncture and other reflex-point techniques, and the
of the more popular soft-tissue manual techniques, in- manner in which these procedures have been incor-
cluding muscle energy techniques, trigger point therapy, porated in the practice of chiropractic. The use of
active release techniques, and Graston instrument- acupuncture is described in terms of both traditional
assisted soft-tissue manipulation. Chinese medicine and Western or scientific theory.
Traction, with or without a manipulative thrust or These therapies can be applied by means of acupunc-
pressure, is a common tool used by chiropractors, and ture needles and different needling techniques, or can
is also one of the oldest methods of treating spinal disuse finger pressure, electrical stimulation, and laser
orders. Chapter 42 by James Cox and M.R. Gudavalli therapy in an attempt to stimulate the acupuncture
provides an overview of spinal traction and places it in points. The relationship between acupuncture points
historical context. The multiple forms of traction are and the classic trigger points is discussed and a brief
defined and described, with particular attention pro- overview of the literature and the mechanisms and clin-
vided to the use of flexion/distraction-aided spinal ma- ical trials supporting acupuncture is provided.
nipulation. The literature addressing the use of flexion/ Chapter 46 by Craig Liebenson and Clayton Skaggs
distraction-aided spinal manipulation is reviewed, and provides an overview of the use of active care (reha-
treatment protocols are provided. The chapter dis- bilitation) that is increasingly being integrated into the
cusses the rationale and indications for the various practice of chiropractic. The authors define and de-
forms of spinal traction, as well as potential contraindi- scribe the subcategories of active care and provide
cations and complications of this treatment approach. an overview of the biopsychosocial model of back pain.
With the increased interaction between chiroprac- The literature addressing the use of active care tech-
tors and medical specialists there has been resurgence niques for patients with back pain is reviewed and treat-
in the use of medication to assist in the administration ment protocols using various forms of active care are
of spinal manipulation. In Chapter 43, Frank Kohlbeck outlined. Drs. Liebenson and Skaggs discuss the ra-
reviews the use of manipulation that is performed while tionale and indications for the various forms of active
the patient is under sedation or in combination with the care, as well as any potential contraindications and
administration of local anesthetic, steroid, or scleros- complications from this treatment approach. They con-
ing injections. This chapter provides an overview and clude with a review of the specific outcome measures
historical context of treatment protocols that combine commonly used to assess the efficacy of rehabilitation
spinal manipulation therapy with the administration of programs.
adjuvant medication. Definitions and descriptions are I would like to thank each of the authors for their
given for the subcategories of medicine-assisted manip- contributions to this section and to this text. This work
ulation, and the published clinical trials and limitations will provide the reader with a greater understanding of
of these studies are reviewed. Treatment protocols for the various tools and techniques that are used by chiro-
specific subcategories of medicine-assisted manipula- practors in an attempt to reduce pain and suffering in
tion are outlined, and the rationale and indications for their patients.
each are discussed. Paul D. Hooper
C H A P T E R
37
EVOLUTION AND BASIC PRINCIPLES OF
THE CHIROPRACTIC ADJUSTMENT AND
MANIPULATION
Paul D. Hooper
O U T L I N E
INTRODUCTION Types of Manipulation or Adjustment Techniques
A BRIEF HISTORY OF SPINAL MANIPULATION Nonspecific Long-Lever Manipulation
Spinal Manipulation Before Chiropractic Specific Short-Lever Manipulation
Chiropractic Enters the Scene Toggle–Recoil
CHIROPRACTIC ADJUSTMENT Joint Play
Evolution Traction and Distraction
Meric System Mechanically Assisted
Major and Minor Subluxations Objectives of the Chiropractic Adjustment
Recoil Adjustment Static versus Dynamic Model
Hole in One Models: Mechanical versus Neurological
MANIPULATION TECHNIQUES AND THE Anatomic
CHIROPRACTIC ADJUSTMENT Systems
Passive Movement Physiological
Active Motion and Exercise CONCLUSION
Mobilization and Stretching SUMMARY
Graded Oscillation or Mobilization QUESTIONS
Grade V Mobilization ANSWERS
Manipulation and the Chiropractic Adjustment REFERENCES
OBJECTIVES 6. To describe the different models used to explain

the objectives of the chiropractic adjustment and
1. To provide a brief history of spinal manipulation manipulation.
prior to chiropractic.
2. To review the impact of chiropractic on manipula-
tive technique and briefly discuss early chiroprac-
INTRODUCTION
tic techniques.
3. To review different types of manual therapies. The use of spinal manipulation, referred to by chi-
4. To review different types of manipulative tech- ropractors as “the chiropractic adjustment,” is neither
niques. new nor unique to chiropractic. In one form or another,
5. To attempt to differentiate manipulation from the spinal manipulation therapy (SMT) has been used
chiropractic adjustment. for centuries by lay practitioners and various health
745
professionals. However, unlike some other historical noted in The Lancet (1867) that doctors would do well
forms of treatment, such as bleeding and the use of to observe bonesetters and to learn from them. Inter-
calomel, spinal manipulation has remained popular. estingly, for many medical physicians, this attitude
In fact, the interest in manipulation has recently flour- holds true today.3
ished. In the past few decades, research has provided
some evidence regarding the efficacy of spinal ma- Chiropractic Enters the Scene
nipulation for certain musculoskeletal conditions and With the “discoveries” and teachings of A. T. Still (the
explanations for its effect. It was recently stated that, father of osteopathy) and D. D. Palmer (the father
“Spinal manipulation represents the best example of of chiropractic) came a new era in the use of spinal
the legitimization over the past two decades of a con- manipulation. Still claimed that lesions in the spine
troversial modality for the treatment of spinal disor- lead to disturbances in the circulatory system that ulti-
ders. This evolution of a treatment modality from the mately lead to disease. His writings predated Palmer’s
fringes of health care to one of primary consideration by nearly a quarter of a century and, while the profes-
is a triumph of science and research over dogma and sions developed in different ways, they shared many
opinion.”1 common thoughts and theories. Palmer was probably
influenced by Still, who referred to himself as “The
Lightening Bonesetter.” Both used their hands to in-
A BRIEF HISTORY OF SPINAL MANIPULATION fluence the muscles, joints, and ligaments of the spine
in an effort to eliminate what each thought was the
Spinal Manipulation Before Chiropractic
“cause” of disease.
Manipulation has been part of various healing art
forms for the past 2500 years. A 2000-year-old text, The
Yellow Emperor’s Classic of Internal Medicine, describes CHIROPRACTIC ADJUSTMENT
massage and exercise. And, while not specifically
Evolution
mentioned, it is generally thought to have included
manipulation.2 In many parts of the world, including With the growth of the chiropractic and osteopathic
Asia, Europe, Africa, and Central and South America, professions came increasing diversity in the tech-
spinal manipulation is practiced in a variety of forms. niques of spinal manipulation. In 1927, Stephenson
Even Hippocrates, the father of modern medicine, was categorized manipulation techniques into four me-
a proponent of spinal manipulation. In his work On chanical methods: the shove, push–pull, recoil, and
Joints, he describes the use of SMT for both scoliosis toggle–recoil.4 Along with changes in the methods of
and the treatment of “subluxations.” Over the cen- adjusting came additional theoretical models that al-
turies, Hippocrates’ influence had a substantial effect tered the application of technique and often estab-
on the application and development of manipulation, lished the basis for the formation of entirely new
and a table he designed specifically for manipula- schools of chiropractic.
tion remained in use for more than 2000 years. In Palmer developed the concept that the adjust-
1674, Johannis Scultetus described Hippocrates’ table ment repositioned displaced vertebrae and, therefore,
in The Surgeons Store-House. In the seventeenth cen- treated disease by relieving impingement on nerves.
tury, Friar Thomas Moulton wrote The Compleat Bone- He described disease as “nothing more or less than
Setter, which included methods of manipulation of functions performed in either a too great or too lit-
the extremities. By the nineteenth century, however, tle degree.” His theory was that “pressure on nerves
SMT had been largely abandoned, perhaps because causes irritation and tension with deranged function
of increasing concern about the hazards associated as a result.” Practice was simply a matter of locat-
with manipulation of joints that had been invaded ing the subluxated vertebra and adjusting it, thereby
by tuberculosis. However, although some physicians correcting the “cause” of disease and allowing the
backed away from manipulation, patients did not. self-healing force (i.e., innate intelligence) to restore
People suffering from rheumatism, lumbago, sciat- the body to health. Both D. D. and B. J. Palmer em-
ica, and a variety of other musculoskeletal complaints phasized that a subluxation was a static malposition
found their way to bonesetters and other folk practi- of the vertebral body and that palpation was one of
tioners providing manipulation. Toward the end of the the most important examination procedures to iden-
nineteenth century, traditional medicine was giving a tify the offending lesion.
mixed message regarding SMT. On the one hand, the
norm was to criticize bonesetters and their practices. Meric System One of the more influential aspects in
On the other hand, physicians saw their patients seek the development of chiropractic adjusting techniques
the care provided by the lay practitioners and recog- was the meric system. Developed by Stephenson, this
nized how popular their techniques were. James Paget system held that levels of spinal subluxation were
EVOLUTION AND BASIC PRINCIPLES OF THE CHIROPRACTIC ADJUSTMENT AND MANIPULATION 747
connected to various organ systems according to the Hole in One Another concept that affected the appli-
innervation of the autonomic and peripheral nerves.4 cation of the chiropractic adjustment, was the contro-
For example, because the upper regions of the tho- versial introduction of the “hole-in-one” technique.
racic spine are known to innervate the stomach, con- To explain this technique, B. J. Palmer reasoned that
ditions affecting this organ were attributed to spinal because the atlas was the most important area of the
subluxations in that region, termed the vertemere. It spine and the most frequently subluxated region, pres-
was argued that adjustments of subluxated verte- sure exerted on the spinal cord by a subluxated atlas
brae released the nerve’s energy and corrected organ was an important component in the “disease” pro-
functions in the related vertemere. Clinical experience cess. Because all spinal nerves pass through the atlas
confirmed this hypothesis to the satisfaction of early by way of the spinal cord, thereby exposing them to
chiropractors and “nerve tracing” was added to their pressure, this was the spinal level that needed to be
examination techniques, following nerve paths from treated. Such was his belief in this concept that, for
a spinal level to the innervated diseased organ. Im- many years, students at Palmer College were not al-
portant in this process was the idea of increased skin lowed to adjust anything other than the atlas. B. J.
temperature in relation to the subluxation. Palmer eventually refined his recoil adjustment and
tailored it to the upper cervical level, introducing the
Major and Minor Subluxations Another early contribu- atlas recoil technique.
tion to the development of chiropractic theories was While the Palmers’ contributions to the develop-
the concept of major and minor subluxations. Sim- ment of the chiropractic adjustment were substantial,
ply stated, major subluxations were seen as the cause, they were not the only ones interested in the tech-
not only of symptomatology, but of the development niques of spinal adjusting. As early as 1906, the con-
of secondary and/or compensatory biomechanical cept of subluxations altering vertebral function was
changes at other levels of the spine. Many clinicians introduced. Smith, Langworthy, and Paxson likened
felt that these compensatory changes could often be a subluxation to a wheel whose hub was off-center.
seen to produce many of the patient’s symptoms. Only They also added the concepts of motion assessment
treatment of the major subluxations, however, would and gait analysis to the patient evaluation process. In
remedy the situation. This concept became a princi- 1906, they established their ideas of the necessary ele-
ple of Gonstead’s technique, Gillet’s palpation proce- ments for proper chiropractic care: correct philosophy,
dures, and other procedures. Minor subluxations were well-developed technique, dependable system of di-
the result of major subluxations and therefore not the agnosis, and reliable and extensive system of care.5
focus of treatment. Over the years, further developments in adjus-
tive techniques included the use of short levers, two-
Recoil Adjustment As his theories continued to evolve, person techniques, straps, traction, mechanical de-
B. J. Palmer introduced the recoil adjustment. He the- vices, and “nonforce” techniques. In addition, many
orized that it wasn’t really the chiropractor who was chiropractors incorporated manipulation of periph-
responsible for repositioning the subluxated vertebra. eral, or nonspinal, joints in their treatments.
Rather, it was the body’s own internal, or innate in-
telligence, that intuitively “set the bone” in place. The
MANIPULATION TECHNIQUES AND THE
doctor simply initiated the process by setting the bone
CHIROPRACTIC ADJUSTMENT
in motion in an appropriate direction, and the body
would do the rest. He believed the recoil adjustment There are an array of procedures that fall into the
was far superior to the slower, lunging thrusts that larger field referred to as manual medicine, manual
were prevalent at the time, and that the effect was a therapy, or manipulative therapy. In fact, all of the
combination of both the external force provided by methods in which the hands are used for some form
the thrust and the internal innate recoil force within of therapeutic objective can be included under these
the patient. From the patient’s perspective, the recoil headings. If we simply focus on those procedures that
was undoubtedly more comfortable than the stiff-arm are considered to be “chiropractic techniques,” the
procedures of the day. In addition, this new approach list is very extensive. According to the Job Analysis of
took into account such features as line of drive, patient Chiropractic,6 roughly 80% of chiropractors use some
positioning, and speed and accuracy of thrust. Great form of full-spine and extremity adjusting approach
care was taken with exact hand placement prior to in their practice. Table 37–1 provides a sample of these
delivering the adjustive thrust and various methods various techniques. One of the reasons why there ex-
were developed to add speed and force (e.g., triceps ist such a large variety of manipulation techniques
thrust combined with body drop). Adjustments were involves the way in which clinicians modify or per-
applied on the basis of the meric system using the sonalize their procedures. Chiropractors often begin
concept of major and minor subluxations. to modify the manipulative methods they have been
TABLE 37–1.Percentage of Chiropractors Using PASSIVE ROM ACTIVE ROM
Various Adjustive Techniques, 1991 vs. 1998
Adjustive Procedures % 1991 % 1998 Physiological

Barrier
E.P.Z.
Diversified 91.1 95.9 E.B.
Extremity adjusting No data 95.5 P.S. J.P.
Activator methods 51.2 62.8 Anatomic Neutral
Joint Trauma or
Limit Pathology
Gonstead 54.8 58.5
Cox/flexion–distraction 52.7 58.0
Thompson 43.0 55.9
Sacro-occipital technique 41.3 49.0 E.P.Z. = End Play Zone
E.B. = Elastic Barrier
Applied kinesiology 37.2 43.2 J.P. = Joint Play
Nimmo/receptor tonus 40.3 40.0 P.S. = Paraphysiological Space
Cranial 27.2 37.3
Adjustive instrument No data 34.5 FIGURE 37–1. Joint motions and manipulative techniques.
Palmer upper cervical/hole in one 26.0 28.8 (Modified from Bergmann TF, Peterson DH, Lawrence DJ. Chiropractic
Logan basic 30.6 28.7 technique: Principles and procedures. New York: Churchill Livingstone,
1993:87.)
Meric 23.4 19.9
Pierce-Stillwagon 19.7 17.1
Other 15.0 14.8
in the joint and surrounding tissues. Because the pro-
Adapted from Christensen MD, ed. Job analysis of chiropractic. Greeley, cedure must be repeated and performed several times
CO: National Board of Chiropractic Examiners, 2000. a day, it is often performed by nurses, aides, and the
patient’s family.
taught very early in their career and adapt their ap-
proach to the particular patient and region they are Active Motion and Exercise
treating. For patients who recover sufficiently to actively par-
Despite the wide variety of manipulation tech- ticipate in therapy, the natural progression of ther-
niques, there are a number of principles that provide apeutic techniques is from passive motion to active
a system for classification. The various manual tech- motion and exercise. Active motion simply involves
niques are divided into the following broad cat- having the patient move the affected joint through
egories: massage, passive movement, mobilization, its full, pain-free range of motion. Exercise adds re-
and manipulation or adjustive techniques. These pro- sistance to active motion and has the additional ad-
cedures use varying degrees of force, use different vantage of developing muscle strength. Once patients
techniques, and have different goals and objectives. can tolerate active motion, passive motion is typically
In addition, these techniques are applied at different discontinued.
positions within a specific range of motion of a joint
(Fig. 37–1).
Mobilization and Stretching
Passive Movement It is important to distinguish between mobilization
One method of using the hands to maintain mo- and manipulation techniques. The term mobilization
tion in a joint is referred to as passive movement. In refers to manual procedures that are designed to in-
this method, the clinician or therapist systematically crease the range of motion beyond the resistance bar-
moves the joint through each of its normal motions, rier, which may limit attempts at passive range of
from the neutral point to the point of resistance or motion and/or exercise (Fig. 37–2). These mobiliza-
pain. Unlike other techniques, no attempt is made to tion techniques include methods of stretching muscles
move the joint past this point. Another unique feature and ligaments. Other mobilization techniques incor-
of these techniques is that each direction of potential porate the movement of joints in nonphysiological di-
joint motion is included and the entire length of the rections of motion, similar to that seen with the use of
range of motion is traversed. These procedures are of- manipulation techniques. The primary difference be-
ten used on patients who are unable to move their own tween mobilization and manipulation (adjustment) is
joints, such as those with stroke or following acute in- the absence in mobilization of an applied thrust, as
jury. The goal of these passive movement techniques is described by manipulation. Consequently, mobiliza-
to prevent stiffening or shortening of the ligamentous tion techniques are often referred to as “nonthrust”
structures, as well as maintain motion and lubrication techniques.
Joint Pathology Grade V Mobilization

(sprain, orthopedic
6 subluxation, dislocation) According to Maitland’s classification, a grade V mo-
Tension Reduction
bilization procedure is referred to as manipulation.7
SEPARATION (mm)
5.4 mm
5
It is differentiated from grades I to IV by the appli-
4.5 mm Paraphysiological Zone
4 cation of speed and force, often accompanied by an
Repeat "CRACK" audible “click” or “pop.” In other words, a manipu-
3 Mobilization lation involves the application of a high-velocity low-
2
Preliminary Tension amplitude thrust to the joint. This thrust moves the
1.8 mm joint beyond its physiologic range of motion, through
the paraphysiological space, to the anatomical limits
Rest 2 4 6 8 10 12 14 16 18
of motion (see Fig. 37–2).
Mobilization
Elastic Barrier Limit of Anatomical Manipulation and the Chiropractic Adjustment
of Resistance Integrity
While the difference between mobilization and ma-
LOAD (Kg = N/10) nipulation is clear, the difference between spinal ma-
nipulation and the chiropractic adjustment, if any ex-
FIGURE 37–2. Passive range of motion barrier. (Modified from ists, is less apparent. Many chiropractors feel that the
Bergmann TF, Peterson DH, Lawrence DJ. Chiropractic technique: Prin- chiropractic adjustment has more control over the spe-
ciples and procedures. New York: Churchill Livingstone, 1993:87.) cific direction of the thrust, resulting in a more con-
trolled force and presumably different physiologic
Graded Oscillation or Mobilization and neurologic effects. In reality, the difference may
Maitland, an Australian physiotherapist, popularized be one of intent rather than substance. From a histor-
the use of mobilization. In an attempt to differen- ical and philosophical point of view, the chiroprac-
tiate some of the various mobilization procedures, tic adjustment has been used to promote a return to
Maitland proposed four levels or grades of mobiliza- health by freeing the nervous system of any imped-
tion: iments to normal nerve function. Because chiroprac-
tors attribute more benefits to their adjustments than
Grade I is a fine oscillation with very little force or other health professionals attribute to their manipu-
depth. It is performed in the early portion of the lation, chiropractors have a tendency to believe that
available range of joint motion. their techniques are superior. As a practical matter,
Grade II is a mobilization that incorporates a greater however, manipulation and adjustments both involve
depth or degree of motion, but remains within the thrusting techniques directed at improving the func-
first half of the joint range of motion. tion of joints and therefore share many similarities.
Grade III mobilization involves a deeper, more aggres-
sive movement that is performed at the limits of Types of Manipulation or
motion. Adjustment Techniques
Grade IV mobilization is a deep, fine oscillation that There are numerous methods or techniques employed
is carried out at the limits of potential motion. by clinicians who practice spinal manipulation, in-
cluding nonspecific long-lever and specific short-
Typically, these procedures are performed in a se- lever techniques, toggle–recoil techniques, joint play
quential manner, beginning with grade I and progress- techniques, traction-assisted methods, and various
ing to grade IV. As range of motion increases and pain instrument-assisted methods. Many of these specific
decreases, higher grades of mobilization technique approaches are discussed in more detail in other chap-
are incorporated. Maitland stated that the selection ters within this section.
of grade to be used should be based on three criteria:
the degree of pain and symptoms that the patient is ex- Nonspecific Long-Lever Manipulation As the name im-
periencing, the amount of restriction and immobility, plies, these manipulation techniques employ the use
and the skill and confidence of the practitioner. For of long-lever systems. A long bone (often a shoul-
example, when a new injury occurs with significant der or leg) is used as a lever to exert force into the
pain, swelling, and restriction, a lower grade of mo- spine. A common example of this type of manipula-
bilization might be used. As the condition improves, tion technique is the side-lying or side-posture “lum-
the decrease in pain and swelling is associated with a bar roll” (Fig. 37–3). Because of the potential to exert
gradual increase in movement, and higher grades of large forces, long-lever techniques require care and
mobilization techniques may be included in the treat- skill and are therefore not often used. However, care-
ment regimen. ful and skilled use of directed long-lever techniques
plied very specifically to a vertebra with the clinician

exerting minimal force.
Joint Play Gillet and Faye have been instrumental in

teaching techniques that involve moving joints in
directions not commonly moved during exercise.8,9
Joint play techniques are based on the idea that be-
cause of inherent ligamentous laxity, most joints have
some degree of play at rest. When any particular joint
lacks this play because of fibrous thickening and sub-
sequent tightening of the ligaments, it may be ma-
nipulated in specific directions to increase joint play.
FIGURE 37–3. Lumbar spinal manipulation. (Modified from
This may be especially important if the joint is locked
Murtagh JE, Kenna C, Sorrell C. Back Pain & Spinal Manipulation: A
practical guide. Butterworth-Heinemann, 2nd ed., 1997, Stoneham, MA.)
in a slightly abnormal position. A number of manip-
ulation techniques for increasing joint play in both
vertebral and peripheral joints have been described
may be helpful in situations such as when small clin- and taught. In addition, specific palpation procedures
icians encounter large patients. (i.e., motion palpation) have been designed to evalu-
ate normal joint movements, including joint play.
Specific Short-Lever Manipulation The mainstay of tradi-
tional chiropractic adjustive procedures involves the Traction and DistractionAs mentioned earlier, manual
application of high-velocity low-amplitude (HVLA) and mechanical traction have been used to facilitate
thrusting techniques to short levers of the spine, manipulation techniques since Hippocrates. These
such as a spinous or transverse process. The princi- techniques commonly involve some form of pulling
pal goals of these techniques vary from procedure to or thrusting methods performed while traction is ap-
procedure, and include correcting misalignments or plied to the area. They may also incorporate the use of
subluxations, eliminating fixations or restrictions in specific tables and traction devices. These procedures
intersegmental motion, and producing a variety of re- are discussed in more detail in Chapter 42, “Traction
flex changes, both neurological and muscular. A large and Distraction Techniques.”
number of these techniques share common features.
Each technique allows that vertebra can be adjusted Mechanically AssistedOver the years, there have been
in a number of different directions, for example, pos- a number of mechanical devices developed to assist in
terior to anterior, inferior to superior, and lateral to the delivery of a motion, force, or thrust to the spine.
medial. To facilitate this degree of specificity, the pa- These include special tables with drop-away pieces,
tient is placed in very specific positions to allow for manual and motorized tables that move up, down,
control of the depth and direction of the force to be and sideways, and small, hand-held instruments such
applied. While proponents of each of the various tech- as the Activator adjusting instrument (AAI). Some of
niques make claims about the efficacy of their partic- these are promoted as assistive devices that aid the
ular methods, it has yet to be established that such clinician with the delivery of the desired force. Oth-
precise application of force does in fact bring about ers have been suggested as potential replacements
specific vertebral movements or different changes in to manual manipulation, as described in Chapter 40,
clinical outcomes “Low-Force and Instrument Technique.”
Toggle–Recoil A number of chiropractic techniques em- Objectives of the Chiropractic Adjustment

ploy the use of specialized tables that allow for pre- Over the past 100 years, many different theories have
cise positioning of the patient. Many of these tables been proposed to explain the objectives of the chiro-
also provide additional leverage that may be helpful practic adjustment. The spectrum of theories ranges
to the clinician. Certain chiropractic techniques (e.g., from Palmer’s original hypothesis that misplaced
Thompson) require the patient to be placed on a table vertebrae or subluxation impacted the spinal nerve,
especially constructed in such a way that one vertebral thereby reducing the flow of the innate life force, to
segment is locked or blocked while a controlled, rapid theories stating that spinal manipulation simply im-
force is applied to the adjacent vertebra. The portion proves motion in a dysfunctional joint, thereby re-
of the table supporting the vertebra being adjusted ducing symptoms. A more detailed description of the
then drops out from under the patient (approximately basic science research on this topic is described in Sec-
1 cm), allowing for the introduction of a recoil effect. tion 2 of this text. It is important to point out that while
Properly performed, high-velocity forces can be ap- some chiropractors feel that manipulation is aimed at
Models of Objectives of
TABLE 37–2. in addressing this lesion, is that of altered spinal mo-
an Adjustment tion. As stated earlier, changes in joint function result
in a reduction of joint motion and joint play. Simi-
Static model versus dynamic model larly, Gillet used the concept of joint restriction or fix-
Mechanical model versus neurologic model ation when he developed his methods of palpation
Anatomic model (i.e., motion palpation).8 Faye further developed these
Systems model methods, articulating the concept of a subluxation
Physiologic model complex.9 In Faye’s model, the subluxation complex
Pathologic model includes changes in articular mechanics, which he re-
Health model ferred to as kinesiopathology, in addition to changes
in neurologic input and output (neuropathology), and
Reproduced with permission from Grice A, Vernon H. Basic principles even tissue structure (histopathology). This functional
in the performance of chiropractic adjusting: Historical review, classifi-
cation, and objectives. In: Haldeman S, ed. Principles and practice of or dynamic model suggests that manipulation (i.e., the
chiropractic, 2nd ed. Norwalk, CT: Appleton-Lange, 1992: 455. chiropractic adjustment), rather than replacing mis-
aligned vertebra to their “normal” position, actually
frees them from a position in which they are “fixed,”
removing subluxations, this term is probably not a sin- allowing them to assume whatever position the de-
gle entity and an exact definition and description of mands of daily activities require.
this lesion is not possible. Gatterman states that there
are more than 100 synonyms for subluxation, includ- Models: Mechanical versus Neurological
ing facilitated segment, chiropractic subluxation com- In the early days of the chiropractic profession, Palmer
plex, manipulable lesion, motor unit derangement taught that the “subluxation” created problems be-
complex, segmental dysfunction, and vertebral sub- cause of its impact on the spinal nerves, and thus on
luxation syndrome.10 A working definition of sub- the nervous system as a whole. His teachings cred-
luxation may be that it simply represents the entity ited the chiropractic adjustment with restoring normal
against which manipulation is directed. nerve function. According to Palmer, the subluxation
Table 37–2 lists models for the objectives of an was important because of the relationship between the
adjustment.11 According to Grice and Vernon, these vertebrae and the spinal nerves. According to this neu-
various models are used by chiropractors to rational- rologic model, the adjustment may achieve a reduc-
ize the clinical application of spinal adjustments in or- tion in nerve pressure, a reduction of pain, alteration
der to exert some benefit on the health of their patients. (either stimulation or inhibition) of reflex pathways,
and/or alteration of neurohumeral responses.11 The
Static versus Dynamic Model neurological aspect has been divided into two spe-
One of the most widely debated issues about the objec- cific categories: impulse-based (referring to reflex
tive of the chiropractic adjustment relates to whether disturbances) and nonimpulse-based (related to nerve
the subluxation should be thought of as static or dy- compression).12
namic. Early proponents of Palmer’s teachings de- More recently, many chiropractors have taken the
scribed the subluxation as “a partial dislocation of position that spinal manipulation has a largely me-
adjacent vertebral units.” Spinal subluxations were chanical effect, with a secondary neurophysiological
defined by their positional “listing” and terms such response in pain and muscle spasm. Using this model,
as “retrolisthesis” and “anterolisthesis” were added the objectives of the adjustment include a realign-
in an attempt to describe the precise position of the ment of joint surfaces, an increase in joint mobility,
displaced vertebra and the direction of misalignment. a reduction of muscle spasm, and an improvement of
Most chiropractic technique systems continue to use posture and locomotion.11 In addition, some have fo-
some form of this positional concept and often name cused their attention on the effect of manipulation on
targeted vertebra using positional determinants such the intervertebral disc, while others have been more
as PRS, meaning the vertebra is displaced in a posterior interested in the facet joints. Bergmann et al. list a
direction, rotated to the right, and displaced superiorly. number of elements that may be involved: joint fixa-
With this in mind, the adjustment is delivered with tion or locking, intraarticular block, interarticular ad-
the intent of “repositioning” the involved vertebra to hesions, interdiscal block, muscle spasm, myofascial
a more correct position relative to its neighboring seg- cycle, and periarticular fibrosis and adhesions.13
ments. The use of x-ray marking systems, such as that
employed by the Gonstead system, add to this sense Anatomic According to Grice and Vernon,11 those as-
of static “malposition.” cribing to the anatomic model evaluate the body sys-
A more contemporary model of the subluxation, tem on a gross postural basis. Consideration is given
and subsequently of the role of the spinal adjustment to the body and the individual as a whole, and to
the musculoskeletal system as an adaptive mecha- rections (i.e., flexion, extension, right and left rotation,
nism. In turn, the spine is subdivided into several right and left lateral flexion), the addition of a thrust is
components: multisegmental (cervical, thoracic, lum- probably not limited to one direction but exerts some
bar, etc.), intersegmental (three-joint complex), in- effect in all directions. At this point of time it is not
frasegmental (foraminal environs), and intrasegmen- possible to state that there is a difference in the effect
tal (spinal cord and its primary receptor and effector of an adjustment when it is delivered with the patient
neuronal pools). The objectives of manipulation re- seated in a Gonstead cervical chair, prone on a me-
late to changes in each of these subcomponents, both chanical table, or supine on a flat bench. The ultimate
independently and separately. effect of the manipulation procedure on the specific
vertebral level may well be similar. Many practition-
Systems The objectives of an adjustment may also be ers select the specific type of manipulation procedure
thought of using a systems model. The adjustment to be used based on factors such as personal prefer-
may be seen to affect an individual spinal segment, ence, patient need, and ease of application.
an entire region of the spine, or the locomotor sys-
tem as a whole. This model may be illustrated by the
SUMMARY
commonly seen leg-length testing, wherein the chi-
ropractor relates spinal lesions to such an imbalance. 1. Spinal manipulation predates the introduction of
Fuhr discusses the role of isolation testing using leg- chiropractic by thousands of years, with texts from
length discrepancies in Chapter 40, “Low-Force and 500 bc mentioning its use as a therapy. It has been
Instrumentation Technique.” used by many systems of health care throughout
the world, including in Asia, Africa, Central and
Physiological This model consists of three major ar- South America, and Europe, for hundreds of years.
eas: regulatory, functional, and psychosocial. The first 2. With the development of the chiropractic pro-
component views changes in regulatory effects of the fession, spinal manipulation techniques were
neurohormonal system as the objective of manipula- adapted and modified according to practitioner
tion. The functional model includes changes in behav- preferences, renamed chiropractic “adjustments,”
ior that are associated with pain relief, relaxation, pos- and formed the basis of different technique sys-
tural improvements, and ease of locomotion. Finally, tems. Some of the earliest chiropractic techniques
the psychosocial model includes attention directed at include the meric system, where manipulation to
the whole person, and at the impact that illness may different spinal levels was given to influence organ
have on patient’s lives. systems thought to be related by virtue of the ori-
In this model, the recognition of the patho- gins of the autonomic and peripheral nerves; the
logic process, limitations of tissue adaptability, and recoil adjustment, where great care was taken with
contraindications to manipulation are addressed. the setup prior to delivering the adjustive thrust
The spinal subluxation and/or joint dysfunction are and various methods were developed to add speed
viewed as both a cause and a result of pathology. and force; and hole in one, a refined recoil adjust-
Treatment may be directed at either the dysfunction ment technique applied only to the upper cervical
or at resulting symptoms. Interest in the detrimental vertebra and thought to influence the spinal cord.
effects of joint immobility on articular cartilage has 3. Manual therapy methods include massage, pas-
lead to the term immobilization degeneration.14 With sive movement, mobilization, and manipulation
this in mind, manipulation, and the attending increase or adjustive techniques. These procedures use
in joint mobility, may be seen not only to exert a me- varying degrees of force, different lever systems,
chanical effect, but ultimately to assist the body in and have different, albeit similar, goals and objec-
remodeling joint tissues. tives.
4. Manipulation and chiropractic techniques include
nonspecific or long lever, where a thrust is deliv-
CONCLUSION
ered through a long lever such as the thigh or leg;
Most chiropractors use a somewhat mixed model of specific or short lever, where a thrust is given to a
the vertebral subluxation. The lesion is described as a specific spinal contact such as a spinous or trans-
combination of malposition and altered function that verse process; toggle–recoil, where a rapid shal-
can exist in association with pathological changes in low thrust is given to a spinal contact with a sud-
the spine. The use of manipulation techniques, how- den withdrawal of the contact hand; mobilization,
ever, is more often a skill influenced by personal pref- where repeated, shallow movements are applied
erence and patient needs. Techniques are selected, in to a joint without delivering a thrust; traction and
part, based on the decision to use a thrust or not to use distraction, where force is applied to a joint to sep-
a thrust. Given that vertebrae move in six primary di- arate its articulating surfaces; and mechanically
assisted manipulation, which uses a variety of me- 2. The primary difference between a graded oscil-
chanical aids such as motorized tables or hand- lation or mobilization and a manipulation is the
held instruments to deliver or assist the delivery speed and force with which the procedure is de-
of a thrust. livered. A mobilization is delivered within the pa-
5. Although some believe that chiropractic adjust- tient’s ability to resist, whereas the manipulation
ment techniques are unique and different from procedure is delivered with a speed and force the
spinal manipulation, when both involve similar patient cannot resist.
techniques there is little in the way of measurable 3. The term impulse-based refers to reflex distur-
differences between the two. In the end, the differ- bances and the term non-impulse-based refers to
ence may be one of intent rather than effect, with nerve compression effects.
chiropractic focusing on the impact of manual ther- 4. The models used to describe the objectives of
apy on overall health and manipulation focusing the chiropractic adjustment include static ver-
on localized effects. sus dynamic model, lesion model, mechanical
6. Numerous models have been proposed to at- versus neurologic model, anatomic model, sys-
tempt to explain the objective of the chiropractic tems model, physiologic model, pathologic model,
adjustment. These models include static, where wellness model, and health model.
a treatment is given to correct a misaligned joint 5. Maitland, an Australian physiotherapist, pro-
or vertebra; dynamic, where a treatment is given posed five levels of mobilization. Grade I is a fine
to correct a lack of movement in a joint or verte- oscillation with very little force or depth in the
bra; mechanical, where treatment is given to re- early portion of the available range of joint mo-
align joint surfaces, increase joint mobility, reduce tion. Grade II incorporates a greater depth or de-
muscle spasm, and improve posture and locomo- gree of motion, but remains within the first half
tion; neurological, where treatment is given to in- of the joint range of motion. Grade III involves
fluence the nervous system and reduce pain, al- a deeper, more aggressive movement that is per-
ter reflex pathways, and/or alter neurohumoral formed at the limits of motion. Grade IV mobi-
responses; anatomic, where treatment is given to lization is a deep, fine oscillation that is carried
improve posture and anatomic equilibrium; sys- out at the limits of potential motion. Grade V is
tems, where treatment given to a specific area may the term assigned to manipulation, where a thrust
influence other areas in the body; and physiolog- is applied into a joint’s paraphysiologic range of
ical, where treatment is given to influence pain motion.
regulation through hormonal secretion, improve
function, and influence psychosocial responses to
pain. REFERENCES
1. Haldeman S. Spinal manipulative therapy: A status re-
QUESTIONS port. Clin Orthop 1983;179.
2. Veith I. Juang Ti Nei Ching Su Wen (The Yellow Emperor’s
1. Although spinal manipulation is an ancient art, classic of internal medicine). Berkeley, CA: University of
chiropractors have made significant contributions California Press, 1966.
to the evolution of manipulation procedures. What 3. Anderson R. Spinal manipulation before chiroprac-
are some examples of these contributions? tic. In: Haldeman S, ed. Principles and practice of chi-
2. What is the difference between a graded oscillation ropractic, 2nd ed. Norwalk, CT: Appleton-Lange, 1992:
procedure and a manipulation? 3–14.
3. What is the difference between an impulse-based 4. Stephenson RW. Chiropractic textbook. Davenport, IA:
Palmer School of Chiropractic, 1927.
model and a non-impulse-based model?
5. Smith O, Paxson M, Langworthy SM. Modernized chi-
4. The objectives of the chiropractic adjustment are
ropractic. Cedar Rapids, IA: American School of Chiro-
described using various models. List the models practic, 1906.
that are in common use. 6. Christensen MG, ed. Job analysis of chiropractic. Greeley,
5. What are the grades of mobilization according to CO: National Board of Chiropractic Examiners,
Maitland? 2000.
7. Maitland GD, Vertebral manipulation, 5th ed. London:
Butterworth, 1986.
ANSWERS 8. Gillet H. Belgian chiropractic research. Brussels, Belgium:
Author, 1952.
1. Some of the contributions include the meric sys- 9. Shafer RC, Faye LJ. Motion palpation and chiropractic
tem, major and minor subluxations, toggle–recoil technique. Huntington Beach, CA: The Motion Palpa-
adjustments, and instrument-assisted adjusting. tion Institute, 1989.
10. Gatterman MI. Foundations of chiropractic: Subluxation. workshop. In: Korr I, ed. The neurobiological mechanisms
St. Louis: Mosby, 1995. in manipulative therapy. New York: Plenum Press, 1978.
11. Grice A, Vernon H. Basic principles in the performance 13. Bergmann TF, Peterson DH, Lawrence DJ. Chiro-
of chiropractic adjusting: Historical review, classifica- practic technique: Principles and procedures. New York:
tion, and objectives. In: Haldeman S, ed. Principles and Churchill Livingstone, 1993:141–150.
practice of chiropractic, 2nd ed. Norwalk, CT: Appleton- 14. Lantz CA. Immobilization degeneration and the fixa-
Lange, 1992:443–458. tion hypothesis of chiropractic subluxation. Chiropr Res
12. Korr I. Objectives and hypotheses in the design of the J 1988;1:21–46.
C H A P T E R
38
HIGH-VELOCITY LOW-AMPLITUDE
MANIPULATIVE TECHNIQUES
Thomas F. Bergmann
O U T L I N E
INTRODUCTION Adjustive Mechanics
DEFINITION AND USE OF HIGH-VELOCITY Characteristics of the Impulse Thrust
LOW-AMPLITUDE THRUST CONCLUSION
Short and/or Long Levers SUMMARY
Specific versus Nonspecific QUESTIONS
Application of Force ANSWERS
Effects of HVLA KEY REFERENCES
Cavitation REFERENCES
niches in medical, osteopathic, and physical therapy

OBJECTIVES
practices, chiropractic has done more than any other
1. To review the support from various health care profession to promote its use in the treatment of neuro-
fields for the use of the high-velocity low-ampl- musculoskeletal dysfunction. Chiropractic has main-
itude thrust. tained that manipulation of the articulations of the
2. To distinguish between the use of short and long human body, and especially the spinal column, is a
levers with thrust techniques. valuable clinical intervention. Adjustments may be
3. To differentiate between specific and general condone manually or mechanically, actively or passively,
tacts taken with thrust technique. all with the purpose of restoring normal articular re-
4. To discuss the physics of the force developed and lationship and function, as well as reestablishing neu-
applied with thrust technique. rological integrity, thereby influencing physiological
5. To present the hypothetical and theoretical effects processes.1 Traditionally, the form of manual therapy
of thrust techniques. identified with the chiropractic profession is the high-
6. To review the phenomenon of cavitation as it re- velocity low-amplitude (HVLA) thrust applied with a
lates to thrust technique. specific contact using a short lever in a spinal segment
7. To discuss the principles of adjustive mechanics. or extremity joint.
8. To identify the specific characteristics of the im- Numerous forms of manual therapy are used by
pulse thrust. chiropractors.2 The assumption that all forms of man-
ual therapies, adjustments, or manipulations have the
same effect has not been established in the literature.3
Many technique systems do not use HVLA thrusts
INTRODUCTION
and certain patient presentations may contraindicate
The most commonly used treatment approach by the use of a thrust technique, for example, the el-
chiropractors is manipulative therapy and, specifi- derly patient with osteoporosis, the extremely acute
cally, the adjustment. Although manipulative therapy pain condition, and specific bony pathologies such
has been used for centuries and still occupies small as neoplasms or infections. Clinician characteristics
755
TABLE 38–1.Common Factors in the Application because it produces the effect of joint separation or
of Manual Therapy gapping and the possible momentary restoration of in-
voluntary movement or joint play.6 Kappler used ve-
Factor Possiblities locity and amplitude to describe the nature of the final
activating force in distinguishing thrust techniques.7
Speed High velocity He stated that the HVLA technique involves a quick
Low velocity thrust carried through a short distance, while a low-
Amplitude High amplitude velocity high-amplitude procedure is one in which the
Low amplitude rate of motion is slow and the distance is great. He
Leverage Long lever further stated that some thrusts involve high-velocity
Short lever high-amplitude maneuvers where the corrective force
Specificity Specific contact (single joint) can be exerted through a fairly large rather than min-
General contact (multiple joints) imal distance. In some situations, the velocity can be
Direction Anterior to posterior, posterior to anterior varied such that a manipulation technique becomes a
Inferior to superior, superior to inferior low-velocity low-amplitude procedure. He gave no
Lateral to medial, medial to lateral rationale for the appropriate use of one procedure
Prestress Assisted over another, but does give examples of inappropri-
Resisted ate applications. In his opinion, techniques that use
a rebound thrust in which the force is directed away
from the barrier are inappropriate. He further stated
that inappropriate technique is the use of a high-
may also determine the use of nonthrust techniques. velocity high-amplitude thrust where the barrier is
The doctor’s size, strength, or speed may also lead not engaged; that is, the starting point is the neutral
the doctor toward non-HVLA techniques. Regard- midrange. He felt that both of these instances pro-
less of the form of manual therapy, these com- duce excessive force that may be harmful. Macdonald
mon characteristics of the manipulation must be and Bell used HVLA thrust techniques applied to
considered: speed, amplitude, leverage, specificity, di- specific hypomobile vertebral motion segments from
rection, and prestress (Table 38–1). which the presenting pain was deemed to originate
and found that for patients suffering from nonspe-
cific low back pain, a positive response to this form
DEFINITION AND USE OF HIGH-VELOCITY
of osteopathic manipulation occurred when the pain
LOW-AMPLITUDE THRUST
duration was of 14–28 days.8
There are numerous descriptions of the HVLA thrust Curtis described manipulation as consisting of in-
in both the chiropractic and manual medicine litera- direct, specific adjustments that use long levers (such
ture that warrant some discussion. Haldeman noted as rotation of the spine using the legs and upper thorax
that, although there are a large variety of tech- as levers) or short levers (rotation of one or two ver-
niques within the entire field of spinal manipula- tebrae using the transverse processes as levers).9 The
tion and that each has reputed different therapeutic rotation involves taking up the slack of the paraverte-
goals and unique underlying biomechanical or phys- bral tissues and locking the facet joints of the vertebra,
iological principles, the most commonly used ma- followed by a small-amplitude high-velocity thrust.
nipulative technique is the short-lever, high-velocity He further pointed out that it is difficult to study the
adjustment.4 He characterized this technique as a efficacy of spinal manipulation because of the wide
quick, small-amplitude, high-velocity thrust that is variability in the definition of manipulation.
delivered to one of the small vertebral processes (spe- Cremata et al. described the Gonstead adjustment
cific, short-lever contact) in a specific direction. as an HVLA thrust applied to short-lever arms such
From an osteopathic perspective, Greenman has as the spinous process or transverse process.10 They
written that the HVLA thrust technique is one of felt that specificity is critical in the point of contact, as
the oldest and most widely used forms of manual well as the line of correction used, and implied that
medicine.5 He further stated the procedures are usu- specificity is necessary to reduce the likelihood of joint
ally applied as precisely as possible to a single joint injury by forcing the joint in an inappropriate direction
level and for specific joint motion loss. It was his opin- while maximizing the potential for repositioning and
ion that the HVLA thrust appears to be much more restoring function to the dysfunctional articulation;
effective in subacute and chronic conditions than in no evidence for this statement was provided. One of
acute somatic dysfunction. However, he offered no the most widely quoted descriptions of this treatment
data to support these statements. Heilig has stated is by Sandoz, who defined the chiropractic adjust-
that the HVLA manipulative technique is important ment as a passive manual maneuver during which the
HIGH-VELOCITY LOW-AMPLITUDE MANIPULATIVE TECHNIQUES 757
three-joint complex is suddenly carried beyond the specificity, which is thought to influence a specific joint
normal physiological range of movement without ex- complex for a specific joint dysfunction.
ceeding the boundaries of anatomical integrity.11,12 Long-lever techniques may use a specific or gen-
In their randomized controlled trial for cervical eral primary contact on the body part, but the sec-
manipulation, Howe et al. described the method of ond contact is remote from the segment, forming a
manipulation as moving the joint or joints as far as broad or long leverage system of forces.18 Maigne
comfortably possible and then applying a quick thrust used the term indirect manipulation for long-lever
of moderate force but small amplitude in the same procedures, stating that the body is used as a lever to
direction.13 Although not definitively stated, the im- move the vertebral column.19 All side-posture lumbar
plication was that a specific hand contact was used and pelvic techniques employ a long lever, the femur
on a localized spinal segment (short lever). Maigne of the flexed knee, as a means to apply preadjustive
used the term direct manipulation to define a spe- tension or the thrust itself. Nwuga also used the term
cific hand contact that applies direct pressure on the indirect manipulation to describe techniques that use
spinal column, either over the transverse processes or the limbs as natural levers to influence the spinal col-
the spinous processes (short lever).14 The pressure is umn and cites side-posture low back techniques as
then followed by a very quick release. examples.17
Long- and short-lever combinations are frequently
Short and/or Long Levers used to deliver a manipulation force. The long lever
A lever is considered a simple tool used for reduc- provides the necessary leverage for general distrac-
ing work through increased mechanical advantage. In tion and articular prestress to the spine, while the short
manipulative therapy, it is accepted that while tech- lever focuses the force to a smaller section. Integration
nique applications may be highly variable, the under- of a short-lever contact allows the technique to become
lying principles are fairly constant. The lever is used more efficient and more specific.18
to produce motion at an articulation or group of artic-
ulations. The longer the lever is, the greater the me-
chanical advantage. Levers are used to assist the ap- Specific versus Nonspecific
plication of force in order to cause motion between the The term specific contact has two meanings in the liter-
affected segments. Levers help to generate sufficient ature. First, it can refer to the point on the clinician’s
forces that will not be dissipated by the elasticity or hand or body that makes contact with the patient. Sec-
mobility of other spinal or appendicular structures.15 ond, it can describe the actual anatomical part of the
White and Panjabi described the manual application patient that is being contacted. Virtually all texts writ-
of forces directly to the spinous process and posterior ten on manipulative therapy procedures using thrust
elements of a given vertebra in terms of component techniques describe specific hand contacts used by the
vectors with 6 degrees of freedom: translation along clinician. While there are some different terms used,
the X, Y, and Z axes and rotation about the X, Y, and Z with few exceptions the descriptions are the same.
axes.16 The issue of leverage becomes more complex Similarly, the part of the patient’s body that is being
when vectors of forces are considered in connection contacted is described in common terms among au-
with muscle attachments and the effect of soft tissues thors. Specific contact in reference to a patient’s spine
on the intervertebral joint. means a contact is made on a spinous process or lat-
Application of forces to spinous processes or lateral process (articular process or lamina in the cervi-
eral processes (articular, transverse, or mammillary) cal spine, transverse process in the thoracic spine, or
in the spine represents short-lever procedures. Short- mammillary process in the lumbar spine) via the over-
lever techniques are also used in the extremities when lying soft tissues. These points of contact constitute a
a direct contact is taken on the involved segment. short lever when an external force is applied to them.
Greenman defined the short lever as one in which Specificity in either case is thought to be important
a portion of one vertebra (spinous process) is held to influence a definite intervertebral joint complex for
firmly while a force is applied to a bony prominence identified joint dysfunction. A specific manipulation
of the adjacent vertebra.5 A force is then applied attempts to focus the force of the thrust on one artic-
with sufficient velocity to move one segment on the ulation or joint complex. A nonspecific manipulation
other. Velocity relates to the speed in which the im- is used to affect a region or group of articulations.
pulse is given. Nwuga believed that with short-lever Grieve uses the terms localized and regional to distin-
techniques, the amplitude of the thrust (the distance guish between procedures that affect a single joint or a
in which the thrusting force is applied) is less than sectional area.20 In addition, the term general has been
with long-lever techniques to achieve the same move- used to denote the nonspecific, regional, or sectional
ment at the joint being treated.17 The implied ratio- forms of manipulation.21 Techniques that use broad
nale for the use of short-lever procedures is to increase contacts taken over multiple sites with the purpose of
improving motion and/or alignment in an area that is resistance to deformation.25 Furthermore, any forces
generally stiff or distorted are considered nonspecific. acting internally to this system (e.g., muscular forces
in the clinician) do not enter into these equations.26
Application of Force In contrast, Hessel et al. conducted a study to quan-
Especially important in the performance of adjus- tify the forces exerted during spinal manipulation.27
tive techniques is an awareness of spinal and ex- The force characteristics were analyzed with respect
tremity joint architecture, facet and disc plane ori- to preloading force, peak force, duration of manipu-
entations, and arthrokinematics. When subluxation/ lation, impulse of manipulation, and point of appli-
dysfunction is identified, the chiropractor must be cation of peak force. The results demonstrated some
able to effectively induce joint separation and correc- common characteristics (e.g., preload force always fol-
tive joint movements without producing joint com- lowed by a large thrusting force) as well as significant
pression, injury, or distraction at undesired segmental differences between manipulators. The values for the
levels.22 Most adjustive techniques are directed at pro- preload force, peak force, duration and impulse were
ducing joint distraction either along or at right angles found to have large standard deviations for a given
(perpendicular) to the articular plane. adjuster.27 This was a small study, limiting its gener-
The adjustive thrust can be defined as the appli- alizability, but it appears reasonable to speculate that
cation of a controlled directional force. The adjustive the magnitude of force and impulse generation will
vector describes the direction of applied force; the ad- vary from chiropractor to chiropractor and patient to
justive thrust refers to the production and implemen- patient. Nonetheless, there are critical forces that must
tation of that force. The adjustive force is typically be produced by the clinician to develop the thrusting
generated through a combination of practitioner mus- mechanism for joint gapping.
cular effort and body-weight transfer. The chiropractic Variables that must be considered when describ-
adjustive thrust is an HVLA force designed to induce ing a technique are the rate of application and the
joint distraction and cavitation without exceeding the magnitude of the forces. Because the adjustment is
limits of anatomic joint motion. considered a physical application of a well-directed,
The average adjustive force produced by spinal specific force to the body, it is necessary to de-
manipulation can be expressed in terms of the kinetic scribe and measure the magnitude, duration, direc-
energy (mass and velocity) of the clinician, and the tion, and variability of the adjustive forces.28 Wood
combined mechanical resistance to deformation (stiff- and Adams used a specially designed force transducer
ness and elasticity) of both clinician and patient.23 to demonstrate that for a specific type of lumbar ad-
Production of an HVLA thrust necessitates reflex con- justment, rather high forces are generated (182.2 ± 66.6
tractile speed and stabilizing contractions of specific newtons) for short durations (434 ± 249 msec).29 These
muscles (e.g., triceps and pectorals), as well as suffi- results carried a fair degree of reproducibility across
cient transfer of body weight or mass. Production of male and female chiropractic physicians possessing
the necessary force (F ) for a manipulative thrust re- similar practice experience but having different grip
quires a certain amount of mass (m) to travel a short strengths, ages, and body weights. Therefore, there is
distance quickly (acceleration [a ]). Herzog identified at least a preliminary study that demonstrates consis-
four external forces that must be considered when tency among clinicians to be able to generate similar
performing a thrusting technique.24 These include the HVLA thrusts on segmental contact points (specific
weight force at the center of gravity of the clinician, hand contact on short levers) in the lumbar spine.
and three contact forces (forces that occur where the The critical force and energy that must be supplied
clinician is in contact with the environment). Herzog by the doctor to bring a spinal synovial joint to cavita-
modified Newton’s equation (F = ma) by including the tion depend on a multitude of factors.30 High-velocity,
weight force of the clinician (W) and the force of the short-duration, short-amplitude, adjustive impulse,
ground acting on the left and right foot of the clinician countertension, and preadjustive tension are thought
(R1 , R2 ) to obtain F = ma –W – R1 – R2 . He pointed out, to be common procedures that facilitate joint distrac-
however, that to apply these equations the model of tion while helping to isolate the specific joint and
the thrusting procedure is one of a free-falling clinician minimize dissipation of the forces produced.25 One
impacting a stationary patient, a model that is not very of the primary psychomotor skills needed to gen-
realistic. A more meaningful adjustive force equa- erate the force for a thrusting joint manipulation is
tion includes not only the doctor’s mass and impact speed. To overcome inertia, a high velocity developed
velocity, but also certain intrinsic physical properties over a short time must be produced. Sufficient speed
of the doctor and patient such as stiffness and elastic- over a short time is thought to facilitate joint isolation
ity. It has been proposed that average adjustive force is by causing the contact segment to reach maximum
equal to the square root of the product of the extrinsic joint distraction before a noncontacted segment can
impact kinetic energy and the combined mechanical be set into motion.25 However, Haas suggested that if
sufficient countertension can be produced (i.e., ten- contact pressure and distribution.35 Mean peak con-
sion in the opposite direction of the thrust), distraction tact pressures were estimated at 680 kilopascals (kPa)
or cavitation can be accomplished with less speed.25 (100 pounds per square inch [psi]) for one physician
Another important psychomotor skill is the abil- and 1486 kPa (215 psi) for the other. Peak contact
ity to control the depth of the thrust. Short amplitude pressure was focused under the doctor’s proximal hy-
serves to protect the joint from overdistension past the pothenar to an area only a small fraction of the total
limit of anatomical integrity,11 as well as protect ad- area covered by the doctor’s contact hand. Kristukas
jacent motion segments from unwanted and unnec- and Backman labeled this region the intense contact
essary distraction by isolating the joint of interest.25 area and defined it as the area over which two-thirds
Amplitude is controlled through regulating the dura- of peak contact pressure readings are recorded.35
tion and velocity of the thrust. The use of preadjustive Although adjustive pretension and peak forces
tension can limit the dissipation of energy that occurs may vary between doctors, certain consistent charac-
because of damping forces. Preloading the joint limits teristics of HVLA adjustments stand out. They all pro-
further motion during the thrust so that force and en- duce a high-velocity force with a consistent preload
ergy are not lost to other areas.25 Use of preliminary phase (preadjustive tension) and a rapid acceleration
distraction reduces the force necessary for joint cav- phase. The adjustive thrust has a very short duration
itation. The resulting enhanced efficiency facilitates and a focused area of contact pressure and force. It
a more gentle adjustment with less exertion by the also appears that trained chiropractors have the abil-
clinician.25 ity to modify prethrust tension, peak velocity, and
Adjustive thrusts may be delivered in a variety of duration of adjustive thrust according to the area
ways. Some of the common distinguishing attributes treated and the amount of prethrust tissue resistance
include the physical means the doctor uses to deliver encountered.
the thrust, such as arm-centered thrust versus body-
centered thrust. Other factors include the positioning Effects of HVLA
of the joint when the thrust is delivered (e.g., in a neu- Manual therapy is applied in many forms, including
tral position as compared to a point near the joint’s end massage, mobilization, muscle energy techniques, ad-
range of motion), whether the adjustment is delivered justment, and manipulation. The common character-
with or without an active recoil,31 and whether the istic in all of these methods is the application of ex-
thrust is delivered with or without a post–pretension ternal forces to the body to affect the flexibility and
pause. Herzog et al. measured forces during the ap- function of the spine and its contiguous tissues.36
plication of supine cervical, prone thoracic, and side- Most thrusting forms of manipulative therapy will
lying sacroiliac adjustments. The peak thrust forces result in movement of joint surfaces, either directly
averaged 400 newtons (N) for the thoracic spine and or indirectly. The purpose of these procedures is to
ranged between 220 and 550 N during the applica- restore normal articular relationship and function,
tion of sacroiliac adjustments; this is equivalent to restore neurological integrity, and influence physi-
50–125 pounds of force. These forces corresponded ological processes. Various forms of manipulation
to approximately one-third to two-thirds of the treat- affect different aspects of joint function. The therapeu-
ing doctor’s body weight.32,33 Thrust duration times tic emphasis is not on forcing a particular anatom-
measured in the thoracic spine ranged from 100 to ical movement of a joint, but on restoring normal
150 msec and never exceeded 200 msec.34 Force mea- joint mechanics. For academic purposes, the effects of
surements in the cervical spine were markedly less manipulation can include a combination of mechani-
than in other regions with peak forces averaging cal, soft tissue, neurological, and psychological effects
100 N. Thrust duration times were also significantly (Table 38–2). Although these are discussed as separate
less than in the thoracic and sacroiliac regions, rang- entities, it is unlikely for them to occur in isolation.
ing from 80 to 100 msec. Kirstukas and Backman mea- Even when one effect is predominant, other effects
sured prone unilateral thrusts in the thoracic spine will occur either directly or indirectly.
using contact pressure measurements and table force Manipulative treatment is directed at movement
measuring equipment.35 Two chiropractors applied restriction of joints or motion segments of the spinal
six unilateral adjustive thrusts to the apex of the sub- column. Hoag et al. stated that a major subdivision
ject’s thoracic spines over two sessions. The results of osteopathic manipulative therapy involves tech-
demonstrated significantly greater thrust forces than nique directed mainly to osseous structures and de-
Herzog and colleagues, with one chiropractor av- signed to restore normal joint mobility and weight
eraging 630 N and the other 960 N of peak thrust distribution.15 They described the procedures used as
force. Thrust duration times averaged 96 msec and positioning the patient in such a way that the applied
were consistent between physicians. Kirstukas and force will cause motion between the affected segments
Backman also were the first to measure and report on without being dissipated by the elasticity or mobility
TABLE 38–2. Effects of Manipulation averaging about 1 degree and were recorded up to
approximately 2 degrees. Significant movement was
Mechanical Changes Soft Tissue Changes localized to the motion segments immediately infe-
Alter joint position Alter connective tissue texture rior and superior to the point of contact. None of
Influence joint motion Influence muscle tone the vertebral motion segments had preexisting fix-
Affect spinal curves Affect muscle length and ations and all had returned to their resting state
Cavitation strength within 10 minutes after the application of the adjustive
thrust.
Neurological Changes Psychological Changes
Clinical investigations on the effects of spinal ma-
Alter motor, sensory, and Placebo factor
nipulation on muscle activity are limited. Investiga-
reflex activity
tions have centered on the effects during and after
Influence the autonomic Patient satisfaction
the application of manipulation. Using surface elec-
nervous system
tromyelography (EMG), Herzog and colleagues in-
vestigated the immediate effects of thoracic spinal ma-
nipulative therapy on paraspinal muscle activity.39,40
of other spinal or appendicular structures. After ten- They applied prone unilateral quick HVLA and slow
sion is taken up in muscles and ligaments from above (3–4 seconds) “manipulations” to the thoracic trans-
and below the site to be mobilized, a force is deliv- verse processes. Both procedures consistently in-
ered, usually to the upper of the two segments and duced momentary increased muscle activity during
in a direction most likely to restore normal motion. their application.39,40 The high-velocity manipula-
This procedure implies a specific short-lever contact tions were associated with a fast, burst-like EMG sig-
on a spinous process or transverse process. Frequently, nal and the slow manipulations with a gradual in-
the procedure is accompanied by a cracking sound, crease in EMG activity. Cavitations induced during
which is regarded by patients as the sine qua non of a the application of the slowly applied manipulation
proper osteopathic treatment, although it is not gen- were not associated with increased EMG activity, lead-
erally considered necessary to obtain a proper manip- ing the authors to speculate that cavitation alone is
ulation. The thrust movement is rapid (high-velocity) not sufficient to induce a reflex muscular response. In
and of short distance (low-amplitude), but carefully contrast, Triano was unable to record any significant
calibrated according to the age and condition of the myoelectric activity or muscular responses with the
patient and the nature of the skeletal disorder. application of HVLA side-posture lumbar-adjusting
A number of beneficial effects of chiropractic ad- procedures.37 Investigations into more prolonged ef-
justive therapy have been demonstrated clinically. fects on resisting muscle activity, although limited,
However, the specific mechanism of action has not show reduction in paraspinal muscle activity and im-
been fully described.33 It is assumed that the exter- balance with full-spine adjusting procedures.36,41
nal forces applied with adjustive therapy move spinal The reduction of pain and disability after spinal
articulations and stretch and stimulate associated soft manipulation is well recognized and clinically docu-
tissues. The last decade has seen significant evaluation mented.42–51 The mechanisms by which manipulation
and measurement of the forces produced in the appli- inhibits pain, however, are still under investigation.
cation of HVLA adjustments, but very little is known Proposed hypotheses suggest that manipulation has
about the internal loads and effects of these forces on the potential to remove the source of mechanical pain
biologic tissue and the potential biomechanical differ- and inflammation and/or induce stimulus-produced
ences that may exist between adjustive methods.33,37 analgesia.
Investigation of spinal movements induced by ad- The psychological effect of the laying on of the
justive thrusts is limited. Only one study using HVLA hands is probably also important. Paris states that
procedures has been conducted. The investigations the addition of a skilled evaluation involving palpa-
were limited to evaluating the movements generated tion for soft-tissue changes and altered joint mechan-
by unilateral posterior to anterior thrusts in the lower ics convinces the patient of the interest, concern, and
thoracic spine of fresh-frozen cadavers.38 Significant manual skills of the clinician.52
segmental translational and angular movements were
measured. The movements were recorded using bone Cavitation
pins embedded in the spinous process of three adja- During an adjustive procedure, the joint is taken be-
cent vertebra and high-speed cinematography. Poste- yond the elastic barrier, creating a sudden yielding
rior to anterior and lateral translational movements of the joint as it enters the paraphysiological space.
averaged 0.5 mm and ranged up to 1 mm. Axial ro- This sudden separation of a joint produces the “crack-
tations averaged about 0.5 degrees and were noted ing” sound that is termed cavitation. Adjustive thrusts
up to nearly 1 degree. Sagittal rotations were greater, are frequently associated with this “cracking” sound.
Typically, this occurs at the end range of passive joint ment because it represents motion induced only after
motion when the thrust overcomes the remaining joint cavitation.11
fluid tension. The quick separation of the joint is theo-
rized to produce negative pressure within the joint, the Adjustive Mechanics
induction of joint cavitation, and an associated “crack- Each grouping of adjustments have their own me-
ing” sound. Cavitation is the “formation of vapor and chanical characteristics dependent on adjustive con-
gas bubbles within fluid through the local reduction tacts, patient positioning, doctor positioning, and ad-
of pressure” and is a well-established physical phe- justive vectors. Efficient and effective selection of
nomena in peripheral joints. Evidence strongly sug- manipulative technique cannot be made without an
gests it also occurs during the application of spinal understanding of each adjustment’s unique physi-
adjustive therapy.11,53,54 It has long been known that a cal attributes.22 For example, side-posture lumbar ad-
liquid confined in a container with rigid walls can be justments may be used to develop rotational tension
stretched, and if stretched sufficiently, causes cavita- and perpendicular facet distraction. In contrast, prone
tion to occur. The pressure inside the liquid drops be- lumbar adjustments maintain a more neutral posi-
low the vapor pressure, bubble formation and collapse tion of the lumbar spine and therefore minimize the
occur, and a cracking sound is heard.55 The case for amount of rotational tension. Side-posture positions
synovial joint cavitation and cracking is supported by also provide additional leverage and more latitude
experimental evidence conducted on metacarpopha- in the development of and use of the doctor’s body
langeal (MCP) joints, the cervical spine, and the tho- weight, providing a possible mechanical advantage.
racic spine.11,26,56–60 Therefore, if rotational lumbar distraction is desired, a
Brodeur53 has presented a slightly different model side-posture adjustive method should be considered
of joint cavitation and cracking based on a mecha- over a prone method. If lumbar distraction without
nism described by Chen and Israelachvili.61 Within rotational tension is desired, then a prone lumbar po-
this model, the capsular ligament plays a primary sition might be more appropriate.
role in the production of joint cavitation and crack- Localization refers to the preadjustive procedures
ing. During the first phase of joint manipulation as that are designed to localize adjustive forces and joint
the joint is being loaded and the joint surfaces are distraction. They involve positioning, removal of ar-
being distracted, the joint and the capsular ligament ticular “slack,” and the development of appropriate
are seen as invaginating (drawing inward) to main- contact points and adjustive vectors. These factors
tain a constant fluid volume within the joint space. are critical to the development of necessary pread-
As distractive pressure is increased, the capsular lig- justive tension and adjustive efficiency. Attention to
ament reaches its elastic limits and snaps away from these components is intended to improve adjustive
the synovial fluid producing cavitation at the capsu- specificity and to further minimize the distractive ten-
lar synovial interface. A rapid increase in joint volume sion on adjacent joints.
follows and the gas bubbles formed at the periphery Preadjustive joint tension and localization are de-
rush to form a single coalesced bubble in the center pendent on patient placement and leverage. Local-
of the joint space. Brodeur speculates that the “snap- ization of adjustive forces may be enhanced by using
back” of the capsular ligament is the event respon- careful patient placement to position a joint. Locking
sible for the audible crack.53 He also proposes that adjacent joints and positioning the joint to be adjusted
this mechanism explains why cavitation does not oc- at the apex of curves established during patient posi-
cur in some individuals with very tight or loose joint tioning enhances adjustive specificity. Joint localiza-
capsules: “For loose joints, the volume of the articu- tion and joint distraction may be further enhanced if
lar capsule is larger and traction of the joint does not forces are used to either assist or oppose the adjustive
cause a sufficient tension across the ligament to initiate thrust. Assisting or opposing forces may be generated
the snap-back of the joint capsule. Similarly, an overly either during the adjustive setup and/or during the
tight joint reaches the limits of its anatomical integrity adjustive thrust.
before the joint capsule can begin to invaginate.” The notion of applying assisted and opposing
Besides the cracking itself, cavitation is consid- forces during the performance of manipulation was
ered to be associated with several postadjustive phe- first described relative to thoracic manipulation by
nomena, including a transitory increase in passive the French physiatrist Robert Maigne.62 In the chiro-
range of motion, a temporarily increased joint space, practic profession, Sandoz was the first to describe
an approximate 20-minute refractory period during similar terms.11 He proposed using the terms assisted
which no further joint cracking can be produced, in- and resisted to describe patient positions that either
creased joint separation, and an increased placebo ef- assist or resist adjustive thrusts. Good presented ex-
fect. Sandoz has labeled the postadjustive increase amples of these concepts in relation to the diversified
in joint range of movement paraphysiologic move- techniques.63 As originally described, assisted and
resisted methods were only applied to side-posture commonly applied in the treatment of rotational
lumbar adjustments and procedures involving a sin- dysfunction.
gle primary thrust.11 Both methods are employed to
improve the localization of preadjustive tension. Their Characteristics of the Impulse Thrust
application is based on the mechanical principle that An impulse thrust is an HVLA force performed in a
the point of maximal tension is developed at the point manner to minimize the normal elastic recoil that oc-
of opposing counterrotation. Assisted and resisted curs after the quick cessation of an adjustive thrust.
methods are distinguished from each other by the po- This is accomplished by maintaining mild pressure
sitioning of vertebral segments relative to the adjus- and contact with the surface for a short period af-
tive thrust. In both circumstances, the trunk and verter the termination of the adjustive thrust. The ad-
tebral segments superior to the adjustive contact are justive velocity may be varied, with either a slow or
prestressed in the direction of desired joint movement. fast termination. Impulse thrusts are most commonly
In the assisted method, the contact is established on delivered with the affected joint prestressed to reduce
the superior vertebral segments and movement of the articular slack, but should not be delivered with the
trunk and the thrust are directed together. Assisted joint stressed beyond its elastic limits. Impulse thrusts
procedures are designed to induce preadjustive ten- may be primarily arm-centered or body-centered, or
sion and achieve positions that assist the adjustive combine forces generated through the doctor’s arms
thrust. Resisted procedures employ patient positions and body. All adjustive thrusts involve relatively high-
in which the segments superior to the adjustive con- velocity forces but vary in the degree of associated
tact are stabilized or moved in a direction opposing the body weight coupled with the adjustment. Where less
adjustive thrust. In the resisted method, the con- mass and total force are desired, the thrust is typically
tact is established on the lower vertebral segment delivered only through the upper extremities. This is
and the directions of trunk movement and adjus- commonly the case in the adjustive treatment of the
tive thrust are in opposing directions. Sandoz sug- cervical spine and small extremity joints, and in the
gested that resisted positions bring maximal tension treatment of pediatric, geriatric, or frail patients.
to the articulation superior to the established con- During the delivery of arm-centered thrusts, the
tact and assisted positions bring maximal tension to doctor’s torso is stationary. The adjustive force is
the articulation inferior to the established contact.11 produced by the initiation of pushing, pulling, or
Therefore, either method can theoretically be used to rotation forces generated through the doctor’s fore-
induce cavitation and motion within the same artic- arms, elbows, and/or shoulders. Arm-centered
ulation. While the movement generated is the same, thrusts may be delivered through one arm or both
the points of contact and the line of drive are different arms. When one arm is the focus of the adjustive
(Table 38–3). force, the other arm (indifferent hand) either rein-
Counterresisted methods incorporate segmental forces the contact or stabilizes the patient at another
contacts established on both sides of the joint to be site. When used for stabilization, the indifferent hand
adjusted.22 Pretension and the adjustive thrusts are maintains the patient in a neutral position or induces
directed in opposing directions to maximize distrac- positions or forces that assist or resist the adjustive
tion across a given joint. The adjustive thrust may force.
be focused through segmental contacts or incorpo- When more total force is desired, the doctor trans-
rate additional contacts and reinforcing thrusts ap- fers additional weight from the trunk and/or pelvis
plied at levels superior to and inferior to the seg- into the adjustive thrust. In body-centered (body-
mental contacts. In the spine, this procedure is most drop) thrusts, the majority of the adjustive force
is generated by propelling the weight of the doc-
tors’ trunk through the adjustive contacts. This is ac-
Characteristics of Assisted and
TABLE 38–3. complished with a quick and shallow flexion of the
Resisted Methods doctors’ trunk and lower extremities, along with a
simultaneous contraction of the abdominal muscles
Assisted Methods Resisted Methods and diaphragm. Schafer and Faye described the ab-
dominal and diaphragmatic contractions as a process
Contact on the superior Contact on the inferior similar to the event that occurs during sneezing.64
vertebrae vertebrae During the delivery of a body-drop thrust, it is
Prestress in direction of Prestress in opposite direction critical that the upper extremities remain rigid. If the
thrust of thrust joints of the upper extremity give way during the de-
Affect the joint below Affect the joint above contact livery of an adjustive thrust, the adjustive force is dis-
contact point point sipated. Rigidity is ensured by locking the upper ex-
tremity joints and by combining the trunk acceleration
with a simultaneous shallow thrust through the upper ferred to as short-lever techniques. Other methods
extremities. use an indirect contact on adjacent joints or body
Adjustments delivered with the patient in the parts (long levers).
prone position may be delivered as pure body-drop 3. Manipulation procedures that employ a direct con-
procedures, pure arm-centered thrusts, or as com- tact tend to be more specific than the methods that
bined body-drop and arm thrusts. Lumbar and pelvic use longer levers.
side-posture adjustments, which commonly demand 4. The adjustive thrust can be defined as the applica-
more total force, invariably involve the transfer of tion of a controlled directional force. This force is
trunk and pelvic weight along with a simultaneous typically generated through a combination of prac-
arm thrust. To transfer the additional body mass into titioner muscular effort and body weight transfer.
the patient, the doctor typically establishes additional 5. The effects of manipulation include a variety of
contacts along the lateral hip or pelvis of the patient. mechanical, soft-tissue, neurological, and psycho-
A common technique variation in side-posture logical effects.
lumbar adjusting couples a segmental contact with a 6. The sudden separation of the joint during ma-
reinforcing thrust through the doctor’s leg. Instead of nipulation is often accompanied by joint “cavita-
the doctor’s weight resting against the patient’s upper tion.” This is caused by pressure changes that occur
thigh and hip, a contact on the patient’s knee is estab- within the joint and may be an important compo-
lished. The impulse is then delivered by combining a nent of a successful treatment.
pulling impulse with the arm and a quick extension of 7. The principles of adjustive mechanics include at-
the doctor’s knee. In this method, the leg provides the tention directed at adjustive contacts, patient posi-
additional leverage and force instead of the doctor’s tioning, doctor positioning, and adjustive vectors.
body weight. 8. An impulse thrust is a high-velocity low-ampli-
tude force that is accompanied by maintaining
mild pressure and contact with the surface for a
CONCLUSION
short period after the termination of the adjustive
Research investigating the characteristics of a vari- thrust.
ety of chiropractic adjustive procedures, including
their mechanism of action, is growing. The accep-
tance of spinal manipulation by other health care
QUESTIONS
professions, industry, and the general population con-
tinues to grow despite controversies that still exist in 1. Which health care professions use the high-
clinical practice. Advocates of manipulative therapy velocity low-amplitude thrust for treating muscu-
in the healing arts of chiropractic, medicine, osteopa- loskeletal problems?
thy, and physical therapy have independently con- 2. What is the difference between a long or short lever
cluded that the HVLA thrust is an important clin- and a general or specific contact?
ical intervention for the treatment of dysfunctional 3. In what terms is the adjustive force defined?
conditions associated with the neuromusculoskeletal 4. What is cavitation and what is its significance?
system. 5. How does an assisted prestress differ from a re-
The controlled delivery of the adjustive thrust de- sisted prestress in the delivery of an HVLA thrust?
mands much discipline and skill. It takes extensive
training and time to perfect adjustive skills and ac-
quire the ability to sense and control the appropriate
ANSWERS
depth and force of an adjustive thrust. Chiropractors
have devoted years of training to refine their manip- 1. Manual therapy in the fields of chiropractic, os-
ulative skills and have developed an arsenal of tech- teopathy, medicine, and physical therapy includes
niques to fit each of the multiple clinical situations and the use of HVLA.
patient characteristics they are likely to encounter. 2. Localization: Use of short levers and specific con-
tacts (i.e., spinous processes, transverse processes)
will localize the force produced by the adjustive
SUMMARY
thrust to a single joint or joint complex, whereas
1. There is growing support from various health care long levers and general contacts allow the force
fields for the use of the high-velocity low-ampli- produced by the adjustive thrust to be spread over
tude thrust (i.e., the chiropractic adjustment). a larger area affecting multiple joints.
2. There are a variety of manipulative procedures 3. The adjustive force can be expressed in terms of the
that use a direct contact on the joint to be adjusted impact kinetic energy (mass and velocity) of the
(e.g., spinous process). These procedures are re- clinician, and the combined mechanical resistance
to deformation (stiffness and elasticity) of both Roston JB, Wheeler HR. Cracking in the metacarpopha-
clinician and patient. langeal joint. J Anat 1947;81:165.
4. When a liquid confined in a container with rigid Sandoz R. Some physical mechanisms and effects of spinal
walls is stretched sufficiently, cavitation occurs. adjustments. Ann Swiss Chiropr Assoc 1976;6:91–141.
The pressure inside the liquid drops below the Triano J, Schultz AB. Loads transmitted during lumbosacral
spinal manipulative therapy. Spine 1997;22(17):1955–
vapor pressure, bubble formation and collapse
1964.
occur, and a cracking sound is heard when the Triano JJ. Studies on the biomechanical effect of a spinal
joint is taken beyond the elastic barrier, creat- adjustment. J Manipulative Physiol Ther 1992;15:71–75.
ing a sudden yielding of the joint as it enters White AA, Panjabi MM. Clinical biomechanics of the spine, 2nd
the paraphysiological space. This sudden separa- edition. Philadelphia: JB Lippincott, 1990.
tion of a joint that produces the cracking sound
is termed cavitation. The significance of this pro-
cess includes a transitory increase in passive range REFERENCES
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Physiol Ther 1986;9(3):189. tebral motion unit prestress. Chiropr Tech 1992;4(4):117–
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C H A P T E R
39
MOBILIZATION TECHNIQUES
John Scaringe and Craig Kawaoka
O U T L I N E
INTRODUCTION —Seated Transverse Process Contact for
TERMINOLOGY Posteroanterior Glide
Mobilization —Prone Hypothenar Spinous Process Contact for
Distraction Posteroanterior Glide
Nonthrust Mobilization with Movement Procedures
Thrust —Counterrotation SNAGS
JOINT MOVEMENT AND MANUAL THERAPY —SNAGS
OVERVIEW OF MOBILIZATION TECHNIQUES Spinal Mobilization Procedures (Lumbar Spine)
Maitland Oscillatory Mobilization Procedures
Kaltenborn —Side-Posture Lumbar Intersegmental Rotation
Traction Mobilization with Movement Procedures
Mulligan —SNAGS
Others Lower Extremity Mobilization Procedures
Cyriax (Knee Joint)
Mennell Oscillatory Mobilization Procedures
McKenzie —Anteroposterior Glide of the Tibia
Cox —Anteroposterior Glide of the Proximal Fibula
MECHANISMS OF ACTION Mobilization with Movement Procedures
INDICATIONS AND CONTRAINDICATIONS —Painful and/or Limited Flexion and Extension
EVALUATION AND TREATMENT METHODS of the Knee
Spinal Mobilization Procedures (Cervical Spine) Upper Extremity Mobilization Procedures
Oscillatory Mobilization Procedures (Shoulder Complex)
—Seated Spinous Contact for Posteroanterior Oscillatory Mobilization Procedures
Glide —Combined Distraction and Posterior Glide of the
—Prone Double-Thumb Spinous Process Contact Head of the Humerus in the Glenoid Cavity
for Posteroanterior Glide Mobilization with Movement Procedures
—Supine Lateral Flexion —Glenohumeral Joint
Mobilization with Movement Procedures LITERATURE REVIEW
—Sustained Natural Apophyseal Glides SUMMARY
—Rotation SNAGS QUESTIONS
—Lateral Flexion SNAGS ANSWERS
Spinal Mobilization Procedures (Thoracic Spine) KEY REFERENCES
Oscillatory Mobilization Procedures REFERENCES
767
tion of mobilization techniques is that both the pa-

OBJECTIVES
tient and clinician are relaxed, with the clinician in
1. To define and describe categories of the various control.
forms of mobilization techniques. These techniques are appropriate for any articula-
2. To provide an overview of the main proponents of tion of the body, and treatment can be applied to one
mobilization techniques. or more segments. Like manipulation, mobilization
3. To describe the focus of the treatment approaches is used on many different conditions, both acute and
advocated by various proponents of mobilization. chronic, and can be used independently or in com-
4. To discuss proposed mechanisms of action for mo- bination with other treatment procedures. The mobi-
bilization techniques. lization effort is applied in a graded manner, with each
5. To review the indications and contraindications of grade increasing the motion in its movement arc.
mobilization therapy.
6. To review some of the principal techniques of mo-
TERMINOLOGY
bilization for the cervical, thoracic, and lumbar
spine, as well as the knee and shoulder. Not everyone agrees on the meaning of related ter-
minology. Terms such as articulation technique, joint
mobilization, and nonthrust manipulation have been
used to describe mobilization in an attempt to dif-
INTRODUCTION
ferentiate it from the chiropractic adjustment. Other
Traditionally, the chiropractic profession has relied authors use the term mobilization in a more general
on the use of high-velocity low-amplitude manipu- manner for any form of passive movement.2 Artic-
lation techniques, referred to as the adjustment, and ulation technique is defined as the use of a passive
has not placed as much emphasis on using the var- movement directed at a joint, without a high-velocity
ious forms of mobilization. The use of manipulation thrust, while remaining within the joint’s physiologic
techniques involves the application of a high-velocity range of motion.3 Of particular importance is the fact
low-amplitude thrust that is often accompanied by that an articulation or joint mobilization procedure is
and often characterized by an audible cavitation or performed slowly enough so the patient is able to stop
“crack.” In contrast, mobilization techniques are de- it at any time during its application.
fined by a lack of thrust and are often referred to as Another form of mobilization is referred to as an
nonthrust or nonimpulse techniques. There is a grow- oscillatory technique, which uses a gentle, coaxing,
ing interest on the part of chiropractors in the use of repetitive and rhythmic movement. This technique is
mobilization methods as an adjunct or alternative ap- combined with a sustained stretch in order to increase
proach to the management of spinal pain syndromes. motion and decrease pain. The advantage of mobiliza-
This chapter reviews the application of the various tion over manipulation is that it can be used over a
forms of nonthrust mobilization techniques. wider range of conditions, and may be useful where
The goals in treating a patient with nonimpulse thrust techniques might be contraindicated.
mobilization procedures are similar to those seen with
the use of manipulation or adjustment: to restore nor- Mobilization
mal symmetrical range of motion, to stretch the con- Distraction This refers to the separation of adjacent
nective tissues around a restricted articulation, and to joint surfaces. It is often called long axis distraction
restore normal end feel. However, unlike manipula- and/or separation. This movement is used to reduce
tion, which is typically applied with a single thrust, pressures on articular and intraarticular surfaces. It
mobilization is often applied in a repetitive manner. stretches the joint capsule and adhesions and is some-
Mobilization is also performed within the patient’s times used to reduce dislocations.
ability to resist the applied motion. The procedures
are dependent on patient response. One common tech- Nonthrust This is oscillatory motion within or at the
nique uses a series of gentle, rhythmic, oscillatory mo- end of accessory motion. This movement is used to
tions, wherein a force is applied in an arc or plane produce a mechanical effect of permanently stretch-
against the resistant barrier. According to Greenman, ing connective tissue. It may also be used to produce a
mobilization is really an extension of joint motion neurophysiological effect by stimulating mechanore-
testing.1 He adds that diagnosis and treatment de- ceptors in the joint, muscle, and cutaneous tissues.
pend on the operator’s palpating skill and experi-
ence. In addition, it is essential that the clinician has Thrust This refers to the application of a speed and
a good understanding of the articular anatomy and force that the patient cannot resist. These procedures
is able to visualize the restricted range and arc of are discussed in Chapters 37, “Evolution and Basic
movement. Of particular importance in the applica- Principles of the Chiropractic Adjustment and
MOBILIZATION TECHNIQUES 769
Manipulation,” and 38, “High-Velocity Low- Joint movements are classified as follows4 :
Amplitude Manipulative Techniques.”
1. Classical movements: Traditional types of joint
movement such as flexion and extension. Some-
JOINT MOVEMENT AND MANUAL THERAPY times referred to as “osteokinematic” movements,
To properly appreciate the different approaches to may be produced actively or passively, and are de-
mobilization, it is important to appreciate the in- fined as
tricacies of joint movement. As with manipulation, • Active joint movement (under voluntary mus-
mobilization techniques take into account both phys- cle control), used to assess muscle function and
iological and accessory joint motions. Physiological the range of joint motion.
motions are those movements that are most often as- • Passive joint movement (performed by the ex-
sociated with joint motion such as flexion–extension, aminer), used to assess end feel and noncon-
abduction–adduction, and medial–lateral or internal– tractile tissues.
external rotation.5 In contrast, accessory motions are 2. Accessory movements: Motions that combine with
movements that occur within the joint itself, and are the classical movements to allow full range of mo-
necessary for normal physiologic motion to occur. tion and are differentiated between
They may not, however, be created actively. An exam- • Joint-play motions that only occur when exter-
ple of an accessory motion may be seen in the simul- nal forces are applied to the joint. These mo-
taneous roll and slide that occurs in the glenohumeral tions are used to assess the joints ability to ac-
joint as the arm is raised. Another example of an accept and absorb external forces.
cessory motion is joint distraction and compression. • Component motions, which are those move-
Accessory motions are produced by external forces ments that occur in an associated joint in order
such as capsular tension, and are sometimes referred to allow an active movement to occur. An ex-
to as “joint play” (Fig. 39–1).6 ample of a component motion is the distraction
The accessory motions are dependent on the cur- that occurs at the distal tibiofibular joint dur-
vature of the articular surface, where the convex suring dorsiflexion of the ankle. These motions are
face has a greater curve (smaller radius of curvature) used for purposes of examination in order to as-
than that of the concave surface.7 Accessory motion sess whether or not the associated joint is caus-
occurs so that the motion of the larger convex surface ing dysfunction and preventing active motion.
doesn’t “run out” of the smaller concave surface; this 3. Arthrokinematic movement: A combination of clas-
motion can be isolated passively. MacConaill classifies sical and accessory motion, defined as the move-
the synovial joint into four structural classifications ment that takes place within the joint.
that determine the type and amount of movement that
occur7 :
OVERVIEW OF MOBILIZATION TECHNIQUES
1. Unmodified ovoid: Ball and socket, triaxial (e.g., hip There are a wide variety of mobilization procedures
and shoulder) in common use, many of which have common fea-
2. Modified ovoid: Ellipsoid, biaxial (e.g., metacar- tures, while others are rather unique. Interestingly, it
pophalangeal joints) has been stated that many of the manual evaluation
3. Unmodified sellar: Saddle, biaxial (e.g., first car- and treatment techniques differ more on the basis of
pometacarpal joint) the philosophy and training of the practitioner rather
4. Modified sellar: Hinge, uniaxial (e.g., interpha- than the validity of any specific theory.8 The common
langeal joints) elements of various mobilization techniques include
history taking and active testing of movement, while
commonalities for treatment procedures are palpa-
tion, manipulation, mobilization, and patient educa-
tion. With growing interest in the manual therapies,
Farrell and Jensen stated, “As practitioners become
more eclectic in evaluation and management of pa-
x tients, the lines between evaluative approaches are
likely to continue to blur over time.”9
In an attempt to understand the various ap-
proaches, this section looks at some of the more popu-
lar mobilization methods. It is worth noting that many
FIGURE 39–1. Accessory motions. of the individuals who have developed a specific
approach to mobilization have also spent consider- to identify any precautions against treatment. Mait-
able time and energy teaching others their techniques. land stresses the process of “listening” to the pa-
Consequently, although each “brand” of mobilization tient, both in the words spoken and in the body’s
technique has both followers and detractors, a fair response to the examination and treatment. An im-
amount of overlap may be seen between the various portant component of Maitland’s examination proce-
schools of thought. dure was that limited functional activities are marked
with an asterisk to use later as an objective outcome
Maitland measure.10
One of the more influential individuals to teach mobi- Subjective evaluation determines the course of the
lization techniques is Geoffrey Maitland, whose con- objective evaluation, the vigor of which is based on
cepts have been widely taught around the world; his the SINS algorithm: Severity, Irritability, Nature, and
conceptual model for evaluation and treatment is also Stage of pathology.9 This examination includes the in-
known as the Australian approach.9 Maitland advo- volved joints, muscles within the area of complaint,
cates treating all joints in a passive manner, using and any joints that may refer pain to the area. All
the presenting signs and symptoms of the patients joint ranges of motion are observed for pain, spasm,
as the foundation for treatment. He stated that there and resistance to active motion. Passive motion is also
are no set or invariable techniques, and insisted that examined, followed by the assessment of accessory
the technique must be constantly modified for each motions. At least one “asterisk” is sought during ac-
patient until the treatment objective is achieved. Hav- tive movements. Reproduction of the chief complaint
ing stated that a classical diagnosis can be inade- (i.e., pain, stiffness, or muscle spasm) with motion is
quate, or sometimes inappropriate, Maitland rarely termed a “comparable sign.” Normally, several com-
describes specific lesions in joints or soft tissues, al- parable signs are found. If one comparable sign is
though he does use his technique on many commonly found to be highly irritable to the joint, the exami-
known diagnoses. Maitland advocates changing as nation is discontinued. Treatment progression is as-
the patient’s signs and symptoms change,10 stressing sessed using changes in a comparable sign.
the importance of continuous analytical assessment Following the objective evaluation, the patient is
(Fig. 39–2).10,11 then categorized as follows10 :
The key component of Maitland’s method is a
meticulous evaluation, which provides the basis for Group 1: Main complaint is pain, which limits motion.
treatment. The determination of how gentle or vig- Group 2: Main complaint is loss of movement, with
orous the examination should depend on pain, stiff- pain being of little significance.
ness, and spasm in response to active and passive Group 3a: Pain and joint stiffness occur simultane-
physiological and accessory motions.12 The first part ously, but pain is dominant, and the increase in
of the examination is the patient interview, used pain intensity is proportional to the increase in
to determine the precise location and behavior of strength of resistance.
pain, as well as any other pertinent information. This Group 3b: Pain and joint stiffness occur simultane-
helps not only to isolate the source of pain, but also ously, but stiffness is dominant, and the increase in
stiffness is proportional to the increase in strength
of resistance.
Group 4: Periodic and transient pain.
Assessment
These groupings are used in determining the treat-
ment technique. It is important to note that the pa-
tient is not locked into any one group. In fact, a pa-
Examination tient may move from one group to the next during a
Treatment course of treatments, altering treatment accordingly.10
According to Maitland, the goal of mobilization is to
restore normal function to a joint and its surround-
ing tissue. Specific treatment goals and strategies are
formulated using the data from the examination and
results of the initial treatments.9 Maitland uses ac-
cessory and physiological oscillatory mobilizations
for joint dysfunction.10 For the most part, Maitland’s
treatment approaches are directed at the joint’s inher-
FIGURE 39–2. Evaluation, assessment, and technique. ent resistance.9
An important contribution by Maitland to the use Neutral joint Limit of joint End of range
of mobilization procedures is his description of five Position movement due
different grades of mobilization11 : to dysfunction
Grade I: A small-amplitude movement performed

Kaltenborn
only at the beginning of the active end range.
Grade I
Grade II: A large-amplitude movement performed
through the freely mobile range but not through Grade II Grade III
any part of the restricted range.
Maitland
Grade III: A large-amplitude movement performed
up to, but not exceeding the passive end range. Grade I
Grade II
Grade IV: A small-amplitude movement applied well
into resistance. Grade III
Grade V: Equivalent to a manipulation where a high- Grade IV Grade IV+
velocity low-amplitude force is performed at end
range in an attempt to exceed the elastic barrier to
movement.
Figure 39–3 compares Maitland’s grades of mobi- Acute conditions – limiting factor Chronic conditions –
lization to those of Kaltenborn. is inflammation and pain limiting factor is adhesions
Physiological and accessory motions are both
used in mobilization movements. Painful joints are FIGURE 39–3. Comparison of mobilization grades.
treated with accessory and physiological movements
of grades I and II, whereas stiff and painless joints are using only one technique per treatment to determine
treated with only physiological movements of grades if it is beneficial.12
III and IV. Joints with intermittent pain are treated by
using a combination of movements. Most peripheral Kaltenborn
mobilization is used within, or up to, the pathologi- Freddy Kaltenborn founded and greatly influenced
cal limit of a joint, and only rarely does it reach the the Nordic system of manual therapy, which in-
anatomical limit (Table 39–1).12 tegrates physical therapy, medicine, and physi-
According to Maitland, after each treatment pro- cal education. The Nordic system has three major
cedure, the patient is asked to perform the movement principles: diagnosis, treatment, and research. This
that initially produced the complaint to measure any technique was designed specifically to relieve pain, in-
change resulting from treatment. Maitland stressed crease mobility, limit movement, and inform, instruct,
TABLE 39–1. Comparison of Accessory and Physiological Movement
Accessory Movement Procedures Physiological Movement Procedures
Used when resistance is largely from the Used when resistance is primarily from
ligaments and joint capsule and minimal the muscles
muscular resistance is encountered
Can be performed in any part of the Is only effective at the end of the
physiological range of motion physiological range of motion
Can be performed in any direction Can only be performed in one direction
(Posteroanterior, anteroposterior,
superiorly, inferiorly)
Causes less pain per degree of range Causes more pain per degree of range
of motion of motion
Used for tight joint structures Used for tight muscles
Is safer than other methods because it Is not as safe as other methods because it
uses short-lever arm techniques uses long-lever arm techniques
Modified from Gould JA, Davies GJ. Orthopedic and sports physical therapy. St. Louis: Mosby, 1985.
and train patients.13 Like many of his Scandinavian that describe the shapes and positions of articulation.7
colleagues, Kaltenborn followed Cyriax’s philosophy An ovoid joint consists of a concave surface articulat-
of identifying specific lesions through a detailed eval- ing with a convex surface, while a sellar joint is one
uation and treating them accordingly.14 in which each articular surface consists of both a con-
Kaltenborn’s evaluation process was based not vex and concave surface. Articular positions include
only on the biomechanics of joint motion, but was open- (loose) and closed-packed. The open-packed
also influenced in part by his osteopathic roots and the position is any position where there is less than com-
concepts of somatic dysfunction. He labeled the exam- plete congruence between the articular surfaces and
ination as “present episode,” a process that involves the surrounding ligaments are loose; this is an ideal
inspection, palpation, functional examination, neuro- position to perform distraction and movement exam-
logical testing, and other examinations as needed.15 ination. The closed-packed position occurs when the
Like Cyriax, Kaltenborn used a combination of proce- joint surfaces are in maximal contact. In this position,
dures in his testing and analysis of general movements it is difficult to separate the articular surface and the
of active, passive, and resisted motion. The Nordic capsule and ligaments are tight. The closed-packed
system specifically uses the translatoric (linear) ap- position also involves joint compression and is con-
proach rather than rotary movements to evaluate the sidered to be undesirable for joint mobilization.15
range of motion and quality of movement: The “convex–concave” rule is one of the key as-
pects of the Nordic system and is used as a guide in de-
Normal joint movement is divided into two termining the direction of joint movement, especially
categories: (1) the standard (uniaxial/ when direct joint challenge (motion palpation) is not
anatomical) movements, and (2) combined possible. This indirect method of assessment is used
(multiaxial/functional) movements. The com- when the patient has severe pain limiting movement,
bined movements are further divided into the joint is hypomobile or has little movement nor-
coupled movements, which tend to have the mally, and/or the examiner is not experienced enough
largest range of motion and softest end-feel, to assess dysfunctional gliding movements with di-
and noncoupled movements, which consists rect joint testing. In the convex–concave rule, the bone
of all the other combined movements.13 with the convex joint surface is moved in the oppo-
Spinal disorders are divided into lesions with or site direction of the restricted bone movement, while
without neurological findings. Lesions with neuro- the bone with the concave joint surface is moved in
logical signs are treated with traction. Lesions with- the same direction of the restricted bone movement
out neurological signs are treated based on the find- (Fig. 39–4).
ings of hypomobility or hypermobility of the joint.13 An essential part of Kaltenborn’s joint mobiliza-
Prior to manual mobilization, the clinician must de- tion procedure is long-axis distraction. Traction and
termine whether the problem is primarily in the joint gliding movements are divided into three grades or
or associated soft tissues, whether joint hypomobil- stages, determined by the amount of “slack” remain-
ity or hypermobility is present, and whether pain or ing in the joint capsule and surrounding soft tissues.
inflammation is dominant. During the examination,
accessory movements are used to determine if the Traction Stage one traction nullifies pressures within
pathological joint is of a biomechanical nature. Pro- the joint without separation of the joint surface. This
viding that a treatable lesion is present with a suitable can be applied with many mobilization movements in
working diagnosis, a gentle treatment is performed. order to prevent trauma to the joint, or may be used
Confirmation that the final diagnosis is correct is seen alone for pain relief. Stage one traction is used with
in the success of this treatment.15 stage two and three gliding procedures.
It is important to appreciate the normal articular Stage two traction takes up allowable soft-tissue lax-
shapes and positions in order to determine the de- ity in the joint, causes the joint surfaces to separate,
sired direction of the mobilization treatment. As stated and relieves pain. Stage two movements do not pro-
earlier, MacConaill has defined arthrokinematic terms duce appreciable stretch on the joint capsule.
Bone
t s u r f a ce
J o i n t s u rfac
x
x
oin
e
Bon
J
e
convex moving, concave moving,

concave stable convex stable FIGURE 39–4. Concave–convex rule.
Stage three traction is the most aggressive of the

three, with distraction applied to the point that the
soft tissues around the joint are stretched.12,13
Treatment is performed with translatoric traction
and gliding movements (instead of rotational, angu-
lar movements) so that compression of a joint can
be avoided. To treat hypomobile joints, short trans-
latoric movements are used at right angles (traction) FIGURE 39–5. Concave–convex movement.
or parallel (gliding) to the perceived treatment plane.
When applied slowly these techniques are ideal for
stretching the joint and surrounding tissues; when 3. It remains stationary when the convex joint partner
applied rapidly they are considered manipulation. moves (Fig. 39–5).
Kaltenborn13 developed a grading scale for his mobi-
lization procedures that is slightly different from that Pain-free movement is achieved when the mobi-
proposed by Maitland (see Fig. 39–3): lization is performed at a right angle or parallel to
the treatment plane and is sustained throughout the
Grade 1: Small amplitude at the beginning of the range movement.18 Unlike other mobilization procedures,
of motion to loosen the joint. Used for pain modu- Mulligan performed his techniques on patients while
lation and symptom control, and as an adjunct to they were moving, either actively or passively, or
all gliding procedures. while they were performing a resisted muscle con-
Grade 2: Larger amplitude at end range that takes up traction. The technique is performed in symptom-free
slack to tighten the joint. Used for pain modula- ranges of motion, a factor that probably makes it safer
tion and symptom control and for mobilization of than many other manual therapy approaches.19
minor joint restrictions. In addition to his mobilization with movement
Grade 3: Greater force is applied after slack is taken techniques, which were used in the peripheral joints,
up to stretch tissue crossing the joint. Used for both Mulligan also developed a series of gliding tech-
manipulation and mobilization. niques for the spine. He called these techniques
natural apophyseal glides (NAGS) and sustained
For optimal results, appropriate sequencing of natural apophyseal glides (SNAGS). NAGS are acces-
treatment technique is important when using mul- sory movements that involve gliding a spinal facet
tiple treatment techniques in one session (e.g., soft- on an adjacent facet while the patient remains pas-
tissue massage or stretching before mobilization treat- sive; SNAGS are similar procedures performed while
ment for relaxation, or strengthening or coordination the patient is actively moving through a painful or
exercises after treatment to maintain gains achieved restricted range of motion. MWM is used to denote
through treatment). Treatment results must also be SNAGS used in peripheral joints. Mulligan’s concepts
monitored to confirm the biomechanical diagno- are outlined below.16,19
sis. The patient is taught home treatment and self- The techniques are all performed within a pain-
care, such as automobilization, stretching, muscle free range. Some palpable or pressure pain is accept-
strengthening, coordination exercise, and autotrac- able, but not to the point of the initial pain. Different
tion. According to Kaltenborn,13 it is important to in- therapies should be considered until pain, weakness,
form, instruct, and train the patient on exercises and to and/or stiffness is eliminated. A minimal amount of
educate the patient to improve function, compensate force is used in the glide, which can be increased if
for injuries, and prevent reinjury. the treatment is for stiffness rather than pain. Over-
pressure may be applied, but only if it is painless. In
Mulligan the presence of a highly irritable joint, undertreating
In 1980, Brian Mulligan developed a technique he is preferable to overtreating in the early stages of care.
termed “mobilization with movement” (MWM).16,17 The accessory treatment force, as applied in NAGS
His techniques are articular in nature and are thought and SNAGS, follows the facet planes of the spinal
to produce both a biomechanical and a neurological joints and therefore changes direction at different ver-
effect. Like Kaltenborn, Mulligan’s treatment concept, tebral levels. In MWM, the direction of treatment force
in part, centers on the appropriate treatment plane of is dictated by the shape of the articular surfaces, forces
the joint. According to Mulligan, the treatment plane around the joint, and the type of joint. For example,
has three important characteristics: the force for hinge-type joints (e.g., knee, elbow) is ap-
plied at right angles to the movement, while the force
1. It lies over the concave articular surface. applied to parallel joints (e.g., long bones, tarsal and
2. It moves with the concave joint partner. carpal joints) must vary with the changing positions
of adjacent bones during movement. As seen with the treatment of joint dysfunction. He addressed the
Maitland’s methods, treatment force is tested in vari- diagnosis of “joint dysfunction” with his mobiliza-
ous directions until the most effective force is discov- tion treatments. His assessment was limited to the
ered. Once discovered, the force is usually applied in evaluation of the joint and, as such, assessed the
one direction and sustained until the patient is able to amount of joint pain and the degree of movement limi-
move the painful and/or restricted joint freely. tation. Joint dysfunction was defined as a loss of move-
Pain and restricted joint motion are caused by a ment of an involuntary nature occurring in a syn-
positional fault or tracking problems that may de- ovial joint. These involuntary accessory movements
velop as a result of subtle biomechanical changes after are referred to as “joint play.” According to Mennell,
an injury. For such subtle biomechanical changes to the soft-tissue assessment is left to traditional medi-
develop in a normal joint, an alteration in one or cal methods and such disorders are not treated with
all of the following needs to occur: the joint surface mobilization.6
shape, cartilage thickness, fiber orientation of liga-
ments and capsule, and direction of forces in mus- McKenzie Robin McKenzie, while not usually asso-
cles and tendons. These structures allow free, con- ciated with mobilization techniques, used repetitive
trolled movements while minimizing compressive active movement and patient self-treatment in his
forces produced by these movements. These normal assessment protocol. In other words, McKenzie pro-
movements are kept in balance by the propriocep- moted a form of self-mobilization. As with other
tive feedback system. Mulligan developed his tech- mobilization techniques, the common elements be-
nique to correct joint “tracking” problems or “posi- tween these various practitioners are the testing of
tional faults” by repositioning them and restoring the joint movement, palpation, manipulation, mobiliza-
normal pain-free motions. tion, and patient education. McKenzie’s teachings re-
In addition to Maitland, Kaltenborn, and Mulli- volve around his concept that sitting posture, loss of
gan, a number of other individuals have had a sig- extension, and frequency of flexion all contribute to
nificant influence on the development of the man- spinal pain.21 He taught that patients should be in-
ual therapies. Some of the better recognized include volved in self-treatment, primarily through the use
James Cyriax and John Mennell. While not typically of various repeated movements. McKenzie’s key con-
thought of in reference to mobilization procedures, cept is that during movements of the spine, a posi-
Robin McKenzie and James Cox also developed pro- tional change to the nucleus pulposus takes place, pro-
cedures that use repetitive joint movements, as both ducing a symptomatic response.
evaluation and treatment methods. The evaluation framework McKenzie developed
pays particular attention to questions of where and
Others how the pain began, whether it is constant or inter-
Cyriax James Cyriax was instrumental in developing mittent, what makes it worse or better, details about
a system for the diagnosis and treatment of muscu- previous episodes, and the like. The physical exam-
loskeletal conditions. Cyriax placed a heavy emphasis ination is used to assess sitting, standing, and pos-
on reaching a correct diagnosis in order to successfully ture, as well as flexion, extension, and side gliding
treat the proper tissue. He described the following movements. Of particular concern to McKenzie is
principles: All pain arises from a lesion, all treatment how the pain behaves in relation to movement. Un-
must reach the lesion, and all treatment must exert a like other manual evaluation techniques, McKenzie
beneficial effect on the lesion.20 Perhaps his most sig- used repetitive movements to assess the behavior of
nificant contribution was a process that he referred pain.
to as “evaluation by selective tension.” By using this
process, an affected joint may be evaluated based on Cox As with McKenzie, James Cox is not typically as-
its response to active, passive, and resisted movement. sociated with mobilization techniques. However, his
The purpose is to distinguish between inert (joint cap- treatment procedures, which use a repetitive force
sule, ligament, bursae, fascia, dura mater, and nerves) produced via a therapeutic table, are considered a
or contractile tissues (muscles and tendons) as the form of passive movement (i.e., mobilization) and are
pain producer. This evaluation by selective tissue ten- described in detail in Chapter 42, “Traction and Dis-
sion has become a fundamental concept in orthopedic traction Techniques.”
assessment.
MECHANISMS OF ACTION
Mennell Proponents of manipulative therapy found
a strong ally in John Mennell, an American physi- Exactly what happens when a joint is mobilized is still
cian who placed primary emphasis on synovial joint open to debate. Each of the proponents of mobilization
examinations and the use of joint-play techniques for have offered their own theories, many of which have
not been adequately tested. These theories propose may take place at the spinal cord level with some influ-
that mobilization can reduce mechanical blockage in ence from higher levels of the central nervous system.
joint structures, remove positional faults, stretch and A gentle method of affecting both type I postural and
tear adhesions in and around the joint, relax muscles type II dynamic mechanoreceptors is by oscillations,
associated with the joint, and reduce pain, thereby even for hypermobile joints.4 Wyke stated that “the ex-
allowing free joint movement. This section looks at perience of pain from lumbosacral tissue is inversely
the effects of mobilization. proportional to the discharge from mechanoreceptors
Lewitt found that an inert structure within a joint located in the same or related tissue from which the
may restrict the joint’s mobility, and results in what he pain is arising. The impulses of the mechanoreceptors
calls a “mechanical block.”22 The discharge of afferent discharge through the presynaptic inhibitory neurons
joint impulses and muscle recruitment are associated and, as a result, depress centripetal flow of nociceptive
with this mechanical blockage. Lewitt,22 Schaible and activity.”31,32
Grubb,23 and Taylor et al.24 have postulated that re- Manually sustaining pain-free accessory reposi-
flex muscle splinting can cause restricted joint mo- tioning of the joint while having the patient perform
tion as a protective mechanism for the joint, which is physiological motion in the previously painful direc-
held in mid-range in an effort to reduce nociceptor tion might change the mechanics of the joint and re-
discharge. When joints are treated directly, this may duce the dysfunction.
have a secondary affect on muscle activity. In elec-
tromyelography (EMG) studies, a reflexive effect on INDICATIONS AND CONTRAINDICATIONS
segmental muscles has been shown to occur after joint
mobilization and manipulation.24–26 In other studies, The criteria for applying joint mobilization techniques
a passive movement in end range has been shown to are similar to those for manipulation and include:
cause a reflex inhibitory effect on muscles surround-
ing a joint.27,28 With this in mind, Exelby suggests that • Limited range of motion
for mobilization to be effective, it must be performed • Muscle spasm
into resistance, but without pain18 ; otherwise an ad- • Pain
verse reaction, such as protective muscle spasm, might • Scar tissue or contracted tissue
occur. • Soft-tissue swelling, inflammation, or restriction
Hsieh and colleagues found that the direction of
Contraindications for mobilization are often based
effective MWM glide is in the opposite direction of
on clinical judgment, and are related to skill and train-
the position fault as demonstrated on magnetic res-
ing, as well as the nature of the specific technique
onance imaging (MRI).29 Consequently, the direction
used; in the hands of a skilled clinician, there may be
of the positional fault and the mechanism of injury is
very few absolute contraindications to mobilization.
thought to be the same. These authors concluded that
For example, a hypomobile segment adjacent to an
the direction of treatment by MWM should be in the
unstable segment can nevertheless be mobilized with
opposite direction of the mechanism of injury. Follow-
caution.33 The following is a list of contraindications
up MRI scans showed no changes in positional fault
to mobilization, although, as always, clinicians must
despite a decrease in pain and improved functioning
exercise their own judgment prior to administering
after treatments. However, repeat MRI scans showed a
any therapy to a patient4,32 :
change in bony position during a course of treatment
with MWM. These authors suggest that this change • Tuberculosis
in bony position may have brought about the correc- • Metastasis
tion in the nociceptive and motor system dysfunction, • Osteomyelitis
and led to the long-term change of pain relief and im- • Acute inflammatory joint disease
proved function. • Bleeding disorders
Wilson feels that mobilization sedates the nervous • Advanced osteoporosis
system, particularly the dorsal horn, and that by bom- • Fracture
barding it with normal impulses, it gradually be- • Progressive neurological signs
comes accustomed to receiving them.19 Accordingly,
these normal afferent discharges provoke a reciprocal Mobilization techniques are measured in terms of
normal efferent discharge to the structures that con- remediation or prevention of impairment, functional
trol joint movement. Melzack and Wall theorize that limitation, and disability. Anticipated goals of treat-
when large proprioceptive fibers are stimulated, they ment are:
quickly send a large volume of impulses to the small
nociceptive fibers, which, in turn, block pain sensation • Increased ability to perform movement tasks
and eliminate the need for muscle splinting.30 This • Decreased edema, lymphedema, or effusion
• Improved joint integrity and mobility and support the patient’s head against the clinician’s
• Improved motor function (motor control and mo- abdomen or chest.
tor learning) The middle phalanx of the clinician’s left little fin-
• Reduced muscle spasm ger hooks around the spinous process of the superior
• Decreased pain vertebra (hook the spinous process of C5 to mobilize
• Improved quality and quantity of movement be- the C5-C6 joint). The thenar of the opposite (right)
tween and across body segments hand covers half of the little finger and an anterosu-
• Reduced risk of secondary impairment perior force toward the patient’s eyeball (along the
• Reduced soft-tissue swelling, inflammation, or facet plane) is applied with the thenar contact. Six to
restriction 10 oscillations should be applied. This procedure can
• Increased tolerance to positions and activities also be used unilaterally over the facet joint. An im-
• Decreased use and cost of health care services proved contact on the spinous process can be achieved
• Increased ventilation, respiration (gas exchange), by flexing the patient’s cervical spine to the level of in-
and circulation volvement.
Prone Double-Thumb Spinous Process Contact for Posteroan-

terior Glide An alternative to the previous procedure
EVALUATION AND TREATMENT METHODS
may be performed while the patient lies prone with
This section describes a variety of mobilization proce- the head resting in the neutral position and the chin
dures for the spine and peripheral joints. While this is slightly tucked in (Fig. 39–7). The clinician contacts
not intended to be a comprehensive dissertation, ex- the involved spinous process with a reinforced (dou-
amples of oscillatory mobilization and mobilization ble) thumb contact. Force is transmitted through the
with movement procedures are used to illustrate some clinician’s thumbs in a posterior to anterior direc-
of the more commonly used techniques (Tables 39–2 tion by movement of the trunk and arms. Oscillations
and 39–3). should be gentle and rhythmic in the desired grades of
motion.
Spinal Mobilization Procedures (Cervical Spine)
Oscillatory Mobilization Procedures This procedure is used to increase
Supine Lateral Flexion
the amount of lateral flexion in the cervical spine.
The patient is supine while the clinician stands at the
This pro-
Seated Spinous Contact for Posteroanterior Glide
head of the table slightly on the side of the involved
cedure is used to improve posterior to anterior glide of articulation (Fig. 39–8). The clinician’s hands cradle
the cervical facets. The clinician stands on the left side the patient’s occiput and cervical spine. The clinician
of the patient in such a position that the patient’s left contacts the posterior cervical spine on the opposite
shoulder is stabilized with the clinician’s lower trunk side of the painful articular pillar with an index finger
(Fig. 39–6). The clinician should cradle the patient’s contact. The patient’s head is laterally flexed toward
head with the clinician’s left hand so that the forearm the contact point to gap the involved facet joints. At
is comfortably resting across the patient’s right tem- tension, grades III and IV techniques may be applied
poromandibular area. Do not move the patient. The through the side of the index finger contact in a lateral
clinician should attempt to “mold around” the patient to medial direction.
TABLE 39–2. General Rules for Applying Mobilization with Movement Procedures
Mobilization Procedures
Sustained Natural Apophyseal Glides Sustained natural
Create a relaxing environment. apophyseal glides are concurrent joint gliding and ac-
Do not create more pain. tive movement techniques performed with the patient
Stabilize one side of the joint with one hand while moving in the weight-bearing (seated) position. When possi-
the other side of the joint with the opposite hand. ble, overpressure at the end range of motion should
Consider specific direction, velocity, and amplitude be performed. SNAGS are not an oscillatory mobiliza-
of movement. tion procedure. They can be performed throughout
The assessment procedure can be used as the treatment the cervical and upper thoracic spine (thoracic and
procedure. lumbar SNAGS are described later) and are applied
Continuously reassess the treatment procedure. along the treatment planes of the levels involved. This
Understand the indications and contraindications for manual technique is used to increase motion and/or decrease
therapeutic procedures. the pain associated with it. SNAGS should not be
painful.
TABLE 39–3. Treatment Techniques
Painful Joint Provoked

Painful Joint Stiff Joint by Muscle Spasm
Joint position In available range (resting End of range In available range (resting
position) position)
Oscillations Yes Yes No
Amplitude Large Small (interspersed with larger Sustained traction to point of
movements) discomfort
Speed Slow Quick Slow
Rhythm Smooth A series of distinct abrupt Position is held waiting for pain
movements (staccato) and spasm to decrease
Grade Maitland grades I and II; Maitland grades III and IV; Maitland grades I and II;
Kaltenborn grades I and II Kaltenborn grade III Kaltenborn grades I and II
Treatment session 20–60 seconds, 3–5 times per May be held at end range for 10–20 seconds (may be held up
session as long as 5 minutes (active to 1 minute)
movements should be used
between mobilizations)
Sessions per week Daily (reevaluate if no 2–3 (include a daily home Daily (reevaluate if no
improvement is noted after program) improvement is noted after
2–3 sessions) 2–3 sessions)
Technique The technique should be very The technique is firm but Traction slowly to point of pain.
comfortable and smooth. The comfortable. The speed is Traction is nudged a fraction
amplitude is large and the quick and the rhythm is and held again. Small
speed slow. The capsule and staccato. Keep tension on the oscillations (3–4) may be used
surrounding soft tissues may capsule and surrounding soft in a very slow manner if pain is
be taut, but never stretched. tissues. The aim is to stretch not increased
The aim is to increase and increase range of motion
movement within the joint
without stretching
FIGURE 39–6. Seated posteroanterior glide oscillatory mobi- FIGURE 39–7. Prone posteroanterior glide oscillatory mobi-
lization in cervical spine. lization in cervical spine.
In a patient presenting with right-sided neck pain

when rotating the head to the right, contact the in-
volved painful facet on the right while the patient
rotates the head to the right. If this does not relieve
the pain, attempt another level. If this is unsuccess-
ful, slightly change direction of your line of drive or
alter the force of your contact. If you are unsuccess-
ful with the above, contact and glide the facet on the
left (opposite) side while the patient rotates the head
to the right. And finally, if you are still unsuccessful,
attempt gliding the right facet while the patient the
head rotates to the left side.
Lateral Flexion SNAGSThis technique is used to increase

lateral flexion in the cervical spine. It is performed
the same way as for rotation except the patient per-
FIGURE 39–8. Supine lateral flexion oscillatory mobilization in
cervical spine.
forms active lateral flexion. The clinician can apply
a spinous process or articular pillar contact. Remem-
ber to maintain the glide along the treatment plane
Rotation SNAGS The patient is seated with the clinician and have the patient apply overpressure for a few
standing behind the patient (Fig. 39–9). The medial seconds.
border of the distal phalanx is used to contact the ar-
Spinal Mobilization Procedures (Thoracic Spine)
ticular pillar of the involved (painful) side. The clin-
ician’s other thumb is placed over the contact thumb Oscillatory Mobilization Procedures
and generates the force needed to glide the facet.
The thumbnail should be placed at a 45-degree angle Seated Transverse Process Contact for Posteroanterior Glide
sloping up toward the patient’s eye (along the treat- Performed with the patient in the weight-bearing
ment plane of the facets). The clinician’s other fingers (seated) position, transverse process procedures can
should rest gently on each side of the neck or upper be performed from C6-C7 to the lower thoracic spine
thorax. While the appropriate glide is being main- and are applied along the treatment planes of the
tained, the patient slowly rotates the head in the re- levels involved. This technique is extremely useful
stricted painful direction. Having the patient push on in postural dysfunctions (forward head syndrome)
the side of the face with the hand provides overpres- and degenerative lower cervical and upper thoracic
sure at the end range of motion. Overpressure should spine, and is used to improve posterior to anterior
be used if the patient can achieve full pain-free rota- glide.
tion. Repeat several times and then reassess the pa- The clinician stands on the left side of the patient
tient’s range of motion without applying SNAGS. in position so that patient’s left shoulder is stabilized
FIGURE 39–10. Seated posteroanterior glide oscillatory mo-

FIGURE 39–9. Seated rotation SNAGS in cervical spine. bilization in thoracic spine.
with the clinician’s lower trunk (Fig. 39–10). The Mobilization with Movement Procedures
clinician should cradle the patient’s head with the
clinician’s left hand, attempting to “mold around” Counterrotation SNAGS Counterrotation dysfunctions
the patient and support the patient’s head against the of the lower cervical and upper thoracic spine are suc-
clinician’s abdomen or chest. cessfully treated with SNAGS. As explained earlier,
The middle phalanx of the clinician’s left little fin- SNAGS are not an oscillatory mobilization procedure.
ger hooks around the posterior aspect of the spinous Rather, they are concurrent joint gliding and active
process of the superior vertebra (hook the spinous pro- movement techniques performed with the patient in
cess of T1 to mobilize the T1-T2 articulation). The in- the weight-bearing (seated) position. Counterrotation
dex and thumb of the opposite (right) hand form a SNAGS are used to increase motion and/or decrease
“V” and contact the transverse process of the inferior pain associated with lower cervical and upper thoracic
vertebra. The line of drive is along the facet plane. The pain and stiffness. The most common sites are the C5-
clinician is attempting to move the superior facet of the C6 and C6-C7 articulation; however, T1-T2 and T2-T3
lower vertebra up under the inferior facet of the supe- also can be involved.
rior vertebra. Six to 10 oscillations should be applied To perform these procedures, the patient is seated
to several levels. Oscillation should be applied at the with the clinician standing to the posterior side
rate of 2–3 oscillations per second. This procedure can (Fig. 39–12). The clinician places the right thumb to
also be used unilaterally over one facet joint by plac- the right side of the spinous process of C5 and the
ing greater force to one side with your thumb or index left thumb to the left of C6 (for a C5-C6 dysfunc-
finger contact. Do not support the head with larger tion). By moving the thumbs transversely across, the
patients or when mobilizing the lower thoracic spine. clinician is augmenting right rotation on C6. While
Instead, reach across the patient’s body and support sustaining the pressure, ask the patient to move the
the opposite shoulder. Cervical retraction exercises are head into right rotation. Having the patient push
an excellent adjunct when treating patients with this on the side of the face with the hand provides
procedure. overpressure at the end range of motion. Overpres-
sure should be used if the patient can achieve full
Prone Hypothenar Spinous Process Contact for Posteroante- pain-free rotation. Repeat several times and then re-
rior Glide This variation of the previous procedures is assess the patient’s range of motion without applying
performed while the patient is prone with the clinician SNAGS.
standing at the side of the treatment table so that the
clinician is over the involved area of the thoracic spine SNAGS In the middle and lower thoracic spine, this
(Fig. 39–11). The clinician contacts the spinous process technique can be used to restore rotation, flexion, ex-
with a reinforced hypothenar and applies a posteroan- tension, and lateral flexion. Unilateral contact over
terior force by transmitting the body weight through the facet joint should be attempted first, followed by
the contact point. Oscillations are performed with the spinous process (central SNAGS), and, finally, by the
same frequency and number of repetitions as with the opposite facet. Often, correcting both left and right
seated procedure. rotation is necessary on the same visit.
FIGURE 39–11. Prone posteroanterior glide oscillatory mobi- FIGURE 39–12. Seated counterrotation SNAGS in lower cer-
lization in thoracic spine. vical spine.
FIGURE 39–13. Seated SNAGS in lower thoracic spine. FIGURE 39–14. Side-lying rotation oscillatory mobilization in
lumbar spine.
The patient is seated with the hands placed be-
hind the patient’s neck or crossed in front of the pulls it upward. At tension, the segments are rotated
chest to move the scapulae away from the midline gently with short-amplitude oscillatory movements.
(Fig. 39–13). Using the thenar eminence on the facet
joint area (transverse process), the clinician lifts in an Mobilization with Movement Procedures
anterior and superior direction by using the clinician’s
knees. Added leverage can be obtained by tucking the
SNAGS As with the cervical and thoracic regions,
clinician’s elbow against the clinician’s torso and lift-
SNAGS can be used in the lumbar spine to restore
ing with the lower part of the body. Overpressure dur-
rotation, flexion, extension, and lateral flexion. Unilat-
ing rotation can be achieved by pulling on the patient’s
eral contact over the facet joint should be attempted
opposite shoulder at the end of motion.
first, followed by spinous process (central SNAGS),
Spinal Mobilization Procedures (Lumbar Spine) and, finally, by the opposite facet. These techniques
are very useful when applied with spinal movement
Oscillatory Mobilization Procedures
in extension, flexion, or lateral shift. The patient can
be placed prone, seated, or standing.
Side-Posture Lumbar Intersegmental Rotation This proce-
dure is used to increase intersegmental rotation in the Lower Extremity Mobilization Procedures
lumbar spine. With the patient in the side-lying po- (Knee Joint)
sition, the clinician places the index finger on the in-
Oscillatory Mobilization Procedures
terspinous ligament at the affected levels (Fig. 39–14).
With the opposite hand, gently flex the superior leg
while palpating for tension at the interspinous liga- Anteroposterior Glide of the TibiaThe patient is supine
ment and gapping of the spinous processes. It is at with the involved knee flexed to 90 degrees(Fig. 39–
this position that the leg is fixed and the superior foot 15). The clinician sits on the distal aspect of the
is tucked behind the popliteal fossa of the inferior leg. patient’s foot for stabilization and grasps the posterior
While palpating the interspinous ligament of the af- aspect of the proximal tibia with the fingers (thumbs
fected levels, gently rotate the patient’s upper body by are placed in either side of the tibial tuberosity). From
pulling on the inferior arm (arm resting on the table) this position, a posterior-to-anterior and anterior-to-
until the palpating finger feels movement of the supe- posterior force can be delivered.
rior spinous process. The clinician fixes the patient’s
upper body by resting the clinician’s forearm against The patient is
Anteroposterior Glide of the Proximal Fibula
the patient’s upper chest near the axilla while placing supine with the involved knee extended. The clin-
the opposite forearm over the patient’s ischium. The ician contacts the superior fibular head with the
clinician’s thumb of the superior hand is placed on the clinician’s thenar and stabilizes the patient’s knee
lateral side of the superior spinous process and presses with the opposite hand. An anterior-to-posterior
downward toward the floor. The index finger of the glide is generated through the thenar of the contact
inferior hand hooks the inferior spinous process and hand.
FIGURE 39–15. Anteroposterior glide of tibia oscillatory mo-

bilization.
FIGURE 39–16. Combined distraction and posterior glide os-

Mobilization with Movement Procedures
cillatory mobilization of humerus.
Painful and/or Limited Flexion and Extension of the KneeAs

with other hinge joints, the general rule is to apply the tion of the glenoid and scapula, it is best to contact
glides perpendicular to the primary movement. In the the coracoid process and slide off onto the anterior
case of flexion or extension pain/limitations, medial- humeral head (avoid too much pressure over the sen-
to-lateral glide and then lateral-to-medial glide are sitive coracoid). The other hand stabilizes the scapula.
the treatment directions of choice. With medial pain, Ask the patient to abduct or flex the arm while ap-
glide the tibia medially, and with lateral pain, glide the plying posterolateral pressure on the humerus. Pro-
tibia laterally. Rotational mobilizations are also often gressions include wall push-ups, weighted or re-
needed to relieve the patient’s knee pain or to improve sisted arm press, and wall technique for flexion and
the patient’s function. Knee glides can be performed extension.
supine, prone, or standing.
Upper Extremity Mobilization Procedures LITERATURE REVIEW

(Shoulder Complex) The use of mobilization has been evaluated in a num-
Oscillatory Mobilization Procedures ber of studies. In some, the efficacy of mobilization has
been compared to manipulation. In others, mobiliza-
Combined Distraction and Posterior Glide of the Head of the tion has been compared to an assortment of nonman-
Humerus in the Glenoid Cavity For this procedure, the ual therapies such as physical modalities (e.g., heat,
patient is positioned supine with the involved arm ultrasound, electrical stimulation). Unfortunately, in
flexed to 90 degrees and the elbow bent comfortably
(Fig. 39–16). The clinician stands/kneels perpendic-
ular to the patient and grasps the patient’s humerus
as proximally as possible, using both hands and in-
terconnecting the fingers. The clinician stabilizes the
distal humerus by resting the patient’s elbow on the
clinician’s shoulder closest to the patient. A lateral and
posterior gliding motion results in separation (distrac-
tion) of the joint surfaces.
Mobilization with Movement Procedures
Glenohumeral JointIndications for MWM of the shoul-

der a include painful arc, or painful and/or restricted
flexion or abduction. The clinician stands on the op-
posite side of the involved glenohumeral joint and
contacts the head of the humerus with the clinician’s
thenar eminence (Fig. 39–17). Because of the orienta- FIGURE 39–17. MWM of glenohumeral joint.
many of the studies, the specific form of mobilization pain.42 One early study on a small group of patients
or the specific techniques used are inadequately de- by Bitterli et al. did not show a change in headache
scribed. It is, therefore, difficult to draw specific con- following mobilization.43
clusions about the benefits of any particular technique Gross et al. provided an overview of conservative
compared to any other. On the other hand, there are treatments (i.e., drug therapy, manual therapy, patient
numerous studies that have demonstrated support for education, and physical modalities) in reducing me-
a variety of manual therapy techniques. chanical neck pain.44 Twenty-four randomized con-
Blomberg et al. compared various forms of man- trolled trials and eight before–after studies met their
ual therapy (i.e., manipulation, specific mobilization, selection criteria. Although there were limitations in
and muscle stretching) with steroid injections for these studies, the authors concluded that the best
patients with acute and subacute low back pain.34 available evidence supports the use of manual ther-
In this randomized controlled trial, patients receiv- apies in combination with other treatments for short-
ing manual therapy had significantly less pain and term relief of neck pain.
disability in the immediate posttreatment phase as Nwuga compared mobilization against a control
well as at 90 days follow-up. In addition, the man- group with disk protrusion and nerve root compre-
ual therapy group also had a faster rate of recov- ssion.45 The mobilization was described as a lum-
ery and lower drug consumption. Andersson et al. bar rotatory oscillation with a “push–relax” technique
also found less medication use in manual therapy into the painful range of motion. The control group
patients.35 was treated with shortwave diathermy and lumbar
In a blinded, randomized trial of patients with flexion exercises. Both groups received proper lifting
chronic back and neck complaints, Koes et al. showed and posture instructions. The mobilization group had
a faster and greater improvement in physical func- significant increases in lumbar motion and straight-
tioning in patients receiving manual therapy when leg raise.
compared to physiotherapy, treatment by a general Farrell and Twomey compared a combination of
practitioner, or placebo therapy.36 In this study, man- passive mobilization and manipulation against the
ual therapy was slightly better than physiotherapy af- control group receiving microwave diathermy, ab-
ter 12 months. Also, in a comparison of manipulation dominal exercise, and ergonomic instruction for low
and mobilization of the spine with various forms of back pain.46 The manipulation/mobilization group
physiotherapy, Koes et al. demonstrated that for pa- was symptom-free approximately 1 week sooner than
tients with chronic conditions (i.e., duration of 1 year the control group, but after 4 weeks, 91% of all the
or longer) improvement was greater in those treated subjects became symptom-free. Mathews et al. com-
with manual therapy.37 pared the use of mobilization and manipulation to
A number of investigators have looked at the use of a control group for patients with low back pain.47
flexion–distraction techniques, previously described The groups were further divided based on the pres-
as “passive mobilization.” Bergmann and Jongeward ence of a limited straight-leg raise. The manipula-
describe a positive effect on sciatica using a combi- tion/mobilization group was given treatment daily
nation of flexion–distraction methods (mobilization) for 2 weeks, while the control group received in-
and side-posture manipulation.38 Cox et al. reported frared treatments for 15 minutes three times per
on the successful reduction of an L5-S1 disc herni- week. Those subjects with straight-leg raise limita-
ation through distraction manipulation technique,39 tions showed significantly higher recovery rates in
and Hession and Donald described the use of flexion the manual therapy group than the control group,
distraction and rotational manipulation in the treat- but there was no difference between the nonlim-
ment of multiple disc herniations.40 iting straight-leg raise groups for either treatment
Hurwitz et al. searched four computerized biblio- procedure.
graphic databases to identify articles on the efficacy Hoving et al. investigated the effectiveness of spe-
and complications of cervical spine manual therapy.41 cific mobilization procedures, physical therapy (exer-
Of three randomized controlled trials identified, two cise therapy), and continued care by a general prac-
showed a short-term benefit for cervical mobilization titioner (analgesics, counseling, and education) on
in patients with acute neck pain. The authors conclude 183 patients with nonspecific neck pain greater than
that both spinal manipulation therapy and mobiliza- 2 weeks’ duration.48 Subjects were randomly as-
tion of the cervical spine probably provide at least signed to one of the three treatment groups for
some short-term benefits for some patients with neck 6 weeks. Outcomes included success rate reported
pain and headaches. After an analysis of the literature, by the patient (successful if patient reported “com-
Aker et al. concluded that there had not been suffi- pletely recovered” or “much improved” on an or-
cient studies to adequately prove the effectiveness of dinal six-point scale), physical dysfunction, pain
any treatment approach for patients with acute neck intensity, and disability. Subjects receiving specific
mobilization techniques reported significantly greater titive force that is produced via a specially de-
success rates when compared with subjects receiv- signed therapeutic table.
ing exercise therapy or continued care with a gen- 4. The proposed mechanisms of action for mobiliza-
eral practitioner. Pain intensity, disability, range of tion therapy include reduced mechanical block-
motion, and general health scores were consistently age in joint structures, removal of positional faults,
better in the mobilization group, but the differ- stretching and tearing adhesions in and around the
ences were not statistically significant. The authors joint, relaxing muscles associated with the joint,
concluded that manual therapy, consisting of spe- and reducing pain, thereby allowing free joint
cific mobilization techniques, is a favorable treat- movement.
ment option for patients with neck pain com- 5. Clinical indications for mobilization treatment
pared with physical therapy or care by a general include limited range of motion, muscle spasm,
practitioner. pain, scar tissue or contracted tissue, and soft-
tissue swelling, inflammation, or restriction.
Contraindications for mobilization include tuber-
culosis, metastasis, osteomyelitis, acute inflamma-
tory joint disease, bleeding disorders, advanced
SUMMARY
osteoporosis, fracture, and progressive neurologi-
1. Mobilization is defined as the use of a passive cal signs.
movement directed at a joint, without a high- 6. Various mobilization techniques have been pro-
velocity thrust, while remaining within the joint’s posed for the cervical, thoracic, and lumbar spine,
physiologic range of motion; this movement may as well as for the shoulder and knee joints. Some of
be an oscillatory technique (gentle, coaxing, repet- the specific techniques for the cervical spine are the
itive, rhythmic movement) or a sustained stretch. seated spinous contact for posteroanterior glide,
Various categories of mobilization techniques in- prone double-thumb spinous process contact for
clude distraction, which involves a separation of posteroanterior glide, supine lateral flexion, sus-
joint surfaces, nonthrust, where an oscillatory mo- tained natural apophyseal glides (SNAGS), rota-
tion is applied within or at the end of accessory tion SNAGS, and lateral flexion SNAGS. Some of
motion, and thrust, which involves the application the specific techniques for the thoracic spine are the
of a speed and force that the patient cannot resist. seated transverse process contact for posteroante-
2. Mobilization techniques have been used in the rior glide, prone hypothenar spinous process con-
management of musculoskeletal diseases for a tact for posteroanterior glide, and counterrotation
number of years. Some of the notable proponents SNAGS. Some of the specific techniques for the
of this treatment method are Geoffrey Maitland, lumbar spine are the side-posture lumbar interseg-
Freddy Kaltenborn, Brian Mulligan, James Cyriax, mental rotation and SNAGS. Some of the specific
John Mennel, Robin McKenzie, and James Cox. techniques for the knee joint are the anteroposte-
3. Named clinical mobilization protocols include rior glide of the tibia, anteroposterior glide of the
Maitland, which advocates a meticulous exami- proximal fibula, and painful and/or limited flex-
nation of the patient and no set technique, prefer- ion and extension of the knee. Some of the spe-
ring to modify the technique until the stated goal cific techniques for the shoulder joint are the com-
(i.e., reduced pain, increased motion) is achieved; bined distraction and posterior glide of the head of
Kaltenborn, which also advocates a thorough ex- the humerus in the glenoid cavity and the gleno-
amination, and placed an emphasis on joint biome- humeral joint mobilization.
chanics and anatomy, preferring long axis dis-
traction and translatoric traction with no rotation;
Mulligan, which advocates that mobilization must
QUESTIONS
only be performed at a right angle or parallel to the
treatment plane and must be sustained through- 1. What is the difference between mobilization and
out movement; Cyriax, which places a heavy em- manipulation?
phasis on reaching a correct diagnosis in order to 2. What are the goals of mobilization?
successfully treat the proper tissue with manual 3. Describe the various grades of mobilization ac-
therapies; Mennell, which places his primary em- cording to Maitland.
phasis on synovial joint examinations and the use 4. What is the relationship between evaluation, as-
of joint-play techniques for the treatment of joint sessment, and treatment?
dysfunction; McKenzie, which uses repetitive ac- 5. What is a commonality regarding the examination
tive movement and patient self-treatment in his procedure for the various proponents of mobiliza-
assessment protocol; and Cox, which uses a repe- tion techniques?
2. Paris SV. A history of manipulative therapy through the

ANSWERS
ages and up to the current controversy in the United
1. Mobilization is characterized by the absence of the States. J Man Manipulative Ther 2000;8(2):66–77.
thrust that is associated with manipulation. It is 3. Hertling D, Kessler RM. Management of common muscu-
also characterized by the fact the patient can resist loskeletal disorder: Physical therapy principles and methods,
the treatment. 3rd ed. Lippincott-Raven Publishers, 1996.
4. Paris SV. Mobilization of the spine. Phys Ther 1979;59
2. The goals of mobilization are similar to those of
(8):988–995.
manipulation: relief of pain, improvement of range
5. Olson VL. Evaluation of joint mobilization treatment.
of motion, relaxation of muscle spasm, and im- A method. Phys Ther 1987;67(3):351–356.
provement of function. 6. Mennell J. Joint pain. Boston: Little, Brown, 1964.
3. Maitland provided five different grades of mo- 7. MacConnaill MA. The movement of bones and
bilization, ranging from a gentle oscillation per- joints: The significance of shape. J Bone Joint Surg Br
formed in the early range of motion to a more ag- 1953;35:290–297.
gressive movement performed at the end of range. 8. Saunders HD. Evaluation, treatment and prevention of
4. The relationship between evaluation, assessment, musculoskeletal disorders. Minneapolis, MN: Viking
and treatment is integral to the appropriate appli- Press, 1985.
cation of mobilization techniques. Each time the 9. Farrell JP, Jensen GM. Manual therapy: A critical as-
sessment of role in the profession of physical therapy.
patient is treated, the clinician must reevaluate the
Phys Ther 1992;72(12):843–852.
condition, monitor the progress, and adapt any
10. Maitland GD. Peripheral manipulation, 3rd ed. London:
subsequent treatment to the progress that has been Butterworth-Heinemann, 1991.
made. 11. Maitland GD. Vertebral manipulation, 5th ed. London:
5. The various proponents of mobilization therapy, Butterworth, 1990.
including Maitland, Kaltenborn, Cyriax, and oth- 12. Cookson JC, Kent BE. Orthopedic manual therapy—
ers, advocate a thorough patient examination pro- An overview. Part I: The extremities. Phys Ther
cedure, including a detailed history, passive, ac- 1979;59(2):136–146.
tive, and resisted range of motion, and a manual 13. Kaltenborn FM. Orthopedic manual therapy for phys-
assessment of joint play, in order to determine the ical therapists Nordic system: OMT Kaltenborn-
best type of mobilization technique to apply. Evjenth concept. J Man Manipulative Ther 1993;1(2):
47–51.
14. Cyriax J. Textbook of orthopedic medicine: Diagnosis of
soft tissue lesions, 6th ed. Baltimore: Williams and
KEY REFERENCES Wilkins, 1975:28–48, 61–91.
15. Kaltenborn FM. Manual mobilization of the extremity
Cox JM. Low back pain, 3rd ed. Fort Wayne, IN: Author, 1980.
joints: Basic examination and treatment techniques, 4th ed.
Cyriax J. Textbook of orthopedic medicine: Diagnosis of soft tissue
Oslo, Norway: Orthopedic Physical Therapy, 1989.
lesions, 6th ed. Baltimore: Williams and Wilkins, 1975:
16. Mulligan BR. Mobilization with movement (MWM).
28–48, 61–91.
J Man Manipulative Ther 1993;1(4):154–156.
Gould JA, Davies GJ. Orthopaedic and sports physical therapy.
17. Mulligan BR. Spinal mobilisation with leg movement
St. Louis: Mosby, 1985.
(further mobilization with movement). J Man Manipu-
Kaltenborn FM. Manual mobilization of the extremity joints:
lative Ther 1995;3(1):25–27.
Basic examination and treatment techniques, 4th ed. Oslo,
18. Exelby L. Peripheral mobilization with movement.
Norway: Orthopedic Physical Therapy, 1989.
Man Ther 1996;1:118–126.
Kaltenborn FM. Orthopedic manual therapy for physi-
19. Wilson E. The Mulligan concept: NAGS, SNAGS and
cal therapists Nordic system: OMT Kaltenborn-Evjenth
mobilizations with movement. J Bodywork Move Ther
concept. J Man Manipulative Ther 1993;1(2):47–51.
2001;5(2):81–89.
Maitland GD. Peripheral manipulation, 3rd ed. London:
20. Cyriax J. Treatment by manipulation, massage and in-
Butterworth-Heinemann, 1991.
jection. In: Cyriax J, Textbook of orthopaedic medicine,
Maitland GD. Vertebral manipulation, 5th ed. London: But-
8th ed. Vol 2. Baltimore: Williams and Wilkins, 1971:1,
terworth, 1990.
50–53.
Mathews JA, Mills SB, Jenkins VM, et al. Back pain and sciat-
21. McKenzie R. The lumbar spine: Mechanical diagnosis and
ica: Controlled trials of manipulation traction, sclerosant
therapy. Wellington, New Zealand: Spinal Publications,
and epidural injections. Br J Rheumatol 1987;26:416–423.
1985.
Mennell J. Joint pain. Boston: Little, Brown, 1964.
22. Lewit K. Manipulative therapy in rehabilitation of the loco-
Mulligan BR. Manual therapy NAGS, SNAGS, MWM, etc., 4th
motor system, 2nd ed. London: Butterworth, 1985.
ed. Wellington, New Zealand: Plane View Services, 1999.
23. Schaible H, Grubb B. Afferent and spinal mechanisms
of joint pain. Pain 1993;55:5–54.
REFERENCES 24. Taylor M, Suvinen T, Rheade P. The effect of grade
4 distraction mobilization on patients with temporo-
1. Greenman PE. Principles of manual medicine, 2nd ed. Bal- mandibular pain-dysfunction disorder. Physiother The-
timore: Williams and Wilkins, 1996. ory Pract 1994;10:129–136.
25. Thabe H. EMG as a tool to document diagnostic find- 37. Koes BW, Bouter LM, van Mameren H, et al. A random-
ings and therapeutic results associated with somatic ized clinical trial of manual therapy and physiotherapy
dysfunction in the upper cervical spinal joints and for persistent back and neck complaints: Subgroup
sacroiliac joints. Man Med 1986;2:53–58. analysis and relationship between outcome measures.
26. Murphy BA, Dawson NJ, Slack JR. Sacroiliac joint ma- J Manipulative Physiol Ther 1993;16(4):211–219.
nipulation decreases the H-reflex. Electromyogr Clin 38. Bergmann TF, Jongeward BV. Manipulative therapy in
Neurophysiol 1995;35:87–94. lower back pain with leg pain and neurological deficit.
27. Baxendale RH, Ferrell WR. The effect of knee joint dis- J Manipulative Physiol Ther 1998;21(4):288–294.
charge on transmission in flexion pathways in decere- 39. Cox JM, Hazen LJ, Mungovan M. Distraction manipu-
brate cats. J Physiol 1981;315:231–242. lation reduction of an L5-S1 disk herniation. J Manipu-
28. Lundberg A, Malmgren K, Schomberg ED. Role of lative Physiol Ther 1993;16(5):342–346.
the joint afferents in motor control exemplified by ef- 40. Hession EF, Donald GD. Treatment of multiple lum-
fects on reflex pathways from 1b afferents. J Physiol bar disk herniations in an adolescent athlete utilizing
1978;284:327–343. flexion distraction and rotational manipulation. J Ma-
29. Hsieh CY, Vicenzino B, Yang CH, Hu MH, Yang C. Mul- nipulative Physiol Ther 1993;16(3):185–192.
ligan’s mobilization with movement for the thumb: A 41. Hurwitz EL, Aker PD, Adams AH, Meeker WC,
single case report using magnetic resonance imaging Shekelle PG. Manipulation and mobilization of the cer-
to evaluate the positional fault hypothesis. Man Ther vical spine. A systematic review of the literature. Spine
2002;7(1):44–49. 1996;21(15):1746–1759.
30. Melzack R, Wall PD. Pain mechanisms: A new theory. 42. Aker PD, Gross AR, Goldsmith CH, Peloso P. Con-
Science 1965;150:971–979. servative management of mechanical neck pain: Sys-
31. Wyke BD. The neurology of low back pain in the lum- temic overview and meta-analysis. BMJ 1996;313:
bar spine. In: Jayson IV, ed. Back pain. London: Pitman 1291–1296.
Medical, 1980:265–339. 43. Bitterli J. Zur Objektivierung der manual therapeutis-
32. Paris SV. Spinal manipulative therapy. Clin Orthop chen. Beeinflussbarkeit des spondylogenen Kopf-
1983;179:55–61. schmerzes. Nervenarzt 1977;48:259–262.
33. Turchin C, Mootz RD. Mobilization concepts and their 44. Gross AR, Aker PD, Quartly C. Manual therapy in
application to mechanical dysfunction in the lower ex- the treatment of neck pain. Rheum Dis Clin North Am
tremity. Chiropr Tech 1995;7(3):82–93. 1996;22(3):579–598.
34. Blomberg S, Svardsudd K, Tibblin G. A randomized 45. Nwuga VCB. Relative therapeutic efficacy of vertebral
study of manual therapy with steroid injections in low- manipulation and conventional treatment in back pain
back pain. Telephone interview follow-up of pain, dis- management. Am J Phys Med Rehabil 1982;61:273–278.
ability, recovery and drug consumption. Eur Spine J 46. Farrell JP, Twomey LT. Acute low back pain: Compar-
1994;3(5):246–254. ison of two conservative treatment approaches. Med J
35. Andersson GB, Lucente T, Davis AM, Kappler RE, Lip- Aust 1982;1:160–164.
ton JA, Leurgans S. A comparison of osteopathic spinal 47. Matthews JA, Yates DAH. Reduction of lumbar disc
manipulation with standard care for patients with low prolapse by manipulation. BMJ 1969;20:696–699.
back pain. N Engl J Med 1999;341(19):1426–1431. 48. Hoving JL, Koes BW, de Vet HCW, et al. Manual ther-
36. Koes BW, Bouter LM, van Mameren H, et al. The effec- apy, consisting of specific mobilization techniques, is
tiveness of manual therapy, physiotherapy, and treat- the best treatment option for patients with neck pain
ment by the general practitioner for nonspecific back compared with physical therapy or continued care by a
and neck complaints. A randomized clinical trial. Spine general practitioner. Ann Intern Med 2002;136(10):713–
1992;17(1):28–35. 722.
C H A P T E R
40
LOW-FORCE AND INSTRUMENT
TECHNIQUE
Arlan W. Fuhr
O U T L I N E
INTRODUCTION THEORETICAL CONSIDERATIONS
HISTORY OF ADJUSTING INSTRUMENTS CLINICAL CONSIDERATIONS
History of Activator Methods Clinical Research
ASSESSMENT METHODS Case Series and Case Studies
Development of AMCT Isolation Tests Safety
Proposed Mechanisms of Isolation Testing CHALLENGES AND FUTURE POSSIBILITIES
Articular and Periarticular Structures SUMMARY
Reliability of Leg-Length Analysis QUESTIONS
AMCT Basic Scan Protocol ANSWERS
Initial Leg Check KEY REFERENCES
ACTIVATOR ADJUSTING INSTRUMENT REFERENCES
subluxation by means of exerting a minimal amount of

OBJECTIVES force. The Activator Methods Chiropractic Technique
1. To provide an overview and historical context of (AMCT) evolved from the low-force tradition and can
the use of adjusting instruments in chiropractic. serve as an example of this broad category of adjust-
2. To provide an overview and historical context ing procedures. Recent surveys by the National Board
of Activator Methods Chiropractic Technique of Chiropractic Examiners show that AMCT is one of
(AMCT). the two most widely used chiropractic techniques in
3. To provide an overview of isolation testing. the United States, and the percentage of practition-
4. To provide an overview of the development of the ers using AMCT has increased from 51.2% in 1991 to
Activator adjusting instrument (AAI). 62.8% in 1998.1 Chiropractors reported using AMCT
5. To discuss some of the proposed mechanisms of with 21.7% of their patients in 1998. In Europe, it was
action for the AAI. estimated the technique was used in 14% of chiroprac-
tic cases in 1994.2 The AMCT is also widely used in
Canada.3,4 Although this method of adjusting remains
controversial, its popularity warrants that a discus-
INTRODUCTION sion be included in any review of chiropractic treat-
Chiropractic treatment and adjusting techniques con- ment methods.
sist of both assessment and intervention procedures.
Particular techniques appeal to certain chiropractors,
HISTORY OF ADJUSTING INSTRUMENTS
and are preferred by some patients. Low-force tech-
niques cover a broad category of chiropractic ma- Chiropractors have used instruments for delivering
nipulation methods by which an attempt is made to a spinal adjustment since the early years of the pro-
achieve the correction of the manipulable lesion or fession. Keating cites a 1935 report in which an
787
adjusting instrument that may have been used by thrust very similar to “the force displacement pattern
Montana Crow Native American medicine men to re- of the toggle mechanism.”14
lieve digestive ailments is mentioned. He felt that in- Grostic described a “cam-stylus” adjusting in-
strument adjusting “was apparently an ancient and strument that could be motorized or computer-
indigenous American art.”5 The Crow used a type of operated, resulting in variable cam rotation speeds.14
thrust perhaps similar to a percussion treatment. As Examples of the cam-stylus adjusting instrument are
early as 1901, Minnesota chiropractors were using the the Life College Adjusting Instrument14,15 and the
“stick method” developed by Thomas H. Storey in Pettibon Adjusting Instrument.15
which a wooden mallet and a stick covered with what
appeared to be a rubber tip from a crutch were used to History of Activator Methods
“set the spine.”6,7 D. D. Palmer, sometime after 1910, After assessing the need for treatment, all chiroprac-
had a rubber hammer (pleximeter) that he used ex- tic methods blend the dimensions of location, ampli-
perimentally to adjust vertebrae.8 tude, force, speed, and direction (referred to as the line
A number of spinal-thrusting instruments be- of drive [LOD]). The Activator Methods Chiropractic
gan to appear during this same time period, includ- Technique was developed in an attempt to integrate
ing one developed by Palmer’s former partner Alva these fundamental components of the adjustment into
Gregory and another by Albert Abrams, a medical a low-force technique through the use of an adjusting
physician who developed the so-called spondylother- instrument.
apy. In Man and His Poisons, Abrams described a During the 1960s, Warren C. Lee and Arlan W.
“mallet and pleximeter for evoking the concussional Fuhr were trained in and practiced the Logan Basic
vertebral reflexes,” and later described the “plexor and Toftness low-force adjustment techniques. They
and pleximeter” as part of his “spondylotherapeu- sought to establish more sensitive methods for iden-
tic armamentarium.”9 Abrams described another de- tifying subtle musculoskeletal dysfunction and seg-
vice that delivered blows to both sides of a spinous mental facilitation, and to assess any improvement in
process. It consisted of metal and was covered with the patient’s condition that may result from treatment.
layers of felt and rubber to eliminate any possible In 1965, Fuhr studied the directional nonforce tech-
trauma resulting from concussion.10 Abrams also de- nique, which involved preadjustment and postadjust-
scribed a pneumatic hammer with concussors and the ment leg-length measurements and double-thumb-
so-called Electro-concussor that came with two con- lock toggle adjusting. Fuhr later met Mabel Deri-
cussors and “which deliver blows to both sides of a field and incorporated the Derifield system of pelvic
spinous process.”10 analysis that used a relative leg-length measurement
Benedict Lust, the “father of naturopathy in Amer- into the assessment regimen. At about that same
ica” and publisher of the Naturopath, ran advertise- time, Fuhr also incorporated the work of Leon Lewis
ments for the “Benko Hand Concussion Set,” in- Truscott of San Jose, California, and his ideas
cluding one that appeared in 1924 and declared, regarding leg-length measurement at the adductor tu-
“. . . every practitioner of experience will confirm bercles. Truscott believed “that bodily imbalance was
the statement that spinal concussion is one of the always associated with ill health.”16 He particularly
most powerful adjuncts to drugless therapy. . . .”11 related cervical dysfunction to functional leg-length
Mechanical concussors were depicted in a book by shortening and used a light pressure test and atlas ad-
J. S. Riley, a student of Alva Gregory,12 and con- justments to treat this. This approach evolved into the
cussion and vibratory devices were sold by the Zoe present day AMCT pressure testing.
Johnson Company of St. Joseph, Michigan, for many In 1985, the practitioners of AMCT began to fo-
years. cus on the scientific investigation of their principles.
In the early 1930s, B. J. Palmer introduced the That same year, Activator Methods was awarded the
HIO (hole-in-one) upper cervical technique, which in- first grant ever given to a chiropractor or chiroprac-
volved the use of a toggle recoil adjustment. In this tic organization by the National Institutes of Health.
procedure, the patient was positioned on his or her The award was a Small Business Innovative Research
side and received “a high-velocity, short-lever, pisi- Grant for the study of safety and effectiveness of the
form or crossed-thumb contact ‘toggle’ thrust deliv- mechanical adjusting instrument on osseous struc-
ered to the atlas (or axis) vertebra followed by a rapid tures. In 1990, the AMCT became the first “brand
‘recoil.’”13 The toggle recoil thrust and the difficulties name” technique to write a critical self-review in a
chiropractors encountered in delivering it skillfully paper entitled “The Current Status of Activator Meth-
and uniformly gave rise to a generation of mechani- ods Chiropractic Technique, Theory, and Training.”17
cal instruments that attempted to replicate the forces The first peer-reviewed paper concerning the history
generated through this adjustment. Some of the earli- of AMCT appeared in the Chiropractic Journal of Aus-
est devices resembled a punch press and delivered a tralia in 1994.18 Cooperstein noted that AMCT was the
LOW-FORCE AND INSTRUMENT TECHNIQUE 789
first named or brand chiropractic adjusting system to observing leg-length changes in response to these
attempt to apply the Kaminski model for the valida- maneuvers.
tion of a chiropractic technique.19,20 Prone leg-length comparisons in response to isola-
tion testing became the AMCT method for determin-
ing sites and indications for treatment. The traditional
ASSESSMENT METHODS functional short leg was renamed the pelvic-deficient
Development of AMCT Isolation Tests leg. The pelvic-deficient leg is not an anatomically
short leg, but rather appears short because of pre-
The early specialized Tri-W-G (Softec) adjusting tables
sumed torque and rotation in the pelvis. This phe-
developed for AMCT had a manually operated foot
nomenon led to the development of a series of
piece that required the chiropractor to pull up with the
provocative maneuvers to test for subluxation com-
left hand to secure the table into the locked position.
plexes or dysfunctions of the vertebrae and other ar-
Repeating this action many times over the course of
ticulations. As the technique was taught to other chiro-
the day produced a constant, dull aching pain in the
practors, they, in turn, began sending in their own clin-
left rib cage of this author at the level of the twelfth
ical observations. These were tested by Lee and Fuhr
thoracic vertebra. The pain worsened when he raised
and eventually submitted to a standard of care review
his left arm above his head. He asked an associate to
panel of AMCT instructors. The reviewers used these
observe his leg lengths when he performed the ma-
tests on their own patients and informally noted the
neuver and the associate noticed that the leg lengths
results. Tests considered clinically useful were incor-
changed dramatically in response to his arm raising.
porated into the main body of the AMCT protocol.
This observation led to the development of the first
“isolation test” specific to the twelfth thoracic vertebra Proposed Mechanisms of Isolation Testing
and to the hypothesis that when a patient performed
The osteopathic researcher Irvin Korr suggested that
a maneuver that increased tension around or upon a
neural receptors associated with facilitated segments
dysfunctional joint complex, the resulting neuromus-
continually fire impulses into the cord via the dor-
cular facilitation reflexes could affect leg length. Fur-
sal root fibers as long as the receptors are under ten-
thermore, it was proposed that this procedure could
sion. He also proposed that the receptors fired at
be used as a clinical tool to locate an area of muscu-
frequencies proportional to the tension.22 According
loskeletal dysfunction.
to Denslow, a Korr colleague, higher tension creates
Slosberg supported the idea that facilitation alters
higher afferent bombardment for the duration of the
leg lengths when he wrote:
tension.23 These concepts were used to explain the ob-
served leg-length alterations and the associated leg-
Normal muscles respond to such normal, in- length reactivity produced by the isolation tests, pres-
nocuous movements by appropriately con- sure tests, and stress tests developed by Fuhr and
tracting briefly to perform the requested move- Lee.21,24
ment and then relaxing. Such responses do not Korr’s description of the osteopathic lesion, or fa-
appear to alter relative leg lengths. However, cilitated segment, has many similarities to theories
when a muscle group is facilitated, then its reused to explain the chiropractic subluxation. Accord-
sponse to stretch or contraction may be both ing to Korr, the spinal lesion consists of contiguous
excessive and prolonged. Such alterations of structures with altered biomechanical relationships
muscle response apparently affect the func- leading to localized effects such as inflammation and
tional leg lengths and result in alteration of the pain, as well as regional or organ system effects in
relative leg lengths.21 neurologically related structures.25,26 Korr stated that
facilitation means that the tissues innervated from
Repeated clinical observations suggested that cer- the lesioned segment are sensitized to all the influ-
tain movements of the torso, head, and extremities ences operating within and outside the individual.22
produced leg reactivity, and that leg differences were He suggested that facilitation of the sensory path-
minimized following adjustment using the Activator ways in the lesioned segments creates exaggerated
adjusting instrument (AAI). responses in affected spinal segments acting as a
This concept was extended through observation “neurologic lens,” focusing activity. Facilitation of
of musculoskeletal imbalances in the lumbar and the motor pathways leads to sustained muscular ten-
cervical spine, as well as the extraspinal regions. With sions, exaggerated responses, postural asymmetries,
a patient prone on the treatment table, certain maneu- and limited and painful motion. “Since muscles have
vers seemed to point to dysfunction of musculoskele- a rich sensory as well as motor innervation, un-
tal structures. It was postulated that a chiropractor der these conditions they and related tendons, liga-
could thus identify the area requiring treatment by ments, joint capsules, et cetera, may become sources of
relatively intense and unbalanced afferent streams of Indahl et al. observed that stimulation of animal
impulses.”22 The early work of Korr, Denslow, and discs induced reactions in paraspinal muscles on con-
others used qualitative, descriptive, observational, tralateral paraspinal segmental levels, whereas stimu-
and retrospective cohort studies to draw inferences. lation of facet joint capsules induced mostly unilateral
Thus, their findings must be interpreted cautiously. segmental level reactions.38 These authors concluded
Nansel theorized that, given the rich supply of that there might be interactive responses between in-
muscular proprioceptive afferents from muscle spin- jured or diseased structures (disc or facet joints) and
dles and Golgi tendon organs, changes in muscular paraspinal musculature. Changes in articular pressure
activity may be a result of musculomuscular reflex from resultant normal loads and stresses on joints
mechanisms.27 Deep intervertebral “shunt” (multi- could thus create, through complex afferent-efferent
fidus and rotatores) muscles contain a large pro- reflex activities, changes in muscle tone that act to
portion of proprioceptive endings, allowing them to stabilize certain joints while allowing full motion in
sustain their contractions for long periods of time to others. Alterations in joint integrity, postural stresses
maintain postural states.27–29 Evidence suggests that and strains, and pressure changes as a function of mis-
such regionally distinct, deeply lying “shunt” mus- alignment could create aberrant afferent signals from
culature is the major source of proprioceptive infor- proprioceptive and nociceptive pathways. These may
mation related to static posture, as well as to the vari- be expected to lead to inappropriate increases in mus-
ous dynamic (length-tension) considerations in spinal cle tone, which may be monitored clinically. In regard
segmental motion.27 Studies have established the seg- to AMCT, such alterations may result in unilateral
mental neuronal innervation and control of adjacent muscular hyperexcitability as a mechanism of func-
intervertebral musculature,30 which may be intimately tional leg-length inequality and leg reactivity associ-
involved in the subluxation complex. ated with isolation and stress tests.39–42
Bolton recently suggested that vertebral displace-
ment is signaled by afferent nerves arising from deep Reliability of Leg-Length Analysis
intervertebral muscles.31 The central nervous system Prone leg-length comparisons with isolation test-
is informed of velocity and relative positions of ver- ing is a fundamental tool in the AMCT assessment.
tebrae by the multifidus and rotatory muscles. Ac- Reliability studies have determined leg-length in-
cording to Bolton, afferent nerves from zygapophy- equality in position 1 (i.e., prone, straight leg) to be
seal joints are less likely to be involved in signaling a stable clinical phenomenon, and have generally
vertebral displacement. shown a good degree of agreement among trained
examiners.41–44 Jansen and Cooperstein found that the
functional short leg is a stable clinical entity when they
Articular and Periarticular Structures used a so-called friction-free table in their research.45
Ligamentous structures, including the intervertebral They observed leg-length discrepancies under a va-
disc, facet capsule, surrounding spinal ligaments, and riety of postures and movements when subjects lay
ligaments of the extremities, are furnished with a prone.
rich supply of mechanoreceptors and free nerve end- In a study involving four examiners who evalu-
ings (nociceptors) in humans.32–35 Pressure and me- ated 30 subjects by means of the AMCT leg-length
chanical receptors also exist in the skin, muscles, ten- procedure in position 1, Fuhr and Osterbauer found
dons, joint surfaces, and periarticular regions. Some that five of six pair-wise interexaminer comparisons
are low-threshold, such as the muscle spindle recep- yielded “good” concordance (κ = 0.53).41 However,
tors, Golgi tendon organs, pacinian corpuscles, and the order of examiners was not randomized, creating
proprioceptive receptors within articular and periar- the possibility of unwanted order effects. Their posi-
ticular surfaces. Higher-threshold receptors include tive results were supported in a later study by Nguyen
the so-called type III and IV receptors. et al. in which 34 subjects were examined by two expe-
Mechanoreceptors are more richly distributed rienced AMCT instructors, yielding a total agreement
throughout the cervical facets than throughout the of 85% (κ = 0.66, p <0.001).44 In this study, the order
thoracic and lumbar facets.36 Some of these nerve end- of examiners was randomized.
ings form receptive fields that demonstrate higher Youngquist et al. reported the first study to evalu-
neuronal discharge rates with displacement of artic- ate the interexaminer reliability of isolation testing.41
ulation in a particular direction.31,37 Bolton suggests They sought to determine whether prone leg-length
that there is good evidence that displacements of ver- analysis in association with an isolation test maneu-
tebrae modulate nerve discharge from afferents in ver was reproducible. Two examiners evaluated 72
muscle spindles and other low-threshold receptors, subjects who were divided into groups of 34 and
such as the Golgi tendon organs in the deep interver- 38 patients on two separate occasions. Subjects were
tebral muscles.31 evaluated for the presence/absence of atlas segment
TABLE 40–1. Summary of Tests and Adjustments in AMCT Basic Scan Protocol
Raise Legs to Position 2—Pelvic-

Possibility 1 Deficient Leg Lengthens
Subluxation Test performed Adjustment: Contact + line of drive (LOD)

Knee
Medial knee joint Pressure test medial collateral ligament Contact medial knee joint; LOD is lateral and
lateral and inferior inferior
Talus Adjust when test for medial knee joint is Contact medial border; LOD is posterior-superior
positive and lateral
Lateral knee joint Pressure test lateral collateral ligament Contact lateral knee joint; LOD is medial-inferior
medial and inferior
Cuboid Adjust when test for lateral knee joint is Contact inferior lateral aspect; LOD is
positive posterior-superior and medial
Pelvis
Anterior superior ilium Pressure test crest of ilium inferior-medial Step 1: Contact base of sacrum on side opposite
pelvic-deficient leg; LOD is anterior-inferior
Step 2: Contact crest of ilium; LOD is
inferior-medial
Step 3: Contact ischial tuberosity; LOD is
anterior-inferior
Posterior inferior ilium Pressure test under sacrotuberous ligament Step 1: Contact spine of ischium; LOD is
posterior-superior and lateral posterior-lateral and superior
Step 2: Contact sacrotuberous ligament; LOD is
posterior-lateral and superior
Step 3: Contact lateral aspect of ilium; LOD is
anterior-superior
Symphysis pubis
Instruct patient to squeeze knees together
Superior pubic bone When pelvic-deficient leg lengthens going to Contact superior aspect of pubic bone; LOD is
position 2 inferior
Inferior pubic bone When pelvic-deficient leg shortens going to Contact inferior aspect of pubic bone; LOD is
position 2 superior
Possibility 2 Raise Legs to Position 2—PD Leg Shortens
Subluxation Test Adjustment

L4 — subluxated on side Pelvic-deficient leg goes short on raising legs Contact mammillary process on L4 on side
opposite pelvic-deficient to position 2 opposite pelvic-deficient leg; LOD is
leg anterior-superior
Note: Continue the rest of the AMCT Basic Scan Protocol by next testing L2 and the rest of the vertebrae and shoulders as indicated.
(C1) subluxation by observing leg-length inequality. exhibited significantly more asymmetrical (right ver-
Agreement was significantly greater than chance for sus left) heel movement than controls.
the two samples, with κ = 0.52 (p <0.01, n = 24) for The reliability of leg-length checks should be dis-
the first sample, and κ = 0.55 (p <0.001, n = 48) for the tinguished from the validity of leg-length observa-
second. tions. The former refers to the consistency of findings
DeWitt et al. investigated leg-length inequality fol- (over time or between examiners), and the latter to the
lowing isolation maneuvers using sophisticated op- clinical importance or meaningfulness of observed in-
toelectric measuring equipment.42 Eight healthy sub- equalities of leg lengths. Although studies of the reli-
jects were compared to eight subjects with a history ability of these procedures have provided support for
of chronic spinal complaints. In prone neck extension consistent findings among examiners (in position 1),
(“head up”) maneuvers (the C5 isolation test), patients the validity of AMCT leg-length analysis (and
Activator Methods Basic

TABLE 40–2. ation complexes, normalize posture and leg-length
Scan Protocol inequality, and provide symptomatic relief of many
common complaints. At the same time, use of the pro-
Protocol tocol avoids “chasing symptoms” in a patient with a
mixed or ambiguous clinical presentation.
Lower extremities Upper thoracic spine The AMCT Basic Scan Protocol does not ignore
Medial knee T6 and corresponding rib the possibility of subluxation of vertebrae and other
Lateral knee T4 and corresponding rib joints not included in the protocol. Instead, it is based
T 1 and first rib on clinical observation and the premise that address-
Pelvis Upper extremities ing these major sites of involvement often resolves
Anterior superior ilium Medial scapula minor subluxations and facilitations of vertebrae not
Posterior inferior ilium Lateral scapula included in the basic scan (Table 40–1).
Symphysis pubis The vertebral motor units and other articulations
Lumbar spine Cervical spine and occiput included in the AMCT Basic Scan Protocol are listed
L5, L4, L2 C7, C5, C2, C1 in Table 40–2. Note that there are only a few “key”
Thoracic vertebrae listed for each region of the spine.
T12 Judicious use of the Basic Scan Protocol is consid-
T8 and rib as indicated ered by its practitioners to be consistent with a sound
tradition in chiropractic clinical practice, that is, the
avoidance of overadjusting. These practitioners be-
lieve that one way to limit excessive adjusting is to
associated isolation, stress, and pressure tests) has not adjust only major subluxations occurring at the ma-
been directly addressed. jor stress and transition points in the spine, typically
Several investigations provide indirect data bear-
ing on the meaningfulness of AMCT leg-length evalu-
ations. DeWitt et al. showed that an isolation maneu-
ver (cervical extension) produced leg-length changes
measurable by optoelectric monitoring.42 Shambaugh
et al. demonstrated that right and left cervical rotation
produced leg-length alterations.46 Haas et al. failed to
find significant pre-/posttest changes in leg lengths
in response to pressure testing of thoracic segments.47
However, because none of these investigations em-
ployed AMCT analytic procedures, their relevance to
leg-length checks as used specifically in AMCT was
not established.
AMCT Basic Scan Protocol

Activator Methods Chiropractic Technique attempts
to provide a systematic approach to treatment of a
wide variety of common complaints of neuromus-
culoskeletal origin. Clinical experience suggests that
the majority of vertebral dysfunctions of consequence
tend to be at stress points, often located at the transi-
tional vertebrae of the spine and at select areas in the
feet, knees, pelvis, and shoulders. The AMCT Basic
Scan Protocol consists of tests and adjustments that
address only selected segmental levels or motor units
of the axial skeleton, plus selected other peripheral ar-
eas. More advanced diagnostic procedures are avail-
able beyond the Basic Scan Protocol.
An AMCT rule of thumb is to use the Basic Scan
Protocol for the first two or three visits. In the ex-
perience of many practitioners who use this method
of analysis, assessment and adjustment of segments FIGURE 40–1. Position 1: Example of a left short leg with both
indicated by the Basic Scan Protocol reduce sublux- legs in a prone position.
FIGURE 40–2. Position 2: An originally short leg in the prone FIGURE 40–3. Position 2: An originally short leg in the prone
position becomes longer at 90 degrees flexion. This is called position becomes shorter at 90 degrees flexion. This is called
possibility one. possibility two.
the transitional vertebra areas. Subluxations of other based on the idea that articular dysfunction or biome-
vertebrae may occur secondarily or as compensations chanical aberration in the body will be expressed to
to these primary stresses in the dynamic structure of some degree in the pelvis itself, given that the pelvis
the spine by fixation or aberrant motion. Adjustment is central to much of the biomechanical integrity of the
of major segmental dysfunctions may also eliminate entire human body.
compensatory or minor subluxations.48 Next, the legs are raised and flexed to 90 degrees
(position 2). If the short leg lengthens in position 2, this
Initial Leg Check is called possibility one (Fig. 40–2). After finding pos-
Leg-length analysis serves as a guide to clinical de- sibility one, the doctor proceeds to test the knees and
cision making throughout AMCT. The changes ob- feet for altered biomechanics by applying the appro-
served in the pelvic-deficient or reactive leg help to priate stress test. If the position 1 short leg stays short
identify dysfunctions and “facilitations” at all levels or gets shorter in the flexed position 2, this is called
of the spinal column, as well as articular dysfunc- possibility two (Fig. 40–3). The doctor proceeds to the
tion of the extremities. Although leg-length analysis fourth lumbar isolation test. (For more information,
is central to AMCT, sound clinical judgment and in- see Fuhr et al. in Key References.)
formation gathered from a thorough history and ap-
propriate physical examination form the basis for any
ACTIVATOR ADJUSTING INSTRUMENT
legitimate treatment plan.
In the Basic Scan Protocol, the patient is placed in This adjusting technique has its basis in Logan’s con-
the prone position (position 1) to determine the side cepts of body distortion and the leg-length measure-
of pelvic deficiency (Fig. 40–1). This side is defined ment procedures developed by Van Rumpt, the Der-
as the side of the functional short leg. It is so-named ifields, and Truscott.18 Lee and Fuhr found that the
brae and the nervous system. Therefore they named

the adjusting instrument the Activator, and this led to
the creation of AMCT.
Activator Methods Chiropractic Technique has
been the subject of more studies than most other
named technique systems in chiropractic. The AAI,
listed under the category of “Mechanical Force, Man-
ually Assisted Procedure,” yielded a “promising to
established” rating at the 1992 Mercy Center Consen-
sus Conference.50 A consensus panel commissioned
by the Canadian Chiropractic Association granted a
similar rating for the AAI.51
THEORETICAL CONSIDERATIONS
FIGURE 40–4. Activator adjusting instrument (AAI III) being
used to adjust a left lateral atlas. Two biomechanical studies were funded by a 1985 Na-
tional Institutes of Health grant. Results from these
repetitious use of the thumb toggle produced ex- studies were published in the Journal of Manipulative
treme fatigue, muscle strain, and frequent elbow in- and Physiological Therapeutics.52,53 The first study in-
jury as a consequence of the elbows striking each troduced a novel impedance-head-equipped spring-
other during rapid movement when thrusting into pa- loaded AAI that caused measurable bone movement
tients’ spines. They looked for other means of produc- and detectable electromyographic (EMG) response.
ing a thrust into the spine, a method that would re- This paper encouraged investigation of relative bone
duce physical stress on the clinician and control the movement in response to light manipulative taps to
speed, force, and direction of the adjustive thrusts the spine. This was the first study to confirm that an
(Fig. 40–4).49 AAI thrust could induce motion in a bone. In the sec-
In 1966, Lee and Fuhr were given a dental im- ond paper, the authors suggested that with further de-
pactor, a small instrument designed to tap amalgam velopment, piezoelectric accelerometers attached to
into teeth. They used the impactor as a substitute for an Activator could be used as a noninvasive tool to
the thumb toggle on a few patients. However, this in- study dynamic, relative bone movement.
strument failed as a spinal adjusting device because Greater understanding of biomechanics and neu-
the impactor did not have enough speed or force. rophysiological research has led to refinements in the
Several other devices were tested, including a cen- AAI. In the 1980s and 1990s, research into spinal
ter punch (which required too much preload pressure manipulation (delivered by hands only and by the
before firing) and an instrument that had a moving AAI) began to shed some light on the nature of the
stylus that caused patient discomfort. chiropractic adjustment in terms of time, force, du-
In 1967, Fuhr was given a surgical impact mallet ration, and physiological effects. There have been
designed to split impacted wisdom teeth. The scalpel two general categories of investigation: biomechan-
was replaced with a brake shoe rivet and a small rub- ical and neurophysiological. The AAI evolved in
ber doorstop was attached to the end. This device had response to current knowledge in both domains.
a mechanism of action similar to a hammer striking Under the biomechanical model, issues such as tis-
an anvil that produced a shock force much like a cro- sue compliance (stiffness), response to input force
quet mallet striking two croquet balls. This appara- (impedance), and natural frequency resonance of the
tus tested successfully on patients and was the first spine were explored. In neurophysiological investi-
functional ancestor of the modern Activator adjusting gations, threshold frequencies and minimal forces re-
instrument. This instrument was modified and used quired for stimulation of joint mechanoreceptors were
until 1976. investigated.
Unfortunately, the dental impact mallet did not Initial AAI research investigated spinal joint re-
hold up under the demands of a busy chiropractic sponse to applied forces. Spinal articulations appear to
practice. Freddy Hunziker then designed and built a respond best to certain frequencies of impulses. Keller
more reliable internal mechanism for the instrument, et al. stated that “at the resonant or natural frequency,
which used a hammer–anvil effect to produce a re- the spine will be least stiff and will therefore have
liable and controlled force to adjust osseous spinal the greatest potential for mobility, as much as 3 times
structures.18 By late 1967, Lee and Fuhr believed they greater than the mobility at other frequencies.”54 From
were actively moving bones by using the low-force a therapeutic point of view, one clinical implication of
high-speed mechanical adjusting instrument they had enhanced mobility is the fact that the mechanical re-
developed. They were in effect “activating” the verte- sponse (motion) of the spine will be maximized for a
given force when that force is delivered at the resonant A

frequency of the spine.
[FFT] (max setting)

600
The next research objective was to investigate the 500
effects of AAI adjustments on the human spine in 400
vivo. This procedure required insertion of “Steinman 300
pins” into the spinous processes of human subjects 200
under local anesthesia. The pins were placed into the 100
spinous processes of the L4 and L5 vertebrae of a 0
1 10 100 200
live subject and Activator thrusts were made on the
Freq (Hz)
spinous processes from T11 inferior to the L2 level. 600
[FFT] (min setting)

These thrusts exerted peak forces of approximately 500
72 newtons (N). In response, the L4 and L5 verte- 400
brae experienced an axial displacement, posteroante- 300
rior shear displacement, and rotational displacement 200
at the L3-L4 spinal segment levels.55,56 It was felt that 100
coupled spinal motion was measured in more than 0
1 10 100 200
just the vertebra receiving a direct thrust. This study Freq (Hz)
provided the first substantiated evidence in humans of B
FFT (Load)
vertebral displacement produced by an adjusting in- 1.0E4
strument. Subsequent biomechanical research found, 7.5E3
among other things, that when the instrument was
3.0E3
equipped with a particular type of impedance head,
it produced “a significant improvement in the fre- 2.5E3
quency content” of the force delivered to the spine 0.0E0
(Fig. 40–5).54,56–59 1 10 100 1000
Further improvements in the force–frequency C
spectrum of the AAI have occurred over the years. 5
1 x 10
Force delivery from the instrument was compared
to known and discovered characteristics of the spine 1 x 10
4
and nervous system that resulted in further refine-

3
FFT (load)
ment of the instrument to match these characteristics. 1 x 10

As an example, the Activator II adjusting instrument 2
1 x 10
(AAI II) incorporated an additional integral mass
(about 45 g) attached to the stylus, which reduced 1 x 10
1
momentum and thus better matched the resonance

0
frequencies of the spine. Addition of a preload con- 1 x 10
trol frame provided more reproducible impedance 1 10 100
measurements and eliminated preload compression Frequency (Hz)
that tended to reduce force and change frequency of
the AAI springs.54,55 These refinements enhanced the FIGURE 40–5. A. Force frequency profiles of the AAI I, (B) the
force–frequency spectrum, leading to development of AAI II, and (C) the AAI III.
the Activator III (Figs. 40–6 to 40–8).
During investigations on the effect of the AAI on ical stimulation during spinal manipulative therapy
live subjects, the posterior mechanical behavior of the might, therefore, have a direct bearing on the subse-
human thoracolumbar spine was found to be sensi- quent physiological response of the body.
tive to mechanical frequency and showed significant The Activator instrument was used in a study mea-
region-specific and gender differences.56 In the fre- suring the stiffness of low back muscles in patients
quency range of 30 to 50 Hz, the lumbar spine of this with and without chronic low back pain.60 Activator
subject population was the least stiff and therefore had manipulative thrusts were delivered to several lum-
the greatest mobility. The results of this study indi- bosacral spinal landmarks and neuromuscular reflex
cated that dynamic spinal manipulative therapy pro- responses were measured. Findings from these exper-
cedures that induce impulses at this frequency may iments demonstrated significantly greater stiffness in
produce more spinal motion for a given force. Spinal low back musculature in patients with chronic low
manipulative therapy procedures designed to target back pain. Clinical observations support that patients
the resonant frequency of the spine may therefore re- suffering from back pain respond as effectively to the
quire less force application. The frequency content AAI, which provides a very low force, high-loading-
of the AAI energy impulse associated with mechan- rate thrust to the spine, as they do to hands-only
therapy using higher-force, low-loading-rate

thrusts.61,62 The former procedure produces vi-
brations or oscillations in the spinal structure, while
the latter is relatively static in nature, but of a mag-
nitude that often produces joint cavitation and an
audible pop within the posterior spinal structures.
There is some evidence indicating that the healing
and remodeling of the musculoskeletal system may be
most efficient in response to specific frequency com-
ponents of mechanical signals.56,63,64 This is consis-
tent with the unconfirmed clinical observation that
low-force chiropractic manipulations, when dynamic
in nature, may have therapeutic effects on the spine.
Thus, an interesting hypothesis is that both magni-
tude and frequency content of hands-only and me-
FIGURE 40–6. The Activator I adjusting instrument (AAI I). chanical thrusting manipulations are critical elements
in determining therapeutic effects.55,56,65 Solinger fur-
ther addressed the issue of resonance by comparing
the spine to a damped harmonic oscillator model. He
noted that hands-only and Activator spinal adjust-
ments created the same oscillating frequencies of the
spine, although the hands-only adjustments produced
higher amplitudes.58,65 It has been inferred that both
instrument and hands-only adjustments are similar
in efficacy, if oscillating frequencies are the end result.
This has received some early support in experimental
studies.62,66
Adjustments delivered by AAI have been pos-
tulated to “normalize” articular afferent input to
the central nervous system with subsequent recov-
ery of muscle tone, joint mobility, and sympathetic
activity.67 Gillette hypothesized that a chiropractic
lumbar thrust would produce sufficient force to coac-
FIGURE 40–7. The Activator II adjusting instrument (AAI II). tivate all of the mechanically sensitive receptor types
he reviewed because it generates over 40 N of force.68
Adjustments made with the AAI are thought to ac-
complish the same task, because they have been re-
ported to produce 72 ± 9 N of force.69 Brodeur pro-
posed that the AAI has the capacity to coactivate type
III, high-threshold mechanoreceptors.70 More recent
research shows that both type III and IV receptors
in diarthrodial joints, as well as type II in paraverte-
bral muscles and tendons, are responsive to vertebral
displacement.31 It has also been shown that muscle
activation is elicited by fast thrusts rather than slow
thrusts.71–73
Speed of the thrust was found by Herzog et al.
to be important in eliciting neural responses regard-
less of the presence of cavitation. In a series of tho-
racic spinal thrusts producing audible joint cavitation,
only fast thrusts produced electromyelogram activity
in paraspinal musculature.73 Herzog confirmed that
cavitation is not associated with back muscle reflex
FIGURE 40–8. The Activator III adjusting instrument (AAI III). responses. In his study, magnitude of applied force
was found to have little importance in bringing about
a response in muscle reflexes.74
nipulation produced relative movements in the tar-

get vertebra of 1 mm translation and 1 degree of
rotation. This is comparable to vertebral movement
effected by AAI. Herzog’s group found that while total
forces are greater with manual adjustments—because
of the larger contact area—local peak or specific forces
on the target vertebrae itself are the same for Activa-
tor and manual manipulation. They also found that
manual manipulation delivers the peak force over
150–200 msec. This compares to a delivery of about
3 msec for the AAI.
In measuring reflex responses of back muscles
with surface EMGs in response to Activator treat-
ment, Symons et al. found that approximately 68% of
FIGURE 40–9. Intraoperative lumbosacral spinal manipula-
the thrusts resulted in a detectable reflex response.76
tion.
Specifically, a detectable reflex response occurred with
50% of thrusts in the cervical spine, 59% of thrusts in
Another study was designed to determine the ef- the thoracic spine, 83% in the lumbar spine, and 94%
fect on spinal nerve discharge of an Activator adjust- of thrusts in the sacroiliac joints.
ment delivered directly on a vertebra.75 A patient vol- Colloca and Keller reported that neuromuscular
unteer was prepared for back surgery, an incision was reflex responses were elicited in 95% of patients as a
made over the L3-S2 midline, and the S1 nerve root result of AAI spinal adjustments in 20 patients with
was monitored at the dorsal root ganglion on the right low back pain.77 In this study, surface electromyo-
side (see Fig. 40–9). In phase I, an internal Activator graphic electrodes monitored lumbar paraspinal mus-
adjustment was made directly to the mammillary pro- cles as they responded consistently to a modified
cess of L5. In the second phase, an Activator thrust Activator adjustment of specific vertebral segments.
was made to the skin and tissue overlying the spine Another study of back pain patients found significant
at various locations. In both cases, a mixed nerve root increases in trunk muscle strength as a result of AAI
response was measured. The research yielded several lumbosacral adjustments.78
important findings. First, the Activator impulse tra- Conclusions from this research suggest that biome-
versed the soft tissue and elicited a mixed nerve re- chanical attributes of the therapeutic thrusts appear
sponse similar to direct thrust on bone. Second, the to match optimum frequencies for spinal flexibility
response was sensitive to direction, with an anterior and resonance. The neurophysiological attributes of
superior line of drive increasing the mixed nerve re- the adjustment seem to coincide with stimulation fre-
sponse by as much as three times. This concurs with quencies across the spectrum of neurological recep-
findings of Pickar and McLain.37 Surprisingly, exter- tors within joints in surrounding soft tissue. Because
nal spinal manipulative thrusts caused a greater range joint afferents have receptive fields in which they max-
of neural response in comparison to internal ones, es- imize output, it appears reasonable to consider that
pecially when the line of drive was anterior superior line of drive of adjustment maximizes neurological
in direction (Table 40–3). response. Also, speed appears to matter more than
Herzog and coinvestigators investigated forces mere degree of force in registering mixed nerve im-
delivered to the spine with manual, high-velocity pulses. Thus, velocity (speed + direction) is probably
low-amplitude (HVLA) adjustments.74 Manual ma- a fundamental vector in the chiropractic adjustment.
TABLE 40–3. Average Mixed-Nerve Root Responses (mV) to Spinal Manipulative

Thrusts Delivered Internally and Externally at Different Segmental Levels and with
Differing Force Vectors
L5 Ant LOD L5 Ant-Sup LOD S1 Ant-Inf LOD
Internal spinal manipulative thrusts 500–1200 1200–2600 200–900

External spinal manipulative thrusts 1200 800–3500 900
Ant = anterior; Inf = inferior; LOD = line of drive; Sup = superior.

Adapted from Colloca CJ, Keller TS, Gunzburg R, Vandeputte K, Fuhr AW. Neurophysiologic response to intraoperative lum-
bosacral spinal manipulation. J Manipulative Physiol Ther 2000;23(7):447–457.
ences between the three groups with respect to de-

CLINICAL CONSIDERATIONS
creases in systolic and diastolic pressures and anxiety.
Specificity of the chiropractic adjustment has always Specifically, systolic and diastolic pressures were re-
been of interest to the profession. In fact, speci- duced only in the Activator treatment group. State
ficity has been touted as that which distinguishes anxiety was reduced more in the Activator treatment
chiropractic from other manipulative disciplines. As group, but this decrease was not significantly different
shown in previous animal models and in newer re- from the controls. These results should be interpreted
search, different motions of the spine can result in with caution given the small sample size.
direction-specific neurophysiologic responses. These In another study, 10 consecutive new patients with
are described as “receptive fields” at the level of a history of neck injury and 9 asymptomatic volunteer
the mechanoreceptors.31,35–37 If therapeutic efficacy controls were subjected to a regimen of mechanical
is achieved by maximizing neurological input from force manually assisted short-lever chiropractic ad-
an adjustment, then precision alignment of adjustive justments using an AAI.62 Four of 10 AAI-adjusted
thrusts becomes important. Maximizing neurological patients also received interferential electrical stimula-
responses by specific thrust vectors provides a ratio- tion current to the rhomboids. Visual analogue scales
nale for precise training of the doctor of chiropractic. measured pain while dysfunction was measured by
finite helical axis parameters (FHAP) that closely mir-
Clinical Research rored the clinical condition of patients. The FHAP pat-
One question often raised is whether the AAI adjust- terns in the treatment group differed markedly from
ment is therapeutically equivalent to manual adjust- FHAP patterns observed in the asymptomatic con-
ing. Two studies attempted to address this question by trol group for all but one patient. After 6 weeks, the
means of randomized controlled trials. Gemmell and mean pain scores decreased and function increased
Jacobson compared a single AMCT to a single manual significantly over the course of treatment in com-
adjustment in 30 acute low back pain patients.61 They parison to the control group (p <0.001 for pain and
found no significant differences in pain reduction be- p <0.001 for FHAP). After 1 year, 7 of 10 treated pa-
tween the two methods. Wood and coworkers com- tients noted stability of their symptoms at or near the
pared Activator adjusting to manual manipulation level reported immediately after the 6-week treatment
in the treatment of cervical spine dysfunction.62 The period.
30 patients who had neck pain and restricted range of In a small randomized trial, 14 patients with neck
motion were randomly assigned into two groups: one pain were randomly assigned to either manual ther-
treated with an Activator II instrument, the other by apy or Activator treatment. Both groups saw an appre-
manual HVLA diversified adjusting. At the end of the ciable but not statistically significant reduction in pain
treatment period—a maximum of eight treatments or and increase in range of motion. However, there were
until asymptomatic status was reached—both groups no differences between the Activator and manual ad-
experienced a significant decrease in symptoms. The justing in terms of pain and function outcomes.66
AMCT group showed a greater improvement in cer- Another case series of 10 patients under Activator
vical range of motion from pre- to posttreatment, and management had a significant reduction of pain in
from posttreatment to 1-month follow-up, as com- a chronic sacroiliac joint syndrome. In this study, a
pared to the diversified group. Also, the AMCT group 6-week regimen of AAI adjustments reduced pain
experienced range-of-motion improvement in all di- from mean baseline values of 25 to posttreatment val-
rections, while the diversified group experienced im- ues of 12, and average disability scores diminished
provement in left rotation. Neither study had control from 28% to 13% (both p <0.05).80 Again, small sam-
groups, and thus no comparison to natural history, so ples prevent extrapolation to chiropractic patients in
interpretation about treatment efficacy must be made general.
with caution.
Yates et al. tested whether spinal adjustments of Case Series and Case Studies
T1 to T5 subluxations could have an effect upon blood Polkinghorn and Colloca reported an apparently suc-
pressure and anxiety.79 Twenty-one subjects were ran- cessful treatment for unremitting coccygodynia of
domly assigned to three treatment groups: adjustment 3 weeks’ duration in a 29-year-old female.81 Isolation
by AAI, placebo (AAI set to zero force), and base- tests of the sacrococcygeal region suggested that the
line (no treatment) control. Subjects’ systolic and dias- coccyx had subluxated laterally. Significant relief was
tolic blood pressures and anxiety were measured. All appreciated after the first Activator treatment, an ad-
groups were equivalent in their pretreatment scores justment near the base of the coccyx performed as in-
and stable in blood pressure measurements from base- dicated by AMCT analysis protocol.
line to pretreatment evaluation. Analysis of scores Case studies have reported successful resolution
from pre- to posttreatment showed significant differ- of lumbar disc herniation signs and symptoms and
cervical disc protrusion signs and symptoms by of answers, our treasury of questions has developed
AMCT management.82,83 In the latter case, a 42-year- exponentially.
old woman with cervical disk protrusion unrespon- The journey has involved risks and special efforts.
sive to manual manipulation showed a “favorable” AMCT proponents and practitioners have been chal-
response during the first week of AMCT manage- lenged to greater accountability by the evolving health
ment. All signs and symptoms resolved by the end of care marketplace. This has meant an ever-greater
3.5 months. emphasis on clinical outcomes in practice and re-
Other case studies have shown promise for AMCT search. For AMCT, the challenge requires our con-
analysis and treatment of a torn medial meniscus,84 tinued willingness to alter clinical procedures as the
plantar fasciitis attributed to posterior calcaneus knowledge base in chiropractic expands and unfolds.
subluxation,85 otitis media when related to upper It has been necessary to tolerate a degree of uncer-
cervical segmental dysfunction,86 Bell palsy,87 adhe- tainty and ambiguity in order to maintain that deli-
sive capsulitis (frozen shoulder),88 postsurgical neck cate balance between scientific skepticism and clinical
syndrome,89 chest pain,90 acute torticollis,91 and sci- open-mindedness, and still generate confidence in the
atic neuropathy and low back pain associated with patients who seek our help.
lumbar disc herniation.92,93 In the absence of con- Among the promising directions that deserve fur-
trolled clinical trials, observations from case studies ther exploration are several methods of evaluating the
should always be interpreted as no more than a basis spine, including isolation testing, assessment of spinal
for further research. resonant frequencies in health and disease, and ultra-
sonic indentation of the spine in asymptomatic indi-
Safety viduals versus patients.95 It will be important to bet-
When any health care device is employed, safety ter elucidate the suspected relationship between the
is a primary concern and must be satisfactorily es- physical characteristics of the adjustive thrust and the
tablished. The National Institutes of Health grant force- and frequency-dependent mechanoreceptors of
found that the spring driving this hammer could not the spine, so as to render a more efficient and effective
have produced more than 0.3 joules (J) of potential intervention.
energy.52,53 These projects will continue to require team effort
Nykoliation and Mierau published a review of and multiple skills in the areas of neurophysiology,
three cases of complications following treatment in bioengineering, clinical epidemiology, and the clini-
Canada possibly associated with mechanical adjust- cal arts. The fundamental purpose is to better deter-
ing devices, although the AAI was not identified.94 mine how best to help the patient. This clinical “bot-
The single reported case of stroke was accompanied tom line” also necessitates greater efforts to study and
by “twisting motions” inconsistent with AMCT pro- document clinical outcomes. The work will involve
tocols, and all three incidents lacked clear causal links expanded efforts to produce controlled trials, clinical
to mechanical adjusting. case series, and individual case studies. Patient im-
provements must be the ultimate yardstick by which
we judge success in understanding spinal dysfunction
CHALLENGES AND FUTURE POSSIBILITIES
and its relief. Issues of effectiveness and safety compel
Low-force and instrument adjusting have come some our expanded efforts to understand spinal changes in
distance in the past 35 years, primarily through the relation to health care outcomes.
research on AMCT. From the humble pursuit of
greater accuracy, ease, and efficiency in the clinic,
SUMMARY
the technique has evolved into a nonexclusive but
systematic approach to assessment and intervention 1. Instrument adjusting in chiropractic dates to the
for patients with neuromusculoskeletal and neuro- early years of the profession. Numerous devices
musculoskeletal-mediated conditions. Along the way, have been used to deliver or aid in the delivery
AMCT has spawned many enthusiasts and attracted of spinal manipulation, including a wooden mal-
the scrutiny of scholars and educators here and let and stick, a rubber hammer, various concus-
abroad. Our sophistication in quantifying clinical and sional and pneumatic devices, toggle–recoil in-
laboratory phenomena has grown during this time, struments, and computer-operated devices.
and has given rise to new equipment and to research 2. The Activator Methods Chiropractic Technique in-
questions we could not have imagined earlier. We cludes both treatment and assessment methods.
have begun to explore the clinical utility of AMCT, Treatment mainly involves the use of a low-force
both its components and as an integrated package, technique delivered through a hand-held adjust-
in order to better determine when, where, and when ing instrument, while assessment is performed
not to adjust the patient. Although still woefully short with various forms of leg-length measurements.
3. Isolation testing involves the observation and mea- B. No research support.

surement of leg-length alterations before and after C. Numerous high-quality randomized control-
manipulative treatment, which are thought to be led trials performed in academic settings.
the result of changes in muscular reflexes through D. Several case series and a few small-scale ran-
proprioceptive pathways. domized controlled trials performed by a small
4. The Activator adjusting instrument was devel- group of researchers.
oped in the 1960s by adapting a dental impactor E. No better than control or placebo.
instrument as a means of producing a thrust into
the spine that would reduce physical stress on the
clinician and control the speed, force, and direction ANSWERS
of the adjustive thrusts.
5. The Activator adjusting instrument is thought to 1. E.
exert its effect by restoring the articular struc- 2. D.
tures to a more naturally resonant state in which 3. C.
mechanoreceptors exhibit lower neural discharge 4. D.
rates, sources of mechanical pain may be re- 5. D.
lieved and, as inflammation subsides, aggravated
chemosensitive type IV receptors may reduce
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C H A P T E R
41
SOFT TISSUE MANUAL TECHNIQUES
Stephen M. Perle
O U T L I N E
INTRODUCTION SOFT TISSUE BARRIER
SOFT TISSUE DYSFUNCTION TREATMENT TECHNIQUES
Categories Muscle Energy Techniques/Active Muscular
Limbic System Dysfunction Relaxation Techniques
Reflex Contracture Postisometric Relaxation (PIR)
Interneuron Dysfunction Postfacilitation Stretching (PFS)
Chronic Muscle Shortening Trigger Point Pressure Release
Myofascial Trigger Points Stretch and Spray
—Diagnosis Myofascial Release Techniques
—Perpetuating Factors Active Release Technique
INFLAMMATION AND WOUND HEALING Transverse Friction Massage
MUSCLE INJURIES Graston Instrument-Assisted Soft Tissue Mobilization
Delayed Onset Muscle Soreness SUMMARY
Strains or “Pulls” QUESTIONS
Tendinosis ANSWERS
Tendon Rupture KEY REFERENCES
LIGAMENT INJURIES REFERENCES
joint disorders. In some cases, spinal manipulation can

CHAPTER OBJECTIVES
also be an effective treatment for soft tissue disorders.1
1. To review the five categories of soft tissue dysfunc- However, this is not universally true and at times treat-
tions. ment needs to be applied directly to the soft tissues
2. To review the causes, clinical presentation, diag- through other treatment approaches. The direct man-
nosis, and treatment of trigger points. agement of soft tissue disorders is a component of the
3. To review the stages of inflammation and wound subluxation complex as first described by Faye and
healing later updated by Lantz.2,3 In this chapter, soft tissue
4. To review common muscle injuries. manual techniques will be broadly classified as those
5. To review ligament injuries. primarily intended to treat disorders that are dysfunc-
6. To review commonly used muscle energy treat- tional in nature, or soft tissue injury due to trauma.
ment techniques.
7. To review commonly used myofascial release tech-
niques. SOFT TISSUE DYSFUNCTION
When discussing dysfunction of soft tissues one
predominantly means muscle tissue as it is the
INTRODUCTION
only soft tissue exhibiting active function. Janda has
The primary treatment used by the chiropractic pro- grouped muscular dysfunction into five broad cate-
fession is spinal manipulation, mainly prescribed for gories: limbic system dysfunction, reflex contracture,
805
interneuron dysfunction, muscle tightness, and my- Differential Diagnosis of Tight

TABLE 41–1.
ofascial trigger points. 4 Muscles and Chronic Muscle Shortness
Categories Tight Muscle Chronic Muscle Shortening

Limbic System Dysfunction This is described as lum-
bopelvic or upper thoracic and neck pain in combi- Transient Perpetual
nation with muscle spasm. The area of spasm is not Acute Chronic
anatomically defined; thus there is a fuzzy zone of Symptomatic Not directly symptomatic
transition from normal to spastic and tender muscle. Known precipitating event Unknown cause
This condition is considered to be a somatic manifes- Typical stretches help Typical stretches do not help
tation of psychological stress and should be managed
Modified from Jull GA, Janda V. Muscles and motor control in low back
with appropriate stress management techniques.4 pain: Assessment and management. In: Twomey LT, Taylor JR, eds.
Physical therapy of the low back. New York: Churchill Livingstone, 1987:
253–278.
Reflex Contracture This type of dysfunction may also
be called “muscle splinting,” which often repre-
sents the body’s protective response to joint trauma. (described below): postfacilitation stretching (PFS),7,8
Sometimes this protective mechanism continues be- or postisometric relaxation (PIR).8
yond the time necessary for joint protection. This is felt
to result in a feedback loop where the spasm causes
Myofascial Trigger PointsA myofascial trigger point
pain and this pain, in turn, causes further spasm; this
(TrP) is defined as a hyperirritable spot in skeletal
is termed the pain-spasm-pain cycle. It has been sug-
muscle that is associated with a hypersensitive pal-
gested that the feedback loop can be interrupted by
pable nodule in a taut band. The spot is painful on
the use of tetanizing electrical stimulation.4
compression and can give rise to characteristic re-
ferred pain, referred tenderness, motor dysfunction,
Interneuron Dysfunction This is defined as a localized and autonomic phenomena.9 The referred pain from
muscle spasm that is the result of joint dysfunction. a TrP is typically described as a dull and aching.
The spasm can appear above, below, or at the level of It can often be deep and is rarely burning, and the
the joint dysfunction. This condition may give the pal- area of pain is often not well localized. When using
patory illusion of posteriority of a transverse process
due to perceived increased stiffness when compared
to adjacent areas.4 TABLE 41–2. Shortened and Inhibited Muscles
Chronic Muscle Shortening Janda has described this as Muscles Prone to Muscles Inhibited by
a condition where connective tissue shortens and the Muscle Shortness Muscle Shortening
muscle spindle adapts to this shortened position.4,5
The muscle becomes hyperfacilitated with a decreased Gastrocnemius Soleus Peroneus
contraction threshold, leading to reciprocal inhibition Tibialis posterior Anterior tibialis
and weakening of antagonist muscles. It is impor- Hamstrings Vastus medialis and lateralis
tant to differentiate between chronic muscle short- Iliopsoas Glutei
ening and the more commonly occurring tight mus- Tensor fascia lata Rectus abdominis
cles (Table 41–1).5–7 Although muscles that exhibit Rectus femoris Serratus anterior
chronic shortness (Table 41–2) may cause or perpet- Short hip adductors Rhomboids
uate pain syndromes (Table 41–3), the muscle itself is Sartorius Lower trapezius
usually not painful. Often, however, the attachments Piriformis Short cervical flexors
of these muscles are tender due to the continuous Lumbar erector spinae Extensors of upper limb
increase in tension. Joint dysfunction and chronicity Quadratus lumborum
of myofascial trigger points are common sequelae to Pectoralis major
such chronic muscle shortening. The reciprocal inhi- Upper trapezius
bition due to the hyperexcitability these muscles have Levator scapulae
has been assumed to produce a muscle asynergy. In Scalenes
other words, there can be a lack of synergistic or co- Sternocleidomastoid
ordinated muscular activity during movement with Flexors of upper limb
chronically tight muscles changing the normal pattern
Adapted from Janda V. Evaluation of muscular imbalance. In: Liebenson
of muscle contraction.7 Chronic muscle shortness can C, ed. Rehabilitation of the spine: A practitioner’s manual. Baltimore:
be treated using two forms of muscle energy technique Williams and Wilkins, 1996:97–112.
SOFT TISSUE MANUAL TECHNIQUES 807
TABLE 41–3. Postural Syndromes
Upper Cross Syndrome Lower Cross Syndrome Layer Syndrome
Pectorals Chronic shortness Cervical erector spinae

Upper trapezius Lumbar erector spinae Upper trapezius
Levator scapulae Iliopsoas Levator scapulae
Deep neck flexors Inhibited Thoracolumbar erector spinae
Rhomboids Rectus abdominis Hamstrings
Lower and middle trapezius Gluteus maximus Lower scapular stabilizers
Serratus anterior Lumbosacral erector spinae
Adapted from Jull GA, Janda V. Muscles and motor control in low back pain: Assessment and manage-
ment. In: Twomey LT, Taylor JR, eds. Physical therapy of the low back. New York: Churchill Livingstone,
1987:253–278.
a pain drawing, a patient would prefer to draw pain the palpating finger, when in reality it is the TrP that
with spray paint rather than a pen. Occasionally, the refers to the area of tenderness. TrPs are also described
pain can be very sharp and lancinating or produce to cause referred muscle spasm in the reference zone.
lightning-like stabs of pain. Thus, the symptoms may On rare occasions TrP may cause symptoms described
range from low-grade discomfort to severe and in- as autonomic in nature (Table 41–4).
capacitating torture. The referred pain is commonly One of the hallmarks of the pain from a TrP is its
found in a region or reference zone that is typical for variability. As stated previously, the intensity of pain
the muscle affected with the TrP. This reference zone can vary from hour to hour or day to day. This variabil-
does not fit any typical anatomical distributions (i.e., ity is coupled with the fact that, with rest, a TrP may
it is not dermatomal, sclerotomal, or myotomal).9 An- become latent (asymptomatic) and the patient may
other common feature of the TrP is that the symp- forget the precipitating event. The patient’s muscles
toms vary in intensity such that the patient may report “learn” to avoid pain, and muscle contraction is lim-
day-to-day or even hour-to-hour changes in the pain ited to a force that does not activate the TrP. This can
intensity. This variation in intensity is a continuum result in chronic muscular pain and stiffness. Then,
that ranges from no pain to intense pain. Although when the patient encounters any of the aforemen-
there is no method to place a patient’s current state tioned causes of activation, the patient experiences oc-
of pain along the continuum, this is a useful construct casional reactivation. Thus, there is a typical history of
to explain to patients how their symptoms wax and recurrent symptomatic episodes of acute symptoma-
wane. tology, combined with periods of relative ease.9
When a TrP is causing a clinical pain complaint, Peripheral nerve entrapment is also a common fea-
it is called active. When it is not pain-producing, it ture of TrPs. The patient may then experience symp-
is referred to as latent.9 There are a variety of fac- toms from neuropraxia or from nerve compression
tors that can activate a trigger point (i.e., cause a la-
tent trigger point to become symptomatic). Activation
of a TrP may have direct or indirect causes. Direct Abbreviated List of Autonomic
TABLE 41–4.
causes include acute overload, overwork fatigue, di- Symptoms Caused by Trigger Points
rect trauma, and chilling. Indirect causes include other
TrPs, visceral disease, arthritic joints, and emotional Excessive lacrimation
distress. A trigger point that is activated by another Nasal secretion
trigger point (key TrP) is called a satellite TrP. The Pilomotor activity
satellite TrP always lies in the reference zone of the Changes in sweat pattern
key TrP.9 Reflex vasodilation
Although TrPs are most often associated with re- Postural dizziness
ferred pain, pain is not the only referred phenom- Spatial disorientation
ena. Referred tenderness poses a significant diagnos- Disturbed weight perception
tic dilemma, as one can often precipitate a patient’s Visual and auditory disturbances
symptoms of tenderness by compression in an area of Visceral disorders
the referred tenderness that may be distant from the
Adapted from Simons DG, Travell JG, Simons LS. Travell and Simons’
cause of the tenderness. Thus, one is lead to believe myofascial pain and dysfunction: The trigger point manual. Vol. 1.
that the cause of the tenderness is some tissue under Baltimore: Williams and Wilkins, 1999: 21.
between the TrP taut bands or between the TrP, the facilitate the stretch (e.g., intermittent cold, post-
taut band, and the bone. These patients may present isometric relaxation, trigger point pressure release).
with one or more of the following types of symptoms: Other treatments include trigger point injection and
aching pain from the TrP and/or nerve compression therapeutic ultrasound, although injection is not a
effects, numbness and tingling or hypoesthesia, and procedure typically employed by the chiropractic pro-
sometimes hyperesthesia. Myofascial trigger points fession in the treatment of TrP syndromes. However,
typically cause stiffness, which is worse in the morn- an appreciation of the basics of this technique is essen-
ing and recurs after overactivity or immobility. There tial when considering an interdisciplinary approach
is often an apparent weakness, as the patient learns to muscular pain. The injection is generally done with
what movements to avoid and limits the force of mus- a 22-gauge needle, and can be done with or without
cle contractions to stay below the pain threshold.9 anesthetic. Clinical observation suggests that needling
The causes of TrPs can be classified as both sud- without injecting any medication may be as effective
den and gradual onset. Sudden onset can come from as needling with an injection. Consequently, it is has
acute overload stress, trauma, and extreme exertion. been suggested that the therapeutic component of this
Usually, eccentric muscle contractions are more prob- treatment is the needle piercing the TrP.9,10
lematic. Gradual onset results from overuse, fatigue, It has been suggested that Active Release Tech-
excessive repetitive action, or repetitive action with nique (ART) and Graston Instrument-Assisted Soft
poor biomechanics. Tissue Mobilization may also be effective treatments
for TrPs.11,12 However, these manual methods do not
appear to have the same long history of clinical use
Diagnosis Various diagnostic criteria have been pro-
in the treatment of TrPs as the other treatment ap-
posed, but current best evidence suggests that the di- proaches detailed above. There have been no clinical
agnosis should be made based upon certain essential studies to determine the relative effectiveness of each
criteria and along with confirmatory observations (See of these methods. Thus, the clinician is left to apply
sidebar, Criteria for Diagnosis of a Latent Trigger Point or the treatment that she or he has the most expertise in
an Active Trigger Point.). The most important criterion using, and that complies with patient’s wishes.
for the diagnosis of TrPs is tenderness at a nodule in
a palpable taut band.
Perpetuating Factors A litany of factors (See sidebar,
Perpetuating factors for TrP.) are felt to perpetuate a TrP.
Criteria for Diagnosis of a Latent Trigger Perpetuating factors cause the reactivation of TrPs af-
Point or an Active Trigger Point ter what evidently was effective treatment. It is be-
yond the scope of this text to describe these in de-
Essential Criteria
tail. The reader is referred to Simons and Travell for a
Taut band palpable (if muscle is accessible)
through discussion of perpetuating factors. 9
Exquisite spot tenderness of a nodule in a taut band
Patient’s recognition of current complaint by pressure on
the tender nodule (identifies an active TrP) Perpetuating Factors for TrP
Painful limit to full stretch range of motion
Mechanical Stress
Confirmatory Observations
Joint dysfunction
Visual or tactile identification of a local twitch response
Leg-length inequality
Imaging of a local twitch response induced by needle pen-
Short hemipelvis
etration of tender nodule
Short upper arms
Pain or altered sensation (in the distribution expected
Morton’s foot (short first and long second
from a trigger point in that muscle) on compression of
metatarsals)
tender nodule
Misfitting furniture
Electromyographic demonstration of spontaneous electri-
Poor posture
cal activity characteristic of active loci in the tender nodule
Abuse of muscles (e.g. sustained isometric contractions)
of a taut band
Immobility
Repetitive movement
Adapted from Simons DG, Travell JG, Simons LS. Travell & Simons’
myofascial pain and dysfunction: The trigger point manual, vol. 1. Constriction of muscles
Baltimore: Williams & Wilkins, 1999. Nutritional Deficiencies
Vitamins (B1, B6, B12, folic acid, C)
Minerals (Ca, K, Fe, Mg)
A variety of therapeutic methods have been used
Metabolic and Endocrine Disorders
to treat TrPs. Most of these involve some type of
Hypometabolism (aka hypothyroidism)
muscle stretching with various procedures used to
starts immediately after injury and typically lasts for

Hypoglycemia
up to 6 days. Neutrophils, macrophages, monocytes,
Gout
and lymphocytes migrate to the wound site as a result
Chronic Infection and Infestations
of local chemotactic factors. Polymorphic neutrophils
Viral and bacterial disease
degrade any damaged extracellular matrix. Platelets
Infestations
and macrophages release growth factors that attract
Psychological Factors
pericytes and fibroblasts. Tensile strength is initially
Hopelessness
provided by fibrin, fibronectin, and collagen.17
Depression
The next stage, the proliferative stage, starts at ap-
Other Factors
proximately 5 days post injury and lasts 22 days. En-
Allergic rhinitis
dothelial cells, myofibroblasts, and fibroblasts accu-
Impaired sleep
mulate at the wound site. A new capillary network
Nerve impingement
is established in the wound area. Myofibroblasts and
Adapted from Simons DG, Travell JG, Simons LS. Travell &
fibroblasts, which have aligned themselves with the
Simons’ myofascial pain and dysfunction: The trigger point man- capillaries, secrete extracellular matrix components.
ual, vol. 1. Baltimore: Williams & Wilkins, 1999. Deposition of Type III collagen begins and continues
until day 12, when Type I collagen (the major struc-
tural type) predominates. Myofibroblasts then con-
Muscles, tendons, and ligaments, the “soft tis- tract to shrink the wound while there is a deposition
sues,” are the most common sites of injuries in and removal of extracellular matrix to remodel the
sports.13 Although soft tissue injuries are common wound. Wounds can contract by as much as 70%.17
among athletes, one might view many activities of The maturation phase begins approximately 20
daily living as just an athletic event that is fre- days post injury. The macrophage myofibroblast and
quently less strenuous, but nevertheless has the fibroblast populations at the wound decrease sharply.
potential for injury. These injuries may result from ex- A definitive capillary network is established. Tensile
ogenous and endogenous causes. An exogenous eti- strength increases as more mature Type I collagen bun-
ology would be from contact or impact of some body dles predominate within the scar. The end of the mat-
part with an external object or person. Endogenous uration phase is not well defined, with collagen depo-
injuries are caused by forces generated within the sition continuing for months to years.17
body that exceed the strength of the tissue injured. Pain (dolor), redness (rubor), heat (calor), swelling
This includes overuse, dynamic overload, inflexibility, (tumor), and loss of function (functio laesa) are the clas-
structural vulnerability, and rapid growth.14 Repeti- sic or “cardinal” signs of inflammation.14 With that
tive stress or overuse has been defined by Kiefhaber as in mind, it is very common to assume that local ten-
“a level of repetitive microtrauma, sufficient to over- derness is pathognomonic for the diagnosis of an in-
whelm the tissue’s ability to adapt.”15 Dynamic over- flammatory condition.18 However, many painful and
load describes a tissue that fails due to a sudden ex- tender injuries of the soft tissues do not have any as-
cessive stretching of the tissue.14 sociated inflammatory response.19,20 Accordingly, the
The chiropractic approach to the treatment of these rationale for the common treatment of many condi-
injuries has long stressed early ambulation and early tions may be incorrect. The goal in treatment of soft
mobilization. These concepts are finding new converts tissue injuries often has been to eliminate or mini-
within other professions, including a shift towards ag- mize the inflammatory response, when in fact, some
gressive treatment and rehabilitation techniques that conditions would heal faster if inflammation were
are used in the sports medicine environment.16 Man- promoted.19,21,22 The problem may be that our think-
ual treatment may be applied to tissues other than ing about the treatment of inflammation has been
those injured for the purposes of minimizing biome- ruled by the presence of purposeless inflammation
chanical stress to the injured tissue to allow the tissue (e.g., rheumatoid arthritis, lupus, etc.) even when we
to heal on its own. Treatment may also be applied to are looking at purposeful inflammation (i.e., wound
the injured tissue itself in an effort to accelerate heal- repair).
ing. It is this second approach that will be discussed
in this chapter.
MUSCLE INJURIES
INFLAMMATION AND WOUND HEALING Delayed Onset Muscle Soreness
Wound healing can be divided into three distinct This is the soreness that appears 24 to 48 hours
phases: inflammation, proliferation, and maturation. after strenuous exercise.23 Almost a century ago it
Inflammation, also called the acute vascular phase, was stated that DOMS is the result of torn tissue.24
More recently, histological examination has found that Muscle cells are permanent and thus cannot pro-
the sarcomere’s Z-band is disrupted or undergoes liferate. In the basement membrane of muscle fibers
what has been called streaming (zig-zagging of the are reserve cells that are able to proliferate and dif-
Z-bands).25–28 In addition, the presence of biochem- ferentiate to form new skeletal muscle. Theoretically,
ical markers of muscle injury such as myoglobin,29 it is possible for a complete muscle tear to show
serum creatine kinase,25,29–32 and glutamic oxaloacetic regeneration,17 although scar tissue is more com-
acid transaminase provides further evidence for this monly formed.51 At present no treatments have been
theory.32 shown to produce myoregeneration as opposed to
The symptoms of DOMS are tenderness on palpa- scar formation.52 It has been suggested that ART,11
tion, increased muscle stiffness, and painful contrac- transverse friction massage,7 and Graston Instrument-
tion and stretching.33 It is likely that these symptoms Assisted Soft Tissue Mobilization are manual treat-
are due to local inflammation.33,34 Eccentric exercise ment methods that may be helpful in the treatment of
appears to be the only type of exercise that causes muscle strains and may reduce scar formation.12 All
DOMS.25–32,35–37 The common reason given is that ec- three techniques purportedly remove adhesions both
centric contractions develop greater muscle tension within muscles and between muscles and their fascia,
than concentric contraction.27,32,35,38,39 but this has not been documented.
Massage, stretching, ice, and NSAIDs have all been
recommended as treatments for the prevention of Tendinosis
DOMS. Studies have not found stretching or ice to be In 1976 Puddu et al. coined the term tendinosis to de-
effective, while NSAIDs have had equivocal success.40 scribe long-standing tendon degeneration in the ab-
In a systematic review, Ernst notes that methodolog- sence of histological signs of inflammation.53 This was
ical problems (predominately small sample size) pre- done because a painful tendon was usually diagnosed
vent a definitive determination on the effectiveness with tendinitis or rupture, even though the tendon is
of massage, but he concludes that massage may be not prone to inflammation.54–56 Since that time, the
helpful.41 In a pilot study, Smith et al. found that mas- term tendinosis has come into common usage in the
sage (effleurage, petrissage, wringing, cross-fiber, and literature.14,18,20,21,54,57–65 However, tendinitis is still in
shaking) 2 hours after the end of exercise may help common usage.59
prevent the development of DOMS.40 Their study sug- Tendinosis develops secondary to chronic micro-
gests that massage 2 hours post exercise may interrupt trauma, and there are two pathophysiologic theories:
the cascade of events leading to a full inflammatory hypoxic degeneration involving both tenocyte and
response, which appears to be the cause of the pain. matrix components which may produce oxygen-free
radical species that lead to cell lipid membrane per-
oxidation and cell death, and tendinosis due to aging
Strains or “Pulls”
and with sedentary tissue disuse. These cause fluxes
Muscle strains, which are often called “pulls,” of intracellular calcium ion concentration which may
typically cause injury at the musculotendinous play a role in determining synthesis and tissue degen-
junction.42–45 The most common cause is a high-force eration. Stanish and Curwin appear to be the first to
eccentric contraction. However, passive stretching have recommended an eccentric exercise program for
or strong concentric contractions have also been the treatment and prevention of tendon injuries (See
implicated.13,45 Eccentric contraction is more prob- sidebar, Tendon Eccentric Exercise Program.).66,67 Oth-
lematic due to the greater forces produced.26,32,39,44 ers have come to believe that eccentric strengthening
Since both muscle strain and DOMS share the com- is essential in the treatment of tendinosis.59,62,68 Jensen
mon etiology of eccentric contraction,45 one might re- and Di Fabio conducted the first clinical trial of Stanish
gard these two injuries to be opposite ends of a con- and Curwin’s exercise program, and reported that this
tinuum of injuries caused by eccentric contraction. approach to may be effective.69
Various factors have been identified that appear to
be risk factors for muscle strain. These include mus-
cles with a higher proportion of fast twitch (Type II) Tendon Eccentric Exercise Program
fibers,45 muscles that cross more than one joint,46 and
Stretch
muscles that often function in an eccentric manner.13,45
Hold 15 to 30 seconds–repeat 3 to 5 times
More severe strains are often preceded by a previ-
Eccentric Exercises
ous mild injury.47 Stretching and warming up are
3 sets of 10 repetitions
generally accepted as necessary to prevent muscle
1. Progression only if pain-free
injuries.45,48,49 However, at this time more research is
Days 1 and 2 – slow
needed to determine the effectiveness of stretching in
Days 3 to 5 – moderate
preventing muscle injuries.50
ble at this time.59 Tendon rupture is more likely with

Days 6 and 7 – fast
oblique loading, when the muscle is in maximal con-
2. Increase external resistance – after day 7, repeat cycle
traction or is exhausted, or when the initial length
only if pain-free
of the muscle-tendon unit is short.55 Reduced blood-
Stretch as before
flow is often cited as a predisposing factor in injuries
Ice
to tendons, particularly in the Achilles.14 However,
Crushed ice or ice massage applied to tender or painful
Backman et al. found that in exercise-induced chronic
area for 5 to 10 minutes to reduce swelling and moderate
Achilles peritendinitis and tendinosis there was no
pain
noted impairment of circulation.58 Tendon rupture
There should only be pain in the last of the three sets. If no pain,
may be diagnosed manually by palpating a rolled-up
there is not enough load. If there is pain in all three sets, the muscle belly, with advanced imaging, or through mus-
intensity or speed is too great. cle strength or range-of-motion testing. Severe tendon
Adapted from Stanish WD, Curwin S, Rubinovich M. Tendini-
tis: The analysis and treatment for running. Clin Sports Med
rupture often requires surgical repair.
1985;4(4):593–609.
LIGAMENT INJURIES
The clinical diagnosis of tendinosis rests on pain
and palpable tenderness in the appropriate area.20,62 Ligaments and tendons are very similar in ultrastruc-
Pain will also be elicited with manual stress testing.20 ture and biomechanical properties.74 Studies done
Tendinosis may be best diagnosed by the use of on tendons have been used to determine effects on
MRI.62,70 On T1 and balanced spin echo sequences, ligaments.75 Ligaments are structurally weakened by
intratendinous degeneration will best be visualized.70 immobilization and strengthened by movement and
Initial plain radiographs are recommended, with re- exercise; ligaments may also be injured or torn com-
peat radiographs at 6 to 12 weeks to rule out tumors.63 pletely due to trauma.76,77 This has prompted research
Conservative treatment is appropriate initially, into the effects of early mobilization in the treatment
and attempts should be made to correct any under- of sprains.16 In the two studies that compared mo-
lying causes of tendinosis (e.g., training errors).60,62,63 bilization to surgical repair in patients with grade
Relief of pain is accomplished with PRICEMM (pro- III sprains, the nonsurgically managed subjects had
tection, rest, ice, compression, elevation, medication, outcomes comparable to those surgically repaired. In
and modalities).19,20,63 The goal of conservative treat- most cases they could not be distinguished from the
ment is to promote revascularization and collagen uninjured limb.16 The authors also found that early
repair.20 Theoretically, transverse friction massage mobilization had the same long-term outcome as im-
(TFM) should help accomplish this goal, but in the mobilization, but led to a shorter disability period. In-
only clinical trial of TFM it was no more effective than strumented soft tissue mobilization has been shown to
ultrasound.71 It is possible that TFM does not produce be effective in treating the late effects of ankle sprain.78
enough force to stimulate healing. Studies have shown Thus, it would appear that instrumented soft tissue
that soft tissue mobilization with instruments does in- mobilization may be effective for other ligamentous
crease the activation of fibroblasts and the deposition injuries.12
of collagen.72,73 The amount of fibroblasts recruited is
greater with higher- than lower-pressure soft tissue
mobilization (Graston Instrument-Assisted Soft Tis- SOFT TISSUE BARRIER
sue Mobilization).73 Many of the soft tissue manual techniques to be dis-
Surgical referral of patients with tendinosis should cussed below share a common feature: palpation and
be considered after failure to respond to a structured treatment of a functional lesion that is termed a soft
rehabilitation program of 3 to 6 months, chronic symp- tissue barrier. The barrier is identified when the doctor
toms with or without activities or night pain, pain for tries to move a joint or a soft tissue directly to a partic-
more than 1 year, and altered quality of life.20,63 The ular position (i.e., to displace the joint or soft tissue),
goal of such treatment is to remove the degenerative and there is some restriction or impediment to that
tissue and promote revascularization in the region by movement. This impediment is not pathological but
creating an acute injury.20,62,63 dysfunctional in nature. Theories abound regarding
the nature of the barrier, but none has been adequately
Tendon Rupture validated.
Tendon rupture appears to be a sequela to chronic Figure 41–1 shows a conceptual model of the forces
tendinosis due to the degeneration that is character- involved and the movement that one feels when pal-
istic of tendinosis.14 Reliable prediction of which pa- pating a barrier (1st barrier), and palpating the re-
tients will progress to complete rupture is not possi- sponse of the barrier to partially (2nd barrier) and then
Treatments Start at Barriers

Barriers Lack of
Barrier
1st 2nd 1st 2nd
Force Applied
Force Applied
Displacement
FIGURE 41–1. Model of diagnosis of soft tissue barrier by

palpation and change after treatment (2nd barrier and lack of
Time
barrier.)
Displacement
completely effective treatment (lack of barrier). When
one encounters a barrier, there is a perceived abrupt
increase in the stiffness of the joint/tissue. The per-
ception of this stiffness has been called “palpation of
tissue tension.” The location of the stiffness within the
joint/tissue ROM will change after an effective treat-
ment (2nd barrier). When treatment is complete, no Time
further perception of a barrier will be present (lack of
barrier). FIGURE 41–3. Model for treatment of soft tissue barrier—
Treatment is initiated by displacing the tissue in- force and displacement vs. time.
volved toward the barrier. This results in an increase in
force as the resistance of the tissue to displacement is
encountered Fig. 41–2. The force and displacement are TREATMENT TECHNIQUES
held for a period of time and then, in what feels like
either the viscoelastic phenomena of creep (e.g., in- Muscle Energy Techniques/Active Muscular
creased displacement with a static load) or load relax- Relaxation Techniques
ation (e.g., decreased force with a static displacement), Many different stretching methods are used to treat
the displacement increases or the force decreases, re- muscle dysfunction (e.g., postisometric relaxation,
spectively, depending on one’s technique Fig. 41–3. hold relax, contract relax antagonist contract). If
Clinicians often describe this feeling as if the tissue is one looks at these treatment methods in a dispas-
melting under contact. sionate way, one will observe a commonality of
approach.79 These techniques may be called active
muscular relaxation techniques (AMRT),8,80,81 or muscle
energy techniques.79 They fit Greenman’s definition of
muscle energy technique even though muscle energy
Treatments technique is by itself a specific therapeutic method
1st 2nd developed by Fred Mitchell, an osteopath.82
Force Applied
Muscle energy technique has been defined as “a

manual medicine treatment procedure that involves
the voluntary contraction of patient muscle in a pre-
cisely controlled direction, at varying levels of inten-
sity, against a distinctly executed counterforce applied
by the operator.”82 The purpose of the muscle energy
techniques, generally, is to restore normal movement
Tissue Displacement by removing a barrier to movement.79,82 The theory
behind muscle energy techniques is that the muscle
FIGURE 41–2. Model for treatment of soft tissue barriers— contraction neurologically inhibits either pain or in-
force vs. tissue displacement. voluntary muscle contraction long enough to allow
TABLE 41–5. Muscle Energy Variables
Variable Levels
Magnitude of doctor’s force relative to Dr. < Pt. (concentric contraction)

patient’s Dr. > Pt. (eccentric contraction)
Dr. = Pt. (isometric contraction)
Percent of patient’s contraction effort From maximal volitional effort to just
initiating contraction
Location within range of motion for At barrier or before barrier
contraction
Duration Typically 7–10 seconds
Direction of doctor’s contraction Toward barrier (direct)
Away from barrier (indirect)
Passive and/or active stretch Passive—doctor does the stretch
Active—patient contracts the antagonist
to stretch the antagonist
End point of stretch At or past the new barrier
Starting point of stretch At or before the new barrier
Adapted from Chaitow L. Muscle energy techniques. New York: Churchill Livingstone, 1996: 1–14.
movement past the barrier.79 It has been shown that may or may not be repeated after some period) or
contraction does alter pain threshold.83 Both recipro- rhythmic low-amplitude contractions. If the doctor is
cal inhibition (antagonist contracts) and postisomet- pushing toward the barrier, this is termed direct force.
ric relaxation (agonist contracts) have been reported Conversely, when the doctor pushes away from the
to reduce muscle hypertonicity.79 Muscle energy tech- barrier, the force is said to be indirect. In some in-
niques have also been suggested as a method to treat stances, the patient may be required to hold his or
joint dysfunction (i.e., subluxation).82,84 her breath and/or look in a particular direction with
There are many variables (Table 41–5) that one can the eyes (typically eyes toward the direction of move-
choose from when performing a muscle energy tech- ment). Following the period of contraction, the muscle
nique. What differentiates one particular muscle en- is lengthened. This may be accomplished in a passive
ergy technique from another is that each technique manner, or the patient may contract the antagonist
has its own established set of values for each of these muscle to assist the doctor or may produce the stretch
variables.79 The principal component of the muscle on his or her own. The muscle to be stretched can be
energy techniques is the magnitude of force the doctor brought to a new barrier or may be extended beyond
applies relative to that produced by the patient when the new barrier. If more than one cycle of muscle en-
the muscle is contracted. There are three options: The ergy technique is used within one treatment session,
doctor’s force may match the patient’s, resulting in the techniques employ different waiting periods be-
no joint movement (i.e., an isometric contraction); tween cycles. Finally, for subsequent cycles of treat-
the doctor’s force overcomes the patient’s, producing ment, the muscle contraction can be initiated at the
movement in the opposite direction the patient is try- same range as the first treatment or it may occur at
ing to create (i.e., an eccentric contraction); and the the new barrier.79
doctor’s force is less than the patient’s, resulting in
movement in the direction the patient is trying to cre- Postisometric Relaxation (PIR)This method, developed
ate (e.g., a concentric contraction).79 by Karel Lewit, is typically used as a treatment for
Other variables include the point in the patient’s TrPs although it may also be used for joint dysfunc-
available range of motion in which the contraction tion or chronic muscle shortness.8,9,82,84 To perform
is initiated. The contraction can be initiated at the PIR, the clinician positions the patient so that the
soft tissue resistance barrier or at some lesser point muscle harboring the TrP or other barrier is under
in the patient’s range of motion. The percentage of the slight tension, but below the threshold of tension that
patient’s maximal effort that is used can vary from would exacerbate the patient’s pain. The patient ini-
maximal volitional effort to a barely perceptible con- tiates a very light contraction of the affected mus-
traction. Typically, contractions are 7–10 seconds in cle against the clinician’s resistance for 5 seconds.
duration. There can be a single contraction (which The patient then inhales and holds his or her breath
while continuing to contract for 5 more seconds. The til the barrier releases, and the slack is taken up until
patient then exhales slowly and relaxes the muscle. another barrier is reached. The pressure applied prob-
The load is expected to decrease as the displace- ably will cause the patient some discomfort, but one
ment increases. This can feel like the muscle’s resis- should be careful not to apply too much force and
tance is melting under the doctor’s resistance. Thus, precipitate pain. Simons et al. suggest reasons for in-
the clinician moves the patient to take up slack in effective trigger point pressure release: a TrP that is
the muscle. Care must be taken to just take up the too irritable to treat mechanically, the doctor uses too
new freedom of movement offered by the muscle and little or too much pressure, and the presence of per-
not to try to forcibly stretch the muscle. Subsequent petuating factors.9
cycles of PIR do not increase force.9,79 After the treat-
ment, the muscle should be moved through its com-
plete ROM (both shortened and lengthened). In addi- Stretch and Spray Stretch and spray is a manual tech-
tion, moist heat applications minimize posttreatment nique where a topical vapocoolant spray is used over a
soreness.9 TrP. The spray is passed along the muscle from the TrP
to its reference area. Following the spray, the doctor
Postfacilitation Stretching (PFS)Janda has described a provides a light force to stretch the muscle. It should
variation on muscle energy treatments intended to be noted that the operative part of the treatment is
specifically treat chronic muscle shortening.7,8 The believed to be the stretch and the spray is only a dis-
joint that is moved to stretch the involved muscle is traction. In other words, the cold is used to distract the
brought to the midrange of its available movement. nervous system from the pain produced by stretching
The patient then contracts the muscle isometrically for of the muscle that harbors the TrP, thus allowing the
7–10 seconds. The contraction utilizes maximal effort muscle to be stretched.
against the doctor’s resistance in a direction towards Note: The spray that is used is a fluorocarbon and
the barrier (direct technique). Then the patient relaxes as such is known to have a negative effect on the ozone
quickly, and the doctor performs a very rapid stretch layer. As a result, stretch and spray is being used less
until a new barrier is reached. The stretch is held for by clinicians in favor of the other techniques presented
10 seconds and then the joint is brought back to a po- herein.
sition of relaxation and held there for 20 seconds. This
treatment is typically repeated 3–5 times, each time Myofascial Release Techniques
starting at the midrange of motion.7,8 There are numerous methods that are called myofas-
cial release techniques (MRTs). A partial list can be
Trigger Point Pressure Release Trigger point pressure found in Table 41–6. These techniques may be sub-
release was formerly known as ischemic compres- classified by their purported effect. The “anatomical”
sion. However, it is not clear that ischemia is nec- techniques are thought to exert their effect primarily
essarily involved with the release of TrPs by man- through the skin and superficial connective tissues,
ual pressure, and Simons et al. recommend that the whereas the “mechanical” techniques seek to make
term ischemic compression be replaced by trigger mechanical, histological changes in the myofascial
point pressure release.9 The procedure is a treat- structures. Finally, the “movement” techniques are
ment where the clinician applies deep, firm, manual performed by having the clinician guide the patient
pressure directly over the TrP nodule or hypertonic
fibers, and holds the manual pressure for a speci-
fied period of time.9 In the chiropractic profession TABLE 41–6. Myofascial Release Techniques
this method is commonly known as Nimmo tech-
nique, named for the chiropractic pioneer who first Category Technique
developed the procedure. Raymond Nimmo actually
coined the name receptor tonus control method (RTCM) Anatomical Connective tissue massage
for his technique, but common usage of the term (Bindegewebsmassage)
Nimmo technique overshadowed his preference for Hoffa massage
RTCM.85 Mechanical Rolfing structural integration
Trigger point pressure release is a relatively simple Trager
treatment method. The examiner finds a TrP by palpat- Barnes myofascial release
ing the middle of a muscle. The muscle is lengthened Active release technique
within the patient’s comfortable range of motion. At Movement Alexander technique
this point, a slowly increasing amount of pressure is Feldenkrais method (awareness through
applied directly over the TrP until the doctor feels a movement and functional integration)
barrier to movement. The pressure is held steady un-
through a series of movements intended to change orized that transverse friction massage (TFM), where
aberrant patterns. massage is performed by placing a finger over a
painful or injured area in a tendon and moving the fin-
Active Release Technique Active release technique ger back and forth over that same area without lifting
(ART) is the myofascial technique perhaps most com- it from the skin, would speed healing by reducing the
monly used by members of the chiropractic profes- formation of scar tissue. He wrote that the transverse
sion. ART is a proprietary treatment method which direction would result in minimizing further injury
was initially introduced in the literature as myofas- that longitudinal massage would cause. Also, TFM
cial release techniques (MRTs).86–90 Leahy contends was thought to stimulate posttreatment hyperemia,
that ART is an effective treatment for cumulative in- which would speed healing.7 However, Stratford et al
jury disorders and peripheral nerve entrapments.11 It found that TFM was no better than ultrasound in treat-
is based on the principle that soft tissues are intended ing “tendonitis.”71
to glide smoothly between themselves and that with
overuse, “adhesions” are formed that impede this Graston Instrument-Assisted Soft
glide. ART is intended to remove the “adhesions,” Tissue Mobilization
thus allowing free movement between and within the A variation of TFM, Graston instrument-assisted soft
soft tissues. While these techniques are widely used tissue mobilization (GISTM) was developed in 1987
and growing in popularity, the published literature on by David Graston after finding that TFM was helpful
ART has been limited to opinion and case reports. for an injured knee. The stainless steel instruments
The method looks very similar to a technique were created to reduce stress on Graston’s thumbs
used in massage therapy called “pin and stretch.” (the contact point for the TFM). Basic science research
The adhesion is pinned under the doctor’s hand on GISTM has found that the technique increases
contact, starting with the trapped tissue in a short- the population of fibroblasts in the injured area and
ened position. The body is then moved through the quantity of collagen deposited.72,73 Gehlsen et al
a range of motion that lengthens (stretches) the found that extremely hard pressure results in sta-
trapped tissue as it is held under the doctor’s con- tistically greater numbers of fibroblasts when com-
tact. The body movement can be performed ei- pared to lighter pressure or surgical repair.73 Case re-
ther passively or actively. Passive movements are ports have suggested that GISTM might be effective in
preferred when there is extreme sensitivity or the treating ankle sprains,78 lateral epicondylitis,91 carpal
movement required is too complex for the patient tunnel syndrome, medial epicondylitis, wrist tendini-
to perform on his or her own. Active movements tis, rotator cuff injury,92 Achilles tendinitis, cervical
are preferred because they empower the patient, pain, and low back pain.93 Further, it is suggested
reduce the pain associated with the procedure, and that GISTM has been effective for myofascial pain
allow the doctor a second hand for treatment.11 syndromes, other tendinosis, and sprains.12 A typical
Leahy suggests the following guidelines to im- treatment begins with a cardiovascular warm-up to
prove clinical effectiveness.11 When the doctor “traps”
the “adhesion,” one should attempt to maximize the TABLE 41–7. Graston Instruments
contact area to allow for better penetration to deeper
tissues. The contact should be “soft hands” to allow
Instrument
the doctor’s hands to maximally conform to the pa-
Label Representative Uses
tient’s tissues. Adhesions impair the lengthening of
muscles and thus should be “broken up” with lon-
GT1 Evaluation and treatment of soft tissue
gitudinal pressure when trapping the “adhesions.” If
problems over large surface areas
at all possible, active rather than passive movement
GT2 Evaluation and treatment of convex-shaped
should be used. Treatment should emphasize slower
tissues
motion, which can decrease discomfort while allow-
GT3 Localizing and treating specific* soft
ing deeper penetration. Obviously, treatment must
tissue problems
be performed with sensitivity to the patient’s toler-
GT4 Evaluation and treatment of
ance as well as the tolerance of the tissue treated. At
concave-shaped tissues
least one day, if not more, should be allowed between
GT5 Evaluation and treatment of convex-shaped
treatments.
tissues
Transverse Friction Massage GT6 Evaluation and treatment of carpal tunnel,
digit, and specific soft tissue problems
Mennell first described friction massage in the 1940s.
James Cyriax then suggested that friction massage * Specific refers to a localized soft tissue problem identified with another
should be transverse to the tissue involved. He the- instrument.
increase blood flow. GISTM is then applied followed 4. Common muscle injuries include delayed onset
by high-repetition, low-weight exercises, stretches of muscle soreness, which appears 24 to 48 hours af-
the tissue treated, low-repetition, high-weight exer- ter strenuous exercise, is marked by tenderness on
cises, and cryotherapy.12 palpation, increased muscle stiffness and painful
There are six different Graston instruments (la- contraction, and stretching soreness, likely due to
beled GT1 to GT6) (Table 41–7), each with a different internal Z-band disruption, and is usually treated
shape to conform to different areas of the patient’s with massage, stretching, ice, and NSAIDs; mus-
body. GISTM is used both as a diagnostic method cle strains, which are most commonly caused by
as well as a treatment. A lubricant is placed on the a high-force eccentric contraction, typically caus-
patient’s skin over the region to be diagnosed and ing injury at the musculotendinous junction, and
treated. The instrument is glided over the skin with are treated with active release technique, trans-
moderate pressure. Areas of dysfunction, typically reverse friction massage, and Graston instrument-
ferred to as restrictions, can be felt through the instru- assisted soft tissue mobilization; tendinosis, which
ment. When restrictions are found, repeated strokes describes long-standing tendon degeneration in
of the instrument are used to treat the dysfunction. the absence of histological signs of inflammation,
develops secondary to chronic microtrauma, is di-
agnosed by pain and palpable tenderness in the
SUMMARY
appropriate area, and is treated with rest, reha-
1. Janda has grouped muscular dysfunction into five bilitation, cross-friction massage, soft tissue mobi-
broad categories: limbic system dysfunction, de- lization, or surgery after failed conservative treat-
scribed as lumbopelvic or upper thoracic and neck ment; and tendon rupture, which appears to be a
pain in combination with muscle spasm; reflex sequela to chronic tendinosis due to the degenera-
contracture, which often represents the body’s pro- tion that is characteristic of tendinosis, may be di-
tective response to joint trauma; interneuron dys- agnosed manually by palpating a rolled-up muscle
function, where localized muscle spasm is the re- belly, with advanced imaging, or through muscle
sult of joint dysfunction; muscle tightness, where strength or range-of-motion testing, and in severe
connective tissue shortens and the muscle spindle cases often requires surgical repair.
adapts to this shortened position; and myofascial 5. Ligaments are somewhat similar in structure to
trigger points, described as hyperirritable spots in tendons, are structurally weakened by immobi-
skeletal muscle associated with a hypersensitive lization, are strengthened by movement and exer-
palpable nodule in a taut band. cise, and are prone to traumatic tearing or rupture.
2. Direct causes of TrPs include: acute overload, over- Depending on the severity of injury, treatment may
work, fatigue, direct trauma, and chilling. Indirect consist of early mobilization, instrumented soft tis-
causes of TrPs include: visceral disease, arthritic sue mobilization, or surgery.
joints, and emotional distress. The diagnosis of 6. Commonly used muscle energy techniques in-
TrPs is made by finding tenderness at a nodule clude postisometric relaxation (PIR), which is typ-
in a palpable taut band. TrPs are usually treated ically used as a treatment for TrPs, where the
with some type of muscle stretching with various patient initiates a very light contraction of the af-
procedures used to facilitate the stretch (e.g., infected muscle against the clinician’s resistance for
termittent cold, postisometric relaxation, trigger 5 seconds, inhales and holds his or her breath
point pressure release). Other treatments include while continuing to contract for 5 more seconds,
trigger point injection and therapeutic ultrasound. exhales slowly and relaxes the muscle, and the
3. Wound healing can be divided into three distinct clinician increases the displacement as the mus-
phases: inflammation, which starts immediately af- cle relaxes; postfacilitation stretching (PFS), which
ter the injury and lasts up to 6 days, during which is intended to specifically treat chronic muscle
neutrophils, macrophages, monocytes, and lym- shortening, where the joint that is moved to
phocytes migrate to the wound site and degrade stretch the involved muscle is brought to the
damaged extracellular matrix and initiate prolif- midrange of its available movement, the patient
eration and maturation; proliferation, which starts contracts the muscle isometrically for 7–10 sec-
after 5 days and last 15–20 days, during which onds with maximal effort against the doctor in
endothelial cells, myofibroblasts, and fibroblasts a direction towards the barrier, the patient re-
accumulate at the wound site and secrete extra- laxes quickly, the doctor performs a very rapid
cellular matrix components to repair the collagen; stretch until a new barrier is reached and held
and maturation, which starts after 20 days and con- for 10 seconds, and then the joint is brought back
tinues for months, during which time the tensile to a position of relaxation and held there for
strength of new collagen increases. 20 seconds; trigger point pressure release, where the
clinician applies deep, firm, manual pressure di- 2. It feels like one is pushing against a portion of the
rectly over the TrP nodule or hypertonic fibers, and soft tissue that gets harder as one pushes.
holds the manual pressure for a specified period of 3. Graston stimulates fibroblasts to replicate and syn-
time; and stretch and spray, where a topical vapo- thesize more collagen.
coolant spray is passed along the muscle from the 4. Pain that is a dull, aching, often deep, and rarely
TrP to its reference area and following the spray, burning. Area of pain that is often not well lo-
the doctor provides a light force to stretch the calized. Occasionally it is sharp, lancinating, or
muscle. lightning-like stabs of pain, referred tenderness,
7. Commonly used myofascial release techniques in- referred muscle spasm, variable irritability, symp-
clude active release technique (ART), a proprietary toms from peripheral nerve entrapment (numb-
treatment method initially introduced as myofas- ness and tingling, hypoesthesia, and sometimes
cial release techniques (MRTs), which involves hyperesthesia), and autonomic phenomena.
pinning a muscular adhesion under the doctor’s 5. Tendinosis is the degeneration of tendon generally
hand contact, starting with the trapped tissue in a thought due to overuse that is commonly misdi-
shortened position, and then moving the related agnosed as an inflammatory tendinitis.
joint through a range of motion that lengthens
(stretches) the trapped tissue as it is held under the
doctor’s contact, either passively or actively; trans-
verse friction massage (TFM), which is performed by KEY REFERENCES
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C H A P T E R
42
TRACTION AND DISTRACTION
TECHNIQUES
James M. Cox and M. R. Gudavalli
O U T L I N E
INTRODUCTION Lumbar Spine Distraction Adjustment
Terminology Distraction Adjusting for Radiculopathy Patients
TRACTION AND DISTRACTION MANIPULATION Distraction Adjusting for the Nonradiculopathy
Techniques Patient
Static Traction Lumbar Spine Automated Axial Distraction
Manual Distraction for Nonradiculopathy Patients
Constant Continuous Traction Thoracic/Thoracolumbar Spine Automated Axial
Intermittent Traction Distraction
Gravity Traction Foramen Magnum Pump and Upper Thoracic Spine
Distraction Manipulation Technique
Effects of Traction Spondylolisthesis and Transitional Segment Patients
Indications for Spinal Traction and/or Distraction Side-Lying Manual or Automated Axial Distraction
Contraindications to Spinal Traction Adjustment
Background and Objectives Supine Distraction Technique Procedures
Role of Distraction Adjustments in Spinal Care LITERATURE REVIEW
Rationale Effects of Traction
Effects on the Spinal Unit Biomechanics of Low Back Flexion–Distraction
Application of Distraction Adjustments Therapy
Tolerance Testing Vertebral Motions During the Flexion–Distraction
—Cervical and Thoracic Spines Procedure
—Flexion of the Cervical Spine Dimensional Changes in Intervertebral Foramen
Lumbar Spine Tolerance Testing Loads on the Internal Tissues During
—Central the Flexion–Distraction Procedure
—Lateral Intradiscal Pressure Changes During
—Ankle Cuff the Flexion–Distraction Procedure
ADJUSTING PROCEDURES Intervertebral Disc Pressure Changes During Different
Cervical and Thoracic Spine Distraction Adjustment Table Motions
Axial Distraction Adjusting with or without Electromyographic Activity of Trunk Muscles During
Flexion Added Flexion–Distraction Treatment of Lower Back Pain
Procedures When No Radiculopathy Is Present SUMMARY
Thoracic Disc Herniation QUESTIONS
Upper Thoracic Spine Pain and Loss of Range of Motion ANSWERS
Rotation for Scoliosis of the Cervicothoracic Spine KEY REFERENCES
Foramen Magnum Pump REFERENCES
821
of common types of low back pain. These refer-

OBJECTIVES
ences were then evaluated and categorized by the
1. To provide an overview and historical context of expert panel for each procedure.3 Many, but not
the use of spinal traction. all, of these clinical trials and several review pa-
2. To give definitions and describe subcategories of pers have come to the conclusion that manipulation
the various forms of traction. is safe and effective for the treatment of low back
3. To review the role of distraction-aided manipula- pain.
tion in spinal complaints.
4. To review some of the proposed effects of Terminology
flexion/distraction-aided spinal manipulation. The terms spinal manipulation and adjustment have
5. To review the concept of tolerance testing. been defined as the skillful or dexterous treatment
6. To review some of the treatment protocols using whereby a corrective force or passive movement of
distraction-assisted manipulation for the cervical, the joint is made to realign vertebrae or articulations
thoracic, and lumbar spine. to their normal juxtaposition.4 For the purpose of this
7. To review the literature regarding the proposed discussion, traction refers to the use of an unassisted
effects of traction. multilevel traction force applied to the spine. Distrac-
8. To review results of biomechanical studies of tion refers to a doctor-controlled traction force applied
flexion–distraction technique. to a specific level of the spine. Distraction adjusting in-
volves a combination of passive movement of a spinal
joint while under a doctor-controlled traction force.
INTRODUCTION The purpose of this procedure is to restore normal
joint positioning and motion.
Over the past 50 years, spinal manipulation has been
equated with the practice of chiropractic. It has been
stated that 94% of all manipulative therapy proce- TRACTION AND DISTRACTION MANIPULATION
dures in the United States are performed by doctors
of chiropractic,1 and that chiropractic represents the Traction is not a new or novel adjunct to spinal ma-
most rapidly growing segment of the professional nipulation. It has been described in the works of
health care services market.2 The rising credibility of Hippocrates,5 and by a French surgeon in the fif-
the chiropractic profession, as well as changing atti- teenth century.6 Hippocrates may have been one of
tudes among health care providers, has been accom- the first to apply combined traction and spinal ma-
panied by an increased use of chiropractic services, nipulation (Fig. 42–1).7,8 However, the application of
particularly spinal manipulation. traction with the inclusion of joint manipulation, de-
Along with the growing interest in and use of ma- scribed in this chapter, has a relatively short history.
nipulation has come an increasing demand for re- This chapter focuses on the history, methods, and re-
search and investigation into manipulation. The most search findings of distraction adjustments and the me-
frequently studied chiropractic adjustive procedures, chanical changes in the spine that occur when these
according to a recent expert panel that rated references procedures are administered.
in the medical and chiropractic literature, are side-
Techniques
posture, high-velocity low-amplitude (HVLA) thrust
techniques, distraction (mostly flexion–distraction), There are a wide variety of traction procedures de-
and mobilization. This panel looked for clinical tri- scribed in the literature. Some, such as the traction
als, case series, and case reports on the treatment applied to broken bones, enjoy common use. Others,
FIGURE 42–1. Hippocrates ap-

plying a spinal adjustment. (From
Lind G. Auto-traction. Treatment of low
back pain and sciatica. Thesis, University
of Linkoping, 1974:26.)
TRACTION AND DISTRACTION TECHNIQUES 823
such as gravity traction, are much less commonly seen • Separation of the vertebral bodies with enlarge-
in clinical application. ment of the intervertebral space, producing a suc-
tion effect within the disc.
Static Traction In this form, shorter periods of traction • Stretching of muscles, with the tautening of the
are combined with relatively higher weights (traction posterior longitudinal ligament, exerting a cen-
forces). These forces are typically applied for a pe- tripetal force on the adjacent annulus fibrosus.
riod of time ranging from a few minutes to as long as • Separation of the apophyseal joints.
30 minutes. Split tables are most effective and help to • Enlargement of the intervertebral foramina.12
reduce friction between the patient and the table. • Suction force on the disc. A subatmospheric pres-
sure is induced when the bones move apart, with a
centripetal force on the contents of the inner disc.13
Manual Distraction The doctor applies the traction
force in a controlled fashion. This can be done by hand
Traction
Indications for Spinal Traction and/or Distraction
or with a movable, sectioned manipulation table that
and/or distraction has been recommended, based pri-
allows all ranges of motion to be applied to a specific
marily on clinical experience of practitioners that use
joint.
this technique, as the initial manipulative treatment
in the following conditions:
Constant Continuous Traction Low weights are used to
apply traction over a long period of up to several • Degenerative disc disease
hours. The main objective is to attain a restful and • Facet hyperextension subluxation with facet tele-
sustained position of the spine. scoping of the superior facet of the inferior verte-
bra into the foramen
Intermittent TractionThe traction force is applied and • Stenosis in which the lateral recess is narrowed by
withdrawn repetitively for relatively short periods. hypertrophic facet arthrosis
Both manual and/or mechanized methods may be • Spondylolisthesis
used. Coplans has suggested the use of 12 rhythmic • Transitional segment
distractions per minute for 10 minutes using a 30– • Retrolisthesis subluxation
40-kg (66–88-lb) traction force.9 The patient is posi-
tioned with the knees and hips supported in flexion Traction has also been used in the case of interver-
to abolish the lumbar lordosis and to increase the ef- tebral disc herniation based on literature suggesting
ficiency of traction being used. that intradiscal pressure drops under traction as is de-
scribed later in this chapter in the section Intradiscal
Pressure Changes During the Flexion–Distraction Proce-
Gravity Traction Traction is applied by inverting the pa-
dure. The theory is that this decrease in pressure needs
tient with gravity boots, by flexion at the waist over
to be maintained only for a short period of time, as
a specific device, or by means of a chest harness. This
osmotic forces will soon equalize pressure with that
last system, called gravity lumbar reduction, is re-
of the surrounding tissue. When this equalization oc-
ported to reduce symptoms in 70% of patients with
curs, the suction effect is diminished or lost and the
protruding lumbar discs without surgical reduction.10
continuation of distraction could theoretically have a
It has also been used for lumbosacral strain, mechan-
detrimental effect. Saunders noted that when treat-
ical back syndromes, spondylolisthesis, scoliosis, lat-
ment time is kept under 10 minutes and sustained
eral recess stenosis, and postsurgical management of
treatments under 8 minutes, this adverse change is
patients with residual pain.
not observed.14
An average weight of 16 kg (35 lb) with about
Distraction Manipulation Manually controlled distrac- 30 degrees of flexion of the cervical spine is generally
tion is applied to the intervertebral disc space and ar- recommended when the patient’s symptoms are very
ticular facets while the patient is positioned on a table severe. Less than 13.6 kg (30 lb) is ineffective, whereas
that is specifically designed for this application. The more than 18 kg (40 lb) may irritate nerve roots. The
facet articulations are manipulated throughout their traction force is usually applied and ended gradually,
physiologic ranges of motion as distraction is applied with no jerky movements, starting with a force of 9–
to a specific spine level. It has been demonstrated that 11.3 kg (20–25 lb) and increasing the weight to patient
approximately 5% of patients cannot tolerate distrac- tolerance.13
tive manipulation.10,11 After distraction or traction, the vertical height
and sagittal diameter of the intervertebral foramina
Traction has been reported to accom-
Effects of Traction theoretically will increase in size. In this position,
plish the following spinal changes: the other motions of the facet joints, namely, lateral
flexion, circumduction, rotation, and extension, can and flexion motions at the intervertebral joint of inter-
then be applied. Application of distraction to the facet est. It has been hypothesized that during this proce-
joints initially should allow the other facet motions dure intradiscal pressures decrease, thereby provid-
to be carried out without danger of inflicting lateral ing an opportunity for a disc protrusion to reduce.
recess stenosis by invasion of the superior facet of Studies supporting this theory have been carried out
the inferior vertebra upward and anteriorly into the to measure the changes within the intervertebral disc
foramen. of the lumbar spine in unembalmed cadavers dur-
Spinal traction and distraction have been recom- ing this procedure and are presented at the end of
mended when rotational manipulation has failed to this chapter (see Intradiscal Pressure Changes During
relieve pain; when there has been postsurgical return the Flexion–Distraction Procedure). It is theorized that
of pain or failure to gain relief from surgery; in patients distraction adjusting has the following benefits:17
with degenerative disc disease, with or without nerve
root irritation; where relaxation of paravertebral mus- • It increases the intervertebral disc height and re-
cles is desired; and when there is a need to increase moves annular distortion within the pain-sensitive
the vertical and sagittal diameters of the intervertebral peripheral portion of the disc. The annulus fibro-
foramina to reduce nerve root compression forces.15,16 sus bulges into the concave side or the posterior
lordotic curve of the lumbar spine, and distraction
Contraindications to Spinal Traction As with any other under slight traction is thought to reduce this pro-
form of treatment, the use of traction is associated with trusion.
some element of risk. Consequently, it should only be • It decreases intradiscal pressure with the creation
used upon careful selection of patients that includes of a centripetal force on the protruding nucleus
an adequate case history, appropriate physical exam- pulposus, thus allowing the nucleus pulposus to
ination, and any needed radiographic imaging. The assume its more central position within the annu-
following conditions are considered to be contraindi- lus fibrosus.
cations to the use of spinal traction: • It removes subluxation of the facet articulations
and restores physiological motion to the posterior
• Acute trauma to soft tissues elements of the vertebral motion segment.
• Fracture • It improves posture and locomotion while reliev-
• Tumor (primary or metastatic) ing pain, improving body function, and restoring
• Infection (spondylitis or osteomyelitis) a state of well-being.
• Vertebrobasilar or carotid artery ischemia
• Rheumatoid arthritis with instability of the upper
cervical spine Role of Distraction Adjustments in Spinal Care
• Acute sprains and strains Degenerative disc disease increases weight bear-
• Claustrophobia from being placed in ankle cuffs ing on the facet joints, resulting in impaired facet
or a pelvic harness joint function and degenerative osteoarthrosis of the
• Aortic aneurysm zygapophyses.18,19 Hypertrophic vertebral endplate
• Temporomandibular joint disease disc disease is associated with stenosis of the verte-
bral and osseoligamentous canals (intervertebral fora-
It should also be pointed out that systemic blood men), with resultant compromise of the cauda equina
pressure will often increase during lumbar traction; and its exiting nerve roots. Distraction of the lum-
consequently, patients who are hypertensive should bar spine is thought to establish patency of the ver-
be monitored for any adverse effects. tebral and osseoligamentous canals by increasing the
height of the intervertebral disc space, decreasing disc
Background and Objectives As mentioned previously, protrusion, and opening the lateral recesses of the
the use of flexion–distraction in combination with vertebral canal while placing distension on the facet
manual manipulation is one of the most commonly joints.20 It is our opinion that adjusting facet joints
used techniques in chiropractic practice. These pro- by placing them through their physiological ranges of
cedures are often referred to as Cox distraction ad- motion while distraction is applied to the spine de-
justing when used with a specific adjusting table (i.e., creases the chance of inflicting foraminal narrowing
the Cox table). These methods are used primarily by when other physiological ranges of motion of lateral
chiropractic physicians in the treatment of low back flexion and rotation movements are employed.
and leg pain, and in patients with cervical complaints. A vertebral motion segment (disc and facet articu-
The Cox distraction adjusting procedure consists of lations) must function within its physiological ranges
placing the patient in a prone position on a flexion– of motion (flexion, extension, lateral flexion, circum-
distraction instrument and then creating distraction duction, and rotation) to be considered a normal
articulation. Because a healthy spine is strong and a. Make a diagnosis.

flexible, and a painful back is often weak and rigid, b. Restore normal mobility.
the ultimate goal in the treatment of low back pain c. Relax or stretch extraneous structures.
is to regain the normal physiological ranges of joint d. Restore mobility by passive movements to in-
movement. Manipulating lumbar facet joints through trinsic structures by slow and rhythmical meth-
their physiological ranges of motion, under distrac- ods rather than sharp quick movements (i.e.,
tion, may assist in regaining normal mobility of the long-lever techniques).
motion segment, and thereby the spine as a whole. e. Use indirect specific adjustments to restore mo-
Regardless of the nature of the specific low back bility.
pain condition, distraction adjusting to increase spinal f. Use a specific thrust to alter the relationship of
flexibility coupled with strengthening the muscles one vertebra with the one above and below.
of the abdomen, low back, and lower extremities is g. Use the minimum amount of force consistent
desirable.21 with achieving your objective. Undue force is
negative.
Rationale The use of distraction adjusting can be 4. The osteopathic lesion has been defined as any
traced to the osteopathic profession and the work of structural disturbance with consequent functional
McManis as described by Stoddard.22 A number of deflection. An osteopathic lesion is also defined as
reasons to consider distraction have been discussed any departure from the normal relation of skeletal
in the osteopathic literature: units that affects function detrimentally through
limitation of articular motion.22
1. It is assumed that distraction ensures adequate ve- 5. The purpose of traction adjusting is either the repo-
nous drainage in the vertebral column and that sitioning of a herniated disc or the realignment of
all the intervertebral joints should be freely move- adjacent vertebral bodies.22
able. Any restriction of movement (the most im-
portant quality of the osteopathic spinal lesion) Figure 42–2 summarizes the proposed benefits of
in the spinal column is expected to slow venous distraction of the lumbar spine.20
drainage in that area.
2. It has been suggested that the adjustment of po- Effects on the Spinal Unit Figure 42–3 summarizes the
sition, the freeing of longitudinal adhesions, the theoretical physiological and therapeutic effects of ap-
relief of nerve root pressure, the separation of plying a flexion–distraction adjustment to the lumbar
apophyseal joints, and the obtaining of a circu- spine. These effects are described as follows:
latory effect have the ability to decongest the
intervertebral foramen and reduce the hydrostatic • The posterior disc space increases in height.20,23–25
pressure inside the disc. • Flexion decreases disc protrusion and reduces
3. Stoddard stated principles of osteopathic tech- stenosis.20,23,24,26 Note: Discs protrude and degen-
nique as follows22 : erate into the concavity of a curve, into the side
FIGURE 42–2. A. MDP and left lateral prolapse at L4-L5 accompanied by invasion of the neural foramen by HNM. B. During
traction: regression of HNM from the discal space and withdrawal of HNM from neural foramen. (Reproduced by permission from Onel
P, et al. Computed tomographic investigation of the effect of traction on lumbar disc herniation. Spine 1989;14(1):86.)
FIGURE 42–3. Theoretical physiological and therapeutic ef-

fects of applying a flexion–distraction adjustment to the lumbar
spine. FIGURE 42–4. Tolerance testing for axial distraction of the
cervical and thoracic spines.
of extension,27 and thus the need to reduce lum-
bar lordosis to reduce disc protrusions and reduce
spinal stenosis. head is then moved cephalad on the table headpiece
• Flexion stretches the ligamentum flavum to reduce as the doctor stabilizes the vertebra. This applies long
stenosis.20,24 axis distraction to the segment using only the weight
• Flexion opens the vertebral canal by 2 mm (16%) of the patient’s head. The doctor can also contact the
or 3.5–6 mm more than extension.28,29 posterior arch of the vertebra above the level to be tol-
• Flexion increases metabolite transport into the erance tested and apply cephalad traction with his or
disc.30 her hand as the floating headpiece is moved cepha-
• Flexion opens the apophyseal joints and reduces lad. The patient is asked to report any sign of arm dis-
posterior disc stress.30,31 comfort, pain in the spine or spasm, of paravertebral
• The nucleus pulposus does not move during muscles (Fig. 42–4).
flexion.32 Intradiscal pressure drops under distrac-
tion to below 100 mmHg.23,33 On extension the Flexion of the Cervical Spine The testing procedure for
nucleus or annulus is seen to protrude posterior flexion tolerance is applied in a similar manner as is
into the vertebral canal.26,34–36 done for axial distraction. The patient is asked to re-
• Intervertebral foraminal openings enlarge, pro- port any sign of arm discomfort or pain in the spine
ducing patency for the nerve roots.31 or spasm of paravertebral muscles.
The procedure demonstrated in Figure 42–4
should be repeated with the occipital restraint in place
Application of Distraction Adjustments to determine patient tolerance. Lateralization of pain
Tolerance Testing Prior to the application of distraction into the upper extremity or discomfort at any spine
adjusting, patient tolerance to the procedure needs to area or paravertebral muscles or ligaments indicates
be tested. This need not be done with every treatment, an aggravation of the condition and the need to reduce
but is necessary prior to first adjusting the patient amplitude and/or duration. The technique should al-
and at any time a new procedure is added. For tol- ways be applied below the level of patient tolerance.
erance testing of the cervical spine, place the patient For example, if there is no pain when using the head as
in a prone position with the C5-C6 level of the spine at a traction force while the doctor contacts the spinous
the opening between the cervical and thoracic section process, but use of the occipital lift assist aggravates
of the instrument. Tolerance testing for the lumbar the patient’s complaint or creates a new pain, the doc-
spine is performed with the patient in a prone posi- tor should start with treatment and not use the oc-
tion, with the anterior superior iliac spines positioned cipital lift assist until such time as it does not cause
on the lower two inches of the thoracic cushion. Ankle discomfort to tolerance testing.
rests should be properly placed for patient comfort. Lateral flexion, circumduction, rotation, and ex-
tension motions of the cervical spine are tested for
The doctor’s hand should
Cervical and Thoracic Spines tolerance by slowly performing these maneuvers and
be used to stabilize the posterior arch inferior to the asking the patient if he or she feels pain. The treat-
spinal segment to be tested for tolerance. The patient’s ment is applied well below any amount of motion or
distraction that causes any pain or muscle irritation • When using the headpiece, the doctor should con-
for the patient. trol the amplitude, frequency, and time of spinal
adjustment, always treating within patient toler-
ance as noted during tolerance testing. Discom-
Lumbar Spine Tolerance Testing
fort at any spine level during distraction adjusting
Central The weight of the patient’s legs is used as the
of the cervical spine necessitates lesser degrees of
traction force when testing tolerance in the lumbar
distraction until no discomfort is felt.
spine. The caudal piece of the table is moved down-
• Long-axis distraction can be applied alone or com-
ward 2 inches while under distraction and held for
bined with flexion, lateral flexion, circumduction,
4 seconds. The doctor’s hand stabilizes the spinous
rotation, and extension motions of the cervical
process above the disc and facet joints being tested
spine.
for tolerance. The patient is asked to report any sign
• Occipital lift assist use should be guided by doctor
of leg discomfort or pain in the spine or paravertebral
preference and the results of tolerance testing.
muscles. All levels of the spine to be treated should be
• The headpiece can be used to apply axial dis-
tolerance tested.
traction with or without the range-of-motion ad-
justment procedures of flexion, extension, lateral
Lateral As the doctor holds the patient’s ankle, axial flexion, rotation, and circumduction. This can be
flexion distraction is applied with 2 inches of down- accomplished by using either a free-floating head-
ward table movement in order to test lateral tolerance. piece (the doctor moves the headpiece as it applies
This position is held for 4 seconds and the patient is distraction) or by using a fixed headpiece (axial
asked to report any sign of leg discomfort or pain in distraction of the headpiece is fixed as the doc-
the spine or paravertebral muscles. Tenderness un- tor applies distraction coupled with flexion, lateral
der the doctor’s contact hand at the spinous process flexion, circumduction, rotation, or extension).
is common and requires a contact with light enough
pressure so as to minimize any discomfort. Again, all
levels to be treated are tested. Axial Distraction Adjusting with
or without Flexion Added
Ankle Cuff With the cuffs on the patient’s ankles, the A herniated cervical disc or stenosis as a result of bony
doctor should palpate tightening of the posterior mus- hypertrophy of the foramen is commonly present in
cles and ligaments of the spinal segment being tested the patient presenting with radiculopathy. Only axial
as the axial distraction is applied with 2 inches of distraction with or without flexion added should be
downward table movement and held for 4 seconds. used in treating the patient with radiculopathy. Ax-
The doctor asks the patient to report any sign of leg ial distraction can be applied using the weight of the
or spine discomfort. Again, tenderness at the spinous head as the sole traction force, with the doctor con-
process contact may be present and necessitate a tacting the posterior arch of each vertebra. It may also
lighter contact for patient comfort. As with the cervical be applied with doctor-assisted cephalad contact on
spine, lateralization of pain into the lower extremity the spinous process at the level of desired spinal seg-
or increase of pain at the spine or paravertebral level ment distraction, or with the occipital lift assist in
muscles or ligaments indicates an aggravation of the place. The patient’s response to tolerance testing for
condition and the technique needs to be applied at each of these procedures dictates which application is
a lesser amplitude and/or duration to ensure patient used.
comfort. For example, if there is no pain when using Flexion can be added to the cervical spine as tol-
the lower extremities as a traction force when the doc- erated by the patient. The flexion angle applied is the
tor contacts the spinous process, but the use of the angle that relieves, and does not aggravate, patient
ankle cuffs aggravates the patient’s pain, the doctor symptoms, and may be preset or added simultane-
should start without the ankle cuff stretch assist until ously with axial distraction. The occipital lift assist is
such time as it does not cause discomfort to tolerance used providing the patient feels no discomfort when
testing. tolerance testing is performed. Flexion alone, or with
axial distraction, may be the best adjustment setup for
some patients. The doctor determines the flexion and
ADJUSTING PROCEDURES axial distraction degree by a combination of patient
comfort and symptom response. Once again, the pa-
Cervical and Thoracic Spine tient’s response to tolerance testing directs application
Distraction Adjustment of the technique. Figure 42–5 shows the angle of axial
The following summary of facts is important in cervi- and flexion distraction with the occipital restraint in
cal spine distraction adjusting: place.
FIGURE 42–6. Applied lateral flexion.

FIGURE 42–5. The angle of axial flexion and distraction with
occipital restraint in place. to be adjusted. As an example, if the C6 posterior arch
is contacted, the C5-C6 facet joints will be adjusted in
Three sets of 20-second distraction sessions are ap- this manner.
plied to the patient with radicular symptoms. Each Circumduction is applied by coupling the motions
20-second session consists of five 4-second periods of of axial flexion and lateral flexion, starting from the
combined distraction–flexion motions to the involved neutral horizontal axis and moving the facets through
spinal level. the range of motion that is comfortable and slightly
beyond the taut point or elastic resistance of the joint
Procedures When No Radiculopathy Is Present capsule. Cavitation of the facet joints may be felt or
heard in these movements. Figure 42–6 illustrates the
Patients with neck pain, with or without shoulder and
combined flexion and lateral flexion motion for this
upper arm discomfort that is not dermatomal in na-
application.
ture, are treated with distraction adjustment of the
Rotation is applied by contacting the posterior arch
intervertebral disc and facet joints at single or mul-
below the spinal segment to be adjusted; that is, while
tiple levels of the cervical or thoracic spine. The in-
rotating the C5-C6 facet joints, the C6 arch is contacted
dications for this procedure are pain in the cervical
and stabilized. Axial distraction with or without flex-
and thoracic spine caused by degenerative disc dis-
ion added is then applied, followed by a rotational
ease, facet subluxation, or facet arthrosis; mechanical
motion.
spinal pain or stiffness; pain or difficulty in applying
Extension is applied by stabilizing the posterior
typical thrust adjustments; loss of range of motion;
arch of the vertebra below the spinal segment to be
whiplash-type injuries; headache; suboccipital tight-
adjusted; that is, while extending the C5 segment, sta-
ness; upper thoracic spine tightness; osteoporosis not
bilization of the C6 posterior arch is applied. Exten-
allowing HVLA thrust adjustment; certain postsurgi-
sion of the cervical spine is then performed by slowly
cal spines; some ankylosis patients; and patients who
bringing the headpiece into extension.
could benefit from relief of muscle spasm, adhesions,
Note: With all of the above ranges of motion, pa-
pain, or loss of mobility prior to applying other ad-
tient tolerance is tested prior to executing the move-
justment techniques.
ment. It should be emphasized that the doctor should
Axial distraction, alone or coupled with flexion, is
always follow the patient response to tolerance testing
administered to a specific cervical or thoracic vertebral
and treat below the level of pain.
segment. Axial distraction is performed as described
earlier, and can be coupled with flexion. Tolerance test-
ing is applied prior to using each adjustment proce- Thoracic Disc Herniation The same technique that is
dure, and the type and amount of axial distraction are used for cervical spine disc herniation is used in tho-
selected based on the results of these tests. racic disc herniation, including the use of tolerance
Lateral flexion is applied to a specific spinal level testing. Contact the posterior arch below the disc to
by first placing the segment into axial distraction be distracted; that is, when treating a T7-T8 disc her-
or axial flexion distraction, and while isolating the niation, the contact point is the posterior arch of T8.
segment in this position, lateral flexion is added Distraction is then applied for three 20-second pumps,
(Fig. 42–6). The doctor’s contact hand on the spine with each 20-second pumping adjustment consisting
will stabilize the motion segment below the segment of five 4-second pumping motion cycles (Fig. 42–7).
FIGURE 42–7. Distraction is applied with a pumping motion.
FIGURE 42–9. Procedure for foramen magnum pump.

Upper Thoracic Spine Pain and Loss of Range of Motion
In this situation, the upper four to six thoracic seg-
extremities and pelvis weight as the traction force
ments are laterally flexed while flexion and extension
(Fig. 42–9). The occipital restraint can also be used.
are applied as shown in Figure 42–8. This combined
The doctor can also contact specific spinal segments
adjustment procedure returns range of motion, re-
to produce axial distraction from that level. This is
lieves muscle tightness, and allows for the application
a relaxation-type distraction or preparation that may
of high-velocity low-amplitude thrust adjustments to
be helpful prior to the other adjustment procedures.
be given more easily. Experience suggests this is very
It may also be the only adjustment required for the
comforting for the patient with upper thoracic tight-
patient.
ness, headache, and shoulder pain.
Lumbar Spine Distraction Adjustment
The cer-
Rotation for Scoliosis of the Cervicothoracic Spine
vical headpiece rotates in an attempt to derotate the As with the cervical and thoracic spine, patient toler-
convex curve of a scoliosis. During this procedure, ax- ance testing must also be done in the lumbar spine. As
ial distraction with lateral flexion is administered into stated earlier, this need not be done at every treatment,
the convexity of the scoliotic curve. only prior to first adjusting the patient and any time
a new procedure is added. For tolerance testing of the
Foramen Magnum Pump In this procedure, contact with lumbar spine, the patient is placed in a prone position
the occiput is followed by axial distraction of the spine. with the anterior superior iliac spines positioned on
The doctor contacts the occiput to stabilize the head as the lower 2 inches of the thoracic cushion and ankle
long-axis distraction is applied through movement of rests properly placed for patient comfort.
the caudal section of the table. Automated distraction
Distraction Adjusting for
movement of the caudal table section uses the lower
Radiculopathy Patients
As in the case of the cervical spine, a herniated lum-
bar disc or bony hypertrophy stenosis of the forami-
nal nerve root opening is commonly involved in the
patient with low back pain and radiculopathy. Only
manually controlled axial flexion–distraction is used
in the early phase of treatment of these patients. No
automated axial distraction or range-of-motion ad-
justing is used in radicular patients until at least a 50%
relief of the patient’s radiculopathy has been achieved.
The patient is placed on the flexion–distraction ta-
ble as described above. Tolerance testing is carried out
and the technique is applied using only lower extrem-
ity weight as the traction force, with ankle-assisted
distraction, or with the ankle cuffs in place. The mode
FIGURE 42–8. Combined adjustment procedure for the tho- of distraction is dictated by tolerance testing as previ-
racic spine. ously described.
FIGURE 42–10. Application of distraction for the radiculopa- FIGURE 42–11. Lateral flexion is added to the adjustment
thy patient. procedure.
The spine is distracted until the doctor senses • Lateral flexion—This is applied to a specific
that the interspinous space and paravertebral mus- spinal level by first placing the segment into
cles are taut. This is the treatment position from which flexion–distraction, and then adding lateral flexion
flexion–distraction will be applied to the posterior (Fig. 42–11). The doctor’s contact hand is on the
arch and disc. Next, the spinous process is contacted spinous process above the motion segment to be
with a thenar or an index–thumb contact above the placed into flexion–distraction; that is, if the L5
disc to be distracted and/or flexed. Three 20-second posterior arch is contacted, the L5-S1 facet joints
distraction–flexion sessions are given to the level will be adjusted into lateral flexion.
of disc herniation or stenosis. During each 20-second • Circumduction—This is applied by coupling the
period, five 4-second pumping actions are applied to motions of flexion and lateral flexion, starting from
the interspinous space (Fig. 42–10). Patient tolerance the neutral horizontal axis and moving the facets
is constantly monitored. through the range of motion that is comfortable
Flexion is applied to the lumbar spine as toler- and slightly beyond the taut point of elastic resis-
ated by the patient. The angle of flexion used is the tance of the joint capsule. Cavitation of the facets
one that relieves and does not aggravate the patient’s may be felt and/or heard in these movements. This
symptoms. It should not exceed 2 inches of down- uses the same application as that for lateral flexion,
ward movement of the caudal section of the flexion– with the exception that the motions of flexion and
distraction table (this is measured as 2–6 degrees of lateral flexion are coupled in a smooth motion in
motion). circumduction (lateral flexion is performed under
static flexion).
Distraction Adjusting for the Nonradiculopathy • Extension—This is applied by stabilizing the pos-
Patient terior arch of the vertebra below the level to be
When treating patients without radicular pain, the adjusted; that is, if extending the L5 segment, sta-
facet joints of the lumbar spine are placed through bilization of the S1 posterior arch is applied. Exten-
physiological ranges of motion as tolerated by mo- sion of the lumbar spine is performed by slowly
tion palpation testing. The patient is placed on the bringing the caudal section into extension as pa-
flexion–distraction table as described earlier and tol- tient tolerance is monitored.
erance tested for each range of motion to be applied.
The following motions can be applied manually or Lumbar Spine Automated Axial Distraction
with automated distraction: for Nonradiculopathy Patients
Tolerance testing is done prior to applying each range
• Flexion—Contact the spinous process with a thenar of motion. This technique can replace manual flexion–
or thumb–index contact above the motion seg- distraction providing tolerance testing is negative.
ment to be flexed. The spinal segment is brought Automated axial distraction is applied to the spine as
to tension and flexion–distraction is applied from the facet joints are placed through their physiological
this taut point at approximately one repetition per ranges of motion (see Fig. 42–11). Automated distrac-
second until flexion increases the opening of the tion is operated from the switch on the bar that the
spinal segment as felt by the doctor’s contact hand. doctor’s hand is contacting.
FIGURE 42–12. Application of an HVLA thrust. FIGURE 42–13. Foramen magnum pump and upper thoracic
technique.
Thoracic/Thoracolumbar Spine Automated

patient’s occiput or upper thoracic spinous processes
Axial Distraction
cephalad as the caudal section of the instrument is
The thoracic and thoracolumbar spines can be ad- either manually or mechanically distracted. This ap-
justed using the automated axial distraction tech- plies a gentle, full distraction to the spine and relieves
nique. In patients who are difficult to adjust with tension, muscle tautness and suboccipital and upper
HVLA techniques, or in patients who don’t tolerate thoracic spine tightness. This allows the chiropractic
such methods, automated axial distraction is a tech- adjustment to be given with greater ease for the doctor
nique that may be used to regain flexibility and obtain and less discomfort for the patient. It can be applied
relief of pain. Candidates for this procedure include at each level of the thoracic or cervical spine, as well
patients with such conditions as disc degeneration, as at the occiput.
facet arthritis, osteoporosis, ankylosis of the spine as
in diffuse idiopathic skeletal hyperostosis or ankylos- Spondylolisthesis and Transitional
ing spondylitis, rib calcification, healed compression Segment Patients
fracture, bypass surgery, and surgical fusion, as well These patients may or may not have radiculopathy.
as any patient who cannot or will not tolerate a more Regardless, they are treated as any other patient con-
vigorous HVLA adjustment. dition except that the doctor’s contact hand will be
Figure 42–12 shows the patient receiving a thoracic on the spinous process of the segment above the level
adjustment as axial distraction is administered to the of spondylolisthesis or transitional segment. If it is
spine with the cuffs on the patient’s ankles. The doctor an L5 spondylolisthesis or transitional segment, the
makes the usual adjustment setup for HVLA adjust- doctor will contact the spinous process of L4 as the
ment, but instead of thrusting on the motion segment, distraction procedure is administered. The treatment
the doctor allows the table to distract the spine under of radiculopathy or nonradiculopathy patients with
this contact until tissue elasticity is felt and movement these two conditions is performed as with other treat-
into the paraphysiological zone of the facet joints oc- ments; that is, tolerance testing and manual or au-
curs. Cavitation of the joint may be heard or felt with tomated axial distraction with ranges of motion are
this procedure. If no cavitation is felt, a gentle HVLA given as outlined under the treatment of radicular (see
thrust can be applied, at which point cavitation may Distraction Adjusting for Radiculopathy Patients above)
be felt or heard. and nonradicular patient conditions (see Distraction
The doctor’s hand contact is applied at one or Adjusting for Nonradiculopathy Patients above).
several levels of the thoracic or thoracolumbar spine
where the adjustment is to be delivered. This tech- Side-Lying Manual or Automated Axial
nique may be useful in treating the thoracolumbar Distraction Adjustment
spine where the classic HVLA thrust adjustment is
Patients are sometimes in too much pain to lie prone
very uncomfortable.
for distraction adjusting. Conditions causing this pain
include acute sprain/strain, annular tears of the lum-
Foramen Magnum Pump and Upper Thoracic bar spine disc, acute disc herniation (contained or non-
Spine Technique contained), sciatic scoliosis, pregnancy, scoliosis, com-
Figure 42–13 shows the foramen magnum pump pression fracture, hyperlordosis, hyperkyphosis, facet
distraction technique. The doctor’s hand lifts the imbrication, spinal stenosis, heart or lung diseases that
FIGURE 42–14. Side-lying flexion–distraction adjustment. FIGURE 42–15. Treatment of scoliosis.
interfere with breathing or prone posture, and some also be used for treatment during pregnancy to avoid
patients’ preference to not lie prone. pressure on the abdomen.
Figure 42–14 shows flexion distraction applied to
the spine for a herniated lumbar disc or spinal stenosis Supine Distraction Technique Procedures
causing radicular pain. Here, the lateral flexion move- In some patients with hyperkyphosis, scoliosis, and
ment of the instrument provides the flexion distrac- healed compression fractures, distraction performed
tion while the doctor’s contacting fingers control the with the patient lying supine on the instrument with
interspinous pressure. The three 20-second distraction the thoracolumbar spine on the thoracic middle sec-
sessions, each consisting of five 4-second pumping tion yields pain relief and increases ranges of motion.
motions, can then be applied in this manner. Here, gentle extension and axial distraction can be ap-
Automated axial distraction is applied to the lum- plied to the spine to treat hyperkyphosis of compres-
bar motion segments. The doctor’s index finger or sion defects (Fig. 42–16). The patient’s tolerance to the
thumb–index finger contact is made on the spinous procedure should be carefully monitored. Lateral flex-
process above the disc and facet motion segment to ion can be used with or without axial distraction for
be adjusted, and stabilization of the motion segment treating a scoliotic spine in this procedure.
is maintained as the caudal section of the instrument
moves into axial distraction.
Lateral flexion and circumduction can be applied LITERATURE REVIEW
in this side-posture position by using the flexion and
Effects of Traction
extension motions of the caudal section of the table.
Extension of the lumbar spine is executed as the Several studies have investigated the effects of the var-
doctor’s fingers apply posteroanterior pressure on the ious forms of traction. Static traction, intermittent trac-
spinous process at the spine level to be extended. Slow tion, manual traction, and no traction were compared
extension is applied as the doctor stabilizes the spine in 100 patients with cervical spine disorders. The
and patient tolerance is constantly monitored. This
technique can be helpful for treating flexion defor-
mity from compression fracture, hyperkyphosis of the
sagittal lumbar curve, and anterior disc herniation.
Figure 42–15 shows the method of approaching
scoliosis through distraction. The convexity of the sco-
liosis curve is placed down on the table and the caudal
section of the instrument is flexed into the convexity
of the scoliosis. The doctor lifts the patient’s convex
scoliotic curve with the palpating fingers as the scoli-
otic curve is laterally flexed into the convexity of the
curve. Axial distraction can be applied in the posi-
tion of reduced convexity of the scoliotic curve. Side-
lying scoliosis distraction adjusting allows a smoother
stretching of the spine with greater convex reduction
than prone adjusting. The side-lying techniques may FIGURE 42–16. Supine distraction adjustment.
patients, all of similar age, sex, diagnosis, and chronic- tradiscal pressure can be maintained for 3 months.
ity, were randomly assigned to one of the four treat- Clinical experience shows that it takes approximately
ment types, and scheduled for two weekly visits over a 3 months until a patient can carry out the activities of
6-week period. Intermittent traction patients per- daily living without danger of recurrence.49
formed significantly better than those assigned to no Despite the widespread use of traction, some sug-
traction or static traction in terms of pain, flexion, and gest that little is known of the about its effects, and clin-
rotation movements.37 ical support remains largely anecdotal. The efficacy of
It is important to increase the disc space in the treat- traction is unclear because of generally poor design of
ment of disc disease. The kyphotic posture created by the clinical trials to date, and because subgroups of pa-
traction is thought to allow a decrease in nerve root tients most likely to benefit have not been specifically
pressure by improving blood flow through the veins studied. Traction has, however, been shown to sepa-
of the spine and by absorbing edema fluids. Further- rate the vertebrae and it appears that large forces are
more, by reducing intradiscal pressure, the protruded not required. Vertebral separation could potentially
disc may have a tendency to return to its original lo- provide relief from radicular symptoms by removing
cation. In addition to any effect on the disc, it has direct pressure or contact forces from sensitized neu-
been proposed that elongation of paravertebral mus- ral tissue. Recent research on mechanisms proposed
cles and ligaments may relieve spasm and pressure to explain the effects of traction such as the reduction
on nerves and blood vessels.38 However, Jette et al. of disc protrusion or altered intradiscal pressure has
evaluated the ability of 20 minutes of intermittent been unable to confirm these effects.50 These authors
supine traction to produce muscle relaxation of the conclude that traction is most likely to benefit patients
cervical spine.39 They found no change in myoelectric with acute (less than 6 weeks’ duration) radicular pain
activity of the upper trapezius muscle and concluded with concomitant neurological deficit. The apparent
that supine traction did not produce cervical muscle lack of a dose–response relationship suggests that low
relaxation. doses are probably sufficient to achieve benefit.
Traction stretches the back so that vertebrae are The Cottrell 90/90 Backtrac System flattens the
pulled away from each other, and radiographic stud- lumbar spine and reduces the lumbar curve to elon-
ies suggest that spinal traction is capable of distracting gate the lumbar intervertebral disc spaces and in
vertebrae and diminishing disc protrusion in patients this way was assumed to reduce pressure on the
with herniated discs.40 In a study of 30,000 patients disc.51 Pre- and posttreatment myelograms of patients
under traction for lumbar disc herniation, Neugebaur 2–6 months after treatment, however, showed no dif-
described three potential therapeutic effects of distrac- ference in size and location of the disc herniation de-
tion: The disc height is reestablished, the interverte- spite marked clinical relief of pain.52
bral foramina are enlarged, and stretching of the an- Extension has been recommended in conjunction
terior and posterior longitudinal ligaments brings the with distraction in order to reduce disc lesions.53
vertebrae back into normal position.41 Sustained lum- McKenzie proposed that following reduction of the
bar traction of 54.4 kg (120 lb) has been reported to disc herniation, extension exercises are used to main-
reduce the defect in myelographic contrast.42 A series tain the correction. This is presumed to maintain the
of epidurograms showed flattening of a disc protru- nucleus pulposus within the disc space while healing
sion after manipulation, accompanied by relief of all of the annular fibers takes place.54–57
symptoms and signs.43 Reduction of protruded nu-
cleus pulposus, approximation of the fissure in the Biomechanics of Low Back Flexion–Distraction
annulus fibrosus, and attainment of normal alignment Therapy
of the articular facets by manipulation have also been Recent funding by the Health Resources and Ser-
reported.44 Tkachenko described 10 cases of acute vices Administration (HRSA) under the Chiroprac-
slipped disc successfully treated by manipulation,45 tic Demonstration Projects (Grant #1 R 18 AH10001–
and Pomosov reported on the reduction of disc hernia- 01A1) has resulted in the beginning of research into
tion in patients undergoing manipulation under anes- the biomechanics of low back flexion–distraction ther-
thesia using a rotation traction maneuver.46 In a study apy. During this study, the following biomechanical
of 281 patients, slipped discs were treated in a 37◦ C parameters were measured while the clinician was
(98.6◦ F) pool with a 6–32-kg weight (13.2–70.4 lb). Four performing the low back flexion–distraction therapy:
patients (1.4%) became worse, 56 (20%) considerably motions of the L4-L5 and L5-S1 joints on unembalmed
improved, and 221 (79%) improved.47 Similar results cadavers, dimensional changes in the intervertebral
were reported in 74 cases of displaced disc treated by foramen (area, height, and width), loads on the in-
suspended traction manipulation.48 ternal tissues, namely, the ligaments and the inter-
Herniation of a nucleus pulposus causing nerve vertebral disc for L4-L5 and L5-S1 motion segments,
compression can heal spontaneously provided low in- intradiscal pressure changes, and electromyographic
FIGURE 42–17. Cadavers placed in the prone flexion– FIGURE 42–18. Markers are positioned from the physician’s
distraction position. hand.
vertebrae for the L5-S1 and L4-L5 motion segments.

(EMG) activity of the superficial muscles surrounding These were described as three rotations and three
the lumbar spine on low back pain patients.58–67 translations at the center of the vertebral disc. The re-
sults showed that vertebral motions were created at
Vertebral Motions During the desired joint of interest, and that the major dis-
the Flexion–Distraction Procedure placements created are flexion (measured in degrees)
Treatment of patients with low back pain or lower ex- and axial distraction (measured in millimeters). As
tremity pain using flexion–distraction therapy is char- the table is moved downward, the vertebrae are sep-
acterized by nonimpulsive loads delivered at slow arated, producing facet gapping, an increase in the
speeds. The procedure is based on the hypothesis that posterior space in the intervertebral foramen, and an
vertebral motion can be created at the joint of interest, increase in the posterior disc height.
intradiscal pressure can be reduced, and facet joint
gapping can be produced. The objective of the first Dimensional Changes in Intervertebral Foramen
part of this study was to measure the vertebral mo- The lumbar spine was dissected after each experi-
tions during the distraction in cadavers.17 ment, and 10 intervertebral foramen (IVF) points were
A total of nine whole, unembalmed cadavers were digitized. Using the displacement and IVF digitization
procured within 24–48 hours of death and immedi- information, changes in IVF area, height, and width
ately frozen at −20◦ C (−4◦ F). Before each experiment, were computed. The results indicated that the IVF di-
the cadavers were thawed at room temperature. The mensions increased by as much as 21% in area, 12% in
cadavers were then positioned in the prone position height, and 5% in width during the flexion–distraction
on the flexion–distraction table in a position similar procedure at the L4-L5 level. The increases in the IVF
to that used for the treatment of a patient (Fig. 42–17). dimensions were 18% percent in area, 8% in height,
A lateral incision parallel to the midline was made and 4% in width at the L5-S1 level. These results in-
over the lower lumbar and sacral region. The inci- dicated that the motions created during the flexion–
sion provided access for the mounting of pins and distraction procedure increased the IVF dimensions,
minimized damage to the musculature. The muscles thereby supporting the hypothesis that this procedure
were retracted to allow pins to be inserted into the ver- created increased space for the neural elements.
tebral bodies of L4, L5, and S1. Four infrared-emitting
diode markers were attached to the pins. The metal Loads on the Internal Tissues During
pins were oriented in a posterolateral direction in the Flexion–Distraction Procedure
such a way that the infrared-emitting diode markers The discrete parameter model is used to estimate the
could be positioned away from the doctor’s hand so as loads on the internal structures of the L4-L5 and L5-
not to interfere with the flexion–distraction procedure S1 motion segments.68 Vertebral motion data obtained
(Fig. 42–18). The marker positions were tracked in from the cadaver experiments for L4-L5 and L5-S1
three-dimensions using OPTOTRAK cameras, a conserved as input for the model to estimate the loads
trol unit, and a computer. The data collected from the on the ligaments and the disc. Stiffness values for disc
markers were analyzed for three-dimensional mo- and ligaments have been published,69 and the results
tions using kinematics software. The relative verte- indicate that the loads can reach 169 newtons (N) for
bral motions were computed with respect to the next the interspinous ligament, 72 N for the supraspinous
ligament, 153 N for capsular ligament, 134 N for pressurizing. The intradiscal pressures were moni-
the ligamentum flavum, and 37 N for the intertrans- tored by means of the computer during the flexion–
verse ligament. A comparison of these loads with the distraction procedure under two conditions: the discs
failure loads of the same ligaments, assuming the unpressurized and the discs pressurized with water.
highest stiffness properties reported in the literature, The pressures were monitored during three separate
indicates that the loads reached are less than 50% trials with 30-minute intervals between each trial.
of their ultimate strength.69 The major loads on the Mean values of the initial pressure, pressure in the
disc are axial force and flexion moment. The flexion distracted position, and the changes in the pressures
moment on the disc varied from a maximum of 12.3 were computed for all 15 cycles of the three trials.
nanometers (nm) for the stiffest material properties to The initial pressures had mean values of 266–
a minimum of 2.1 nm for the degenerated (lowest stiff- 823 mmHg. The decrease in the intradiscal pressure
ness) discs under 6 degrees of flexion angle. The axial varied from 117 to 720 mmHg. The results show a
distraction loads on the disc varied from 137 N to a net definite trend toward decrease in intradiscal pres-
tension load of 221 N. These results on the ligament sure during the flexion–distraction procedure for low
loads suggest that the loads on the disc and the lig- back pain. When the discs were not pressurized, the
aments during the flexion–distraction procedure can pressures went below 0 mmHg. When the discs were
be quantitatively described, and that the ligaments are pressurized, the decrease in intradiscal pressures was
loaded well below their failure loads. much higher. The pressures returned back to their
original values when the spine was brought back to
Intradiscal Pressure Changes During the initial prone position.
the Flexion–Distraction Procedure The intradiscal pressures during in vivo conditions
The flexion–distraction treatment is based on the hy- of daily activities have been measured.70 The intradis-
pothesis that the intradiscal pressure decreases during cal pressure during the vertebral axial decompres-
the procedure and may provide an opportunity for the sion procedure on three patients measured intraop-
disc bulge to reduce. The purpose of this study was eratively shows that the disc pressures reduced dur-
to measure the changes in the intradiscal pressures ing the vertebral axial decompression therapy with
in the lumbar spine on unembalmed cadavers dur- the disc pressures going as low as –160 mmHg.33
ing the flexion–distraction procedure. Two miniature The results of the present study are in general agree-
pressure transducers (model #SPR-524) from Millar ment with the study reported by Ramos and Martin
Instruments (Houston, Texas) were used for this study. using a vertebral axial decompression therapeutic ta-
The pressure transducers were calibrated with known ble. However, in a study of intradiscal pressures at the
pressures in the range of –483 to 1062 mmHg while L3-L4 disc on four volunteers measured during stand-
monitoring the voltage. Five unembalmed whole ca- ing, lying, active traction, and passive traction, an in-
davers were procured for the purpose of the study crease in disc pressure was seen during both active
(four male and one female; age range of 43–75 years). and passive traction.71 Possible reasons for the dis-
The cadavers were frozen at –20◦ C (–4◦ F) immediately crepancy between these studies could be attributed to
after death and thawed at room temperature prior to muscle contraction of the in vivo subjects while under
experimentation. Some of the paraspinal musculature active and passive traction.
was dissected to permit accurate insertion of the nee-
dle and pressure transducer. A 17-gauge Tuohy epidu- Intervertebral Disc Pressure Changes During
ral needle with stylette was inserted into the nucleus Different Table Motions
of the disc (either L2-L3, L3-L4, or L4-L5). The stylette The results for the changes in the intradiscal pres-
was then removed and the miniature pressure trans- sures during flexion, extension, lateral flexion, and
ducer was inserted so that the sensor was exposed to circumduction motions of the table have also been
the nucleus. studied. Miniature pressure transducers (Model SPR-
The pressure transducer was connected to a com- 524) from Millar Instruments were used for this study,
puter through a signal amplifier and analogue-to- and an unembalmed cadaver of a 72-year-old male
digital converter. The cadavers were placed in a prone was used. The cadaver was frozen at –20◦ C (–4◦ F)
position on the flexion–distraction table, similar to the within 24 hours after death and thawed at room
positioning for a living patient. The simulated treat- temperature prior to experimentation. Some of the
ment procedure consisted of five cycles of table mo- paraspinal musculature was dissected to permit accu-
tion in approximately 20 seconds. Discs were pres- rate insertion of the needle and pressure transducer.
surized with a Cornwall continuous pipetting outfit An epidural needle with stylette (17 gauge) was in-
(B-D #3052) connected by flexible tubing to a sec- serted into the nucleus of the disc (L3-L4). The stylette
ond needle in the disc of interest. Luer-Lok stop- was then removed and the miniature pressure trans-
cocks allowed air to be bled from the system before ducer was inserted so that the pressure was exposed
to the nucleus. The disc was pressurized with wa- amplifier, transmitted to an analogue-to-digital con-
ter using a Cornwall continuous pipetting outfit converter, and then stored on a computer.
nected by flexible tubing to a second needle in the disc. Prior to the treatment, subjects were first po-
The intradiscal pressures were monitored during the sitioned in a B200 trunk strength dynamometer
table motions of flexion, extension, lateral flexion, and (Isotechnologies, Hillsboro, North Carolina). This ma-
circumduction. The pressures were monitored during chine constrained the patients and tested the isometric
four cycles of table motions. strength of the trunk muscles. During the B200 test,
A decrease in intradiscal pressure was observed the patient was asked to exert his or her maximum
during the flexion motion of the table, with a corre- voluntary contraction of the trunk muscles in flex-
sponding increase during extension. The pressures in- ion, extension, left and right lateral bending, and left
creased during the right lateral motion, and decreased and right twisting. The EMG activity was collected
during the left lateral motions of the table. During cir- at 1000 samples per second. After the B200 test, the
cumduction, the pressures decreased during the left flexion–distraction procedure was administered to the
lateral and flexion motions, whereas they increased patients. This consisted of tolerance testing of the pa-
during right and flexion combined motions. In all of tient, attaching the ankles to the moving section of
the motions, the pressures returned to their original the table by means of ankle cuffs, and then taking a
values when the spine was brought back to the initial hand contact at the patient’s L4 spinous process and
prone position. It is suspected that one of the reasons applying three repetitions of five cycles of 4-second
for the increase and decrease during lateral motions distraction procedures by moving the caudal section
was the fact that the transducer was inserted some- of the table. The baseline EMG activity was collected
what to the right of the center of the disc. The results, during the initial prone position while the patient re-
however, do show that the pressures were affected laxed on the table. EMG activity was also monitored
during different therapeutic motions of the table, with while applying the flexion–distraction procedure.
a large increase observed under extension. These re- The following observations were made. All muscle
sults have only been obtained in a single cadaver and groups were similarly active, indicating no increase
require further research. in tension on one side of the body. During the treat-
ment, erector spinae muscles were the most active,
Electromyographic Activity of Trunk Muscles followed by the external oblique, and the rectus ab-
During Flexion–Distraction Treatment of Lower dominis muscles. The mean values of the EMG ra-
Back Pain tios (during treatment versus maximum voluntary
The objective of this study was to define the EMG contraction) were small, indicating that muscle activ-
activity of the superficial muscles during the treat- ity during treatment may not influence the treatment
ment of low back pain patients during the flexion– loads. However, the standard deviations were large,
distraction procedure. A total of 33 patients were re- suggesting that there are significant individual vari-
cruited for this study. Informed consent was obtained ations. These variations suggest that the higher the
from these patients for participation in the study. El- amount of muscle activity, the less traction the chiro-
igibility criteria included a primary complaint of low practic physician is able to exert through the spine.
back pain with patients between the ages of 18 and
55 years. Subjects were excluded from the study if
they were taking muscle relaxants, had prior low back
surgery, fractures, or injections, were in litigation, or ACKNOWLEDGMENTS
were currently pregnant. Both males and females were The authors acknowledge the financial support from Health Re-
used and the subjects had a mean age of 44 years. sources and Services Administration via Grant 1 R18AH10001,
Each subject completed several questionnaires. After donations from numerous chiropractic physicians, and the dona-
the questionnaires, diaphoretic dot surface electrodes tion of the table from Williams Healthcare Inc.
were then placed on six major superficial muscles in-
cluding the left erector spinae, right erector spinae,
left rectus abdominis, right rectus abdominis, left ex-
ternal oblique, and right external oblique. In order to
SUMMARY
understand the muscle activity during the flexion–
distraction therapy, baseline EMG signals were col- 1. Spinal traction is not a new or novel treatment
lected while the patient was in a prone relaxed posi- technique for spinal pain. It was described in the
tion, and during maximum voluntary exertions in the works of Hippocrates and by a French surgeon in
three planes (flexion, extension, left and right lateral the fifteenth century. However, the application of
bending, and left and right twisting). The electrode specific traction and manipulation techniques is a
signals were supplied to a Grass Model 7D polygraph relatively new development.
2. Traction can be classified as static traction, the clinical trials to date, and because subgroups
where shorter periods of traction are combined of patients most likely to benefit have not been
with somewhat higher weights (traction forces); specifically studied. Traction separates the verte-
manual distraction, where the doctor applies the brae and large forces are not required.
traction force in a controlled fashion; constant con- 8. A study of spinal flexion–distraction on cadav-
tinuous traction, where low weights are used over ers reported vertebral motions were created at the
a long period of up to several hours; intermittent desired joint of interest, creating facet gapping,
traction, where the traction force is applied and an increase in the posterior space in the interver-
withdrawn repetitively in relatively short periods; tebral foramen, and an increase in the posterior
gravity traction, where traction is applied by in- disc height; intervertebral foramina dimensions
verting the patient with gravity boots, by flexion increased by as much as 21% in area, 12% in height,
at the waist over a specific device, or by means of a and 5% in width during the flexion–distraction
chest harness; and Cox distraction manipulation, procedure at the L4-L5 level; ligaments loads ap-
where manually controlled distraction is applied plied during flexion–distraction were 169 N for the
while the patient is positioned on an adjustable interspinous ligament, 72 N for the supraspinous
assistive table and manipulation is applied. ligament, 153 N for capsular ligament, 134 N for
3. Distraction-aided manipulation may be beneficial the ligamentum flavum, and 37 N for the inter-
in spinal complaints because degenerative disc transverse ligament; and a decrease in intradiscal
disease increases weight bearing on the facet joints, pressure from 117 to 720 mmHg was recorded.
resulting in impaired facet joint function and de-
generative osteoarthrosis of the zygapophyses.
Distraction of the lumbar spine establishes patency QUESTIONS
of the vertebral and osseoligamentous canals by in-
1. What are the names and definitions of six main
creasing the height of the intervertebral disc space,
categories of traction?
decreasing disc protrusion, and opening the lat-
2. What is the rationale cited for the use of distraction
eral recesses of the vertebral canal while placing
in combination with spinal manipulation?
distension on the facet joints.
3. In what ways does distraction adjusting provide
4. Flexion–distraction-aided spinal manipulation
an advantage over high-velocity low-amplitude
has been proposed to increase posterior disc space
thrust techniques?
height; decrease disc protrusion; reduce stenosis;
4. What is tolerance testing and when is it used?
stretch the ligamentum flavum to reduce steno-
5. In what cases do you use supine distraction tech-
sis; open the vertebral canal; increase metabolite
nique?
transport into the disc; open the apophyseal joints
and reduce posterior disc stress; reduce intradis-
cal pressure; and increase intervertebral foraminal
ANSWERS
openings.
5. Tolerance testing involves a gradual introduction 1. The six main categories of traction are static trac-
to the proposed treatment in order to ensure pation, manual distraction, constant continuous trac-
tient tolerance. For example, tolerance testing for tion, intermittent traction, gravity traction, and
axial distraction in the cervical spine would in- Cox distraction manipulation.
volve placing the patient in the supine position on 2. The combination of distraction and spinal manipu-
the treatment table and, while stabilizing the head, lation helps to increase the disc space and improve
gently applying axial distraction pressure while facet joint mobility, and uses less force than the
confirming that the procedure is well tolerated. traditional high-velocity low-amplitude manipu-
6. Treatment protocols for each area of the spine have lation.
been established within distraction-assisted ma- 3. Distraction adjusting provides a more controlled,
nipulation techniques. In general, they involve ap- more comfortable adjustive force than do high-
propriate examination and diagnosis, directional velocity low-amplitude thrust techniques.
tolerance testing, a gradual increase in treatment 4. Tolerance testing is the process of evaluating the
force or time, and directional spinal manipulation. patient’s response to distraction adjusting in order
7. Despite the widespread use of traction, its mecha- to select the most appropriate procedure and the
nism of action remains largely unknown. Research least amount of force necessary. It is used prior to
has been conducted on the use of traction for spinal first adjusting the patient and at any time a new
disorders, mainly lumbar disc herniation, with procedure is added to the adjustment.
mostly positive results. The efficacy of traction is 5. In patients with hyperkyphosis, scoliosis, and
also unclear because of generally poor design of healed compression fractures.
4. Arkansas passes act to protect chiropractic. Arkansas

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the Third World Congress of Biomechanics, Sapporo, during the flexion–distraction procedure for low back
Japan, August 2–8, 1998, p. 284. pain. Proceedings of the 1997 Annual International So-
64. Gudavalli MR, Baker JA, Gillette LA, Patwardhan AG. ciety for the Study of the Lumbar Spine (ISSLS) Meet-
Accuracy studies of an optoelectronic system to mea- ing, June 2–6, 1997, Singapore, p. 165.
sure three-dimensional spinal motion during chiro- 68. Gudavalli MR, Triano JJ. Quantification of the liga-
practic treatments. Proceedings of the Third World ment and disc loads of lumbar spine under combined
Congress of Biomechanics, Sapporo, Japan, August loading of traction and flexion. Adv Bioengineer 1992;22:
2–8, 1998, p. 279. 341–343.
65. Gudavalli MR, Cox JM, Cramer GD, Jedlicka J. 69. Myklebust JB, Pintar F, Yoganandan N, et al. Tensile
Computer- and anatomy-based animation as a strength of spinal ligaments. Spine 1988;13(5):526–531.
tool for demonstrating the effects of the flexion– 70. Nachemson AL, Elfstrom G. Intradiscal dynamic pres-
distraction procedure. Proceedings of the Fifth An- sure measurements in lumbar discs. A study of com-
nual Conference, Association of Chiropractic Colleges, mon movements, maneuvers, and exercises. Scand J Re-
Las Vegas, Nevada, March 12–14, 1998, pp. 126– habil Med 1971;2:1.
127. 71. Andersson GBJ, Schultz AB, Nachemson AL. Interver-
66. Gudavalli MR, Cox JM, Baker JA, Cramer GD, Pat- tebral disc pressures during traction. Scand J Rehabil
wardhan AG. Intervertebral disc pressure changes dur- Med Suppl 1983;9:88–91.
C H A P T E R
43
MEDICATION-ASSISTED
SPINAL MANIPULATION
Frank J. Kohlbeck
O U T L I N E
INTRODUCTION Reported Complications
HISTORICAL REVIEW MANIPULATION WITH PROLIFERANT OR STEROID
PROPOSED RATIONALE INJECTION
MANIPULATION UNDER ANESTHESIA Reported Indications
Reported Indications Protocol
Protocol Reported Complications
Reported Complications CONTRAINDICATIONS FOR MEDICATION-
MANIPULATION UNDER JOINT ASSISTED SPINAL MANIPULATION
ANESTHESIA/ANALGESIA CONCLUSION
Reported Indications SUMMARY
Protocol QUESTIONS
Reported Complications ANSWERS
MANIPULATION UNDER EPIDURAL ANESTHESIA KEY REFERENCES
Reported Indications REFERENCES
Protocol
6. To present limited detail regarding current post-

OBJECTIVES
graduate and continuing education courses teach-
1. To provide an overview and historical context of ing medication-assisted manipulation (primarily
treatment protocols that combine spinal manipu- manipulation under anesthesia) protocols.
lation therapy with the administration of adjuvant 7. To identify issues of concern regarding use of and
medication. reimbursement for medication-assisted manipula-
2. To give definitions and describe subcategories of tion, as well as to propose directions for further
medication-assisted manipulation. investigation of these techniques.
3. To review the literature addressing clinical trials
of medication-assisted manipulation techniques,
INTRODUCTION
discussing the accomplishments and limitations of
these studies. The current resurgence in the use of medication to
4. To outline treatment protocols used in four subcat- assist spinal manipulation stems from diverse clin-
egories of medication-assisted manipulation. ical applications well rooted in the early part of
5. To discuss purported rationale and indications for the past century. Manipulation under anesthesia re-
the various medication-assisted manipulation reg- tains its status as the most prevalent and familiar
imens, as well as potential contraindications and form of medication-assisted manipulation, but re-
complications. cent variations have evolved out of an increasing
841
cooperation between chiropractors and medical phy- ical doctors to abandon use of these therapies. At
sicians. Chiropractors are forging new working rela- the same time, practitioners using spinal manipula-
tionships with anesthesiologists and medical doctors tion without assisting anesthetic agents tended to dis-
specializing in pain management to offer treatments tance themselves from manipulation performed un-
such as manipulation under anesthesia, manipula- der anesthesia that they considered to be nonspecific,
tion under epidural anesthesia, manipulation com- high-force, long-lever procedures with an increased
bined with epidural steroid injections, and manipu- potential for complications. Disinterest by the ortho-
lation with injectants such as steroid and proliferant pedic community was supplanted by the work of
solutions (see sidebar, “Subcategories of Medication- a small number of osteopathic physicians with ac-
Assisted Manipulation”). These therapies are largely cess to medical facilities and an interest in combining
driven by clinicians wishing to expand their ar- manipulation techniques with anesthesia, sedation,
mamentarium for the treatment of musculoskeletal and local injections.6,7 Still, widespread acceptance
pain rather than the support of high-quality research of these procedures was not forthcoming because os-
investigations. teopaths relied less and less on spinal manipulation
while chiropractors—who increasingly provided the
majority of manipulation therapy services in North
Subcategories of Medication-Assisted America—were denied access to medical physicians
Manipulation capable of administering these medications. In addi-
Manipulation under anesthesia (MUA) tion, the 1970s and 1980s marked a period of increased
skepticism regarding spinal manipulation in general.8
• General Anesthesia The advent of clinical guidelines, systematic re-
• Sedation views of the literature, and expert opinion has led to
• Analgesia an increased interest in and acceptance of spinal ma-
nipulation as a treatment modality for low back and
Manipulation under joint anesthesia/analgesia (MUJA) neck pain. This shift in attitude, along with a surge in
public interest in and use of complementary and alter-
Manipulation under epidural anesthesia (MUEA) native medicine, has resulted in growing opportuni-
ties for chiropractors to practice in multidisciplinary
• With/without epidural steroid injection settings. These settings give chiropractors access to
physicians able to administer medication such as
Manipulation with local injectants general anesthesia, analgesics, sedatives, and various
injection techniques. This collaboration has fostered
• Steroid injections renewed interest in protocols combining these medi-
• Proliferant injections cations with manipulation or mobilization. Given that
chiropractors, osteopathic physicians, and physical
therapists all tend to use lighter force and more spe-
This chapter provides an overview of the thera- cific manipulative techniques than those previously
pies that use medication in an attempt to assist and performed by orthopedic surgeons under anesthe-
enhance the delivery and results of manual therapies. sia, it would be reasonable to assume that modern
Historical context is provided by means of a review medication-assisted manipulation carries less risk of
of the pertinent literature. This literature addresses adverse events. Furthermore, it has been suggested
proposed rationales and indications for the use of that recent advances in highly titratable and reversible
medication-assisted manipulation and mobilization, intravenous anesthetics have further reduced risks
as well as potential contraindications and complica- associated with manipulation under anesthesia.9
tions resulting from such treatment. Renewed interest in the use of medication-assisted
manipulation has led to many enthusiastic claims
of success, as well as to application of these pro-
HISTORICAL REVIEW
cedures with somewhat indiscriminate use in pa-
In 1930, The Lancet published a study by E. W. Riches, tients with spinal pain. The task of addressing this
an assistant surgeon at Middlesex Hospital and the lack of consistent clinical protocols is now largely
Hospital of St. John and St. Elizabeth, that reported shouldered by members of the chiropractic commu-
results of 75 patients receiving manipulation under nity. Unfortunately, most current guidelines and post-
anesthesia for low back pain. Similar procedures were graduate curricula regarding medication-assisted ma-
fairly common in many orthopedic practices until nipulation rely on literature that cannot withstand
the mid-1960s.1–5 By that time, an increasing reliance the scrutiny necessitated by the current emphasis
on improved surgical techniques caused most med- on evidence-based medicine. This literature consists
MEDICATION-ASSISTED SPINAL MANIPULATION 843
mostly of case reports and case series describing the reports, and case series. Proposed indications include
successful use of manipulation under anesthesia and acute or chronic cervical pain and cervicobrachial, cer-
other medication-assisted manual therapies in pa- vicocranial, lumbar, pelvic, or lower-extremity syn-
tients with a variety of low-back-related conditions, dromes with somatic dysfunctions that have not re-
including chronic lumbosacral and sacroiliac strain; sponded to conservative management. Some authors
acute and chronic low back pain; recalcitrant low back also report that patients with major disability or severe
pain and lumbar radiculopathy; spinal arthritis; sci- musculoskeletal symptoms may, at least temporarily,
atica; lumbar disk syndrome; myofibrositis with and benefit from MUA.
without disc herniation; postoperative stiffness; psoa- Current osteopathic and chiropractic literature, as
sitis; spondylolisthesis; cervical radiculopathy; cervi- well as instructional materials, appear to reach a con-
cal disc herniation; cervicogenic headache syndrome; sensus concerning the basic indications for MUA.
cervical disc syndrome; constant intractable pain; and These indications include failure, or only moderate
failed back surgery syndrome. Additional case reports success, with a 4–8-week trial of conservative care,
log favorable responses to medication-assisted spinal including manipulation. Patients judged to be candi-
manipulation among patients with cervical or thoracic dates for spinal manipulation therapy but who have
sprain/strain, cervicalgia, brachial neuritis, headache, severe pain, muscle spasm, or tissue irritability pre-
and knee and shoulder injuries. venting manipulation without analgesia or anesthesia
may proceed to MUA without a course of conserva-
PROPOSED RATIONALE tive care and manipulation.9,10
This consensus on general indications does not
A common thread in this literature pertains to the carry over to specific indications for MUA or the
theoretical underpinnings for the use of medication- identification of diagnoses likely to best respond to
assisted manipulation. There is the assumption that MUA. Advocates of MUA often have to develop their
the combined effect of manual therapies and medica- own indications; based on clinical experience these
tion may be more successful than the use of the com- may or may not build upon indications previously
ponent procedures alone. The rationale for the use espoused. For example, Greenman emphasizes the
of manipulation under anesthesia is that anesthesia combination of anesthesia with spinal manipulation
helps to reduce pain and muscle spasm that hinder for the treatment of chronic vertebral somatic dys-
the effective use of manipulation. Many practitioners function and chronic myofibrositis previously un-
emphasize the perceived ability of anesthesia, analge- responsive to conservative care.11 West et al. ex-
sia, or sedation to facilitate breaking up fibrous joint pand these indications, suggesting that MUA may
adhesions to a greater extent than spinal manipulation be useful for patients who are considering spinal
alone. surgery or when the combination of MUA and spinal
Other common forms of medication-assisted ma- injection might potentiate the therapeutic benefit
nipulation include injections of steroids or proliferant of either treatment when used alone.9 Beckett and
agents with or without the use of anesthesia or anal- Francis suggest, with reservation, that the use of anes-
gesia. Manipulation has been combined with steroid thesia or analgesia may be indicated when a pa-
injections in an attempt to decrease inflammation and tient who is a suitable candidate for manual therapy
thereby allow for greater effectiveness of the manipu- requests MUA out of apprehension of receiving ma-
lation. Proliferant agents have been used in an attempt nipulation without medication.10
to strengthen supporting ligaments by encouraging More expansive lists of indications may be found
collagen growth, thereby retaining the effects of main the literature and in the lecture notes from cur-
nipulation for a longer duration. rent MUA postgraduate and continuing education
classes.12–14 Table 43–1 provides some examples of
MANIPULATION UNDER ANESTHESIA clinical indications suggested by these postgradu-
Manipulation under anesthesia (MUA) is a term refer- ate courses. Reported indications include patients
ring to manipulation of the spine while the patient is with bulging, protruded, prolapsed, or herniated discs
under general anesthesia or conscious sedation. Anes- without free fragment who are not suitable candidates
thesia, analgesia, and sedation are employed with the for surgery; frozen or fixed articulations from adhe-
goal of relieving spinal pain, muscle spasm, and pro- sion formation; failed low back surgery; posttraumatic
tective guarding by the patient that may limit the ef- injuries from acceleration/deceleration mechanisms
fectiveness of manipulation. resulting in painful exacerbations of chronic fixations;
chronic recurrent neuromusculoskeletal dysfunction
Reported Indications syndromes that are easily exacerbated; and neuro-
The reported clinical indications for MUA are exten- musculoskeletal conditions not suited for surgery but
sive and based mainly on anecdotal experience, case which have reached maximum medical improvement
TABLE 43–1.Clinical Indications for Manipulation Under Anesthesia (MUA): Examples from Several
Postprofessional, Postgraduate, and Continuing Education Programs
National University of Health Sciences Texas Chiropractic College California Academy for MUA
Unresponsive muscle contracture Patients that have not Traumatic torticollis

Unresponsive articular fixation responded to conservative Old, healed compression fractures
Herniated disc syndromes with no in-office care, and who have Chronic disc changes
fragment chronic and recurrent Acute muscle spasm with associated
Prolonged recurrent conditions; patients in whom subluxation
neuromusculoskeletal syndromes narcotic analgesics are of Chronic muscle contracture
Failed back surgeries little benefit; and most Aberrant or asymmetrical spinal range of
Chronic recurrent headaches patients with herniated discs motion
Recurrent pain that is unresponsive to Chronic fibrositis
conservative care but where Chronic myositis
manipulation or adjustment is the Nerve entrapment
therapy of choice Pseudosciatica
Fibroadhesion accumulation Sciatica <5-mm disc bulge
Failed back surgery
Chronic occipital headaches
Aberrant dural tension
Reflex sympathetic dystrophy
Conditions nonresponsive to narcotic
analgesics
Conditions where MUA may reverse
disability
Data from Lincoln College of Postprofessional, Graduate and Continuing Education web page (http://www.nuhs.edu/postgrad/certification
programs/manipulation.html) last accessed March 2001; Texas Chiropractic College Postgraduate and Continuing Education Courses web page
(http://www.txchiro.edu/pg.asp?pageid = 593) last accessed March 2001; California Academy for MUA, A Division of Innercalm Associates,
Course Notes 2001.
with conservative therapies. High-quality clinical tri- sence of nerve root compression. Patients with nerve
als have yet to be conducted for many of these root compression secondary to disc herniation in the
indications. lumbar spine may expect temporary clinical improve-
At least 17 clinical trials or case reports of manip- ment, but the authors posit that eventually surgical
ulation under anesthesia appear in the English lan- intervention would be required.15 The authors are un-
guage literature between 1933 and 1999. Table 43–2 ambiguous in their conclusion that when there ex-
presents a brief summary of these trials. Most of the ists no definitive evidence of nerve root compres-
studies represent case series or case reports. There sion, a trial of manipulation under anesthesia is
are no randomized controlled trials and only one co- justified.
hort study.15 While these studies cannot support in- Prior to publishing findings from his cohort study,
ferential statements concerning the effectiveness of Siehl reported results from two case series of 723 treat-
MUA, they do speak to the safety of the techniques, ments on a total of 666 patients with manipulation of
as well as provide a basis for their potential clin- the spine under general anesthesia.2,3 Between 1952
ical applications and directions for further clinical and 1964, five case series presented findings from
investigations. more than 1000 patients receiving manipulation under
A cohort study by Siehl et al., published in 1971, anesthesia, including three articles submitted by med-
tracks the clinical progress of 47 low back pain or sci- ical doctors and the articles written by Siehl, an
atica patients in a hospital-based orthopedic clinic.15 osteopath.1,4,5 Wilson and Ilfeld investigated the ef-
Electromyography (EMG) was performed on these fect of manipulation under anesthesia/analgesia on
patients, who were then grouped according to nerve herniated intervertebral disc patients (n = 13), demon-
root compression status (evidence of nerve root com- strating virtually no change in myelography findings
pression or absence of such evidence). The authors (12 patients showing no change in the x-ray appear-
suggest that manipulation under anesthesia would ance of the defect with a slight increase in the size of
probably result in lasting improvements in the ab- defect shown in one patient).1 Transient or no change
TABLE 43–2. Selected Manipulation Under Anesthesia (MUA)
Number of
Study Design Patients Condition Medication Manual Therapy Outcome
Retrospective 75 Back pain Nitrous oxide and Long-lever techniques 75% improved; 25% not
review21 ether (forcible flexion and improved
extension of spine;
rotatory movement
of pelvis)
Case series1 18 Herniated Sodium pentothal Long-lever rotary Baseline myelographic studies
intervertebral (n = 2) or technique indicating herniated
disc 1/150 g intervertebral disc—changes
scopolamine, observed after SMT: no
100 mg change in 12 patients; slight
meperidine, 3 g increase in defect for 1
seconal (n = 16) patient; no defect identified in
5 patients
Case series2 100 cases Low back pain Thiopental sodium Mobilization of lumbar Excellent: 29; good: 32; fair:
with 87 spine and SI joints 26; poor: 10; missing data: 3
patients
Case series4 205 Lumbar IV thiopental Long-lever techniques Excellent: 56; good: 50; fair:
intervertebral sodium 32; immediate failure: 52;
disc syndrome delayed failure: 15
Case series3 666 Back pain At the discretion of Mobilization Good: 60%; fair: 30%; poor:
anesthesiologist, 10%
usually Pentothal
or Surital
Case series5 39 Lumbar IV thiopental Long-lever rotatory Excellent: 11; good: 10; fair: 4;
intervertebral sodium with techniques immediate failure: 3; delayed
disc syndrome succinylcholine failure: 11
Cohort study15 47 Lumbar nerve root General Osteopathic Average clinical scores
compression anesthesia manipulation of improved from baseline to 6
syndrome lumbar spine and 12 months regardless of
improved, unchanged, or
worsened EMG status
Medical records 119 Musculoskeletal General Mobilization Low back cervical spine and
review7 disorders of the anesthesia stretching extremities: excellent: 29;
low back, long-lever thrusts good: 73; fair: 14; no
cervical spine, change: 3
and extremities
Case series16 171 Intractable spinal Thiopental sodium Stretching; long-lever Pain-based scale: 25% cured;
pain plus inhalant techniques 50% much improved; 20%
such as nitrous better; 5% failure
oxide; Innovar
drip for cervical
manipulation
Case report25 1 Low back pain Thiopental sodium Stretching; Resolution of pain
short-lever
adjustment
Case report11 1 Painful stiffness of General Mobilization with Improved cervical mobility;
cervical spine anesthesia impulse reduction in pain with no
(high-velocity further nausea and vomiting
low-amplitude
thrust technique)
(Cont.)
TABLE 43–2. (Continued)
Number of
Study Design Patients Condition Medication Manual Therapy Outcome
Case report17 1 Recurrent HNP IV thiopental Stretching and Avoidance of

with epidural sodium mobilization surgery
fibrosis
Case report18 1 Cervical disk Thiopental sodium Lower-velocity, Patient reported
syndrome high-amplitude improvement
thrust
Case reports20 2 Low back pain with Nitrous oxide, Passive stretching; 0–10 pain scale (10
sciatica thiopental short-lever thrusts being worst pain)
sodium, Patient 1.
midazolam, Improvement from
propofol, and 9+ to 2
succinylcholine Patient 2.
Improvement from
9+ to 3
Both patients had
increased lumbar
ROM
Case series9 177 Acute and chronic IV midazolam; Passive stretching; ROM: CS 47%
spinal pain 0.5–1.0 mg/kg osseous short-lever improvement; LS
disorders propofol arm adjustive 83% improvement
technique VAS: CS 62%
improvement; LS
60% improvement
Medication use:
58% reduction
Case report19 1 Cervical disk Methohexital or Stretching; Pain scale
herniation, propofol short-lever, improvement;
cervical low-velocity thrust 90% improvement
radiculopathy, of neck and upper
and associated back pain;
cervicogenic headaches 95%
headache better
syndrome
Key: CS = cervical spine; EMG = electromyogram; HNP = herniated nucleus pulposus; LS = lumbar spine; ROM = range of motion; SI = sacroiliac;
SMT = spinal manipulation therapy; VAS = Visual Analogue Scale.
in symptomatology following manipulation was re- period averaging about 23 months. Chrisman et al.’s
ported for these patients. These findings suggest that findings in 1964 replicate these results with 21 (54%)
although intervertebral disc herniation should not be of 39 patients with a clinical presentation of interver-
considered an absolute contraindication for manipu- tebral disc rupture experiencing good or excellent re-
lation under anesthesia, the effectiveness of this pro- sults following MUA.5 Patients without evidence of
cedure for this indication is questionable. myelographic defect faired better than those in which
In 1955, Mensor published results of an analysis of a defect was observed. Siehl’s 1963 study expanded
285 patients with medical history and clinical findings on his 1952 earlier report with Bradford.2,3 Altogether,
suggesting protrusion of a lumbar intervertebral disc.4 666 patients received MUA for various diagnoses, in-
Follow-up records were sufficient to allow for the cluding myofibrositis and herniated nucleus pulposus
analysis of 205 patients. All patients received manipu- in combination, alone, and with or without other se-
lation under anesthesia as part of a conservative, non- rious pathology. Overall results were favorable, with
operative treatment regimen. Fifty-one percent of the good results in 60% of the cases, fair results in an-
patients reported satisfactory results after a follow-up other 30%, and poor results in 10%. Siehl indicates
that results were better in patients with a diagnosis alone or as part of a team including medical
of myofibrositis than in those with a diagnosis of her- clinicians.9,17–20 In an article that probably best
niated nucleus pulposus. Patients without a final di- represents the current state of MUA techniques,
agnosis of herniated nucleus pulposus demonstrated Daniel West, a chiropractor working with medical
improvement in 96.3% of these cases, while 70.7% of doctors and a physician assistant, presents the
the cases with the diagnosis of herniated nucleus pul- results of 177 acute and chronic spinal pain pa-
posus showed improvement, which tended to be tem- tients who received MUA treatment.9 Patients were
porary in nature. All of these authors agree that with classified as experiencing lumbar pain problems or
careful patient selection, a trial of MUA should be con- cervical pain problems and all underwent a series of
sidered as a more conservative treatment approach to three manipulations under intravenous sedation. The
surgery. study used commonly accepted outcome measures
These earlier studies focused on patients with low such as the Visual Analogue Scale (VAS), range of
back pain. Two case series, one in the 1970s and one motion, and return to work status. Nine patients were
in the 1980s, expanded the study of MUA to include lost to follow-up, for a total of 168 patients. Average
patients with cervical spine-related conditions.7,16 In VAS scores improved 4.6 points (on a scale of 0–10
1973, Morey advocated the use of manipulation dur- points) 6 months post-MUA for patients with cervical
ing general anesthesia for a small minority of patients pain, while patients with lumbar pain demonstrated
with acute or severe musculoskeletal disorders.7 As an improvement of 4.31 points over the same period.
an osteopath on staff at Northwest General Hospi- Decreases in time lost from work and prescription
tal, he had access to medical records of 119 patients pain medication were also reported for both groups.
receiving MUA over the course of 3 years. The ma- Several key issues representative of most current
jority of cases were for patients with disorders in- approaches for the delivery of MUA are contained in
volving the low back, but a little more than 20% of the work of West et al. These authors recommend a
the patients presented with cervical spine-related con- multidisciplinary approach to patient evaluation and
ditions. Treating physicians rated both groups as re- treatment. Using a diagnosis and treatment algorithm
sponding well and classified results in 85% of 93 low developed in a multidisciplinary environment, these
back cases as good or excellent and 88% of 26 cervical authors emphasize proper patient selection, with cri-
spine cases as good or excellent. Morey recommended teria and MUA protocols similar to those taught in
an accurate diagnosis, appropriate manipulative current chiropractic postgraduate courses.12–14 West
technique, and proper patient selection, and strongly et al.’s work references the efforts of Robert Gordon,
suggested that—with proper attention to these a chiropractor who has spearheaded the creation of
details—MUA may offer patients dramatic relief. the National Academy of Manipulation Under Anes-
In 1986, Krumhansl and Nowacek summarized the thesia Physicians and who currently presents MUA
results of 190 MUA procedures performed over a pe- courses under the auspices of the Lincoln College of
riod of 6 years on 171 patients with intractable spinal postprofessional, graduate, and continuing education
pain.16 These procedures involved a combination of at the National University of Health Sciences. In addi-
lumbar and cervical spine manipulation, some with tion to a reliance on formalized selection criteria and
only one area treated per session and others with both specific treatment protocols, West et al. strongly sup-
areas treated; most patients received manipulation to port the importance of a health care team consisting
both areas at some time during the treatment period. of MUA-trained members, as well as need for specific
The authors classified 75% of the cases as cured or post-MUA treatment and rehabilitation protocols.
much improved, 20% as better but with some remain-
ing dysfunction, and 5% as failures. The study con- Protocol
cluded that patients with intractable spinal pain resis- Current chiropractic MUA guidelines and certifica-
tant to conservative treatment may choose between tion courses suggest that manipulation under anes-
MUA and surgery. These findings suggest that MUA thesia should be part of a multiphase procedure. In
may reduce the need for surgical intervention by 65%, most cases, a trial of conservative management, in-
and the authors state that clinicians who treat spinal cluding spinal manipulation and mobilization, should
pain should become appropriately educated in MUA precede provision of MUA therapy.
procedures in order to offer these techniques. Favorable but limited response to a prior course of
The 1990s saw a shift in the literature with spinal manipulation has been considered predictive
chiropractors providing first authorship for most of positive results.13 Patient selection requires assess-
recent articles about manipulation under anesthesia. ment by an anesthesiologist as well as by a practitioner
With the exception of an article presented in Table skilled in spinal manipulation with a current MUA
43–2,11 the case series and case reports written in the certification. Current protocols are open to serial MUA
1990s represent the work of chiropractic clincians procedures, depending on patient presentation and
response to individual sessions. Reduction in patient mobilization to an area along a specific plane of mo-
symptomatology and improvement in function (e.g., tion precedes the application of manipulation.
range of motion) have been suggested as key guide- The anesthesiologist is usually positioned at the
posts when deciding on the number of MUA proce- patient’s head and neck while monitoring vital signs
dure to perform.10,13 Whether single or multiple pro- and securing a patent airway. For patient safety, the
cedures are performed, virtually every current MUA MUA physician must acquiesce to the anesthesiolo-
protocol requires post-MUA therapy, usually consist- gist’s instructions, being especially mindful of main-
ing of 2–6 weeks of rehabilitation, spinal manipula- taining the airway while working on the cervical
tion, initial passive and subsequent active stretching, spine. For patients undergoing MUA in the cervical
and physical therapy modalities. spine, passive stretching of the soft tissues is per-
Ambulatory surgical centers or hospital settings formed in axial traction, forward flexion, lateral flex-
are recommended as appropriate facilities for MUA, ion, and rotation while the patient is in a supine po-
and should have the necessary equipment for moni- sition (Fig. 43–1). Controlled manipulative thrusts are
toring oxygen saturation, cardiac function, and blood directed to the involved joints in isolated segments
pressure. Emergency resuscitation equipment and an of the spine, with a much smaller force than used in
oxygen dispenser should also be available. The pa- a fully conscious patient (Fig. 43–2). The first assis-
tient may be admitted or coadmitted to the facility tant provides stabilization and maintains correct pa-
by the anesthesiologist involved with the MUA team. tient positioning as directed by the primary clinician
Other members of the MUA team should include a throughout the MUA procedure.
first assistant, who should also be certified in MUA, If the thoracic spine is to be treated, the anes-
and a nurse. thetized or sedated patient should remain in the
Before undergoing MUA, patients should be supine position to facilitate breathing. The supine pa-
advised of the potential risks and benefits of the tient’s arms are crossed over the chest and the practi-
procedure. An informed consent form should be ad- tioner isolates any segments to be adjusted by rolling
ministered that clearly communicates these issues the patient to one side just enough to place a loose
and provides brief explanations of alternative treat- fist under the thoracic spine. Returning the patient
ment procedures. In anticipation of being admitted for to the supine position, the clinician uses the patient’s
MUA, the patient should be instructed to abstain from crossed arms as a second contact point. Manipulation
food or drink for 8–12 hours before the procedure. In is provided using a slight anterior-to-posterior thrust
preparation for the procedure at the facility, the patient and repeated until all identified segments have been
is then connected to a cardiac monitor, blood pressure
cuff, and oximeter. A small intravenous catheter is in-
serted in the patient’s arm. The intricate dance of pa-
tient and physician movement during an MUA proce-
dure requires careful consideration of the placement
of all IV devices and monitoring equipment. Typically,
the patient is placed under twilight anesthesia by a
board-certified anesthesiologist, most commonly us-
ing intravenous propofol and midazolam to provide
sedation and amnesia.
During an MUA procedure, a trained assistant is
necessary to position and stabilize the sedated pa-
tient, as well as assist in the actual MUA. Usually, an
MUA procedure lasts from 10 to 30 minutes, depend-
ing on patient size and number of areas to be treated.
Both high- and low-velocity thrusts are administered.
High-velocity thrusts are purported to break up inter-
segmental adhesions with less force than when anes-
thesia is not used. Low-velocity mobilization is used FIGURE 43–1. The practitioner (right) administers axial trac-
tion to the cervical spine, cupping the patient’s posterior skull
with the intent to passively stretch soft tissue. Specific
with his left hand while he cradles the patient’s jaw with his right
manipulative and mobilization procedures depend on
hand. The first assistant (left) stabilizes the patient with bilat-
each patient and the area of pain and/or dysfunction. eral shoulder/upper trapezius contacts. The anesthesiologist
Pre-MUA evaluations of active and passive end range steps aside to allow the clinician access to the patient’s head
while the patient is fully conscious provide guidance and neck area during cervical spine mobilization and manipula-
for all range-of-motion mobilizations to any region tion. During all other maneuvers, the anesthesiologist monitors
of the spine and extremities during MUA. Generally, the patient from the head of the table.
FIGURE 43–2. The clinician (right side of photograph) adminis- FIGURE 43–4. A straight-leg raise stretch is applied by the
ters cervical spine manipulation using a specific low-amplitude, clinician while the first assistant stabilizes the contralateral leg.
short-lever technique with minimal thrusting force. The clini- All mobilization and manipulation are applied with an aware-
cian’s lower (left) hand and arm are used solely to stabilize the ness of the preprocedure ROM of the fully conscious patient.
patient’s head and neck while the upper (right) hand delivers Maneuvers are typically performed bilaterally.
a controlled thrust. The first assistant stabilizes the patient’s
body by holding the shoulders.
tion. Often, a maneuver similar to a Fabere hip test
is used to mobilize the hips and pelvic girdle, flexing
addressed (Fig. 43–3). Some clinicians also choose the patient’s lower extremity at the knee and plac-
to address shoulder and rib complaints by providing the foot on the table around the level of the pa-
ing mobilization and manipulation to these areas as tient’s contralateral inner thigh, followed by external
needed. and internal rotation at the hip. Traction of the lum-
Various mobilization or stretching techniques are bar spine may be applied by bringing the patient’s
applied to the lumbar spine and pelvis for patients knees to the chest while contacting the lumbar and/or
with complaints involving the low back. Bilateral sacral spine. Rolling the patient from the supine to a
straight-leg raise mobilizations with foot dorsiflexion side-lying position may be facilitated by using a towel
are applied, as well as a variety of knee-to-chest ma- draped across the table underneath the patient. The
neuvers (Fig. 43–4). Traction of the leg may be applied first assistant and primary physician position the pa-
with the hip in neutral, internal, and external rota- tient in a side-lying position with the lower extrem-
ity in flexion. Mobilization and manipulation of the
lumbar spine and sacroiliac joints are provided using
techniques similar to these applied to the conscious
patient, although less force is required (Fig. 43–5). At
the completion of all MUA procedures, the patient is
returned to a supine position and usually transported
to a recovery room. Observation is required until the
patient is ready for discharge from the facility.
Reported Complications
Complications associated with MUA may be a re-
sult of the anesthesia, the manipulation procedure, or
a combination of the two. Cauda equina syndrome,
paralysis, vertebral pedicle fracture, and dens fracture
with C1-C2 dislocation may occur as a result of MUA.
These complications appear in survey articles of com-
FIGURE 43–3. The clinician positions his hand under the pa- plications temporally associated with long-lever ma-
tient’s thoracic spine to act as a fulcrum. The patient is re- nipulation in general, but were not specifically de-
turned to a supine position with arms crossed over the chest signed to address MUA procedures. In the literature
and the clinician applies a quick anterior-to-posterior thrust directly studying MUA procedures, a few complica-
using a contact with his left hand. tions are reported in the earlier case series addressing
joint anesthesia–analgesia (MUJA) as the synthesis

of fluoroscopically guided intraarticular injections of
anesthetic and corticosteroid agents with subsequent
specific mobilization and manipulation of the injected
joints.
Manipulation Under Joint

Anesthesia/Analgesia (MUJA)
Definition
MUJA is the synthesis of fluoroscopically guided in-
traarticular anesthetic and corticosteroid injections with
manual mobilization and manipulation of the targeted
joints.
Indications
Patients with dominant spinal axis pain unresponsive
FIGURE 43–5. Manipulation of the lumbar spine and sacroil-
iac joint is accomplished by placing the patient in a side-lying to the passage of time and to prior treatment.
posture. The first assistant (left) helps to stabilize the patient Patients with severe pain that precludes standard ma-
while the clinician contacts specific sacral and/or lumbar seg- nipulation therapy.
ments to deliver the adjustive thrust. The clinician is positioned Patients with complex problems that require a diagno-
to ensure patient safety. The thrust is delivered only through sis of synovial joint-mediated spinal pain before manipula-
the hand that is contacting the patient’s spine. tion therapy can safely be administered.
Reported results
long-lever, high-force techniques applied under The 1995 article provides results from four case re-
general anesthesia. Riches21 and Chrisman et al.5 ports documenting 90–100% pain resolution with MUJA.
reported exacerbation of symptoms in 1 of 75 and 5 of In 2000, Michaelsen wrote that more than 1000 patients
39 patients, respectively, following MUA. Krumhansl had been treated with MUJA over a 7-year period. Specific
and Nowacek reported two cases of intractable respi- outcomes and complications were not reported.
ratory distress in 171 patients; both resolved after a
Data from Dreyfuss P, et al. MUJA: Manipulation under joint
return to the operative suite.16 They also documented anesthesia/analgesia: A treatment approach for recalcitrant low
“pain paralysis” in an additional two patients who ex- back pain of synovial joint origin. J Manipulative Physiol Ther
1995;18(8):537–546; Michaelsen M, Dreyfuss P. Manipulation
perienced transitory inability to move their lower ex-
under joint anesthesia/analgesia: A proposed interdisciplinary
tremities because of severe pain in the sacroiliac joint treatment approach for recalcitrant spinal axis pain of synovial
for a period of 1 week or less. Neither patient demon- joint origin. In: Lawrence DJ, ed. Advances in chiropractic. Vol. 4.
St. Louis: Mosby, 1997:41–68; and Dreyfuss P, Michaelsen M,
strated sensory or neurological damage and both re-
Horne M. Manipulation under joint anesthesia/analgesia: A pro-
covered completely within 10 days. Wilson and Ilfeld posed interdisciplinary treatment approach for recalcitrant spinal
indicated a slight increase in the size of defect demon- axis pain of synovial joint origin. J Manipulative Physiol Ther
2000;23(2):127–129.
strated by myelography (interpreted as being caused
by herniation of the intervertebral disc) after manipu-
lation in 1 of 18 patients.1 There are no recent reports
of complications following MUA as currently admin- Reported Indications
istered, using lighter anesthetics and less manipula- Dreyfuss and Michaelsen suggest that patients with
tive force. Table 43–3 provides detailed information dominant spinal axis pain of greater than 2 months
on complications reported in the MUA literature. that is unresponsive to prior care, including spinal
manipulation therapy, patients with severe pain that
precludes administration of manipulation without the
MANIPULATION UNDER JOINT
assistance of medication, or patients with complex
ANESTHESIA/ANALGESIA
problems requiring the diagnosis of synovial joint-
Echoing the calls for interprofessional cooperation mediated pain are all suitable candidates for MUJA.
between medical doctors and chiropractors, Mark They believe that the anesthetic component of
Michaelsen, DC, and Paul Dreyfuss, MD, have cham- MUJA provides the following potential clinical and
pioned a specific approach combining manual ther- diagnostic benefits: A single anesthetic block of the
apy with intraarticular injections of medication zygapophyseal joint or sacroiliac joint and its capsule
(see sidebar, “Manipulation Under Joint Anesthesia– that would block the pain-mediated nerve supply may
Analgesia (MUJA)”). They define manipulation under tentatively confirm or deny the working diagnosis of
TABLE 43–3. Reported Complications of Manipulation Under Anesthesia
Number of Complication Rate∗

Reported Complications Patients (%)
One patient out of 75 reported worse back pain as a result of manipulation. Upon 75 1.3
examination, she displayed diffuse tenderness of entire back, but good flexibility
despite radiological evidence of osteoarthritic lipping of the lumbar vertebral
bodies.
One of 13 patients with myelographic evidence of herniated intervertebral disc 13 7.7
showed a slight increase in the defect immediately following manipulation with
anesthesia or analgesia. This patient also noted increased pain in his back and
leg, which subsided in 2 days.
No reported complications in a series of 100 low back manipulations under general 87 0
anesthesia involving 87 different patients.
No aggravation of symptoms by manipulation for the 205 patients in this study. No 205 0
occurrence of motor weakness, paralysis, or complication of the bladder or rectal
sphincter.
No reported complications in a series of 723 cases of manipulation under 666 0
anesthesia performed on 666 separate patients (including the 87 patients
contained in Siehl and Bradford’s 1952 report).2
Five of 39 patients complained of increased lumbosacral pain and muscle tightness 39 13
immediately following manipulation under anesthesia.
No reported complications in 21 patients receiving manipulation under anesthesia 21 0
(MUA)
No reported complications in 119 patients undergoing manipulation under 119 0
anesthesia, 93 receiving lumbar spine manipulation, and 26 receiving
manipulation of the cervical spine.
Four of 171 patients receiving manipulation of the lumbar and/or cervical spine 171 2.3
under anesthesia experienced complications. Two lumbar spine patients were
returned to the operative suite because of intractable respiratory distress, which
was resolved with Valium. Two patients experienced severe pain in the sacroiliac
joints, which prevented leg movement for 3–7 days. Both patients recovered
completely within 10 days.
Case report with full resolution of symptoms and 12-month follow-up. Author states 1 0
similar results in more than 20 MUAs performed, but offers no details.
No reported complications in this study of 100 consecutive cases with pain arising 32 0
from cervical spine. Thirty-two patients received MUA of the cervical spine.
Case report with full resolution of presenting symptoms (painful stiffness of cervical 1 0
spine, intractable nausea) lasting for at least the following 18 months.
Case report of MUA for low back pain with satisfactory results. 1 0
Case report of MUA series for patient suffering restricted cervical spine motion, 1 0
pain, and paresthesia following a motorcycle accident. Resolution of symptoms
reported.
Two case reports of MUA for chronic, severe, low back pain and sciatica that failed 2 0
to respond to numerous surgeries.
Marked improvement in pain and function with decreased dependence on
medication use was reported for both patients.
No complications reported in a case series of 177 patients receiving MUA. 177 0
Case report of MUA for patient with cervical disk herniation, cervical radiculopathy, 1 0
and cervicogenic headache. Patient reported 95% improvement in overall condition.
∗
Total represents unique patients taking into account the duplication of the 87 patients appearing in Siehl and Bradford’s 19522 study and follow-up
study by Siehl in 1963.3
Z-joint- or sacroiliac joint-mediated pain and the anes- procedure may be short-lever, high-velocity low-
thetic block provides a brief window of opportunity amplitude manual techniques, or less forceful spinal
for spinal manipulation while the patient is relaxed joint mobilization therapy. Six to eight sessions
and in a relatively pain-free state. The addition of the of spinal manipulation therapy are recommended
corticosteroid component of MUJA may provide at within the first 10–12 days after the intraarticu-
least two additional benefits: The corticosteroid agent lar injections of anesthetic and corticosteroid. Ac-
alone may provide long-lasting therapeutic effect by tive therapies, such as muscle stretching exercises,
reducing inflammation, and the corticosteroid may aerobic and general conditioning, and strengthening
extend the window of opportunity for spinal manip- exercises, that were not well tolerated before the in-
ulation beyond the anesthetic effects. jection may then be introduced.
Michaelsen and Dreyfuss are cautious regarding
definitive statements concerning MUJA outcomes. Al- Reported Complications
though they report that more than 1000 patients have Having treated more than 1000 patients, Michaelsen
been treated with MUJA over a 7-year period,22 they and Dreyfuss report no complications associated with
recognize a lack of controlled clinical trials or large this technique.22,23
case series supporting these techniques. Detailed case
reports present outcomes of four patients treated with
MANIPULATION UNDER EPIDURAL
MUJA.18 These patients are described as suffering
ANESTHESIA
from lumbar zygapophyseal joint- and/or sacroiliac
joint-mediated pain, which was diagnosed by fluo- Manipulation under epidural anesthesia (MUEA) has
roscopically guided, contrast-enhanced, intraarticular been called a conservative modification of MUA.24 It
anesthetic injections. Each of the four patients had is defined as the use of an epidural segmental anes-
an extensive treatment history, including care pro- thetic, often with simultaneous epidural steroid injec-
vided by family doctors, physiatrists, physical ther- tion, followed by spinal manipulation.
apists, chiropractors, and/or neurologists before un-
dergoing MUJA. The main outcome measure reported Reported Indications
was improvement in pain with each patient experienc- A number of case series and reports propose clini-
ing between 90 and 100% improvement, which was cal indications for MUEA, including chronic mechan-
sustained for a follow-up period of between 4 and ical low back pain, lumbosciatic pain, and recalcitrant
6 months. lumbar radiculopathy.11,19,23,25 Suggested benefits of
MUEA relative to MUA as articulated by Bruce Ben-
Protocol David, MD, and Martin Raboy, DC, are that MUEA
Michaelsen and Dreyfuss are quite precise regard- is a less costly alternative to MUA, patients may be
ing the MUJA protocol. They insist on fluoroscopy- more receptive to the use of local anesthetic rather
guided joint injections of anesthetic and/or corticos- than general anesthesia, and the use of steroid injec-
teroid agents to guide the delivery of medication to tions during the procedure may reduce inflammation
the desired area. Using a radiopaque contrast agent and inhibit reformation of fibrosis and adhesions.26
to confirm needle placement, injected material is de- Table 43–4 contains several case reports and case
livered to the joint or into the tissues surrounding the series that describe the use of MUEA with or without
pain-mediated nerve supply. An anesthetic agent is epidural steroid injection. Ben-David and Raboy26 and
injected into the joint with or without corticosteroids. Aspegren et al.24 present two case reports investiga-
If the injection establishes a diagnosis of predomi- ting the use of MUEA with epidural steroid injection.
nant joint-mediated pain, manipulation is then ap- The use of MUEA with epidural steroid injection
plied. Michaelsen and Dreyfuss state that a minimum for the treatment of one case of L5 intervertebral
of 50% reduction in pain is needed for the patient to disc (IVD) syndrome with peridural scar formation
progress to same-day manipulation. Pain reduction and one case of L4 IVD with radiculopathy is re-
less than this threshold indicates additional pain gen- ported by Aspegren et al.24 Both patients underwent
erators other than the joints injected. A 90–100% pain a trial of conventional care, including oral medica-
reduction following the injection of anesthetic agent tions, physical therapy, and spinal manipulation, be-
is considered a strong indication that the injected sites fore undergoing MUEA with epidural steroid injec-
are the anatomic structures responsible for the pation. Visual Analogue Scales, Oswestry Disability In-
tient’s pain.22 dex, and pain drawings were used to document clini-
Michaelsen suggests that the manipulative pro- cal improvement. Another three cases of MUEA with
cedures used during MUJA are like any other ma- epidural steroid injection are provided by Ben-David
nipulation and no special facility or certification is and Raboy.26 Two patients experienced prior fail-
required.22 Manipulative procedures used with this ure of manipulation therapy administered with no
TABLE 43–4.Selected Case Series and Case Reports for Manipulation Under Epidural
Anesthesia (MUEA)
Number of
Procedure Patients Condition Medication Manual Therapy Outcome
Pressure caudal 62 Low back pain with Morphine, scopolamine Long-lever technique Excellent: 53%;
anesthesia with sciatic 20–30 cc of 1% good: 31%; no
and without neuropathy Xylocaine; 40 mg therapeutic
steroid hydrocortisone tertiary effect: 16%
injection30 butylacetate; saline
MUEA with 500 Chronic 40 mL of 0.75% lidocaine; Rotation of spine; 63% success rate
epidural steroid lumbosciatic 80 mg bilateral stretching (success =
injection (ESI)28 syndrome methylprednisolone; of sciatic nerve complete or near
25 mg hydrocortisone complete relief of
acetate; 300–500 mg all symptoms)
propanidid with 0.6 mg IV
atropine (two-thirds of
patients); general
anesthesia (one-third of
patients)
MUEA with ESI26 3 Low back pain 8 mL of 1.5% lidocaine; Short-lever technique 80–100% pain
80 mg methylprednisolone resolution;
improved function
MUEA with ESI29 10 Chronic low back 10 mg diazepam (oral); 4 cc Short-lever technique Mean improvement
pain of 2% lidocaine; 3.5 cc of 25% on
saline; 15 mg Celestone “improvement
scale”
MUEA with ESI24 2 Recalcitrant 8 cc of 0.25% Marcaine; Passive stretching; Pain reduction;
lumbar 2 cc betamethasone short-lever improved range of
radiculopathy technique motion
accompanying injection. One patient failed to expe- provement reported subsequent to their results with
rience improvement when administered only epidu- earlier conventional care. A large case series by Warr
ral steroid injection with no manipulation therapy. et al. followed 500 patients who had not responded
All three patients reported dramatic immediate im- to conservative care.28 Patients treated with manipu-
provement when manipulation therapy and epidu- lation and epidural steroid injection reported a suc-
ral steroid injection were administered together. Al- cess rate of 63% (defined as complete or near com-
though the effect was transient, the authors report that plete relief of all symptoms, lack of recurrence within
subsequent response to clinical management with ma- the follow-up period, and no requirement of further
nipulation appeared to be enhanced. treatment) with the immediate favorable results ex-
The use of epidural steroid injection and local anes- tending for at least 6 months. The temporary relief
thesia with manipulation is reported in case series experienced by the remaining 37% of patients was at-
detailing patients with chronic mechanical low back tributed to the effects of the steroid injection. Another
pain and chronic lumbosciatic syndrome.12,23,27 A ret- cases series presents an additional 62 cases of patients
rospective analysis by Nelson et al. reports the re- experiencing low back pain following trauma.23 All
sults of 10 of 17 cases of chronic low back pain ex- patients had undergone long periods of conservative
periencing suboptimal (less than 50% improvement) therapy, including bed rest, traction, physical ther-
response to prior conventional care.29 Using an “im- apy, and back supports, which achieved transient re-
provement scale” consisting of a line marked in 10% lief of pain. Twenty-one patients had a prior history
increments from 0% (no improvement) to 100% (com- of surgery. Manipulation following pressure caudal
plete improvement), the patients reported an average anesthesia was administered in all patients and 20 pa-
improvement of 25% with manipulation combined tients also received steroid injections. Excellent results
with epidural steroid injection over and above any im- (i.e., complete and persistent relief of sciatic root pain
for a minimum of 3 months) were reported in 53% the use of cortisone injections into the paracoccygeal
of patients, good results (i.e., transitory elimination structures and into the insertion of the piriformis mus-
or striking reduction of persistent root pain following cle on the greater trochanter as an essential component
each procedure) were reported in 31% of patients, and of a pragmatic approach to low back pain, which also
no appreciable benefit was reported in 16% of patients. includes the use of manipulation, specific mobiliza-
tion, muscle stretching, home exercises, and traction.31
Protocol Seven years earlier, Ongley et al. described an ap-
A medical doctor skilled in epidural injections ad- proach to treatment of chronic low back pain consist-
ministers epidural anesthesia, typically incorporating ing of an injection of a proliferant solution into sacroil-
steroids. A solution containing saline, analgesic, and iac and paraspinal ligaments, which was considered to
antiinflammatory agents such as lidocaine and Cele- be of value when used in conjunction with manipula-
stone or methylprednisolone is injected with fluoro- tion, local anesthesia, and repeated flexion exercises.32
scopic guidance to assure proper needle placement. These regimens were proposed as new approaches for
Spinal manipulation and mobilization of the lumbar the treatment of low back pain and both use injections
spine are usually performed within an hour or so of as one component of a more comprehensive protocol,
the injection. Use of localized injection rather than sys- which also incorporates mobilization and manipula-
temic anesthesia allows the patient a higher level of tion (see sidebar, “Manipulation with Adjuvant Injec-
interaction during manipulation, which can be per- tion”).
formed without the help of a first assistant as is nec-
essary with MUA. The more recent case series and
reports describe a single application of the MUEA Manipulation with Adjuvant Injection
procedure, while the earlier series by Warr et al. doc- Examples with definitions
uments administration of a second epidural injection Manipulation with local steroid injections: Specific man-
if symptoms remained upon evaluation 2 weeks after ual treatment is combined with local anesthetic and corti-
the first injection and manipulation.24,26,28,29 Follow- sone injections. Injection sites determined by physical ex-
up treatment consists of stretching, manipulation, and amination, including palpation.
therapeutic modalities as indicated. Manipulation with proliferant injections: Spinal manip-
ulation is combined with injections of dextrose-glycerin-
Reported Complications
phenol (“proliferant”) solution into soft-tissue structures.
Warr et al.’s 1972 article reports no serious compli- Indications
cation in 500 patients who received manipulation Patients with acute or subacute low back pain re-
with epidural injections, although thecal puncture oc- sponded well to a regimen combining manipulation therapy
curred in 7 (1.4%) cases.28 In these cases, the proce- with local injections of anesthesia and steroids.
dure was abandoned and the epidural injections were Patients with chronic low back pain responded well to
performed successfully 1 week later.28 Brown’s 1960 a protocol combining manipulation therapy with proliferant
study of patients receiving pressure caudal anesthe- injection.
sia in combination with low back manipulation docu- Reported results
ments 4 (6.7%) of 62 cases in which a mild transitory Blomberg et al.’s 1994 randomized controlled trial
(lasting a few seconds) tetanic convulsive episode de- (48 cases, 53 controls) reported statistically signifi-
veloped after 30–40 cc of saline had been injected.30 cant differences favoring the experimental group (local
These episodes were not recognized by the patients injections with manual therapy) over the conventional
and did not produce sequelae. Discontinuation of in- treatment group for such outcomes as range of motion,
jection allowed for successful completion of the ma- standardized physical exam, low back examination, and
nipulation. The more recent case reports and series neurologic findings.
describing currently used fluoroscopically guided in- Ongley et al.’s 1987 randomized controlled trial inves-
jection techniques report no complications.24,26,29 tigating the combination of manipulation with proliferant
injection reported statistically significant differences fa-
voring the experimental over the placebo groups for out-
MANIPULATION WITH PROLIFERANT
come measures, including a disability index, Visual Ana-
OR STEROID INJECTION
logue Scale, and pain diagram.
In addition to the above-described combination ther-
apies, other medication-assisted manipulation ther- Data from Blomberg S, Hallin G, Grann K, Berg E, Sennerby U.
Manual therapy with steroid injections: A new approach to treat-
apies pairing spinal manipulation with injection are ment of low back pain. A controlled multicenter trial with an eval-
discussed in the literature, including manipulation uation by orthopedic surgeons. Spine 1994;19:569–577; and
combined with cortisone injections into paraspinal Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ. A new
approach to the treatment of chronic low back pain. Lancet
tissues or intraligamentous proliferant injections. In 1987;2:143–146.
an article published in 1994, Blomberg et al. discuss
Reported Indications totraction as well. Manual therapies were adminis-

Both of these articles suggest that these treatment pro- tered to patients for 1–2 weeks prior to the procedure
tocols represent a new approach to the treatment of that combined manual therapies with the injections.
low back pain. More specific indications are not pro- Further evaluation of patients nonresponsive to man-
posed, with the population of patients studied con- ual therapies during the first 2 weeks was performed
sisting of acute and subacute subjects with low back using palpation of the paracoccygeal structures and
pain or patients with chronic low back pain.32 piriformis insertion on the greater trochanter. Palpa-
Blomberg et al.’s studies of manual therapy tion findings guided application of local anesthetic
with steroid injections in a multicenter trial com- and steroid injections. Physicians and physical thera-
pare the outcomes of 53 acute or subacute low pists provided follow-up care for patients experienc-
back pain patients who received conventional treating recurrence of pain.
ment to 48 patients who received the experimental A detailed description of a 6-week treatment proto-
treatment, which included manipulation, mobiliza- col combining injection of a proliferant solution with
tion, muscle stretching, autotraction, and cortisone local anesthetic and a single administration of long-
injections.31 Outcomes favor the experimental group, lever manipulation of the lumbar and sacroiliac ar-
revealing reduction in objective findings of low back eas is contained in Ongley et al.’s 1987 article.32 The
pain on physical examination, decreased pain, drug first visit began with all patients receiving 10 mg di-
consumption, sick leave, and disability rating, as well azepam intravenously for relaxation and amnesia. Us-
as an increase in quality of life. The authors concluded ing a single insertion point at the L5 spinous process
that manual therapy with cortisone injections is supe- and a rigid needle, a maximum of 10 mL of 0.5% lido-
rior to primary care conventional activating treatment caine was injected at the tip of the L4 and L5 spinous
while appearing to be less costly. These improvements processes and associated ligaments; the attachment of
seem to be maintained after long-term follow-up. the ligamentum flavum along the borders of the L4
Ongley’s study randomized 81 chronic low back and L5 laminae; apophyseal joint capsules at L4-L5
pain patients into two treatment groups.32 Forty and L5-S1; the attachment of the iliolumbar ligament
patients in the experimental group received manip- on the transverse processes of L4 and L5; the attach-
ulation and injections of local anesthesia (dilute lido- ment of the iliolumbar ligament and dorsolumbar fas-
caine) and a proliferant solution containing dextrose- cia to the iliac crest; and the attachments of short and
glycerin-phenol. Forty-one patients in the control long fibers of the posterior sacroiliac ligaments and the
group received treatment with less extensive use of sacral and iliac attachments of the interosseous sacroil-
initial local anesthesia and manipulation and the sub- iac ligaments. Additionally, 50 mg triamcinolone in
stitution of saline for the proliferant solution. Out- 10 mL of 0.5% lidocaine was injected into the origin
comes were measured using a modified Roland- of the gluteus medius. Manipulation of the lumbar
Morris disability index, the Waddell chronic disability and sacroiliac areas with an assistant immobilizing
index, and a visual analogue scale (VAS). Greater im- the patient’s thorax and the therapist using the thigh
provement in disability and pain scores was reported as a lever to apply rotary and flexion forces was per-
for the experimental group at follow-ups of 1, 3, and formed after the injections. Proliferant solution injec-
6 months. Thirty-five (88%) of 40 patients in the ex- tion was repeated on a second visit in which flexion ex-
perimental group reported greater than 50% improve- ercises were introduced, consisting of repeated active
ment in disability scores as compared with 16 (39%) forward flexion of the lumbar region in a standing or
of 41 patients in the control group. Six-month data seated position. Weekly injections of proliferant solu-
revealed mean disability scores of 3.41 (with 33 rep- tion were administered during the remaining 6 weeks
resenting most disability) in the experimental group with continuation of flexion exercises.
and 8.29 in the control group (p <0.001). Differences
in reported pain (measured using a visual analogue Reported Complications
scale with a maximum of 7.5) at 6 months were also Patient complaints of pain and stiffness for 12–
statistically significant (p <0.001) between the exper- 24 hours after each injection were reported for both
imental group (VAS = 1.5) and the control group groups of patients in Ongley’s proliferant study. An
(VAS = 3.08). increase in menstrual flow was observed for two pa-
tients in the experimental group and for one patient
Protocol in the control group. Two patients in the experimental
Blomberg et al. describe a protocol combining ma- group had postmenopausal spotting 4 weeks after the
nipulation, mobilization, muscle stretching, home start of treatment. One patient in the control group
exercises, autotraction, and cortisone injections.31 Ma- withdrew after the injection on day 2 because of a se-
nipulation with “thrust” techniques or specific mo- vere headache and cough.32 No complications were
bilization of the low back and sacroiliac joints was reported by Blomberg et al. for the patients who re-
provided to all patients. Fifteen patients received au- ceived manual therapy with steroid injections.31
Although there is a growing body of literature

CONTRAINDICATIONS FOR
supporting use of spinal manipulation in select
MEDICATION-ASSISTED SPINAL
patient populations, further research is required to
MANIPULATION
match adjustive techniques with specific patient
Suggested contraindications are categorized as ab- presentations and diagnoses. Controlled clinical trials
solute and relative and may be further discussed in investigating epidural injections and local injections
terms of the component procedures acting separately of anesthetics, steroids, and proliferant agents are
or synergistically. Contraindications to spinal manip- scarce and equivocal. Even scarcer are randomized
ulation therapy without the use of adjuvant med- controlled trials studying the combination of these
ication should also be considered contraindications component therapies. A review of the medication-
to medication-assisted spinal manipulation. Medical assisted manual therapy literature identifies only
conditions that preclude the use of analgesia, anesthe- two randomized controlled trials: one assessing a
sia, or injection of corticosteroids and/or proliferant protocol that combines local proliferant injection with
solution should also be considered contraindications manipulation and mobilization and one assessing the
for these combination therapies. integration of local steroid injection within a prag-
Specific absolute contraindications include any matic manual therapy regimen.31,32 No randomized
form of primary or secondary malignant process in- controlled trials were unearthed that investigate
volving the spinal cord or vertebral structures. Joint MUA, MUJA, and MUEA protocols.
hypermobility or instability, acute inflammatory con- While existing literature remains insufficient to ad-
ditions, bone/joint infection, acute bone fracture in the equately assess effectiveness, tentative statements re-
area to be treated, progressive neurological deficits, garding the oft-raised question of safety may be made.
and the presence of large aortic aneurysms also repre- If one assumes that the existing clinical trials suffi-
sent absolute contraindications. Relative contraindi- ciently tracked and reported complications, adverse
cations include such conditions as osteoporosis, reactions appear minimal and compare favorably with
herniated nucleus pulposus, prior spinal surgery to alternative treatments for patients with the clinical
treatment area, and other relative contraindications of presentations most cited in these studies. However,
spinal manipulation therapy. Existence of these con- it is reasonable to consider that the addition of anes-
ditions may warrant a more careful administration or thesia, conscious sedation, segmental anesthesia, and
modification of the manipulation technique. local injections to spinal manipulation therapy intro-
Potential additional risks are introduced by the duces increased potential for risk. Cautious optimism
use of an anesthetic agent. Anesthesia and seda- cannot replace the need for further and more rigorous
tion reduce the patient’s ability to provide immedi- safety assessment. Additionally, as with any therapy,
ate feedback of experienced pain or to guard against clinicians using these techniques should be properly
overzealous administration of manual techniques. Di- trained in order to minimize any associated potential
minished soft-tissue support of joint complexes in the risk.
sedated patient demands more judicious and, typi-
cally, lighter application of adjustive forces. Because of
the potential numerous changes in patient positioning
SUMMARY
and the diminished respiratory control in patients re-
ceiving medication-assisted manipulation procedures 1. Medication-assisted manipulation techniques fell
that combine anesthesia or conscious sedation with largely in the domain of medical manipulators
mobilization and manipulation maneuvers, close at- during the middle part of the past century. Use
tention must be given to the monitoring and preser- shifted to osteopathic physicians as medical physi-
vation of adequate patient respiration. cians’ reliance on surgical techniques increased.
Further evolution has resulted in chiropractic
physicians increasingly demonstrating the major-
CONCLUSION
ity of interest, clinical application, and technique
Discussion of medication-assisted manipulation development of medication-assisted manipulation
tends to address general issues pertinent to any protocols.
treatment regimen for patients with spinal disorders. 2. Medication-assisted manipulation techniques can
Primary questions concern risks versus benefits be classified as manipulation under anesthesia,
of these procedures as well as effectiveness and manipulation under joint anesthesia/analgesia,
reasonable alternative treatments. The underlying manipulation under epidural anesthesia, and ma-
rationale that these combination therapies are more nipulation with local injections.
effective than their distinct components is difficult 3. Clinical investigations of manipulation under
to assess given the current state of knowledge. anesthesia appear in the professional literature as
early as 1930 in a case series reported by E. W.

QUESTIONS
Riches in The Lancet. Reports of clinical investi-
gations by Siehl, Mensor, Chrisman, and Morey 1. What are the names and definitions of four main
firmly grounded manipulation under anesthe- subcategories of medication-assisted manipula-
sia protocols in the literature. More recent arti- tion?
cles by West, Michaelsen and Dreyfuss, Nelson, 2. What is the rationale cited for the use of anesthetic
Blomberg, and Ongley document current manipu- and analgesic agents in combination with spinal
lation under anesthesia, as well as other variations manipulation therapy?
of medication-assisted manipulation techniques. 3. How do manipulation under epidural anesthesia
4. Manipulation under anesthesia refers to manip- (MUEA) and manipulation under joint anesthe-
ulation of the spine while the patient is under sia/analgesia (MUJA) differ from manipulation
general anesthesia or conscious sedation. Manip- under anesthesia (MUA)?
ulation under joint anesthesia/analgesia is de- 4. Why does Ongley believe that the introduction
fined as the use of fluoroscopically guided intraar- of proliferant agents is beneficial when combined
ticular injections of anesthetic and corticosteroid with spinal manipulation?
agents followed by specific segmental adjusting 5. What does the literature offer regarding the safety
and mobilization of targeted joints. Manipulation of medication-assisted manipulation?
under epidural anesthesia uses segmental epidu-
ral anesthesia in combination with spinal manip-
ulation of the low back, often in conjunction with
ANSWERS
epidural steroid injection. Manipulation with ad-
juvant local injections represent another subclass 1. The four subcategories of medication-assisted ma-
of medication-assisted manipulation using proto- nipulation discussed and defined in this chap-
cols such as the combination of manual therapy ter are manipulation under anesthesia (MUA),
with local injection of proliferant solutions or lo- which refers to the application of spinal manip-
cal injection of analgesic and antiinflammatory so- ulation therapy to a patient while under general
lutions in soft-tissue structures of symptomatic anesthesia or conscious sedation; manipulation
regions. under joint anesthesia/analgesia (MUJA), which
5. Rationales for the addition of these techniques to Dreyfuss and Michaelsen define as the synthe-
the clinician’s armamentarium revolve around the sis of fluoroscopically guided intraarticular injec-
assumption that the combination therapies may tions of anesthetic and corticosteroid agents and
be more effective than the component parts. Anes- subsequent specific mobilization and manipula-
thesia and analgesia introduce an opportunity to tion of the injected joints; manipulation under
apply adjustive techniques to a patient with re- epidural anesthesia (MUEA), which is defined as
duced pain and muscle spasm. Intraarticular in- the use of epidural segmental anesthetic followed
jections provide diagnostic capabilities, as well as by spinal manipulation; and manipulation with
a relatively pain-free window of time in which ma- local injections of antiinflammatory and/or pro-
nipulation therapy can be administered. Local in- liferant agents, which represents an additional,
jection of antiinflammatory or proliferant agents more loosely defined, subcategory of medication-
may enhance the effectiveness of manual therapy. assisted manipulation.
The addition of adjuvant medication presents the 2. The rationale cited for the use of anesthetic and
potential for increased risk relative to standard analgesic agents in combination with adjustive
spinal manipulation therapy, although reported techniques is that they help to eliminate or reduce
complications with currently used techniques are pain and muscle spasm that may hinder the ef-
rare. fective use of traditional spinal manipulation or
6. Medication-assisted manipulation protocols are manual therapies.
typically taught through postgraduate and con- 3. The main difference between manipulation under
tinuing education courses. These courses empha- anesthesia and the techniques using manipulation
size manipulation under anesthesia techniques. under epidural anesthesia or manipulation under
Non-MUA medication-assisted protocols are not joint anesthesia/analgesia is that the application
as widely established and appear to represent less of the anesthetic agent is local as opposed to sys-
prevalent evolutions or modifications of MUA. temic in these latter protocols. Manipulation un-
7. Professions espousing the use and merits of these der anesthesia uses general anesthesia or systemic
techniques should pursue additional investigation conscious sedation while MUEA and MUJA use
of medication-assisted manipulation protocols us- either segmental epidural anesthesia or intraartic-
ing rigorous methodology. ular injection of anesthesia/analgesia.
4. Ongley’s justification for the added use of pro- 7. Morey LW Jr. Osteopathic manipulation under general
liferant agent injections with spinal manipulation anesthesia. J Am Osteopath Assoc 1973;73:116–127.
therapy is that he believes these solutions encour- 8. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL,
age collagen growth, thereby strengthening liga- Brook RH. Spinal manipulation for low-back pain. Ann
ments and retaining the effects of manipulation Intern Med 1992;117:590–598.
9. West DT, Mathews RS, Miller MR, Kent GM. Effective
for a longer duration.
management of spinal pain in one hundred seventy-
5. If one assumes that the existing clinical trials suf- seven patients evaluated for manipulation under anes-
ficiently tracked and reported complications, ad- thesia. J Manipulative Physiol Ther 1999;22:299–308.
verse reactions appear minimal and compare fa- 10. Beckett RH, Francis R. Spinal manipulation under
vorably with alternative treatments for patients anesthesia. In: Lawrence DJ, ed. Advances in chiroprac-
with the clinical presentations most cited in these tic. Vol. 1. St Louis: Mosby-Year Book, 1994:325–340.
studies. 11. Greenman PE. Manipulation with the patient under
anesthesia. J Am Osteopath Assoc 1992;92:1159–1160,
KEY REFERENCES 1167–1170.
12. Francis RS. Manipulation under anesthesia. Postgradu-
Beckett RH, Francis R. Spinal manipulation under anes- ate course sponsored by Texas Chiropractic College,
thesia. In: Lawrence DJ, ed. Advances in chiropractic. Pasadena, TX: 2000.
Vol. 1. St. Louis: Mosby-Year Book, 1994:325–340. 13. Gordon R. Manipulation under anesthesia. Course spon-
Blomberg S, Hallin G, Grann K, Berg E, Sennerby U. Man- sored by the National-Lincoln School of Postgraduate
ual therapy with steroid injections—A new approach Education, a division of the National College of Chiro-
to treatment of low back pain. A controlled multicenter practic, Lombard, IL: 2001.
trial with an evaluation by orthopedic surgeons. Spine 14. California Academy for Manipulation under anesthesia
1994;19:569–577. guidelines. Manhattan Beach, CA: Innercalm Asso-
Dreyfuss P, Michaelsen M, Horne M. MUJA: Manipulation ciates, 2001.
under joint anesthesia/analgesia: A treatment approach 15. Siehl D, Olson DR, Ross HE, Rockwood EE. Manipu-
for recalcitrant low back pain of synovial joint origin. lation of the lumbar spine with the patient under gen-
J Manipulative Physiol Ther 1995;18:537–546. eral anesthesia: Evaluation by electromyography and
Nelson L, Aspegren D, Bova C. The use of epidural steroid clinical–neurologic examination of its use for lumbar
injection and manipulation on patients with chronic low nerve root compression syndrome. J Am Osteopath As-
back pain. J Manipulative Physiol Ther 1997;20:263–266. soc 1971;70:433–440.
Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ. A 16. Krumhansl BR, Nowacek CJ. Manipulation under
new approach to the treatment of chronic low back pain. anaesthesia. In: Grieve GP, ed. Modern manual therapy of
Lancet 1987;2:143–146. the vertebral column. Edinburgh: Churchill Livingstone,
Siehl D. Manipulation of the spine under general anesthesia. 1986:777–786.
J Am Osteopath Assoc 1963;62:881–887. 17. Alexander GK. Manipulation under anaesthesia of
West DT, Mathews RS, Miller MR, Kent GM. Effective man- lumbar post-laminectomy syndrome patients with
agement of spinal pain in one hundred seventy-seven epidural fibrosis and recurrent HNP. ACA J Chiropr
patients evaluated for manipulation under anesthesia. 1993;6:79–82.
J Manipulative Physiol Ther 1999;22:299–308. 18. Hughes BL. Management of cervical disk syndrome
utilizing manipulation under anesthesia. J Manipulative
Physiol Ther 1993;16:174–181.
REFERENCES 19. Herzog J. Use of cervical spine manipulation under
anesthesia for management of cervical disk hernia-
1. Wilson JN, Ilfeld FW. Manipulation of the herniated tion, cervical radiculopathy, and associated cervico-
intervertebral disc. Am J Surg 1952;83:173–175. genic headache syndrome. J Manipulative Physiol Ther
2. Siehl D, Bradford WG. Manipulation of the low 1999;22:166–170.
back under general anesthesia. J Am Osteopath Assoc 20. Davis CG, Fernando CA, da Motta MA. Manipula-
1952;8:239–242. tion of the low back under general anesthesia: Case
3. Siehl D. Manipulation of the spine under general anes- studies and discussion. J Neuromusculoskel Syst 1993;1:
thesia. J Am Osteopath Assoc 1963;62:881–887. 126–134.
4. Mensor MC. Non-operative treatment, including ma- 21. Riches EW. End-results of manipulation of the back.
nipulation, for lumbar intervertebral disc syndrome. Lancet 1930;1:957–960.
J Bone Joint Surg 1955;37A:925–936. 22. Michaelsen MR, Dreyfuss PH. Manipulation under
5. Chrisman OD, Mittnacht A, Snook GA. A study of joint anesthesia/analgesia: A proposed interdisci-
the results following rotatory manipulation in the plinary treatment approach for recalcitrant spinal axis
lumbar intervertebral-disc syndrome. J Bone Joint Surg pain of synovial joint origin. In: Lawrence DJ, ed. Ad-
1964;46:517–524. vances in chiropractic. Vol. 4. St. Louis: Mosby, 1997:41–
6. Rumney IC. Manipulation of the spine and appendages 68.
under anesthesia: An evaluation. J Am Osteopath Assoc 23. Dreyfuss P, Michaelsen M, Horne M. MUJA: Manip-
1968;68:235–245. ulation under joint anesthesia/analgesia: A treatment
approach for recalcitrant low back pain of synovial joint 28. Warr AC, Wilkinson JA, Burn JM, Langdon L. Chronic
origin. J Manipulative Physiol Ther 1995;18:537–546. lumbosciatic syndrome treated by epidural injection
24. Aspegren DD, Wright RE, Hemler DE. Manipula- and manipulation. Practitioner 1972;209:53–59.
tion under epidural anesthesia with corticosteroid in- 29. Nelson L, Aspegren D, Bova C. The use of epidu-
jection: Two case reports. J Manipulative Physiol Ther ral steroid injection and manipulation on patients
1997;20:618–621. with chronic low back pain. J Manipulative Physiol Ther
25. Francis R. Spinal manipulation under general anesthe- 1997;20:263–266.
sia: A chiropractic approach in a hospital setting. ACA 30. Brown JH. Pressure caudal anesthesia and back manip-
J Chiropr 1989;12:39–41. ulation. Northwest Med 1960;59:905–909.
26. Ben-David B, Raboy M. Manipulation under anesthesia 31. Blomberg S, Svardsudd K, Tibblin G. A randomized
combined with epidural steroid injection. J Manipula- study of manual therapy with steroid injections in low-
tive Physiol Ther 1994;17:605–609. back pain. Telephone interview follow-up of pain, dis-
27. Hurwitz EL, Aker PD, Adams AH, Meeker WC, ability, recovery and drug consumption. Eur Spine J
Shekelle PG. Manipulation and mobilization of the 1994;3:246–254.
cervical spine. A systematic review of the literature 32. Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ.
[see comments]. Spine 1996;21(15):1746–1759; discus- A new approach to the treatment of chronic low back
sion 1759–1760. pain. Lancet 1987;2:143–146.
C H A P T E R
44
THE USE OF PHYSICAL MODALITIES
Paul D. Hooper
O U T L I N E
INTRODUCTION Pulse Intensity
GOALS FOR PASSIVE MODALITIES Pulse Frequency
PHYSICS OF THERAPEUTIC MODALITIES Pulse Mode (Delivery Method)
Electromagnetic Spectrum Pulse Duration (Pulse Width)
Laws of Physics Applied to Electromagnetic Energy Polarity
TYPES OF PASSIVE MODALITIES Electrodes
Therapeutic Heat and Cold (The Infrared Modalities) Electrode Placement
Cryotherapy Types of Electrical Stimulation Devices
Ice Packs —Direct Current Stimulators
Ice Massage —Alternating Current Stimulators
Cold Spray (Vapocoolant) Traction
Hydrocollator Packs Types
Paraffin Baths —Manual Traction
Other Forms —Continuous Traction
Therapeutic Ultrasound —Sustained (Static) Traction
Application Parameters —Intermittent Traction
Electrotherapy —Intersegmental Traction
Definition of Terms Distraction Adjusting
Alternating and Direct Current Splints, Braces, and Orthotics
Physiological Response to Electricity SUMMARY
Pulsed and Nonpulsed Current QUESTIONS
Pulse Parameters ANSWERS
Pulse Shape (Waveform) REFERENCES
1. To review the goals of physical modalities. While manipulation is the treatment used most often
2. To briefly review the principles of electromagnetic by chiropractors, it is not the only treatment offered by
energy. most practitioners. Chiropractors have long incorpo-
3. To review the different types of heat and cold rated various physical agents in their treatment reg-
modalities. imen. As far back as 1911, Alva Gregory, founder of
4. To review the use of therapeutic ultrasound. the Palmer-Gregory College of Chiropractic in Okla-
5. To review the use of electrotherapy. homa City, recommended the use of spondylotherapy,
6. To review the use of splints, braces, and orthopedic which included the use of traction, massage, and ther-
devices. apeutic heat.1
861
The use of various physical modalities can be modalities should be used mainly during the early
broadly divided into two important categories: pas- phases of care, when symptoms such as pain, muscle
sive modalities and active modalities. The passive spasm, and swelling predominate. Whatever the na-
modalities include those treatment procedures that ture of the specific condition, the primary goals of the
do not require any effort on the part of the patient. passive modalities during the acute period are2
In other words, the patient is a passive recipient of
1. Pain relief (e.g., TENS, ultrasound, ice, heat, trac-
the therapy, and often receives the treatment while
tion, braces and supports)
quietly lying on a treatment table. Such therapies are
2. Controlling swelling and edema (e.g., electrical
very common in the chiropractic clinic. Included in
stimulation, ultrasound, ice, heat)
this category are treatment procedures such as man-
3. Reducing muscle tension (e.g., electrical stimula-
ual massage, various forms of heat and cold, electrical
tion, heat, massage, traction)
stimulation, therapeutic ultrasound, manual and me-
4. Improving circulation (e.g., electrical stimulation,
chanical traction, and splints and braces. In contrast
heat, ultrasound)
to the passive modalities, active modalities call for
5. Promoting tissue healing (e.g., electrical stimula-
some form of active participation on the part of the pa-
tion, microcurrent stimulation, ultrasound)
tient. These include therapeutic exercise, active reha-
6. Protecting injured tissue and preventing reinjury
bilitation protocols, education and training, and work
(e.g., splints and braces)
hardening. This chapter surveys the use of the pas-
sive modalities in chiropractic practice; Chapter 46, While passive modalities are primarily used dur-
“The Roles of Rehabilitation and Exercise in Chiro- ing the early phases of care, they may also have a role
practic Practice,” addresses the roles of active rehabil- in the treatment of many chronic conditions. Specific
itation and exercise. goals for passive modalities in chronic conditions in-
It is important to point out that while many of the clude
passive modalities enjoy widespread use, both within
the chiropractic profession and among physical thera- 1. Relief of pain (e.g., TENS, ultrasound, heat)
pists, they should not be relied upon as primary treat- 2. Reducing muscle tension (e.g., electrical stimula-
ment procedures. Instead, these methods should only tion, heat, massage)
be considered ancillary and/or supplemental to other 3. Reducing fibrous tissue and adhesions (e.g., elec-
treatment methods, such as manipulation or rehabili- trical stimulation, ultrasound, massage)
tation. For this discussion, the passive modalities are 4. Improving range of motion (e.g., electrical stimu-
referred to as “time-limited passive modalities.” This lation, ultrasound)
indicates that each of these procedures has a some-
Again, it is important to reiterate that treatment
what limited time of usefulness, typically during the
relying solely upon the use of passive modalities is
early phases of care. For example, if transcutaneous
rarely effective; rather, they function as one part of a
electrical stimulation (TENS) is used to control pain
comprehensive treatment plan. Each modality is best
in an acute injury, it should be discontinued when the
applied when the clinician understands the indica-
patient’s pain is under control. Similarly, if therapeutic
tions for the procedure(s) based on the symptoms, as
ultrasound is used in the initial stages of care to im-
well as the benefits and limitations of the modality.
prove circulation in a swollen extremity, it should no
Clinicians should also be well versed in the applica-
longer be needed once the swelling has receded. Un-
tion of passive modalities and the potential for harm
fortunately, many of the passive modalities have been
that accompanies these procedures.
overused in day-to-day practice. The reasons for such
overuse include habit on the part of the clinician, reim-
bursement issues, or patient requests for the soothing PHYSICS OF THERAPEUTIC MODALITIES
effect of hot packs and other physical modalities. As a
result, passive modalities, once incorporated for valid Electromagnetic Spectrum
reasons, are often continued long after their useful- Over the course of time, various forms of heat, cold,
ness is over. Consequently, these treatments are often and electricity have been used in an attempt to allevi-
seen as ineffective or unnecessary. ate pain and suffering. Because most of the modalities
discussed in this chapter represent various forms of
electromagnetic energy, a brief discussion of the elec-
GOALS FOR PASSIVE MODALITIES
tromagnetic spectrum is useful. Simply stated, when
The incorporation of the various physical modalities a sufficient amount of chemical and/or electrical force
is commonplace in the treatment of back pain, neck is applied to an object, the resulting movement of
pain, and other musculoskeletal conditions routinely electrons creates molecular vibration. The resulting
treated by chiropractors. As indicated earlier, these molecular activity is described in terms of a specific
THE USE OF PHYSICAL MODALITIES 863
TABLE 44–1. The Electromagnetic Spectrum
Portion of
Electromagnetic
Spectrum Frequency Wavelength Physiological Effect
Electrical stimulation devices 1–4000 Hz 3 × 108 to 75,000 Km Pain reduction, muscle contraction,
edema reduction
Shortwave diathermy 13.56 MHz 22 m Increased temperature of deep tissues,
27.12 MHz 11 m vasodilation, increased blood flow
Infrared
Cold packs 2.7 × 1012 Hz 111,000 A Superficial temperature change,
Paraffin bath 3.3 × 1012 Hz 90,200 A vascular changes, analgesia
Hydrocollator 3.6 × 1012 Hz 82,500 A
Ultraviolet light 9.38 × 1013 to 3200–2900 A Superficial chemical changes, tanning,
1.03 × 1014 Hz bactericidal effects
Adapted from Hooper PD. Physical modalities: A primer for chiropractic. Baltimore: Williams and Wilkins, 1996.
range of wavelengths and frequencies (i.e., the elec- ities to penetrate to the deeper layers of tissue is
tromagnetic spectrum) (Table 44–1). For example, the based on a number of factors, including the wave-
electrical stimulation devices have a very low fre- length of the energy. Those modalities with the longer
quency and exist at the lower end of the spectrum. wavelengths tend to penetrate more deeply (e.g., ice).
The thermal agents, such as shortwave diathermy, mi- Conversely, the shorter the wavelength, the less the
crowave diathermy, infrared agents (i.e., hot packs, penetration (e.g., hot packs). Because frequency and
cold packs), and ultraviolet light, have progressively wavelength are inversely related on the electromag-
higher frequencies and are located further along the netic spectrum, those modalities with the lower fre-
spectrum. Even x-rays are found on the electromag- quencies have the longer wavelengths. This is partic-
netic spectrum. It is worth noting that the energy ularly important when considering the use of infrared
produced by therapeutic ultrasound machines is not modalities such as moist heat and ice. Because wave-
part of the electromagnetic spectrum, but is a form of length is somewhat dependent upon temperature,
acoustic or sonic energy. However, as the body’s tis- and because colder temperatures have longer wave-
sues absorb the sound waves, this acoustic energy pro- lengths, the cooler the modality, the greater the depth
duces vibration of molecules, which, in turn, is con- of penetration. However, even the coldest modalities
verted into heat, a form of electromagnetic energy. in common use have a relatively minor depth of pen-
The energy forms found on the electromagnetic etration, on the order of less than 0.5 inch. There-
spectrum are referred to as radiant energy. Radiation fore, when the objective of the procedure is to af-
is the process through which radiant energy moves fect the deeper tissues, these modalities are not very
through space. All movement occurs in a straight line, effective.
and when radiant energy strikes an object, such as
the human body, one of several things occurs. The Laws of Physics Applied
energy is reflected, refracted, or absorbed. The energy to Electromagnetic Energy
can be transmitted through space via conduction, as There are a few laws of physics that are relevant to the
when a hydrocollator pack is placed on the patient’s understanding of electromagnetic energy. The first,
skin; convection, as when heat is transferred from the the inverse square law, states that the intensity of the
water in a whirlpool bath; and conversion, as in the radiation is inversely proportional to the square of the
alteration in energy seen in a shortwave diathermy distance from the energy source to the target. This is
unit. most familiar to chiropractors as it relates to the use of
In general, the therapeutic devices found on the x-rays. As the distance from the cathode to the film in-
electromagnetic spectrum can be divided into two creases, the effect of the beam of electrons decreases.
broad categories: those capable of exerting an ef- The same rule applies to all other forms of electro-
fect only on the more superficial tissues (i.e., sub- magnetic energy (e.g., as the distance from the energy
cutaneous), and those capable of exerting a primary source increases, the effect decreases).
effect, not only on the superficial tissues, but also The second law of physics that is relevant to an
on the deeper subcutaneous structures such as mus- understanding of passive modalities is known as the
cles, nerves, and blood vessels. The ability of modal- cosine law. This law states that energy has its greatest
impact when it is at right angles to the target. Once neck and shoulder, while ice and compression would
again, this is best illustrated in the use of x-rays. Those obviously not be wise when treating a spasm of the
electrons that strike the body at right angles have a anterior cervical musculature.
much better chance of penetrating tissue than elec- The body responds to the application of ice in
trons that are at angles other than 90 degrees. stages. Initially, there is an accompanying period of
Next, the law of Grothus-Draper states that any vasoconstriction accompanied by a reduction in blood
energy that is not absorbed by the superficial tissues flow to the area that is cooled. This initial response
is transmitted to the deeper layers. Obviously, the lasts for a period of roughly 15–20 minutes, during
greater the amount of energy that is absorbed, the which time there is typically some degree of analge-
smaller the amount that is capable of penetrating. As sia or pain relief. After the initial period, the body
stated earlier, most of the energy from the infrared responds to further cooling with cycles of vasodila-
modalities is absorbed in the superficial layers, with tion alternated with vasoconstriction. Each cycle lasts
very little eliciting a direct effect on deeper structures. approximately 4–6 minutes, which is referred to as
Finally, according to the Arndt-Schultz law, no re- the “hunting” reaction. The purpose of this cyclic re-
actions can occur unless there is a sufficient amount of sponse is to minimize any damage that might occur
energy to stimulate the tissues that are targeted. This from a drastic reduction in blood flow. Ironically, while
is easily understood with the use of electrical stimu- ice applications are used to reduce blood flow, with
lation. Until there is a sufficient amount of electricity continued cooling, maximal vasodilation occurs.
in the area to depolarize either the sensory or motor While individuals respond differently to most
nerves, no response is observed. treatment forms, the response to ice is similar. Patients
typically experience a sensation of cold, a tingling or
itching sensation, a burning or aching in the deeper
TYPES OF PASSIVE MODALITIES tissues, and numbness. Even though ice application is
Therapeutic Heat and Cold very common, it is helpful to instruct patients regard-
(The Infrared Modalities) ing these sensations and to monitor for any unusual
response. It is also worth noting that if ice is applied
The various forms of topical heat are all comprised of for excessively long periods, it can do far more harm
energy that is found on a part of the electromagnetic than good.
spectrum referred to as the infrared portion. These
modalities are all considered to be superficial thermal Ice Packs While the application of ice packs is
agents because the degree of penetration of the en- widespread, great variation exists in the techniques
ergy is limited. They function through either conduc- used. The following procedure is recommended:
tion (e.g., direct contact) or convection (e.g., heated or
cooled water or air). They may be used either to in- 1. Ice packs should not be applied directly to the skin.
crease the local body temperature (e.g., moist heat) or To protect the skin, place a towel (wet or dry) under
to decrease temperature (e.g., ice packs). The modali- the ice pack.
ties in this category include ice packs, cold whirlpools, 2. Fifteen to 20 minutes is typically adequate for most
warm whirlpools, paraffin baths, hydrocollator packs, injuries. These applications may be repeated as of-
and infrared lamps. The most common applications ten as every hour, but once every 2 hours is usually
in chiropractic practice are ice packs, hydrocollator sufficient.
packs, and paraffin baths. 3. If possible, the injured part should simultaneously
be elevated and compressed.
Cryotherapy Perhaps the most widely used of all the It is worth noting that patient tolerance to ice is not
physical therapies is the application of ice. Everyone particularly good. Because it can be a relatively un-
has had the experience of placing an ice pack on a comfortable form of therapy, patients are often reluc-
sprained ankle or a bruised knee. In fact, the tradi- tant to comply, especially when prescribed as a home
tional rule for treatment of an acute injury is RICE: rest, remedy. This is particularly important when treating
ice, compression, and elevation. Because most acute the elderly, whose thinner skin may not tolerate long
injuries are accompanied by some degree of swelling, exposure to ice.
the principal rationale for RICE is to reduce the accu-
mulation of tissue fluid in the injured area. Rest is used Ice Massage Another form of cold therapy involves
for obvious reasons. Ice is used primarily for its vaso- the application of ice combined with massage. This
constrictive effects, and compression and elevation are technique can be particularly uncomfortable and is
used to assist in drainage. Although the application of probably most often used with athletes, or in the treat-
RICE is commonplace, it is not always applicable. For ment of particularly stubborn chronic conditions. The
example, elevation is not necessary in areas such as the goal of this technique is the anesthesia that follows
Indications, Contraindications, and Physiological Effects for Commonly Used

TABLE 44–2.
Thermal Agents
Therapy Indications Contraindications Physiological Effect
Ice Reduce bleeding; reduce swelling; Raynaud disease; rheumatoid Local decrease in temperature;
reduce muscle spasms; reduce arthritis or gouty arthritis; reduction in metabolism;
blood flow sensory deficits vasoconstriction (initially);
reduced blood flow (initially);
reduced lymphatic and venous
drainage; reduced muscle
excitability; anesthesia
Moist heat; Increase blood flow; reduce pain; Areas of diminished Local increase in temperature;
paraffin increase local circulatory and sensation; malignancy; increased metabolism;
bath metabolic rates; decrease radiation therapy; bleeding vasodilation; increased blood
vascular stasis; enhance tendencies; fevers; flow; increased capillary
absorption of exudates and peripheral neuropathies; permeability; increased
metabolites; enhance local peripheral vascular lymphatic and venous
nutrition; increase lymphatic disorders; over pregnant drainage; increased production
flow; increase elasticity of uterus; children, elderly, or of metabolites; decreased
connective tissue others incapable of muscle tone; analgesia
providing feedback; over
skin rashes or open
wounds; over metal objects
the ice application. During this period of analgesia, method. However, the procedure may still be effec-
fibrous tissue may be vigorously massaged. Ice mas- tively accomplished using the ice massage technique
sage may also be substituted for the vapocoolant spray described earlier. In some areas, such as the ster-
technique of Travell and Simon that is directed at my- nomastoid muscle, where direct application of ice is
ofascial trigger points (TrPs).3 The following proce- unwise, the vapocoolant may still be a useful pro-
dure is recommended: cedure (Table 44–2). For more information on my-
ofascial TrPs, see Chapter 41, “Soft Tissue Manual
1. Fill a Styrofoam cup with water and place in
Techniques.”
the freezer compartment for several hours. When
frozen solid, remove the bottom 1 inch of the cup.
Hydrocollator Packs As with ice packs, the use of heat
2. Place the inverted cup over the body part and rub
in various forms is very common in chiropractic prac-
in a circular motion or in overlapping strokes for
tice. Perhaps the most commonly used of these is the
10–15 minutes, or until the area is numb,
moist heat pack, also referred to as the hydrocollator
3. Follow this application with stretching proce-
pack. This employs the use of a cloth bag containing
dures, deep massage, and/or mobilization and
a fine sandy material. The bag is immersed in hot wa-
manipulation techniques. ◦
ter (76.7◦ C [170 F]) until the sand absorbs the water.
Once the pack is properly moistened, it is removed
Cold Spray (Vapocoolant) The use of a vapocoolant from the water bath and placed on the patient where
spray (fluoromethane) was popularized by Janet it will remain hot for 10–15 minutes. Because the wa-
Travell for the treatment of myofascial TrPs.3 The ter is very warm, it is important to ensure that the
technique relies on the use of a vapocoolant liquid patient is adequately protected from burns. To accom-
(fluoromethane) that is sprayed in overlapping plish this, several layers of dry towel should be placed
sweeps on the surface of the muscle containing a TrP. on the skin, with the pack on top of the towels. The
The purpose of the cool spray is to distract the ner- pack should never be placed directly on the skin. In
vous system temporarily, allowing the muscle to be a recent review of incidents in a chiropractic college
stretched by the clinician. While this procedure was teaching clinic, the most common injury to patients
very popular for a number of years, concern over was burns produced by these hot packs.
the environmental effect of the fluoromethane spray It is worth noting that moist heat does not have
has led to its demise as a commonly used treatment a direct effect on the subdermal tissues. Rather, the
heat only penetrates a few millimeters under the skin. TABLE 44–3. Indications and Contraindications
With this in mind, if the objective is to warm deeper for Ultrasound
tissues such as muscles, other forms of heat will be
more useful. It is the opinion of this author that the Indications Contraindications
primary benefit to the application of such moist heat
packs is the accompanying relaxation that occurs dur- Acute and/or chronic Infection
ing the treatment. When patients in pain are asked to musculoskeletal Peripheral vascular disorders
lie quietly for 15 minutes with a gentle heat applied, conditions Peripheral neuropathies
the soothing effect is obvious. Myofascial TrPs Malignancies
Muscle spasm Over metal implants
Paraffin Baths One of the superficial heating agents Neuralgia Over growing epiphyseal plates
that is particularly useful in chiropractic is the paraf- Neuroma Pregnant uterus
fin bath. This consists of a small container that is filled Calcium deposits Blood-thinning medications
with paraffin wax. The container heats the paraffin Osteoarthritis Over bony prominences
to approximately 51.7◦ C (125◦ F), a point at which Radiculitis Over nerve plexus
the paraffin melts. The application procedure is as Joint contractures Over pacemaker
follows: Over heart, eyes, genitals, brain
1. The patient places his or her hand in the melted

paraffin for a few seconds, allowing the melted
paraffin to coat the hand. As stated earlier, ultrasound is not a form of ther-
2. The hand is then removed from the paraffin bath mal energy and is not found on the electromagnetic
and the paraffin is allowed to cool slightly, at which spectrum. It is actually acoustic energy that is pro-
point the hand is reimmersed in the bath. duced by passing electrical energy through a piezo-
3. This process is repeated from 5 to 10 times until electric crystal contained in a transducer. As the elec-
there is a thick coating of paraffin on the hand. trical energy comes in contact with the crystal, the
4. The hand is then wrapped in cellophane and cov- molecules contained in the crystal begin to vibrate.
ered with a dry towel. This vibration emits sound waves from the transducer
5. The paraffin is allowed to remain on the hand for at a predetermined frequency (1.1 or 3.3 MHz). When
15–20 minutes, at which time it is removed. the transducer is placed in contact with the patient, the
6. Following removal of the wax, the hand should be sound passes through the skin and into the subder-
exercised. mal tissues. The sonic energy causes molecules in the
tissues to vibrate, causing friction, which, in turn, is
The paraffin bath is a very useful tool for certain ex-
converted to energy in the form of heat. Consequently,
tremity conditions such as arthritis, or in the rehabili-
the primary result of ultrasound is the heat generated
tation phase following cast removal for a broken wrist.
in the deeper tissues.
Unfortunately, it cannot be used for axial complaints.
The sound waves generated in this process pass
The heat provided by this modality has enough pen-
easily through liquid, but not readily through air.
etration to warm the muscles and joints and is very
Therefore, to ensure transmission of the energy into
useful prior to exercise (Table 44–2).
the patient, a moist lubricating gel is placed under the
sound head. Tissues are differentially affected by the
Other Forms Several other forms of thermal agents
sound waves. The tightly organized fibers of lig-
have been developed that are not typically found in
aments and tendons have a particular affinity for
the chiropractic office. These include such devices as
the energy, whereas tissues with high water con-
hot and cold whirlpools, infrared lamps, heated air,
tent (e.g., fat and muscles) are not as readily im-
and ultraviolet light.4
pacted. Still other tissues, such as the periosteum, may
Therapeutic Ultrasound be negatively affected by the sonic energy. The ap-
plication procedure for therapeutic ultrasound is as
The therapeutic use of ultrasound is common in chi-
follows:
ropractic. It is used to treat a variety of conditions,
ranging from bursitis to tendinitis, and fibrous tissue 1. The skin to be treated is exposed and gel is placed
to adhesions (Table 44–3). Although widely used, it is over the area.
one of the least understood of all the physical agents. 2. The ultrasound head is placed in contact with the
Supporters claim that it is capable of many things, skin, the machine is turned on, and the timer is set.
including resolving bone spurs. Critics claim it has 3. The duty cycle is set and the intensity is tuned to
nothing but a placebo effect. the desired level.
TABLE 44–4. Ultrasound Parameters
Condition Skin Thickness Time Intensity Duty Cycle
Acute Thin 4–6 minutes 0.5–1.0 w/cm2 Pulsed

Thick 1.0–1.5 w/cm2
Chronic Thin 6–8 minutes 1.0–1.5 w/cm2 Continuous
Thick 1.5–2.0 w/cm2
Key: w = watt.
4. The ultrasound head is moved over the area to of the common terms associated with this modal-
be treated using slow, overlapping, or circular ity. First, electrical current consists of a flow of elec-
strokes. trons along some form of conducting medium. The
electrons that make up the current are particles of
Application Parameters To use ultrasound safely and matter that contain a charge, either positive or neg-
effectively, three different parameters must be con- ative. The strength of the current is measured in
trolled: intensity, duty cycle, and time. The intensity amperes (amps) and represents the number of elec-
of the sound wave is determined based on the type trons. The currents found in most electrical stimu-
of condition, the clinical objectives, and the tissue to lating devices is usually measured in milliamperes
be treated. The duty cycle is determined based on (mA), although some forms of electrical units use an
whether or not deep heating is a desired effect. As a extremely small amount of current that is measured in
general rule, ultrasound should not be used to gener- microamperes.
ate heat whenever a condition is in the acute stage. For electrons to flow, two things are necessary.
Under such circumstances, the ultrasound may be First, an electrical potential difference must exist be-
modified to minimize the generation of heat. This is tween two points. The force producing this poten-
accomplished by reducing the duty cycle to less than tial difference is referred to as the electromotive force
100%. Duty cycles of 20% and 50% are common. Under (EMF), or the voltage. Second, there must be some
such circumstances, ultrasound is used to improve cir- form of conducting medium. Materials have differ-
culation, decrease edema, and promote healing. When ent reactions to the flow of electrons. Some, such as
heat is desired, such as in the treatment of chronic water, allow electrons to flow easily. These materials
problems, the duty cycle should be set at 100%. With are referred to as conductors. Consequently, bodily tis-
regard to the time of application, it is customary to use sues that contain a high water content readily conduct
ultrasound for periods of 10–15 minutes. However, to electricity. Other materials, called resistors, inhibit the
maximize the effect, it is suggested that it be used for flow of electrons. The resistance to current flow is re-
shorter periods. During the acute phase, periods of ferred to as impedance and is measured in ohms. The
4–6 minutes are probably adequate. Longer periods skin is not a very good conductor and represents one
of 6–8 minutes may be more helpful during the more of the major obstacles to the therapeutic use of elec-
chronic treatment phases (Table 44–4).2 tricity.
The flow of electricity is directly related to the
Electrotherapy strength of the current (voltage), and inversely related
One of the more widely used passive modalities is to the resistance (ohms). This relationship is known
electrical stimulation. In various forms, therapeutic as Ohm’s law and is depicted by the formula: cur-
electricity has been used for centuries and descrip- rent flow = voltage/resistance or I = v/r . The amount
tions of the use of electric eels for medicinal purposes of energy that is produced (watts) is a product of the
can be found in the writings of the ancient Egyptians number of electrons (amperes) and the electromotive
and Hippocrates. Scribonius Largus described the use force (volts).
of eels for the treatment of both headaches and gout.5
However, it has only been in the past 40 years or so Alternating and Direct CurrentWhile there are numer-
that electrical currents have become popular as a treat- ous ways of classifying electrical stimulation devices,
ment for musculoskeletal disorders. only two types of current are used. These currents
are defined by the direction of electron flow. Some
Definition of Terms To understand the application of electrical stimulation devices use a current that con-
electrical current, it is first necessary to define some tinuously flows in the same direction, referred to as
direct current (DC). Examples of direct current stimu- may actually promote protein synthesis and stimu-
lating devices are high-voltage galvanic, low-voltage late tissue growth and repair.6 An example of such
galvanic, and the small battery-operated TENS units. an application may be seen with the use of electri-
One unique feature of direct current is its polarizing cal implants to promote bone growth following spinal
effect. This is described in greater detail later in this surgery.
chapter, but with the exception of the low-voltage gal-
vanic devices, the polarizing effect is minimal and can Pulsed and Nonpulsed Current One important distinc-
probably be ignored. tion between electrical currents is the manner in which
The remaining electrical stimulation devices use each is delivered. Electrons may be continuously
an alternating current (AC) (i.e., the current constantly produced in a steady, uninterrupted stream. These
reverses or alternates direction). Examples of alternat- are referred to as nonpulsed currents and are repre-
ing current devices are sine-wave stimulators and in- sented by the low-voltage galvanic currents. These
terferential current stimulators. While these stimula- currents have a strong polarizing effect and are typi-
tors do not have any polarizing effect, for all practical cally used to deliver chemicals such as hydrocortisone
purposes, there are no real therapeutic advantages for through the skin, a process known as iontophoresis.
one form of current over another. Because many of the chemicals used are prescription
medicines, these procedures are not used frequently
Physiological Response to ElectricityThere are three pri- in chiropractic and are not discussed here.6,7
mary responses to electricity: thermal, chemical, and
physical. The thermal effect is produced by vibration Pulse Parameters The electrical current used in most
of the electrons as they pass through the body. The therapeutic electrical stimulation devices consists of
vibration produces friction, which, in turn, leads to a series of pulses. By altering various parameters, a
an increase in temperature. In addition, the resistance number of different physiological responses can be
provided by the skin produces some heat. The second produced. The following parameters may be mod-
effect includes the production of various chemicals, ified: shape, intensity, frequency, mode, duration,
such as potassium and sodium hydroxide, under the phase charge, and polarity.
electrodes. With the exception of the low-voltage gal-
vanic currents, any thermal and/or chemical effects Pulse Shape (Waveform) Each pulse of current has a
produced with most of the electrical stimulating de- particular shape, also known as a waveform (Fig. 44–1).
vices are minimal. These effects are significant with Each waveform has certain characteristics that make it
the low-voltage galvanic currents, however, and their popular, and the proponents of electrical stimulation
use can lead to significant burns. devices often use the type of wave as a sales tool. It is
The primary effects seen with the introduction of worth noting, however, that for all practical purposes,
electrical current into the skin are physiological in na- each waveform is capable of producing the same phys-
ture. These may be divided into two distinct areas, iological effects (e.g., depolarization). A primary ben-
excitatory and nonexcitatory. The most desired effect efit of a specific waveform (sinusoidal vs. square) is
of electrical current is the excitatory effect (i.e., the the degree of patient comfort provided.
impact the current has on the excitable tissues such
as nerves and muscles). When a current with suffi-
cient strength (intensity) and time (duration) is ap-
plied to the tissues, the nerves are depolarized and an
action potential is produced. Depending upon the na-
ture of the stimulus, this depolarization can be used to
elicit a variety of responses, such as inhibition of pain
fibers, muscle contraction, and various autonomic ef-
fects. This is described in greater detail later in this
chapter in the section on pulse intensity.
In addition to their effect on nerves and mus-
cles, electrical currents also have an impact on nonex-
citable tissues such as skin, ligaments, and bone.
While not as well understood, nor as frequently used,
these effects may be beneficial. They may be direct
and include such reactions as increases in cellular
permeability, or they may be indirect and involve
such responses as changes in blood flow. In addi-
tion, there is some evidence that electrical current FIGURE 44–1. Waveforms.
Pulse IntensityAs stated earlier, intensity is a measure ally strong enough to depolarize any nerves or mus-
of the strength of the electrical current and is mea- cles. Consequently, patients do not typically feel any
sured in amperes. Most of the electrical stimulation sensation or experience any muscle contraction.
devices commonly found in the chiropractic clinic use
a current with a maximum strength of approximately Pulse Frequency The pulse frequency refers to the
50 mA. While this is enough to cause some signifi- number of pulsations of current that occur in a 1-
cant discomfort if not properly used, it is not usually second interval, and is measured in hertz (Hz). Fre-
enough to cause serious harm. quency is selected in combination with intensity to
In using electrical stimulation devices, the reproduce the following effects:
sponse to current intensity is very consistent from one
patient to the next. As the current is initiated, the fol- Sensory-level stimulus (SLS)
lowing effects occur:
• 80–100 Hz: This produces a rapid stimulation of
1. Initially, until the current reaches a sufficient inten-
the large, superficial sensory fibers. It is thought
sity to depolarize the more superficial nerve fibers,
to close the pain gate at the spinal cord level and
there is no discernible response. However, while
is used for pain control. This is probably the most
there may be no sensation or noticeable reaction
widely used setting, is seen with the classic TENS
at this level (i.e., below 1 mA), there is evidence
applications, and is often referred to as high TENS.
that these subthreshold currents produce an effect
• 5000 Hz: Similar to the previous setting, this pro-
on the cell membrane and may influence cellular
duces a fine, vibrating or tingling sensation and is
activity and tissue generation.7
used for pain control. It may be more comfortable
2. At some point, as the intensity is increased, the cur-
for some patients. This high-frequency current is
rent reaches a sufficient level to depolarize some of
typically only found with the interferential current
the superficial sensory nerves. This is usually per-
(IFC) or medium-frequency stimulators.
ceived as a tingling sensation (e.g., pins and nee-
dles) underneath the electrodes and is referred to
Motor-level stimulus
as a sensory-level stimulus (SLS). This stimulation
level is most often used for pain control techniques
• 2–5 Hz: This low-frequency motor-level stimulus
that involve the pain gating mechanism.8
is often used over acupuncture points. Known as
3. With further strengthening of the current, a
“acupuncture-like TENS” or “LoTENS,” it is used
stronger stimulus is achieved. When the current
for pain control and is thought to produce an en-
reaches a sufficient strength to depolarize motor
dorphin response.
fibers, a muscle contraction occurs. This is referred
• 1–15 Hz: At a motor level, this frequency produces
to as a motor-level stimulus (MLS) and may be
a pulsing or twitching muscle contraction. It is may
used to decrease muscle spasm, increase circula-
be used to improve circulation and decrease edema
tion, and/or improve muscle strength.
by producing a pumping action of the muscles and
4. As the current is increased even further, a stronger
the blood vessels.
response (both sensory and motor) is experienced.
• 20–50 Hz: At a point somewhere around 15–20 Hz
This is partially a result of the progressive de-
the muscle stops twitching and contracts in a
polarization of an increasing number of fibers. It
steady state, much like a physiological contraction.
is also caused by the depolarization of smaller,
Such steady contractions are referred to as “tetany”
deeper C fibers. At some point, the stimulus be-
and this frequency is used when a smooth contrac-
comes painful. This is referred to as a noxious-level
tion is preferred. This may be used to increase cir-
stimulus (NLS) and may be used for specific pain
culation, to decrease edema, and to maintain mus-
control techniques.
cle tone.
5. Further increases in current intensity are harmful
• Above 50 Hz: As the frequency is increased above
and will not be tolerated by patients.
50 Hz, an increasing number of motor fibers are
It is worth noting that the exact number of mil- depolarized and the muscle contraction grows
liamperes necessary to achieve each of these stimu- stronger. This frequency range produces a contrac-
lation levels will vary from patient to patient. Many tion known as a “fatiguing tetany” and is used to
factors affect current flow, including the size and loca- reduce muscle spasms.
tion of electrodes, the type of current being used, the
thickness of the skin, and the hydration of the patient. Noxious-level stimulus
Some devices (microcurrent) use a current that is
extremely small, in the microamperage range. These • 2–5 Hz: Combined with a strong, noxious stimu-
devices use a subthreshold stimulus that is not usu- lus, this low-frequency range is used to produce a
hyperstimulation analgesia, a form of counterirri- Polarity When a direct current is used, the ions in the
tant. It may also be used over acupuncture points current align in the direction of current flow. This
to produce an endorphin response. process, known as polarization, is really only im-
• 70–100 Hz: This frequency is used at this painful portant with the low-voltage galvanic currents that
intensity in a process known as “brief, intense are used for iontophoresis. It does not occur with
TENS.” This fatigues the sensory nerves and an alternating current, and is minimal with all other
blocks the sensation of pain. direct current devices. The effect under the posi-
tive electrode is different from that occurring un-
Pulse Mode (Delivery Method) The manner in which the der the negative electrode. However, because the
current is delivered is also an important factor. Cur- effect is negligible with most of the devices seen
rents may either be delivered continuously, or they in a chiropractic clinic, it is not discussed in detail
may be periodically interrupted, or turned on and here.2
off (interrupted or reciprocating current). Either type
of current may be used for pain control and/or to Electrodes One of the most important aspects of elec-
produce muscle contractions. However, the degree trical stimulation involves the electrodes. Because
of patient adaptation or accommodation is greater the electrode is the interface between the stimula-
with the continuous current. Consequently, a con- tor and the patient, this aspect must be applied cor-
tinuous current may be more comfortable for many rectly in order to elicit an appropriate response. Many
patients. times, when electrical stimulation fails to achieve
When an interrupted current is used, the amount the desired effect, the problem can be found in the
of time the current is on and off is varied in the fol- electrodes. There are a variety of electrodes avail-
lowing manner: able, including metal electrodes covered by a moist-
ened sponge, carbon-filled silicone, vacuum elec-
trodes, and a self-adhesive variety. The two most
Acute phase: on:off ratio of 1:1, usually 5 seconds on
widely used are the carbon-filled silicone and self-
and 5 seconds off.
adhesive forms. For a variety of reasons, including
Subacute phase: on:off ratio of 1:1, with longer periods,
ease of use and hygiene, the self-adhesive forms are
usually 10 seconds on and 10 seconds off.
preferred.
Later phases of treatment: on:off ratio of 1:4 or 1:5, with
Electrodes also come in a variety of sizes and
10 seconds on and 40–50 seconds off. Patients may
shapes. In general, the current under a small electrode
be asked to move or exercise during the off period.
is greater, or more concentrated, than that under a
large electrode. If small areas are to be treated, such
Whenever an interrupted current is used, it is im- as acupuncture points or myofascial TrPs, small elec-
portant to establish the intensity of the current at the trodes are preferred. If large areas, such as the lower
beginning of the treatment session. Care should be back or the hamstrings are to be treated, then larger
taken to ensure that the current is not raised during electrodes are more helpful. Different shapes are ben-
the off portion of the cycle. eficial for different body parts and may be varied ac-
cording to need.
Pulse Duration (Pulse Width)A basic rule of physiol-
ogy states that in order for a current to elicit a re- Electrode Placement Electrode placement is of particu-
sponse, it must have adequate strength (intensity) lar importance to successful treatment. Placement is
and adequate time (duration). Each pulse of current determined by two factors: the type of stimulator be-
occupies a specific period of time from beginning ing used and the objectives of treatment. Based on the
to end. This time period is referred to as the pulse type of stimulator being used, three basic application
duration or width and is measured in milliseconds techniques are
(msec). The pulse width of most electrical stimula-
tion devices is often preset somewhere around 250 • Monopolar, which is used with direct current ma-
msec, although some machines allow the clinician chines. Each electrode has a specific polarity
to modify this parameter. When this is possible, it throughout the treatment.
is important to remember that the wider the pulse • Bipolar, which consists of two electrodes of alter-
width, the stronger the current. The relationship be- nating polarity. These are seen with alternating
tween pulse width and intensity is illustrated by the current devices.
strength–duration curve. The longer the current is • Quadripolar, which consists of two bipolar leads,
present, the lower the intensity necessary to elicit a usually in a crossing pattern. These are seen with
response. interferential current stimulators.
Electrode placement techniques that are based on High-voltage galvanic stimulators, unlike low-
treatment objectives include: voltage galvanic stimulators, use a direct current with
an extremely short pulse width. Consequently, they
Pain relief do not have a strong polarizing effect and are not
capable of iontophoresis. Instead, the combination of
• Pain gating mechanism: Electrodes may be placed a short pulse width and a high voltage enables the
in such a manner that they surround the painful current to readily overcome the natural resistance
area, they may be placed in the same dermatome of the skin. The current is thus said to penetrate to
as the painful area, or they may be placed at the the deeper layers with ease, rendering the current
corresponding spinal cord level. more comfortable. These devices use a monopolar
• Acupuncture: Like TENS, electrodes may be electrode placement and are directed at pain control,
placed directly over acupuncture or myofascial muscle spasm, edema, etc.
TrPs. TENS units are usually associated with small,
battery-operated units. These devices resemble a
Muscle contraction small pager and are usually powered by a 9-volt bat-
tery. They are used on an “as needed basis” by the
• Electrodes are best placed at the motor points of patient and are helpful for outpatient pain control. In
the muscle. If a large muscle is treated, larger elec- reality, because all of the electrical stimulation devices
trodes are preferable. use skin electrodes to deliver the electrical current,
they are all TENS units.
Note that if a direct current is used, the large elec-
trode is referred to as a dispersive pad. The smaller Alternating Current Stimulators Low-voltage AC stimula-
electrodes are considered to be the active ones. The tors, sometimes referred to as “sine wave stimulators,”
active electrodes should be placed according to the typically use a biphasic (AC) sinusoidal waveform.
above guide. The dispersive pad should be placed They are one of the more common forms of electri-
somewhere on the body such as the buttocks, lower cal stimulation devices, and use a bipolar electrode
back, or thigh. Although it is commonly done, it is best placement.
not to place the dispersive electrode under the patient Interferential stimulators (medium frequency; IFC) use
or on the abdomen. two biphasic sinusoidal AC currents that are designed
to intersect or “interfere” with each other. Each cur-
There are a variety
Types of Electrical Stimulation Devices rent has a background frequency that is in the medium
of electrical stimulators in common use in chiropractic frequency range, usually around 4000–5000 Hz. The
practice. In general, these stimulators should proba- currents are slightly out of phase with each other and
bly all be considered to have similar physiological and the interaction between the currents results in the
therapeutic effects. Electrical stimulators can be clas- same usable frequencies that were described earlier
sified in the following ways: (e.g., 2–5 Hz, 80–100 Hz). Benefits of IFC are related
to the depth of penetration and a widened area that
Direct current stimulators are low-voltage galvanic, is affected by the current. Because of the nature of
high-voltage galvanic, and battery-operated TENS the electrical current, these stimulators are often con-
units. sidered to be the most comfortable form of electrical
Alternating current stimulators are low-voltage sine stimulation device.
wave stimulators, interferential current stimula- Microamperage stimulators use a subthreshold cur-
tors, and others. rent, usually less than 1 mA in intensity. This low-level
current is incapable of depolarizing the nerves. Con-
Direct Current StimulatorsLow-voltage galvanic stimula- sequently, they have a different effect than most other
tors are devices that produce a nonpulsed direct electrical stimulation devices. As previously stated,
current. The current has a strong polarizing effect they are thought to promote tissue healing and regen-
and the therapeutic application is primarily asso- eration.
ciated with iontophoresis. This process is used to
drive chemicals through the skin into the subdermal Traction
tissues. Because many of these chemicals (e.g., hy- Traction, or “the art of drawing,” is actually one of
drocortisone, lidocaine) are prescription medications, the oldest forms of treatment for a variety of muscu-
and because the current is potentially hazardous, loskeletal conditions. Various forms of traction have
this type of stimulator is rarely used in chiropractic been used for centuries to stabilize broken bones, re-
clinics. duce scoliosis, and to treat neck and back pain. One
FIGURE 44–2. Manual traction.
of the most common applications of traction currently seen with the use of a rolled-up towel that is wrapped
in use is for the stabilization of broken bones. In the around the back of the patient’s neck (Fig. 44–2).
practice of chiropractic, traction is used primarily in Tension is gradually applied and released. This
the treatment of neck and back pain, and this section gentle form of traction often provides signifi-
is limited to these conditions. cant relief for conditions such as neck pain and
Traction separates vertebral bodies and facet artic- headaches.
ulations, widens the intervertebral foramina, stretches
muscles and ligaments, and straightens spinal curves. Continuous TractionThis particular form of traction in-
corporates the use of small weights that are applied
Types There are a variety of traction devices and pro- steadily for a prolonged period of time. An example
cedures that may be found in the chiropractic clinic. of continuous traction is seen with the halo device
Some, such as manual traction, are widely used. that is used following a fracture of the cervical spine.
Others, such as inversion therapy, are used only rarely. Primary objectives of this type of traction are to sta-
Each of the various forms has distinct advantages and bilize the injured area during the early phase of the
disadvantages. healing process.
Manual Traction This form of traction involves forces Sustained (Static) TractionLike continuous traction, sus-
that are applied directly by the clinician. The forces tained traction uses a steady force. However, the du-
are often applied in a rhythmic manner by pulling ration of treatment is much shorter, often 20 minutes
and releasing. It is often used in an effort to determine or less. Static traction is used most frequently for the
how a patient will respond to other forms of mechan- treatment of herniations of the intervertebral disc, and
ical traction. An example of manual traction may be is applied in both the cervical and lumbar spine. This
is most helpful in the early phases of care when the promoting tissue healing; and protecting injured
injury is still in the acute stage. During this phase, tissue and preventing reinjury (e.g., by use of
there is often significant muscle guarding and spasm splints and braces).
present. As the patient improves, other forms of trac- 2. Electromagnetic energy travels in wave form. The
tion may become more helpful. electromagnetic spectrum includes energy of vary-
ing wavelengths, such as x-ray and infrared. This
Intermittent TractionAs the name implies, this form of energy can be transmitted by conduction, or di-
traction uses two different forces that are applied in- rect contact; convection, where no direct contact
termittently. In other words, an initial high traction is required; and conversion, such as heat from a
force is applied for a short period (30–60 seconds), af- diathermy unit. The important laws of electro-
ter which the force is lowered. After a short rest period magnetic energy that apply to the use of phys-
(10–20 seconds), the initial traction force is reapplied ical modalities include the inverse square law,
and this cycle of application versus rest continues for which states that energy intensity is inversely
the duration of the treatment. In addition to the sepa- proportional to its distance; the cosine law, which
ration created by the traction, the alteration between states that maximum energy effect will be achieved
traction forces also produces some movement. This at 90 degrees to the target; the Grothus-Draper
is thought to result in some improvement in circula- law, which states that energy not absorbed by
tion and some mild massaging effect. It is often used superficial layers will be transmitted to deeper
for joint dysfunction and degenerative changes in the layers; and the Arndt-Schultz law, which states
spine. that no reaction will occur unless stimulation is
achieved.
Intersegmental TractionThis involves the use of a table 3. Heat and cold modalities are generally used to ei-
that houses a series of rollers that move up and down ther decrease (cold) or increase (heat) blood flow
as they track along the spine. As the rollers travel up to an area. Commonly used forms of heat and cold
and down the spine, they lift and separate the joints therapy modalities include ice packs, whirlpools,
and exert a mild traction effect. These tables often in- paraffin baths, hydrocollator packs, cold spray, in-
corporate the use of vibration and heat and the result frared lamps, and ultraviolet light.
is very relaxing and soothing, much like a therapeutic 4. Therapeutic ultrasound is produced when electri-
massage. While this type of treatment is referred to as cal energy applied to a piezoelectric crystal causes
“intermittent traction,” it is probably better described its molecules to vibrate, emitting sound waves at a
as mechanical massage. predetermined frequency of 1.1 or 3.3 MHz, which
may then pass through the skin and into the sub-
Distraction Adjusting dermal tissues. This causes heat and is thought
The combination of distraction, either manual or me- to aid in healing by increasing blood flow to an
chanical, and spinal manipulation is a popular form area.
of treatment in chiropractic practice. This and other 5. Electrotherapy involves the flow of electrons
forms of traction are described, and their theoretical from a source to the patient through a con-
basis reviewed, in greater detail in Chapter 42, “Trac- ducting medium. Flow may be direct (DC),
tion and Distraction Techniques.” if always in the same direction, or alternating
(AC), if the direction changes. The flow is re-
Splints, Braces, and Orthotics lated to current strength (voltage) and resis-
In addition to those methods described above, chi- tance (ohms), and may be pulsed or nonpulsed
ropractors have available a wide variety of splints, (continuous). Effects of electrotherapy include
braces, and orthotics to offer patients. These de- production of heat and alteration of excitatory
vices are used primarily for the support of anatomic thresholds.
structures, such as muscles and ligaments, in order 6. Traction is used in treating spinal conditions to
to prevent further injury. They include such tools separate vertebral bodies and facet articulations;
as heel cups, heel lifts, elastic braces, hard braces, widen the intervertebral foramina; stretch mus-
body casts, rib belts, lumbar braces, and cervical cles and ligaments; and straighten spinal curves.
collars.2 Forms of traction include manual, continuous, sus-
tained, intermittent, and intersegmental.
7. A wide variety of splints, braces, and orthotic de-
SUMMARY
vices are used in chiropractic practice. The main
1. The primary goals of using passive modalities goal of these devices is to restrict range of motion
are pain relief; controlling swelling and edema; and provide external support to an injured or hy-
reducing muscle tension; improving circulation; permobile joint.
trol, to reduce muscle spasm, to reduce edema, to

QUESTIONS
improve circulation, and to promote tissue healing
1. What is the difference between active and passive and regeneration.
therapy? 5. Separation of vertebral bodies and facet articula-
2. What are the main types of passive therapies used tions, widening of intervertebral foramina, stretch-
by chiropractors? ing of muscles and ligaments, and straightening of
3. What is the electromagnetic spectrum and what spinal curves.
role does it play in passive modalities?
4. What are some treatment goals for the use of elec-
REFERENCES
trical stimulation?
5. What are the effects of spinal traction? 1. Keating JC. B. J. of Davenport: The early years of chiroprac-
tic. Davenport, IA: Association for the History of Chiro-
practic, 1997.
ANSWERS 2. Hooper PD. Physical modalities: A primer for chiropractic.
Baltimore: Williams and Wilkins, 1996.
1. The passive modalities include those treatment 3. Travell JG, Simon DG. Myofascial pain and dysfunc-
procedures that do not require any effort on the tion: The trigger point manual. Baltimore: Williams and
part of the patient. In contrast, those modalities Wilkins, 1983.
that are considered “active” call for some form of 4. Michlovitz SL. Thermal agents in physical therapy.
active participation on the part of the patient. Philadelphia: FA Davis, 1996.
2. The main types of passive therapies used by chi- 5. Krusen FH. Physical medicine. Philadelphia: WB Saun-
ropractors include heat and cold, ultrasound, elec- ders, 1994.
trical stimulation, traction, and splints, braces and 6. Becker RO, Shelden G. The body electric: Electromagnetism
and the foundation of life. New York: William Morrow,
orthotics.
1985.
3. The electromagnetic spectrum represents a range
7. Cheng N, Van Hoof H, Bocks E, Hoogmartens MJ. The
of radiant energy forms such as light, heat, and effects of electric currents on ATP generation, protein
x-rays. Many of the thermal agents found in chi- synthesis, and membrane transport of rat skin. Clin Or-
ropractic practice are forms of electromagnetic thop 1982;171:264–272.
energy. 8. Melzack R, Wall PD. Pain mechanism: A new theory.
4. Electrical stimulation may be used for pain con- Science 1965;150:971–979.
C H A P T E R
45
ACUPUNCTURE, ACUPRESSURE,
AND TRIGGER POINT TECHNIQUES
John A. Amaro
O U T L I N E
INTRODUCTION Complications
HISTORICAL PERSPECTIVES ACUPRESSURE
ACUPUNCTURE TRIGGER POINT THERAPY
Traditional Relationship to Acupuncture Points
Nontraditional Relationship to Motor Points
Acupuncture Points LITERATURE REVIEW
Classification Mechanisms of Action
Effects Clinical Trials
Treatment Methods SUMMARY
Needles QUESTIONS
Techniques ANSWERS
Point Selection KEY REFERENCES
Conditions Treated REFERENCES
Precautions
OBJECTIVES therapies (including acupuncture) during the previ-

ous year had increased from 3.8% in 1990 to 42.1%
1. To provide an overview and historical context of in 1997, and the probability of visiting an alterna-
the use of acupuncture, acupressure, and trigger tive medicine practitioner grew from 36.3% to 46.3%.
point techniques. Along with the increasing use of CAM, the study
2. To briefly review the important aspects of stated that medical schools are beginning to include
acupuncture, acupressure, and trigger point courses about these therapies. Of the 123 courses re-
therapy. ported in their study, common topics included chiro-
3. To provide a brief review of the literature practic, acupuncture, homeopathy, herbal therapies,
regarding acupuncture. and mind–body techniques. Of particular interest to
this discussion, it was estimated that approximately
9–12 million acupuncture treatments are provided an-
nually in the United States.1
INTRODUCTION
In the broader perspective, we are dealing with
In the last few years, interest in various forms of the procedure whereby one person applies a healing
complementary and alternative medicine (CAM) has stimulus to another. It is probable that more people
grown exponentially. A study recently published in throughout the course of history, and throughout the
the Journal of the American Medical Association looked world, have applied direct pressure stimulation over
at the use of alternative therapies in the United States an area of pain than the combined total of any and
during the period 1991–1997. The use of 16 different all other forms of medicine.2 While used for centuries
875
in Asia, during the past three decades acupuncture T2 related to the heart and lungs, whereas T6 related
has rapidly become incorporated in today’s Western to the liver, gallbladder, and stomach, and L1 related
multidisciplinary approach to pain management, as to the kidneys and ureters. Palmer enhanced and pop-
well as in the treatment of a variety of other disorders.3 ularized this concept and added to it by an evaluation
This chapter looks at the use of several re- process he referred to as “nerve tracing.”6 By using
lated methods of treatment—acupuncture, acupres- direct digital pressure, the practitioner would probe
sure, and trigger point therapies. Each procedure has for tenderness from the spinal segment in question to
been widely used by chiropractors and is targeted at the periphery, or from the painful periphery or organ
stimulating specific points on the body. The goals of back to the level of the spine, thus revealing a distur-
such point stimulation include pain relief, elimination bance of what Palmer referred to as “tone.” This same
of unpleasant symptoms, energy balancing, and the procedure has been used for centuries in Japanese pal-
restoration of health. pation of the acupuncture meridians at the level of the
spinal involvement.
By 1911, B. J. Palmer included in his book The
HISTORICAL PERSPECTIVES
Science, Art and Philosophy of Chiropractic Nerve Trac-
The stimulation of points on the body has been part ing photographs of a patient with a history of bilat-
of the chiropractic profession almost since its incep- eral nerve deafness and his specific “nerve tracing”
tion. Both A. T. Still (the founder of osteopathy) and markings.6 The markings on the photographs reveal
D. D. Palmer (the founder of chiropractic) became where the areas of palpable tenderness existed, from
well-known practitioners of magnetic energy (known the spinal articulation of T2-T3 to both ears.
today as “Qi gong”) along with digital pressure point These nerve tracks were not only of diagnostic im-
reflex therapy. D. D. Palmer mentioned “acupunc- portance but were said to be therapeutic as well. Stim-
ture” by name in his 1910 classic Text-book of the Science, ulation along the nerve tracing tracks and locating the
Art and Philosophy of Chiropractic, commonly referred most exacting of the palpable tender points was re-
to as The Chiropractic Adjustor.4 ported to be a highly effective treatment. The fact that
Although usually referred to as “acupuncture” this procedure is similar to the acupuncture method
in the twentieth and twenty-first centuries, “merid- known as “surround the dragon” is probably more
ian therapy” may be a more accurate description of than coincidence.
the true nature of this work. Named “jing luo mai” In specific therapeutic applications of nerve trac-
in China, the term has no direct translation in any ing by early chiropractors, specific points or areas
European language. The word “acupuncture” used in of extreme tenderness along the trajectory of pain
Western cultures comes from the Latin “acus,” mean- were stimulated by means of digital pressure. Partic-
ing needle, and “punctura,” meaning to penetrate. ular attention was given to the area of spinal orig-
Historical archives show this is how Jesuit missionar- ination of these pain patterns. In early chiropractic
ies and European merchants described what they had and osteopathic circles, direct percussion or thump-
observed in the “Far East” on their return to Europe.5 ing over the vertebral area of involvement, as well as
Having witnessed the stimulation of various skin along the area of nerve tracing, revealed tender tra-
points on the body for the relief of pain or for altered jectories that, when treated, were described as result-
dysfunction in China in the twelfth through six- ing in a prompt and positive therapeutic response.
teenth centuries, Europeans brought the knowledge of Alva Gregory, MD, popularized this procedure in the
skin point stimulation for treating a host of maladies early 1900s through his texts Disease and Rational Ther-
home to Europe. Acupuncture, as it was referred to in apy, Spinal Treatment Science and Technique and Spondy-
Europe, was adopted, adapted, altered, and improved lotherapy Simplified. Again, the treatment approach of
until it became a well-recognized healing modality percussion and spondylotherapy and its comparisons
throughout the continent. Clinicians in France, Italy, to the acupuncture “Ah Shi” (tender points) is worth
Germany, Austria, Switzerland, Spain, and England noting.
enhanced and developed the Euro-Asian approach In 1937, Frank Chapman and James Owens devel-
to acupuncture. Acupuncture as a folk art would oped and introduced to the osteopathic and chiroprac-
make its way to the United States through the earliest tic professions a concept of reflex point therapy, the
English emigrants in the seventeenth century. “Chapman neurolymphatic reflexes.”7 These specific
In the late 1890s, the English physician Sir Henry reflex areas became the vehicle for thousands of prac-
Head became known for his investigation and intro- titioners who claimed to treat a variety of maladies in
duction of what has been referred to as “Head’s postu- the 1930s through the 1970s; its use today is relatively
lates.” These were described as well-defined zones at limited. There were 98 specific Chapman reflex areas,
the vertebral levels from T1 thru S4, related to specific 49 of which were on the anterior surface of the body,
organ involvement. For example, the vertebral level with the additional paired 49 found on the posterior
ACUPUNCTURE, ACUPRESSURE, AND TRIGGER POINT TECHNIQUES 877
body. For example, the Chapman reflex to the kid- in mind that acupuncture had been practiced for liter-
neys was on the anterior body slightly superior and ally thousands of years by practitioners in other Asian
lateral to the umbilicus, whereas the posterior area nations including Japan, Hong Kong, Taiwan, and
was over the transverse process of the twelfth tho- Korea. The type and style of acupuncture practiced in
racic and first lumbar vertebrae. The lung reflex was each of the individual countries were as unique and
described on the anterior body at the third intercostal different from one another as were their language, cul-
space at the sternum, whereas the posterior reflex was ture, cuisine, and art. Although there were numerous
between the second and third thoracic transverse pro- similarities and the basic theory was the same, the ex-
cesses. In classic acupuncture, specific points on the planations and practices of acupuncture varied from
anterior body (known as Mu or alarm points) and their country to country.
complementary points on the posterior body (known By 1973 there were approximately 500 medical
as Shu or associated points) have been described for doctors in North America using acupuncture in some
centuries. Even though no specific corollary is drawn form, despite the prevailing attitude by most na-
between these acupuncture points and Chapman’s re- tional and state medical associations that acupuncture
flex points, the existence of the anterior and posterior was not a valid treatment. In a historic move, Ernest
body acupuncture points is, again, worthy of mention. Napolitano, president of The New York Chiropractic
In 1953, Terrence Bennett was credited with the dis- College, sponsored the first acupuncture certification
covery of 38 specific reflex areas, known as “Bennett’s program to be offered in North America. The initial
neurovascular reflex points.”7 According to Bennett, program began in the fall of 1972 and led to certifi-
these points were to be treated with light pressure cation following 100 hours of instruction. However,
stimulation for maximum effect. The points are all in spite of the growing popularity of acupuncture,
found on the anterior torso and frontal and lateral many chiropractic state boards would not allow chiro-
regions of the head. The combination of Chapman’s practors to use penetrating (needle) acupuncture. As
neurolymphatic reflexes and Bennett’s neurovascu- a result, many chiropractors began to use noninva-
lar reflexes contributed significantly to the subse- sive meridian therapy (acupressure) as their primary
quent practice of applied kinesiology as developed by focus of treatment. Many in the profession also be-
George Goodheart.8 In addition, the developer of the gan to use electronic stimulation, which at the time
receptor tonus technique, Raymond Nimmo, taught were simplified transcutaneous electrical stimulation
the use of pressure stimulation at specific reflex areas.8 (TENS) instruments that delivered an electronic im-
All of these reflex points may be considered acupunc- pulse to the acupuncture point. Doctors reported that
ture points and represent the incorporation of point there was little, if any, difference in clinical results
stimulation within the context of chiropractic treat- between needle stimulation and electronic therapy to
ment. It has been suggested that virtually all trigger an acupuncture point.
points, reflex points, and tender points on the body It soon became well-established that acupuncture
are in fact similar to the classic acupuncture points, was a principle, rather than a technique. Clinical
particularly those used in the treatment of painful practices using electronic therapy for acupuncture
afflictions.9 point stimulation were more popular than the ones
In 1971, the use of acupuncture gained a great using needle stimulation as they allowed patients
deal of publicity in the Western world. While re- who were needle phobic to experience the positive
porting on the United States team at the Ping Pong effects of acupuncture. This created an entirely new
championships in Beijing, journalist James Reston breed of patients who, because of their fear of needles,
suffered an appendicitis attack requiring an emer- would otherwise never experience acupuncture. As
gency appendectomy. The procedure, which was per- time went on the electronic instruments became more
formed under acupuncture analgesia, was reported sophisticated and electronic nonpenetrating meridian
in the New York Times in Reston’s classic article “Now therapy became a standard and recognized therapy in
About My Operation.”10 Thus the word “acupunc- many chiropractic practices in North America. Some
ture” and its mysterious concepts were introduced doctors referred to it as acupuncture, whereas others
to a contemporary American public. Soon after Re- simply called it physiotherapy. By the end of 1973, ap-
ston’s article appeared, President Richard Nixon met proximately 1500 chiropractic practitioners were in-
with Chairman Mao in Beijing, an event that ena- volved in some form of acupuncture.
mored the American public with all things Chinese, By 1974, there were approximately 2500 medical
including, furnishings, art, food, and, of course, and chiropractic practitioners using acupuncture—
acupuncture, which soon became a household word. from serious practitioners to mere dabblers. By this
Acupuncture (jing luo mai) as it was, and still is, time, auriculotherapy (ear acupuncture) had been in-
practiced in China is commonly referred to as tradi- troduced. This simple form of therapy focused on spe-
tional Chinese medicine. However, it must be borne cific points on the ear and was accomplished using
electronic stimulation devices designed specifically TABLE 45–1. Acupuncture Meridians

for ear acupuncture. Interestingly, one of the primary
conditions successfully associated with ear acupunc- Meridian Abbreviation
ture was weight loss. Currently, it is estimated that
there are at least 10,000 nonphysician practitioners ac- Lung LU
tively providing acupuncture treatments in the United Large intestine LI
States.11 Stomach ST
Spleen SP
Heart HT
ACUPUNCTURE Small intestine SI
Bladder BL
The practice of acupuncture can be quite varied de-
Kidney KI
pending on the training of the practitioner. On the
Pericardium PC, CX
one hand, traditional acupuncturists apply their craft
Triple energizer TE, TB, TW
based primarily on the concepts of traditional Chinese
Gall bladder GB
medicine. In this regard, acupuncture is a tool that is
Liver LR, LV, LIV
used to enhance the flow of energy throughout the
Governor vessel GV
body. On the other hand, in a more Western or non-
Conception vessel CV
traditional approach, many acupuncture practitioners
use these methods in a much more reductionist man-
ner, primarily as pain-control techniques.
When the body is in balance, there is an unob-
Traditional structed flow of energy, or Qi. This energy flows
Acupuncture based primarily on traditional Chinese through the body by way of a series of imaginary lines
medicine has its roots in Chinese philosophy. Accord- or meridians. There are 12 major (regular) meridians
ing to Chinese philosophy, the human body is in a or energy paths, each associated with one of the ma-
constant state of change, interacting with the forces of jor organs, such as lung meridian or heart meridian
nature. As such, the body is continually attempting to (Table 45–1). The meridians run longitudinally and
achieve a state of harmonious energy balance with its’ are interconnected through a series of transverse
environment. Any imbalance in the energy state will lines.
bring about ill health.3 Each of the meridians is symmetrically distributed
Everything in the universe is comprised of a mix- and follows a distinct and consistent pathway. Along
ture of two opposing, yet complementary forms of en- the course of these meridians are a series of 361
ergy: yin and yang. Yin is said to possess the qualities points, the classic acupuncture points. When energy
of cold, dark, and night, while yang possesses warmth, is insufficient, excessive, or obstructed, the flow of
light, and day. These two forces are not absolute and Qi is considered disrupted, leading to disharmony
may be considered as relative opposites. For exam- and illness. The diagnosis involves an assessment
ple, time may be divided into yin and yang segments, of symptoms and physical examination of the pa-
each with elements of the other, such that, morning is tient with special emphasis on the tongue and pulse
yang within yin, while afternoon is yin within yang. quality. From this, an energy disturbance is identi-
When considering the human body, each organ is sim- fied and a treatment plan is formulated. In traditional
ilarly categorized according to its respective opposing Chinese medicine, treatment involves acupuncture,
forces. The heart, being warm, is associated with yang herbs, diet, Qi gong, and massage. In the West, treat-
energy, while the kidneys are yin. All physiologic ac- ment is often confined to the use of acupuncture point
tivities are both interdependent and in balance with stimulation.
each other. In addition to the regular meridians, there are sev-
Another principle in Chinese medicine is the con- eral other meridians and connecting points. For a more
cept of five elements, or five phases. These five ele- comprehensive discussion of all of these meridians,
ments are represented by wood, fire, earth, metal, and the reader is directed to the Key References below.
water. As with yin and yang, ideally these elements
are complementary and in balance with each other. Nontraditional
In addition, each element (phase) is associated with In addition to the traditional form of acupuncture,
certain qualities and functions. Each of the organs in these therapeutic approaches have been practiced
the body is associated with one of the five elements. with different rationales and referred to as scien-
For example, the heart is associated with fire, while tific acupuncture, acupuncture as a form of trig-
the kidneys are associated with water. ger point therapy, and acupuncture with electrical
stimulation.12,13 According to Gunn, many medical

acupuncturists promote a more scientific form of
acupuncture.14 Rather than focusing on energy bal-
ance, this Westernized version attempts to explain
needle stimulation in terms that do not conflict with 1 cun
current understanding of anatomy and neurophysiol-
ogy. Emphasis is placed on a contemporary examina-
tion and medical diagnosis prior to treatment. Points
to be treated are generally those that are close to neural
structures, such as motor points and Golgi tendon or-
gans, and may be in the same neurological segment as
the injury. Rather than using acupuncture techniques
as an overall approach to health, this approach is tar-
geted at stimulating endorphins and neural mecha-
nisms, such as the pain gate within the spinal cord.
Acupuncture Points
Regardless of the philosophy of the acupuncturist, an
essential aspect of treatment remains the acupunc-
FIGURE 45–1. The anatomical measurement used in acupunc-
ture points, which are located at predictable loca- ture point location is the cun. (Modified with permission from
tions along the meridians. These points are typi- Hsu DT, Cheng RL. Acupuncture. In: Weintraub MI, ed. Alternative
cally found in the skin near major nerve bundles and complementary treatment in neurologic illness. New York: Churchill-
and are characterized by areas of lowered electrical Livingstone, 2001:8.)
resistance.15 In traditional Chinese medicine, these
points are said to be areas where the Qi energy may meridian points are those acupoints located along
be accessed and manipulated. According to Melzack the meridians. The extraordinary points have spe-
et al.,9 these points are very similar, if not identical, to cific names and definite locations but are not associ-
the myofascial trigger points described by Travell and ated in the same way with the meridians. In addition,
Simon.16 many of them have specific effects, such as sedation or
Acupuncture points are typically described ac- stimulation. Finally, the A-shi points are determined
cording to their proximity to nearby anatomical land- based on the presence of positive signs such as tender-
marks such as skin creases or the spinous processes ness. These points are also referred to as tender points
of vertebrae. Each point is situated a specified dis- and are usually located on, or near, diseased areas.
tance from such landmarks. The distance is measured They are primarily treated for pain relief.5
in cun, with one cun being equivalent to the distance
between the two interphalangeal joints measured Effects Traditional Chinese medicine states that the ef-
at the proximal creases of the flexed middle finger fect of stimulating an acupuncture point is dependent
(Fig. 45–1).3 upon the particular needs of the patient. If an acupunc-
Acupuncture points are named for the meridian ture point is stimulated in a healthy patient, nothing
in which they lie, and the points are given numbers will happen. In cases of disease, however, stimula-
beginning at the starting point of the meridian. For tion of the same point will have a different effect,
example, the point large intestine 4 (LI 4) is located at
the distal point of the crease formed when the thumb
LI-13
and index finger are placed side by side (Fig. 45–2).
The naming and numbering of acupuncture points LI-7 LI-12
is an important aspect in treatment for several rea- LI-6 LI-11
LI-3
sons. First, many of the acupuncture points are said to LI-2
LI-5
have specific effects and are used in the treatment of LI-1 LI-10
particular signs and symptoms. Second, combinations LI-9
of acupuncture points, or formulae, are often used as LI-8
treatment guidelines for specific conditions.
LI-4
ClassificationAcupuncture points are generally clas- FIGURE 45–2. Location of LI. 4. (Modified with permission from
sified into three different types: meridian acupoints, Filshie J, White A. Medical acupuncture: A western scientific approach.
extraordinary acupoints, and A-shi acupoints. The New York: Churchill-Livingstone, 1998:8.)
depending upon the condition being treated. For ex-

ample, stimulating pericardium point 6 (PC 6) is said GB - 35
to slow the heart rate in cases of tachycardia, but
quicken the rate in cases of bradycardia.5 Acupunc- GB - 36
ture point stimulation is said to have local, sectional,
distal, and specific effects. Practitioners of scientific
acupuncture describe the effect of point stimulation as GB - 37
dependent upon the parameters of stimulation, rather GB - 38
than the underlying condition. GB - 39
Treatment Methods GB - 41
For the most part, acupuncture is associated with the GB - 43 GB - 40
insertion of fine needles into the acupuncture points. GB - 44
However, there are numerous other methods of stimu-
lating these points including finger pressure (acupres-
sure), tei shin, electrical stimulation, and lasers. Some
GB - 42
of the more exotic methods, for example, moxibustion
and suction, are particularly popular in Asian com-
FIGURE 45–4. Location of GB 37.
munities. Moxibustion involves the practice of burn-
ing herbs over acupuncture points. Interestingly, the
use of acupuncture is said to represent only a small Techniques Because many of the treatment sessions
portion of the practice of Chinese medicine. Instead, may last for as long as 60 minutes, it is important that
many practicing doctors rely much more heavily on the patient be comfortably positioned prior to needle
the use of herbs, diet, and exercise than on the use of insertion. Obviously, the less movement that occurs
needle techniques. after the needles are inserted, the better. In addition,
the acupuncture points to be treated must be readily
Needles The acupuncture needle has evolved sig- accessible to the clinician. Also, because some individ-
nificantly over the centuries. Initially, needles were uals may feel faint at the sight of numerous needles
made from stone, animal bones, and bamboo splin- sticking out of them, it is important to place the patient
ters. Later needles were made of gold, silver, bronze, in a recumbent position.
and other materials. In many areas, needles were Once the clinician has decided upon which points
repeatedly reused. Today, however, concern over are to be treated, these points must be located. This is
bloodborne infections has made the use of dispos- typically done by palpating for the anatomical land-
able needles a standard practice, particularly in the marks and using the traditional cun measurements.
West. For example, gall bladder point 37 (GB 37) is found
Each needle is said to consist of three distinct parts: by palpating for the lateral malleolus of the ankle, and
handle, shaft, and tip (Fig. 45–3). Needles range in size then counting up 4 cun (Fig. 45–4). Points can also be
from approximately 0.22 to 0.45 mm in width, and identified with the use of a point locator, a device used
from 15 to 125 mm in length.3 The size and gauge of to detect skin resistance, and by palpating for point
the needle to be used are based on a number of factors, tenderness, although this latter method is not always
including the location of the acupuncture point and successful.
the age of the patient. Prior to needle insertion, the skin should be
cleaned with alcohol. The needle can be inserted in
several ways. In thick areas, the needle can be inserted
perpendicular to the skin; in less thick areas, the nee-
Hao or fine needle dle can be inserted at an oblique angle; and in very
thin-skinned areas, the needle can be inserted nearly
horizontally to the skin. To minimize discomfort, the
needle should be inserted in a single, rapid movement
accompanied by a slight twirling motion. Small tubes
are often placed directly over the acupuncture point.
Chang or long needle These tubes serve as a guide to provide accurate nee-
dle insertion.
FIGURE 45–3. Acupuncture needles. (Modified with permis- The depth of needle insertion may vary from a few
sion from Xinghua B, Baron RB. Acupuncture: Visible holism. Boston: millimeters to as much as several inches. When the
Butterworth Heinemann, 2001:19.) acupuncture point is precisely located and the needle
inserted to the correct depth, a sensation of warmth traditional Oriental medicine have been used to treat
and fullness is often experienced (termed DeQi muscle more than 43 common disorders, including:
afferents). Needles are typically left in place for several
minutes to as long as an hour. In the past, the needles • Gastrointestinal disorders: food allergies, peptic ul-
were periodically manipulated, vibrated, or twisted cer, chronic diarrhea, constipation, indigestion,
by the clinician. Today, they are often connected to gastrointestinal weakness, anorexia, and gastritis.
electrical stimulation devices. • Urogenital disorders: stress incontinence, urinary
tract infections, and sexual dysfunction.
Point Selection An important aspect of successful • Gynecological disorders: irregular, heavy, or painful
acupuncture treatment is appropriate point selection. menstruation, infertility in women and men, and
Several different methods are used in order to deter- premenstrual syndrome.
mine which points will be used. Traditionally, various • Respiratory disorders: emphysema, sinusitis,
aspects of the patient were assessed, including symp- asthma, allergies, and bronchitis.
toms, demeanor, complexion, pulse quality, and con- • Disorders of the neuromusculoskeletal system: arthri-
dition of the tongue. Based on the evaluation, energy tis, migraine headaches, neuralgia, insomnia,
imbalance along a specific meridian, organ, or both dizziness, and low back, neck, and shoulder pain.
was identified and treatment was initiated. Energy • Circulatory disorders: hypertension, angina pec-
balance was reevaluated at subsequent visits and toris, arteriosclerosis, and anemia.
points were chosen as indicated. In this manner, treat- • Emotional and psychological disorders: depression
ment was individualized and modified continually. and anxiety.
Today, it is more common (particularly in the West) • Addictions: including tobacco and smoking.
to rely on specific groups of points (formula) that • Eyes, ears, nose, and throat disorders (EENT).
have been considered useful for specific conditions. • Supportive therapy: for other chronic and painful
Another method involves the selection of acupunc- debilitating disorders.
ture points that surround the area of involvement.
This method is often used for pain control and is re- Precautions
ferred to as “surround the dragon.” Finally, points As with any other form of therapy, acupuncture in-
in the ear (auriculotherapy), scalp, and hand may volves some small element of risk. Consequently, clin-
be selected. The rationale for this method relates to icians should take necessary precautions to reduce
the concept that the various body parts are repre- any potential problems. Relative contraindications for
sented in a definite manner on the ear, hand, and acupuncture include:
scalp.
• Recent steroid use
Conditions Treated
• Anticoagulant therapy
In traditional Chinese medicine, acupuncture points • Pregnancy
are stimulated for almost every type of ailment. In the
Western world, the treatment is often more symptom- Proper patient education and instruction are also
specific (e.g., musculoskeletal pain). Some of the more important to minimize problems. Patients should be
commonly treated conditions include: instructed not to eat heavy meals or drink alcohol on
the day of treatment in order to reduce the possibil-
• Headache, dizziness, and fainting ity of nausea and vomiting. They should also be in-
• Epilepsy and convulsions formed that symptoms may increase temporarily dur-
• Stroke ing the first 24–48 hours following treatment, and they
• Neuropathies may experience fatigue and sleepiness as a result of
• Parkinson disease treatment.
• Insomnia
• Neck pain Complications
• Dysmenorrhea In addition to general safety considerations, there are a
• Bell palsy number of reported complications that are associated
• Low back pain with acupuncture point stimulation, including stuck,
• Obesity bent, or broken needles. This is more common when
patients are anxious and experience muscle spasms.
There is, however, very limited evidence to sup- Also, there are reports of bloodborne infections,17 der-
port most of these claims. The World Health Or- matitis,18,19 and syncope.20 Many of these problems,
ganization (WHO) recognizes that acupuncture and however, can be avoided by using good technique.
ACUPRESSURE
GB-28
Acupressure involves applying pressure with the
GB-30
thumb or fingertips to the same points that are treated GB-29
with acupuncture needles. The goals are to relieve
pain, to improve circulation, to enhance flexibility
and muscle function, and to promote body balance GB-31
GB-33
and healing.21 The effect is determined largely by the
manner in which the pressure is applied to the body.
For instance, a pinching pressure that is applied for a
short time period will usually have a stimulating ef-
fect. In contrast, a steady pressure that is applied over GB-35
a longer time period will tend to relax or sedate a body GB-39
area. Bekkering and van Bussel state that, on applying GB-40
mild pressure, initially only large A fibers are stim-
GB-41
ulated, producing paraesthesia.22 However, with GB-44
increasing pressure and duration, these large fibers
are blocked, producing numbness. In addition, small FIGURE 45–5. Comparison of acupuncture point and trig-
A fibers are stimulated, producing a sharp pain. Later ger point location. (Modified with permission from Filshie J, White
A. Medical acupuncture: A western scientific approach. New York:
still, most of these fibers are inhibited, and only the
Churchill-Livingstone, 1998:13.)
small C fibers will be stimulated, producing a dull
pain.
Perhaps the biggest advantage of acupressure is disease, arthritis, and stress.26 It is worth noting that
the ease of application. As a result, patients are pain is not the only symptom that is associated with
often taught self-treatment techniques. Also, many TrPs. Other symptoms include tenderness, paresthe-
massage therapists use pressure techniques during sia, muscle spasm, and autonomic symptoms.
their treatment.
Relationship to Acupuncture Points
Whether or not the myofascial trigger points de-
TRIGGER POINT THERAPY scribed by Travell and the classic acupuncture points
Trigger point therapy is based on the theories of Janet are one and the same is not clear. However, they do
Travell,23,24 but was also made popular in the chiro- seem to have a great deal in common (Fig. 45–5).
practic profession by Raymond Nimmo, the devel- In a comparison of the location of TrPs with that
oper of the receptor tonus technique.25 As indicated of acupuncture points that were specifically related
earlier in this chapter, there appears to be a connec- to pain, Melzack et al. found a 71% overlap.9 How-
tion between many of the reflex points and the classic ever, it appears that this overlap may not apply to
acupuncture points. all TrPs or to all acupuncture points. Travell and
Travell and Simons defined a myofascial trigger Simons state that the TrP sites vary from person to
point (TrP) as “a focus of hyperirritability in a tis- person.16 In addition, Gunn identified four different
sue that, when compressed, is locally tender and, if types of acupuncture points based on the particular
sufficiently hypersensitive, gives rise to referred pain type of nerve arrangement.27 Two of these were ner-
and tenderness, and sometimes to referred autonomic vous system structures found in muscles, the Golgi
phenomena and distortion of proprioception.”16 The tendon organs, and the motor point, which may corre-
referred pain from a TrP is typically dull and aching in spond with some acupuncture points. Finally, Travell
nature, but it can often be deep and poorly localized. states that, with the exception of pain relief, many
The pain and other symptoms are commonly found in of the effects that are associated with acupuncture
a region or reference zone that is typical for the muscle point treatment have not been reported with myofas-
affected with the TrP, but does not follow any normal cial trigger point therapy.
anatomical distribution.
The intensity of symptoms varies with time and Relationship to Motor Points
activities. An “active” TrP is one that is currently pro- The motor point corresponds to the place where the
ducing symptoms, while a “latent” TrP is not. Accord- motor nerve enters the muscle, which, like acupunc-
ing to Travell and Simons, a TrP may become active ture points, may be identified by a point of lowered
in several ways, including acute overload, overwork electrical resistance.28–30 Some authors have used the
fatigue, direct trauma, and chilling.16 TrPs are also terms TrP and motor point interchangeably.31,32 How-
described as being activated by other TrPs, visceral ever, motor points are typically located in the middle
portion of the muscle, while TrPs are found through- aging, the quality of many of the studies have been
out the length of the muscles. It may be that there is criticized and it is only recently that there has been in-
an overlap between the location of some TrPs, motor creased emphasis on high-quality clinical research. At
points, and acupuncture points. this point in time, the only statement that can be made
Baldry describes a trigger point approach to is that current research suggests that there may be
acupuncture that has, as its main objective, the relief some role for the use of acupuncture in the treatment
of pain that is referred to some body part from a fo- of pain syndromes and perhaps obesity and nausea
cus of neural hyperactivity in one of several muscu- but the efficacy of this ancient treatment approach has
loskeletal structures.15 Baldry references the works of yet to be established. The popularity of this treatment
Kellgren33,34 and Travell and Bigelow35 in the devel- method, however, has caught the imagination of a
opment of this method. He refers to the tender points number of research centers in the Western world and
as trigger points. greater scrutiny of the claims of health benefit of all
of these approaches can be anticipated over the next
decade.
LITERATURE REVIEW
Research into the stimulation of acupuncture points
and trigger points falls into several areas: physiologi- SUMMARY
cal and neurological mechanisms, efficacy, safety, and, 1. The stimulation of specific points in the body has
more recently, clinical trials. While not intended to be been used in chiropractic almost since the found-
an extensive review of the literature, this section suring of chiropractic. Acupuncture, acupressure, and
veys some of the available evidence for this topic. trigger point therapy are three different types of
therapies that aim to treat or stimulate specific
Mechanisms of Action points to improve health or well-being. Acupunc-
Acupuncture point stimulation has been associated ture was developed in Asia thousands of years
with the release of opioid peptides such as beta- ago and introduced into Europe during the Middle
endorphin, dynorphin, and enkephalin.36,37 This ac- Ages.
tion is known as acupuncture analgesia and probably 2. Acupuncture comes from Chinese traditional
accounts for part of the pain relief and anesthetic effect medicine. According to Chinese philosophy, ev-
that accompanies acupuncture point stimulation. It erything is composed of two forms of energy, yin
appears particularly evident following the use of elec- and yang. This energy, or Qi, flows in the body
troacupuncture that is delivered at specific frequen- along 12 set pathways, or meridians, and can be
cies. Low-frequency stimulation (2 Hz) is reported to disturbed by a number of diffuse factors. The goal
produce beta-endorphin in the brain and enkephalin of acupuncture is to restore optimal energy flow in
in the central nervous system, while high-frequency the body by stimulating various points along the
stimulation (100 Hz) is reported to increase dynorphin meridians, mainly through needle insertion.
in the spinal cord.38 There also appears to be individ- 3. Acupressure involves applying pressure with the
ual variation in response to acupuncture analgesia. In thumb or fingertips to the same points that are
animal studies, nearly two-thirds of the animals are treated with acupuncture needles. The goals of
seen to be high responders (an increase of pain thresh- acupressure are pain relief, improved circulation,
old of more than 60%), while the remaining are low enhanced muscle flexibility and function, and pro-
responders. The mechanisms of being a low responder motion of body balance and healing.
are presumed to be caused by the release of a low level 4. Trigger point therapy involves the use of manual
of opioid peptides, and a high level of cholecystokinin techniques such as massage or myofascial ther-
in response to electroacupuncture.39 apy to remove trigger points, or areas of hyper-
irritability, in muscle bands caused by a variety of
Clinical Trials factors. Many of the common locations for trigger
The literature on this topic is too large to cover in this points are thought to coincide with acupuncture
short chapter but has been the source of considerable points.
academic debate. In 1996, Singh reported that more 5. Acupuncture point stimulation is associated with
than 100 clinical trials had been performed between the release of opioid peptides such as beta-
1976 and 1995 in which acupuncture was used for pain endorphins, dynorphins, and enkephalins. The
control.40 In a review of these clinical trials, Berman literature has reported that more than 100 clinical
states that more than half of these articles indicate that trials had been performed between 1976 and 1995
more members of the acupuncture groups improved in which acupuncture was used for pain control;
than members of the control group, regardless of the the quality of many of these trials was low and
type of control used.41 While these reports are encour- further research is needed in this area.
3. Hsu DT, Cheng RL. Acupuncture. In: Weintraub MI,

QUESTIONS
ed. Alternative and complementary treatment in neurologic
1. What are some of the reflex techniques that have illness. New York: Churchill-Livingstone, 2001.
played a role in the chiropractic profession? 4. Palmer DD. Text-book of the science, art and philosophy
2. What is the principal difference between tradi- of chiropractic. Davenport, IA: Palmer School of Chiro-
tional acupuncture and scientific acupuncture? proctic, 1910.
5. Xinghua B, Baron RB. Acupuncture: Visible holism.
3. What is a meridian?
Boston: Butterworth Heinemann, 2001.
4. Are acupuncture points and trigger points the
6. Palmer BJ. The science, art and philosophy of chiropractic
same? nerve tracing. Davenport, IA: Palmer School of Chiro-
5. Name some of the common disorders treated by proctic, 1911.
acupuncture. 7. Martin R, ed. Dynamics of correction of abnormal function.
Sierra Madre, CA : Ralph Martin, 1977.
8. Chaitow L. Soft-tissue manipulation. Rochester, NY:
ANSWERS Thorsons Publishing, 1987.
9. Melzack R, Stillwell DM, Fox EJ. Trigger points and
1. Some of the reflex techniques include Chapman’s acupuncture points for pain: Correlations and implica-
neurolymphatic reflexes, Bennett’s neurovascu- tions. Pain 1977;3:3–23.
lar reflexes, Goodheart’s applied kinesiology, and 10. Reston J. Now about my operation in Peking. The New
Nimmo’s receptor tonus technique. York Times July 26, 1971:1, 6.
2. Traditional acupuncture is based on the philoso- 11. Culliton PD. Current utilization of acupuncture by
United States patients. Acupuncture: NIH Consensus
phy of Chinese medicine and is intent on balancing
Development Conference on acupuncture. Bethesda, MD:
the energy within the body. Scientific acupuncture National Institutes of Health, 1997.
is based on current knowledge of anatomy and 12. Chapman CR, Gunn CC. Acupuncture. In: Bonica JJ,
neurophysiology and is more intent on pain con- ed. The management of pain. Vol. 2. Philadelphia: Lea
trol and the treatment of specific conditions. and Febiger, 1990:1805–1821.
3. A meridian is one of the channels on which many 13. Han JS, Terenius L. Neurochemical basis of acupunc-
of the acupuncture points are found. ture analgesia. Ann Rev Pharmacol Toxicol 1982;22:
4. It would appear that there is an overlap be- 193–220.
tween some acupuncture points and the myofas- 14. Gunn CC. Acupuncture in context. In: Filshie J,
cial trigger points. However, not all acupuncture White A, eds. Medical acupuncture: A western scientific
point locations and trigger point locations coin- approach. New York: Churchill-Livingstone, 1998:11–
16.
cide. Whether they are the same entity is unclear
15. Baldry PE. Acupuncture, trigger points and musculoskele-
at this point. tal pain, 2nd ed. New York: Churchill-Livingstone,
5. Neuromusculoskeletal pain; gastrointestinal sym- 1993.
ptoms, especially nausea; and respiratory, circula- 16. Travell JG, Simons DG. Myofascial pain and dysfunc-
tory, and emotional symptoms. tion: The trigger point manual. Baltimore: Williams and
Wilkins, 1983.
17. Vittecoq D, Mattetal JF, Rouzioux, Bach JF. Acute HIV
infection after acupuncture treatments. N Engl J Med
KEY REFERENCES 1989;32:250–251.
18. Romaguera C, Grimalt F. Nickel dermatitis from
Baldry PE. Acupuncture, trigger points and musculoskeletal acupuncture needles. Contact Dermatitis 1979;5:195.
pain, 2nd ed. New York: Churchill-Livingstone, 1993. 19. Romaguera C, Grimalt F. Contact dermatitis from
Filshie J, White A. Medical acupuncture: A western scientific a permanent acupuncture needle. Contact Dermatitis
approach. New York: Churchill-Livingstone, 1998. 1981;7:156–157.
Travell JG, Simons DG. Myofascial pain and dysfunction: The 20. Chen FP, Hwang SJ, Lee HP, Yang HY, Chung C. Clin-
trigger point manual. Baltimore: Williams and Wilkins, ical study of syncope during acupuncture treatment.
1983. Acupunc Electrother Res 1990;15(2):107–119.
21. Nickel DJ. Acupressure for athletes. Santa Monica, CA:
Health Acu Press, 1984.
REFERENCES 22. Bekkering R, van Bussel R. Segmental acupuncture. In:
Filshie J, White A, eds. Medical acupuncture: A western
1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends scientific approach. New York: Churchill-Livingstone,
in alternative medicine use in the United States, 1998:105–135.
1990–1997: Results of a follow-up national survey. 23. Travell JG. Rinzler S, Herman M. Pain and disabil-
JAMA 1998;280(18):1569–1575. ity of the shoulder and arm: Treatment by intramus-
2. Tam Po Kwan, Chinese Medical Institute, 1974 (per- cular infiltration with procaine hydrochloride. JAMA
sonal communication). 1942;120:417–422.
24. Travell JG, Rinzler SH. The myofascial genesis of pain. 35. Travell JG, Bigelow NH. Referred somatic pain does
Postgrad Med 1952;11:425–434. not follow a simple “segmental” pattern. Federation Pro-
25. Nimmo RL. Receptor-tonus workshop manual/notes. Au- ceedings 1946;5:106.
thor, 1966. 36. Han JS, Xie GX, Zhou ZF, Folkesson R, Terenius L.
26. Simons DG, Travell JG, Simons LS. Myofascial pain and Enkephalin and β-endorphin as mediators of elec-
dysfunction: The trigger point manual. Vol. 1. Baltimore: troacupuncture analgesia in rabbits: An antiserum
Williams and Wilkins, 1999. microinjection study. Adv Biochem Pharmacol 1982;33:
27. Gunn CC. Type IV acupuncture points. Am J Acupunc 369–377.
1977;5:51–52. 37. Han JS Ding XZ, Fan SG. CCK-8: Antagonism on elec-
28. Cohen HL, Brumlik J. Manual of electroneuromyogra- troacupuncture analgesia and a possible role in elec-
phy, 2nd ed. Hagerstown, MD: Harper and Row, 1976: troacupuncture tolerance. Pain 1986;27:1–15.
74. 38. Han JS, Chen XH, Sun SL, et al. Effect of low- and
29. Goodgold J, Eberstein A. Electrodiagnosis of neuromus- high-frequency TENS on met-enkaphalin-Arg-Phe and
cular diseases, 2nd ed. Baltimore: Williams and Wilkins, dynorphin A immunoreactivity in human lumbar CSF.
1977:3. Pain 1991;47:295–298.
30. Lenman JAR, Ritchie AE. Clinical electromyography, 39. Fei H, Xie GX, Han JS. Low and high frequency elec-
2nd ed. Philadelphia: JB Lippincott, 1977:86–87. troacupuncture stimulation releases [met5] enkephalin
31. Gunn CC, Milbrandt WE. Utilizing trigger points. and dynorphin A and B in rat spinal cord. Chin Sci Bull
Osteopathic Phys 1977;44:29–52. 1997;32:1496–1501.
32. Gunn CC, Milbrandt WE. Shoulder pain, cervical 40. Singh BB. A fully dressed outcome study vs. a naked clinical
spondylosis and acupuncture. Am J Acupunc 1977;5: trial. Presented at Muenchener Modell Methodological
121–128. Conference. Munich, Germany, October, 1996.
33. Kellgren JH. Observations on referred pain arising 41. Berman BM. Overview of clinical trials on acupuncture for
from muscle. Clin Sci 1938;3:175–190. pain. Acupuncture: NIH Consensus Development Confer-
34. Kellgren JH. A preliminary account of referred pains ence on Acupuncture. Bethesda, MD: National Institutes
arising from muscle. Brit Med J 1938;1:325–327. of Health, 1997:8–10.
C H A P T E R
46
THE ROLES OF REHABILITATION AND
EXERCISE IN CHIROPRACTIC PRACTICE
Craig Liebenson and Clayton Skaggs
O U T L I N E
INTRODUCTION Condition-Specific Mechanical Sensitivities
LOW BACK PAIN Centralization Phenomena
PRINCIPLES OF REHABILITATION Identifying the Key Dysfunctions
Diagnostic Dilemma in Back Pain Functional Restoration
Deconditioning Syndrome: Functional and Behavioral Principles
Performance Deficits Neurophysiologic Principles
How Injuries Occur Stability Principles
How the Body Resists Injury Integrating Active Care with Chiropractic
Agonist–Antagonist Muscle Imbalance Reassurance
Spine Stabilizers Reactivation
Fear-Avoidance Behavior Reevaluation
Effective Active Patient Care Reconditioning
Acute Phase Referral
Subacute Phase SUMMARY
Chronic Phase QUESTIONS
CLINICAL APPLICATION ANSWERS
Assessment of the Patient’s Functional Range REFERENCES
OBJECTIVES in the concepts of rehabilitation and the importance of

exercise and maintenance of routine activity. Nowhere
1. To discuss the role of rehabilitation in chiropractic is this more evident than in the treatment of patients
care. with back pain. As interest in the biopsychosocial
2. To review the biopsychosocial model of disease. model has grown,1 chiropractors have taken a lead-
3. To review the various aspects of active care. ership role in the development and promotion of con-
4. To review the literature regarding rehabilitation in cepts and procedures designed to enlist the patient
low back pain. in the patient’s own recovery. Generally referred to
5. To review the concept of spinal stability. as active care, these procedures encourage patients to
participate actively in the resolution of their condition,
rather than waiting for clinicians to “fix” them.
As testimony to the growing interest in such ac-
INTRODUCTION
tive care programs, many chiropractic educational in-
Chiropractors have long been interested in a variety of stitutions have developed extensive coursework and
treatment approaches ranging from nutrition to phys- continuing education programs in the areas of rehabil-
ical modalities to exercise. There is, in particular, a itation and exercise. The publication of Rehabilitation of
growing interest within the chiropractic profession the Spine: A Practitioner’s Manual played a significant
887
role in establishing the chiropractic profession at the underestimation of the anxiety-producing effects of
forefront of spine rehabilitation procedures.2 false-positive results, and an unwillingness by the
The majority of patients seeking chiropractic care clinician to accept small amounts of risk.14 Persis-
do so for low back pain.3 In addition, much of the tent pain reinforces negative attitudes about the re-
research and investigation in the use of rehabilita- lationship of activity and pain as the patient takes
tion and exercise procedures has been done on pa- on the “sick” role.15 The result is activity avoidance
tients with low back pain. Consequently, this chapter and further deconditioning. Unfortunately, recondi-
focuses on the application of these techniques to pa- tioning time is longer than deconditioning time.16
tients with low back pain. It is worth noting, however, Therefore, it is important to reactivate patients as
that many of the procedures that are discussed in this early as possible. Numerous reviews of the literature
context may be useful for patients with a variety of show that gradually resuming activities is both safe
neuromusculoskeletal conditions. and effective for acute, subacute, and chronic back
pain.8–10,17–19
LOW BACK PAIN
PRINCIPLES OF REHABILITATION
The traditional view of back problems is that they
represent acute, self-limiting conditions that resolve Diagnostic Dilemma in Back Pain
within 4–6 weeks.4 However, recent epidemiologic Appropriate management of any condition depends
data conflict with this rather optimistic picture. Back on accurate diagnosis of the patient. Treatment that is
problems are now recognized as chronic ailments not guided by classification of patients into groups
characterized by frequent acute spikes.5 Fortunately, that have unique characteristics amenable to spe-
they are rarely disabling, but the minority of cases cific interventions is far from ideal. Unfortunately,
which involve disability account for a disproportion- less than 20% of back pain patients can be given a
ate percentage of the overall costs related to back clear diagnosis of their condition.8 It should come
pain.6 as no surprise then that back pain is considered one
Low back pain is estimated to cost at least $30 bil- of the most costly health problems in the Western
lion per year in the United States.7 A great deal of evi- world.
dence now exists regarding appropriate treatment for Current guidelines suggest classifying back pain
many spinal disorders, and international guidelines into three groups: those with “red flags” such as tu-
on low back pain have flourished since 1986. Even mor, infection, fracture, or serious medical disease
so, there remain wide regional variations in practice (<2%); those with nerve root compression (<10%);
habits that are inconsistent with the evidence-based and those with “nonspecific” back pain (85–90%).
consensus on appropriate management for spinal Most current research on the effectiveness of different
disorders.8–11 Waddell has stated that the most cost- interventions assumes that the large population with
effective approach to managing this problem is to nonspecific back pain is a homogenous group.20
more aggressively pursue secondary prevention ef- LaBouef-Yde and Manniche have criticized research
forts on subacute patients before chronic disability is that begins with this assumption.21 They explain that
fully established.1 specific interventions, which may be beneficial for a
In particular, the major errors have involved certain subgroup, may not have demonstrable clini-
the traditional emphasis on a biomedical, rather cal effectiveness if given to a more clinically diverse
than a biopsychosocial, approach. The biomedi- population. Thus, many interventions may be erro-
cal approach has involved “labeling” patients as neously assumed to be ineffective. Future research
damaged (e.g., arthritis) or injured (e.g., “ruptured should thus strive to determine if the nonspecific clas-
disc”), overprescribing bed rest, recommending early sification actually represents a homogeneous or het-
imaging, and inappropriate selection of surgical erogeneous population.
candidates.12 In contrast, the biopsychosocial model Work by Erhard and Delitto has convincingly
emphasizes early reassurance and reactivation along shown that subclassification of the nonspecific group
with pain relief measures such as spinal manipu- is possible using available and reliable tests. Treat-
lation for acute patients and exercise for chronic ment that is then matched to the appropriate sub-
patients.1,3,13 classification is superior to unmatched treatments.22
The biomedical approach leads to a cascade ef- Furthermore, when a treatment is driven by subclas-
fect in the clinical management of back pain pa- sification, it is superior to the “generic” treatment rec-
tients. This is often a result of an inadequate history, ommended by Agency for Health Care Policy and Re-
underestimation of the iatrogenic effects of overly ag- search (AHCPR) for the broad nonspecific category.23
gressive diagnosis (imaging) and treatment (surgery), Researchers at Washington University have similarly
THE ROLES OF REHABILITATION AND EXERCISE IN CHIROPRACTIC PRACTICE 889
validated a subclassification scheme based on func-

tional evaluation of movement patterns.24,25 Other Measurements of Deconditioning
work has been done showing that a subgroup of General functional ability
patients have significant psychosocial illness traits • Self-report of activity intolerances (i.e., Oswestry form)
termed “yellow flags,” and that these individuals are • Tests of walking, standing, reaching, and the like
at heightened risk of developing chronic symptoms
and disability.26–28 Specific functional impairments or deficits
The guidelines and related literature clearly point • Tests of strength, range of motion, and the like
out past errors, yet there are still many unan-
swered questions. The fundamental problem in deal-
ing with low back pain continues to be identi- The World Health Organization’s (WHO) Inter-
fying which patients will likely respond best to national Classification of Impairments, Disabilities and
which interventions. For instance, which patients Handicaps (ICIDH) document distinguishes activity
will respond best to manipulation, reassuring coun- level or general functional ability from impairment
sel, exercise, medication, or various combinations in body function or specific functional deficits. Gen-
thereof? General guidelines adhering to a biopsy- eral functional ability is what patients can or cannot
chosocial model have emerged and suggest a new do (or perceive they cannot do) in their daily life, such
path. as walking, sitting, or standing tolerances. In contrast,
specific functional deficits are found only on clinical
Deconditioning Syndrome: Functional and examination and may or may not be related to the pa-
Performance Deficits tient’s symptoms or functional abilities. Specific func-
The inherent difficulty in diagnosing low back pain tional deficits include changes in strength, range of
has led to great frustration for both patient and clini- motion (ROM), endurance, and balance. Identifying
cian. While it is tempting to order advanced imaging and correcting the specific dysfunction(s) (often the
tests to find the “cause” of pain, structural patholo- key maladaptations that are responsible for pain) and
gies are quite common and usually coincidental. Disc general dysfunction suggest a clinical course of action.
bulges, facet joint degeneration, endplate changes, Unfortunately, the clinical path is lined with many
and mild spondylolisthesis all correlate more with age specific dysfunctions that are either adaptive or incon-
than with symptoms. Exceptions include disc extru- sequential; thus the challenge is to find the key dys-
sion, moderate or severe canal stenosis, and nerve root function or functional chain that should be addressed.
compression.29 A patient’s self-report of activity limitation is a
Because most back problems are not caused by valuable tool for measuring clinical outcomes and for
structural pathology (e.g., arthritis, herniated disc) or goal setting. These self-reports are typically question-
serious disease (e.g., tumor, infection, fracture), and naires that are both highly reliable and responsive.32
because the majority benefit from prompt reassur- However, their validity is questionable because they
ance and early reactivation advice, the primary goal do not correlate well with actual measurements
of care should be to reassure patients about the be- of functional performance ability.33 Thus, question-
nign nature of their pain and the safety and value naires, while excellent outcomes measures, may be
of resuming normal activities. This process is termed poor guides for determining appropriate treatment
“the functional approach” and has been advocated strategies.
by authorities in the manipulation and rehabilita- Simmonds and colleagues showed how general
tion field for many years.1,2,30,31 Thus, prevention of functional ability can be measured with simple, re-
deconditioning—both physical and psychological— liable, inexpensive, and time-efficient tests.33,34 Ex-
is a fundamental goal of the modern management of amples of such tests include functional reach, loaded
spinal disorders. reach, timed up and go, and distance walked.35 These
Deconditioning is the diminished ability to per- tests are valuable tools for both identifying functional
form tasks involved in a person’s usual activities of limitations and for establishing realistic goals in the
daily living. In the Agency for Health Care Policy and management of patients with low back pain.
Research’s low back pain guidelines8 it is stated that Another clinical standard involves the use of tests
“the main goal for treatment of back pain has shifted of physical impairments such as ROM or strength.
from treatment of pain to treatment of activity intoler- Unfortunately, most impairments typically measured
ances related to pain.” There are a variety of measure- show a rather tenuous correlation to both pain and
ments of deconditioning, and many promising paths, activity intolerances.36–39 In fact, these measures have
but as yet no gold standard (see sidebar, “Measure- been shown to be related as much to an individ-
ments of Deconditioning”). ual’s motivation to perform as to their actual physical
performance ability.40,41 This may help to explain why muscles are not usually prepared and a sudden, unex-
the relationship between impairment (specific func- pected movement can trigger a painful reaction.56 This
tional deficits), disability (general functional ability), situation is particularly true first thing in the morn-
and pain is so complex.39,42,43 Every clinician can think ing when the motor control system is not warmed
of patients with severe pain and disability who have up or after sitting or bending for a prolonged pe-
very little impairment, while others who are very im- riod because of fatigue. Thus, inappropriate muscle
paired show little evidence of disability. activation sequences during seemingly trivial tasks,
Mannion suggests that because 50% of self- such as bending over to pick up a pencil, can compro-
reported disability prior to treatment and more than mise spinal stability and potentiate buckling of the
50% of it after therapy is unaccounted for by struc- passive ligamentous restraints.57 This motor control
tural, psychological, voluntary performance, or elec- skill is also compromised under challenging aerobic
tromyographic (EMG) fatigue findings, new aspects of circumstances.58
physical function relating to motor control are worthy A study of the biomechanics and neurophysiology
of future investigation.42,43 These aspects include non- of spine stability strongly suggests that rehabilitation
voluntary reflex control of movement, such as position approaches should focus on developing coordination
sense, delayed reaction times, and balance tests.44–49 between agonist and antagonist muscles, fast contrac-
tion of stabilizers, aerobic conditioning, and muscle
How Injuries Occur endurance.
Injury occurs when applied loads exceed tissue toler-
Agonist–Antagonist Muscle Imbalance Agonist–antago-
ance. The spinal column devoid of its musculature has
nist muscle coactivation is a central aspect of joint sta-
been found to buckle at a load of only 90 newtons (N)
bility. Loss of normal function and the balance of ag-
(about 20 lb) at L5.50 However, during routine activi-
onist and antagonists can compromise joint stability.
ties, loads 20 times this are encountered on a routine
A study of the elbow and knee joints showed that an-
basis. Panjabi says, “This large load-carrying capacity
tagonist muscle coactivation is important in helping
is achieved by the participation of well-coordinated
ligaments to maintain joint stability.59 It is well known
muscles surrounding the spinal column.”51 Not sur-
that certain muscles, such as those in the knee,60 lum-
prisingly, the motor control system functions well
bar spine,61 and cervical spine,62 respond to inflamma-
when under load. Muscles stabilize joints by stiffen-
tion or injury by inhibition and atrophy. It is also com-
ing in a manner similar to the rigging on a ship. But,
monly accepted that other muscles, such as the upper
when load is at a minimum, such as when the body
trapezius,63 sternocleidomastoid,64 and lumbar erec-
is relaxed or a task is trivial, the motor control sys-
tor spinae,65 respond to injury or overload by tensing
tem may be caught off guard and injuries are often
or becoming overactive.
precipitated.
Lund et al. theorized that the presence of pain
decreases activation of muscles during movements
How the Body Resists Injury in which they act as agonists, and increases ac-
According to Cholewicki and McGill, spine stability tivation during movements in which they act as
is greatly enhanced by cocontraction of antagonistic antagonists.66 In a wide variety of studies involving
trunk muscles.52 Without this cocontraction, the spinal such diverse locomotor tasks as gait, trunk bending,
column is unstable in upright postures.50 mastication, head raising, reaching, and carrying
Of particular interest, these cocontractions are activities, agonist inhibition, synergist substitution,
most obvious during reactions to unexpected or and antagonist overactivity have been repeatedly
sudden loading.53 Cholewicki et al. showed an in- demonstrated.64,67–70
creased EMG activation of the rectus abdominis in up-
right postures versus flexed postures, thus serving as a Spine StabilizersAs stated earlier, muscles provide low
mechanism to maintain stability in neutral postures.54 back support and stability. Certain muscles in partic-
Stokes et al. described two basic mechanisms by which ular stabilize the low back in various situations: The
this coactivation occurs.55 One is a precontraction to rotatores and intertransversarii muscles resist twist-
stiffen, and thus dampen, the spinal column when ing movements, the pars thoracis component of both
faced with unexpected perturbations. The second is the iliocostalis lumborum and longissimus thoracis
dependent upon a sufficiently fast speed of contrac- muscles can produce the greatest amount of extensor
tion of the muscles to react quickly enough to prevent moment with a minimum of compressive penalty to
excessive motion that would lead to buckling follow- the spine, and the multifidus muscle creates extensor
ing either expected or unexpected perturbations. torque, but only at individual joints.71 Anteriorly, the
With this understanding, clinicians can now ex- oblique abdominal muscles are involved in twisting,
plain to patients quite rationally how trivial trauma side bending, and stabilization when the spine is be-
can cause acute low back pain. With low loading, ing axially compressed.72–74 The one muscle that is
highly active during flexion, extension, and lateral while others become inhibited. He has observed that
bending tasks is the quadratus lumborum.74 Its archi- individuals with neurologic diseases such as cerebral
tecture is ideally suited to perform stabilization be- palsy have predictable spasticity in certain muscles
cause the quadratus lumborum muscle attaches each (e.g., short thigh adductors), while in conditions such
transverse process to the more rigid pelvis and rib as polio, predictable paralysis occurs in other mus-
cage, thereby facilitating a bilateral buttressing effect cles (e.g., muscles of the abdominal wall). He also
for the vertebrae.71 has noted that these same tendencies are seen in in-
Coordination between agonist and synergist mus- dividuals without neurological disease who are ei-
cles, rather than muscle strength, plays a pivotal role ther highly sedentary or are training their muscles
in resisting injury. Sparto et al. reported that spinal inappropriately.
loading forces were increased during a fatiguing iso- This theory has a neurodevelopmental basis. In the
metric trunk extension effort without a loss of torque neonate, the fetal position is maintained by “tonic”
output.75 Torque output remained constant as the contraction of trunk and extremity flexors along with
erector spinae fatigued and substitution by secondary extremity adductors and internal rotators. Reciprocal
extensors, such as the internal oblique and latissimus inhibition (Sherrington law), which is present in early
dorsi muscles, occurred. Two muscles in particular infancy, inhibits the antagonists of the “tonic” muscle
have received the greatest attention for their role in chains. Thus, a substantial muscle imbalance exists
low back pain: the multifidus and the transverse ab- both neonatally and in early infancy. As the infant
dominis. Atrophy of the multifidus muscle in the low develops, the reciprocal inhibition becomes damp-
back has been shown in patients with acute low back ened, thus allowing the “phasic” muscle system to ac-
pain.61 The atrophy seen in acute patients was uni- tivate. As the “reflex bound” infant begins to develop
lateral to the pain and at the same segmental level as its postural control system, “tonic” activity of mus-
palpable joint dysfunction. Recovery from acute pain cles that maintain the fetal posture is superseded by
did not automatically result in restoration of the nor- agonist–antagonist coactivation of muscles necessary
mal girth of the muscle. However, spinal stabilization for movement control and production of the upright
exercises successfully rebuilt the muscle’s size.49 Re- posture. Thus, extensors, abductors, and external ro-
cent research demonstrates that individuals who suc- tators coactivate with their fetal partners to stabilize
cessfully restore normal multifidus girth have fewer joints in “centrated postures” and allow neurodevel-
recurrences of lower back pain at both 1- and 2-year opment of posture.
follow-up.48 Bergmark has done the most to scientifically
EMG studies show that the transverse abdominis present the theory that muscles can be divided into
is recruited prior to any other abdominal muscle when two broad categories based on their function—one
the trunk is subjected to sudden perturbations.76 In functioning to produce movement and the other to
a study looking at abdominal activity during upper control it.85 Superficial muscles are responsible for
limb movements, the transverse abdominis was the producing voluntary movement or torque produc-
only muscle active prior to initiation of arm motions.77 tion, while deep muscles are responsible for main-
The same was found to be true during lower limb taining joint stability. The deep (intrinsic) muscles are
movements.76 responsible for joint stability on an involuntary or sub-
Hodges and Richardson reported that slow con- cortical basis, while movement production is largely
traction of the transverse abdominis during arm or a voluntary act. Table 46–1 shows the different di-
leg movements is correlated with low back pain.76–79 visions of muscles according to their dysfunctional
O’Sullivan et al. found that synergist substitution of tendencies.
the rectus abdominis for the agonist transverse ab-
dominis during an abdominal “drawing in” maneu- Fear-Avoidance Behavior
ver strongly correlated with chronic back pain and Patients’ expectations influence their perfor-
that specific rehabilitation that improved this dys- mance.41,86 Performance is thus limited by psycho-
function was superior to a more general exercise logical as well as physical factors. Patients who equate
approach.80 hurt with harm develop a disabling form of think-
Rood first proposed that muscles can be grouped ing. This is part of fear-avoidance behavior, which
into broad categories on the basis of their functional promotes deconditioning (Fig. 46–1).87 Psychological
characteristics.81 Certain muscles were hypothesized variables have been demonstrated to account for
to function as stabilizers and others as mobilizers. In 26% of self-reported pain and 36% of self-reported
recent decades, Janda and Sahrmann have led the way disability.42,43 The most important psychological
in promoting the concept that muscle imbalance is a characteristics reported by Mannion et al. are the
key factor for altering movement patterns and influ- use of negative coping strategies, self-efficacy beliefs,
encing joint stability and pain.82–84 Janda suggests that fear avoidance, and distress. Interestingly, this study
certain muscles have a tendency to become overactive described three different active care approaches, none
TABLE 46–1. Muscle System Classifications may be responsive to physical interventions such as
exercise and activity modification.
Global–Superficial Many authors have focused on the psychological
Muscles* Local–Deep Muscles† characteristics of chronic patients. Ciccione and Just
found that pain expectancies accounted for 33% of
Gastrocnemius Soleus Quadratus plantae the variance in acute subjects, but for only 16% of
Adductors Peronei the variance in the chronic patients.88 Fear-avoidance
Hamstrings Vastus medialis beliefs such as pain expectancies begin in acute pain
Tensor fascia lata Gluteals and precede other psychosocial problems, which de-
Hip flexors Transverse abdominis velop as acute pain becomes chronic. Vlaeyen et al.
Piriformis Internal oblique have summarized the impact of fear-avoidance be-
Quadratus Multifidus havior on both general and specific functional abil-
lumborum (lateral) ities (see sidebar, “The Impact of Fear-Avoidance
Rectus abdominis Quadratus lumborum (medial) Behavior”).87
External obliques Medial and lower erector spinae
Lateral and Lower and middle trapezius
thoracolumbar The Impact of Fear-Avoidance Behavior
erector spinae
The problem
Upper trapezius Serratus anterior
• Pain catastrophizing (“fearing the worst”) is a precur-
Levator scapulae Deep neck flexors
sor of pain-related fear.
Pectorals Digastricus
• Fearful patients tend to be more hypervigilant—aware
Subscapularis
of possible signals of threat.
Suboccipitals
• Psychophysical reactivity is present in individuals with
Stemocleidomastoid
fear-avoidance behavior if activities are perceived as
Lateral pterygoids
harmful, even if they are not actually harmful.
Masseter
• “Guarded movements,” such as altered flex-
* Typically become overactive or shortened. ion:relaxation ratio, are correlated with fear-avoidance
†
Typically become inhibited or lengthened. beliefs, not actual pain.
Data modified from Bergmark A. Stability of the lumbar spine. A study • Anxious patients predict pain earlier during perfor-
in mechanical engineering. Acta Orthop Scand 1989;60:4–64. mance of physical tasks such as range-of-motion or
straight-leg raise tests.
of which consisted of psychological or cognitive– • Fear and anxiety lead to the tendency to avoid the per-
behavioral approaches, all of which improved ceived threat.
psychological variables related to self-report of pain • Pain-related fear not only leads to poor physical per-
and disability.42,43 These results encourage a new formance, but leads to restrictions in activities of daily
process of thinking where psychosocial factors that living.
have dominated chronic pain and disability profiles • Avoidance behavior is very resistant to treatment be-
cause the individual rarely comes into contact with the
INJURY actual (nonharmful) consequences of the feared situa-
DISUSE tion.
DEPRESSION RECOVERY
DISABILITY
The solution
AVOIDANCE
• A cognitive–behavioral approach addresses the pa-
HYPERVIGILANCE
PAIN EXPERIENCE CONFRONTATION tients’ inaccurate predictions about the relationship be-
tween specific activities and pain.
PAIN RELATED FEAR
• Education of patients with pain-related fear should em-
phasize that this can be self-managed after repeated
PAIN CATASTROPHIZING NO FEAR
desensitization from “graded exposures” to the feared
stimuli.
NEGATIVE AFFECTIVITY
THREATENING ILLNESS INFORMATION • Pain expectancies are corrected with repeated per-
formance of the movements/exercises on subsequent
FIGURE 46–1. Fear-avoidance behavior. (Reproduced with per- days.
mission from Vlaeyen JWS, Linton S. Fear avoidance and its consequences • After multiple exposures, overpredictions of pain inten-
in chronic musculoskeletal pain. A state of the art. Pain 2000;85:317– sity tend to match actual pain experience.
332.)
Effective Active Patient Care propriate patients are superior to a general approach
Acute Phase A number of studies suggest that ac- recommended by recent guidelines.
tive care is effective in patients with acute low back Hides et al. demonstrated that segmental spinal
pain. Information and advice emphasizing the value stabilization exercises could prevent multifidus mus-
of fitness and the safety of resuming activities re- cle atrophy in acute low back pain subjects.49 How-
sulted in superior outcomes when compared to ad- ever, symptomatic and functional recovery occurred
vice reinforcing rest, activity restrictions, and the independent of this intervention despite the fact that
notion that the spine is injured or damaged.17 Reas- patients not receiving the exercises continued to have
suring workers and encouraging resumption of ordi- multifidus muscle atrophy. More recently, Hides et al.
nary activities were superior to medication, bed rest, suggested that such exercises might have a secondary
or mobilization exercises.19 Early behavior modifica- preventive effect by reducing recurrences.48
tion through exercise reduced disability 1 year later.89 As with patients suffering from low back pain,
An eightfold reduction in the risk of becoming chronic early activation has been found to be effective for neck
was achieved from information designed to reduce pain following a whiplash injury.95–97
fear and anxiety and provide self-care advice.90 Lit-
tle et al. recently demonstrated that educational ad- Subacute Phase Because the natural history of acute
vice which encourages early exercise (not just advice low back syndromes is satisfactory recovery with min-
to stay active) or endorsement by a physician of a imal intervention, it has been suggested that the sub-
self-management booklet has been shown to increase acute phase is the ideal time for both active and ag-
patient satisfaction and function while reducing gressive treatment.1,98,99 Hagen et al. reported a recent
pain.18 study using light activity, education about the benign
While there is ample evidence to support the use of nature of pain, and encouragement to stay active.100
activity and exercise in the management of acute back At 1-year follow-up, a significantly greater number of
pain patients, the evidence is inconclusive. A recent, experimental group patients returned to work than
highly criticized Cochrane Collaboration systematic did those who received more traditional manage-
literature review concluded for acute low back pain ment. Lindstrom et al. showed that a graded activity
“. . . there is strong evidence (Level 1) that exercise program reduced disability more than traditional
therapy is not more effective for acute low back pain care.101 Graded activity uses exercise to quota rather
than other active treatments with which it has been than being guided by pain (i.e., less on bad days and
compared.”91 One notable study that influenced these more on good days).
conclusions was by Faas et al., who reported that in
the treatment of uncomplicated acute low back pain,
exercise was no better than usual care by a general Chronic Phase Although the recent Cochrane Collab-
practitioner.92 It has been argued that the Cochrane oration review did not find strong evidence for the
Collaboration review based its conclusion on too few effectiveness of exercise for acute low back pain, it
studies (three randomized controlled trials) and that did conclude that, “. . . there is strong evidence
other factors should be considered when formulating (Level 1) that exercise therapy is more effective than
clinical guidelines and policy.93 usual care by a general practitioner for chronic low
In nearly all studies of exercise evaluated through back pain.”91 One excellent study involving long-
meta-analysis techniques, the same exercise type is term follow-up is that of Indahl et al.13 This program
prescribed randomly to a heterogeneous group of provided education designed to reduce fear. Patients
nonspecific low back pain patients. Yet, in clini- were informed that light activity would not injure
cal practice, most exercise approaches are taught the disc, but instead speed recovery. The return-to-
with emphasis on individualizing the type of exer- work rate was double that seen in the control group.
cise to the functional or mechanical attributes of the O’Sullivan et al. showed that specific spine stabiliza-
individual.22,94 In fact, when a comparison was made tion exercises achieved superior outcomes to isotonic
between individuals performing exercises matched exercises in chronic patients with spondylolisthesis.80
specifically to the patient versus those who were un- Manniche et al. demonstrated that an isotonic regime
matched to the treatment, the matched group signifi- emphasizing endurance training was successful in
cantly outperformed the unmatched exercise group.22 improving outcomes.102 A number of behavioral-
Also, a recent paper by the same authors describes a based exercise regimens using a cognitive–behavioral
study comparing the general exercise recommenda- approach have demonstrated their effectiveness in
tions of the AHCPR guidelines to matched treatment a variety of settings.103–106 Quota-based exercises
based on their subclassification scheme.23 These au- not guided by pain were used in each of these
thors conclude that specific treatments matched to ap- studies.
CLINICAL APPLICATION after rising.111 Disc-bending stresses are increased sig-

nificantly in the morning.112 After even a brief period
Assessment of the Patient’s Functional Range of sitting or stooping in end range, protective joint
A number of key questions, such as those that follow, stiffness is compromised. Even after 30 minutes of rest,
must be answered prior to prescribing an exercise pro- residual joint laxity persisted.113 Therefore, avoidance
gram for a patient with spinal pain: of high-risk activities early in the morning, or after
sitting or stooping in full flexion, is crucial to injury
• What exercises are safe for the patient’s condition? or reinjury prevention.
• What exercises are best tolerated by the individual The suggestions that workers be taught to lift with
patient? their knees rather than their backs are overly simplis-
• What is the most relevant dysfunction that is retic. Most workers have learned various techniques to
sponsible for specific activity intolerances? avoid injury that are inconsistent with this advice. Bet-
ter advice is consistent with the following principles:
Maintain lordosis, avoid end range motion, rotate jobs
According to Dennis Morgan, a pioneer in spinal sta-
to vary loads, allow frequent rest breaks, and keep
bilization training, “the functional position is the most
loads close to the spine.114
stable and asymptomatic position of the spine for the
Evidence from athletes such as gymnasts and Aus-
task at hand.”107 Before exercise can be prescribed, a
tralian cricket bowlers suggests that posterior arch
thorough history and examination of the patient’s me-
damage leading to spondylolisthesis is not just caused
chanical sensitivities must be carried out.108,109
by shear forces, but is also correlated with repetitive
full-range activities.115 Disc injury is shown to be re-
Condition-Specific Mechanical Sensitivities lated to three factors: full end-range flexion in younger
In order to allow recovery from injury, loads known spines,116–118 repetitive end-range flexion loading mo-
to precipitate injury must be avoided. By removing tion in excess of 20–30,000 cycles,119,120 and sedentary
exposure to harmful load, the healing and adaptation sitting occupations.121
process can fulfill its objective of increasing the fail- In summary, patients suffering nerve root syn-
ure tolerance of the tissues. However, if all load is re- dromes caused by a herniated disc should avoid flex-
moved, deconditioning involving disuse atrophy will ion loads in the morning or after sustained sitting, and
occur and instability will be created as an iatrogenic end-range flexion loads throughout the day. Patients
consequence of overly restrictive treatment. suffering posterior joint complex problems such as
Injurious strain occurs when external load exceeds spinal stenosis, spondylolisthesis, or facet syndrome
the failure tolerance or strength of tissues. This in- should avoid any movement or exercise involv-
volves a continuum from simple irritation to frac- ing lumbar hyperextension. A movement bias can
ture, avulsion, or rupture. Most low back strains or often be predicted on the basis of pathology or con-
injuries are not the result of a single exposure to a dition, but confirmation from the history and exam-
high-magnitude load, but instead represent an accu- ination of the actual mechanical sensitivity of the
mulation of trauma from subfailure-magnitude loads patient is necessary in order to customize the exercise
such as repeated small loads (e.g., bending) or a sus- prescription.108,109
tained load (e.g., sitting). In particular, low back injury
results from repetitive motion at end range. Accord-
ing to McGill, it is usually a result of “a history of Centralization Phenomena
excessive loading which gradually, but progressively, McKenzie has provided a guide to exercise pre-
reduces the tissue failure tolerance.”110 scription in his description of the centralization
How can knowledge of mechanism of injury in- phenomena. According to his philosophy, clinicians
fluence our management? McGill states, “Evidence should identify the positions and/or repetitive move-
from tissue-specific injury generally supports the no- ments that increase, decrease, or centralize symptoms.
tion of a neutral spine (neutral lordosis) when per- The movements or positions that reduce symptoms,
forming loading tasks to minimize the risk of low or centralize peripheral symptoms, can be recom-
back injury. Avoiding spine end range of motion, dur- mended as self-treatment.109
ing activity, can reduce the risk of several types of Both history and examination are involved in this
injury.”110 analysis. For instance, the history should identify
Knowledge of the time of day when injury is most what positions or movements aggravate, relieve, or
likely to occur can also influence activity. It has been are neutral to the patients’ symptoms, in particular
shown that the low back is particularly vulnerable in their peripheral symptoms. Sitting and forward bend-
the early morning or after periods of prolonged sit- ing intolerances strongly suggest a disc problem and
ting. Reilly et al. showed that 54% of the loss of disc self-treatment would be “biased” toward extension.
height (water content) occurs in the first 30 minutes Another example of the importance of a thorough
history is that many patients explain that they are performance, psychological, and pain factors.42,43 The
worse after sitting or standing for a prolonged pe- performance factors alone may account for 24.5% of
riod of time. Such postural findings are often the only the variance. Other studies have shown a similar rela-
clues when the examination cannot reproduce time- tionship between functional performance deficits and
dependent mechanical sensitivities. disability.39,122,123 Mannion et al. suggest that because
Examples of specific mechanical sensitivities 50% of self-reported disability prior to treatment and
include postural, movement, and weight-bearing more than 50% of it after therapy are unaccounted for
sensitivities.108 Individuals with postural sensitivities by structural, psychological, voluntary performance,
usually must sit or stand a specific way to avoid pain. or EMG fatigue findings, new aspects of physical
For instance, individuals with a flexion bias will not function relating to motor control are worthy of fu-
be able to stand for prolonged periods because of their ture investigation.42,43 These aspects include those in-
inability to tolerate lumbar extension. They will need volved in nonvoluntary, reflex control of movement
to preposition their spine in some flexion with, for in- such as position sense, delayed reaction times, and
stance, a foot stool. Patients with movement sensitivi- balance tests.42,43,124
ties may have pain during certain activities. A history One key to unraveling the mystery of nonspecific
of pain while bending forward to tie the shoes or put pain is ferreting out the relevant dysfunctions respon-
on pants is an example of a patient with an exten- sible for disturbing the kinetic chain and resulting in
sion bias. Such a patient’s functional range may not biomechanical overload. Using this approach helps to
include flexion of the lumbar spine. A weight-bearing identify likely suspects in the patient’s presentation
sensitivity or gravity intolerance may be revealed by and creates a narrow path of treatment that can be
a history of pain during sitting or standing which is easily reevaluated to determine the accuracy of diag-
relieved when resting. Compression usually aggra- nosis. For instance, a neck pain patient (clinical symp-
vates symptoms in these patients, as does coughing, tom complex) who has pain with cervical extension
sneezing, or any strong muscular contractions. This is (source of biomechanical overload) may be found to
common with acute disc syndromes, and such a pa- have an increased thoracic kyphosis (dysfunctional
tient may have no functional range when upright, but kinetic chain) and trigger points in the upper trape-
be able to train effectively when recumbent. Another zius (functional adaptation). The treatment path
option for the weight-bearing-sensitive patient is wa- would include palliative measures directed at the cer-
ter exercises. vical spine, but if it is empirically determined that cer-
McKenzie explains that the functional portion of vical extension is less pain-provoking following tho-
the examination should not be restricted merely to sin- racic mobilization, then treatment should be focused
gle movements, but that repetitive movements should on this “key link” (thoracic extension) in the kinetic
be tested to ascertain a more accurate patient pro- chain, rather than to the site of symptoms. Relaxation
file. Many patients with an extension “bias” may feel or lessening of the upper trapezius trigger points fol-
pain with the first few extensions but then the area lowing restoration of thoracic mobility would further
“warms up” and the pain dissipates. validate the link between decreased thoracic extension
mobility and sensitivity of the injured cervical spine
Identifying the Key Dysfunctions (Table 46–2).
Identifying the key dysfunction responsible for pain
or activity intolerances is the most difficult part of
the evaluation process. It is much simpler to pro- TABLE 46–2. Goals of Functional Examination
file a patient’s mechanical sensitivities than to find
the cause of the pain. In fact, the cause of pain may Component Goals
be at some distance from the irritated pain gen-
erator (e.g., trigger point or inflamed nerve root). History Identify the clinical symptom
Furthermore, most individuals have many dysfunc- complex
tions, some of which are adaptive and others mal- Examination Identify the tissue injury complex
adaptive or compensatory. Distinguishing between (or pain generator[s])
these dysfunctions is the essence of the functional Identify the dysfunctional kinetic
evaluation, and it remains a most difficult art to chain
master. Identify the functional
The difficulty of this art is made clear by the fact adaptations
that 90% of spinal conditions are often labeled non- Identify the source of
specific. Even though most back pain is called nonspe- biomechanical overload
cific, it should not be assumed that there is no etiology
Data modified from Kibler WB, Herring SA, Press JM. Functional
or mechanism of injury. Mannion et al. showed that rehabilitation of sports and musculoskeletal injuries. Gaithersburg, MD:
51.4% of the variance in disability can be explained by Aspen,1998:3.
Functional Restoration Such behavioral approaches use a discussion

Both behavioral and neurophysiological principles about recovery goals and the means to reach these
are important in progressing a patient toward a com- goals. This discussion can encompass McKenzie’s cen-
plete functional restoration. The goals include re- tralization principles, stabilization’s “neutral” postu-
ducing activity intolerances and improving physical ral awareness concepts, and an appreciation that hurt
performance ability. Behavioral principles necessitate does not necessarily equal harm. A problem-solving
reassurance that “hurt does not necessarily equal approach can be used by teaching patients how to
harm,” while neurophysiologic principles address the take an active role, reduce modifiable risk factors, and
stages of motor learning. avoid impulsively seeking mainly symptomatic relief
(see sidebar, “Problem-Solving Process”).127
Behavioral Principles Ciccione and Just showed that in
susceptible individuals, there is discordance between
pain expectancy and pain intensity with activities.88 Problem-Solving Process
To decrease fear-avoidance behavior, patients should
• Identifying and selecting a problem
be gradually and incrementally exposed to perceived
• Analyzing problem
painful activities. The clinician should guide patients
• Generating potential solutions
to teach them that their expectations are not accurate.
• Selecting and planning solution
In particular, reducing anxiety and pain expectations
• Implementing solution
associated with the specific movements most feared
• Evaluating solution
should become the goal of care.125 As part of this pro-
cess, operant-conditioning therapy involves graded Data from Shaw WS, Feuerstein M, Haufler AJ, Berkowitz SM,
exposures to progressively greater durations, inten- Lopez MS. Working with low back pain: Problem-solving orientation
and function. Pain 2001;93:129–137.
sities, and frequencies of exercises. This is often re-
ferred to as exercise administered and progressed by
quota.89,101,103
Patient education should focus on the fact that nor-
Increasing physical perfor-
Neurophysiologic Principles
mal activities can be resumed (walking, swimming,
mance ability (particularly spinal fitness) requires
biking, etc.) safely while informing the patient about
that exercises with acceptable load profiles be used.
simple activity modifications to reduce biomechani-
Muscle challenge should be high, but joint com-
cal strain. The patient should be advised to stay as
pressive penalty should be minimized.110 This re-
active as possible, to gradually increase physical ac-
quires that a motor-control approach to muscle
tivity, that it is safe to do so as long as pain is not pe-
fitness training be taken. Additionally, the exer-
ripheralizing, and that hurt does not necessarily equal
cises should progress toward functional goals that
harm, but is a result of mobilizing stiff areas. Indahl
et al. have described a few general tenets of the be-
havioral approach (see sidebar, “Specific Reactivation
Advice”).126
Specific Reactivation Advice

Patients were informed or assured that:
• Pain or anticipation of pain could increase muscle ac-
tivation/tension and thus increase pain.
• Light activity would not further injure the disc or other
structure(s) causing pain.
• Light activity would enhance the repair process.
• “Flare-ups” of pain are normal occurrences and do not
signify further “damage.”
• Emotions such as worry or anxiety increase muscle
tension and pain so it is best to try and relax and re-
main active when pain “flare-ups” occur.
Data from Indahl A, Haldorsen EH, Holm S, Reikeras O, Hursin

H. Five-year follow-up study of a controlled clinical trial using light FIGURE 46–2. Thoracolumbar hypertonus. (Reproduced with
mobilization and an informative approach to low back pain. Spine
1998;23:2625–2630.
permission from Liebenson CS, Chapman S. Lumbar spine: Making a re-
habilitation prescription. Philadelphia: Williams and Wilkins, 1998.)
45°
FIGURE 46–3. Faulty hip extension with excessive lumbar

loading/anterior pelvis. (Reproduced with permission from Lieben-
son CS, Chapman S. Lumbar spine: Making a rehabilitation prescription.
Philadelphia: Williams and Wilkins, 1998:14.) B
incorporate how individuals actually use their body FIGURE 46–4. Faulty hip abduction with hip flexion or hip hik-
ing. (Reproduced with permission from Liebenson CS. Manual resistance
in daily life.
techniques in rehabilitation. In Chaitow L, ed. Muscle energy techniques,
Agonist, antagonist, and synergist muscle balance
2nd ed. London: Churchill-Livingston, 2001:151.)
are important for maintenance of stability. Accord-
ing to Richardson et al. the clinician must answer
two basic questions: Does the patient present with The cognitive–kinesthetic stage incorporates finding
unwanted global muscle activity? If so, which mus- and exploring the patients’ “functional range.” This
cles are problematic? These questions must be an- involves incorporating behavioral, McKenzie, and
swered in order to institute best-practice therapeutic spinal-loading principles while teaching patients the
exercise.128 kinesthetic awareness to move within their functional
An example of global muscle overactivity is seen range. Exploring the cat-camel and Brügger relief po-
in thoracolumbar hypertonus during the quadruped sition are excellent example of exercises in this first
single-leg reach (see Fig. 46–2). This is a sign of superfi- stage (Figs. 46–5 and 46–6).
cial muscle overactivity substituting for the deep seg- The second stage is the associative stage. In this
mental stabilizers. Other examples of common “trick” stage the patient practices specific movements to hone
movement synergy involving global or superficial functional stability patterns. Specific functions, such
muscle substitution for deep segmental stabilizers are as the quadruped single-leg raise, side bridge, abdom-
leg raising into extension that occurs with an anterior inal hollowing, and breathing exercises, may be con-
pelvic tilt (rather than neutral spine positioning) and sidered (Figs. 46–7, 46–8, and 46–9).
hip abduction that occurs with excessive flexion or hip
hiking (Figs. 46–3 and 46–4).129
When expanding the patient’s functional range
while avoiding substitution movement patterns, cer-
tain stages of motor learning can serve as stepping-
stones for the patient (see sidebar, “Stages of Motor
Learning”).
A
Stages of Motor Learning

• Cognitive–kinesthetic awareness
• Associative
• Autonomous–involuntary control B
Data from Shumway-Cook A, Woollacott M. Motor control—

FIGURE 46–5. Cat-camel. (Reproduced with permission from
Theory and practical applications. Baltimore: Lippincott Williams
and Wilkins, 1995. Liebenson CS. Advice for the clinician and patient: The trunk extensors
and spinal stability. J Bodywork Move Ther 2000;4(4):246–250.)
by certain principles. For instance, if posture is dis-

turbed such that substitution patterns occur because
of a failure of agonist–antagonist coactivation, then
the exercise is not training stability mechanisms. Sim-
ilarly, if respiration is compromised, for instance by
breath holding, then the deep muscles, such as the
pelvic floor, are not functioning optimally.
The first aspect of any “core” muscle exercise is that
normal respiration is maintained during training. Sec-
ond, proper postural form must be maintained so that
substitution patterns are avoided. Global (superficial)
muscle activity is avoided (e.g., thoracolumbar hyper-
activity). “Trick” movement patterns are avoided (e.g.,
false hip extension, abduction). Table 46–3 illustrates
a training plan.
When training motor control, endurance is more
important than strength. For this reason submaximal
loads are used, but training is performed more fre-
quently. For example, a typical prescription would
involve 8–10 repetitions of slow movements with pro-
FIGURE 46–6. The Brügger relief position. (Reproduced with longed hold times (up to 10 seconds). Exercise fre-
permission from Liebenson CS. Advice for the clinician and patient:
quency of twice a day for up to 3 months is often
Mid-thoracic dysfunction. Part two: Treatment. J Bodywork Move Ther
required.102
2001;5:3.)
Integrating Active Care with Chiropractic

The third stage, called autonomous, is where im-
proved motor control is integrated into activities of The following steps are needed in order to integrate
daily living and sports. Squats, multiplanar dynamic active care into chiropractic practice: reassurance, re-
lunges, squats and lunges with arm reaches, or trunk lief of pain, reactivation, reevaluation, reconditioning,
twists in all planes (sagittal, frontal, and coronal) are and referral.
examples of functional training (Fig. 46–10).
Progressing through these three stages requires a Reassurance The process of reassurance begins with
focused, goal-oriented approach by the clinician and the process of diagnostic triage on day 1. Triage is
patient. The goals are always to reduce activity intoler- done to ascertain that there is no serious disease
ances and improve functional capacity. The means are and to confirm that improvement is likely to begin
specific exercises that enhance kinesthetic awareness, rapidly (within a few days). It is important to dispel
associative skill, and functional use of these improved the myth that imaging is needed or that the spine is
motor control skills. damaged. It is important to identify patients need-
ing referral for further tests or emergent or urgent
Many exercises are touted as train-
Stability Principles treatment.
ing stability or the “core” muscles. However, no ex- Explanation includes a discussion of pain relief op-
ercise is a “core” or stability exercise unless it abides tions, as well as what to avoid and what to do in order
FIGURE 46–7. Abdominal hollowing: (A)

correct and (B) incorrect. (Reproduced
with permission from Liebenson CS. Advice for
the clinician and patient: The role of the trans-
verse abdominus in promoting spinal stability. J
A B Bodywork Move Ther 2000;4(2):109–113.)
FIGURE 46–8. Breathing exercises. (Reproduced with

permission from Liebenson CS. Advice for the clinician and
patient: Mid-thoracic dysfunction. Part three: Clinical issues.
J Bodywork Move Ther 2001;5(4):270.)
to speed recovery. It is important to help the patient erance through safe conditioning. According to the
to see that the goal is avoiding debilitating inactivity. Danish guidelines, the following are the acute pain re-
This requires an interactive approach, which alleviates lief treatments that are recommended, optional, and
fears and overcomes past misconceptions. Establish- recommended against:9
ing simple pain provocation tests and maneuvers for
immediate reexamination is extremely helpful with Recommended
this process. For example, alleviating or improving • Acetaminophen, aspirin, ibuprofen
pain during forward bending or moving out of a chair • Prescription nonsteroidal antiinflammatory
immediately following treatment or exercise builds drugs
confidence and assurance of recovery. The health care • Manipulation
provider should show concern as well as empathy for • Surgery (for cauda equina syndrome)
the patient’s well-being and safety. Guidelines and
patient booklets such as The Back Book can be used
Optional
as aids.130
Early reassurance is part of the biopsychosocial • Modalities
approach. Table 46–4 illustrates the stark contrast be- • Muscle relaxants
tween a traditional biomedical report of findings and
a biopsychosocial one.
Providing pain relief may require the recom-
mendation of over-the-counter medication, referral
for prescription medication, or delivery of skilled
manipulation. If possible, pain relief should occur
within a few days. The purpose is to provide greater
comfort until recovery begins. The main goal is to
avoid the debilitation of rest and to build activity tol-
B
B
FIGURE 46–9. A. Quadruped single-leg reach. B. Quadruped
leg and arm raise. (Reproduced with permission from Liebenson CS.
Advice for the clinician and patient: The trunk extensors and spinal sta- FIGURE 46–10. Horizontal side bridge: (A) start position and
bility. J Bodywork Move Ther 2000;4(4):246–250.) (B) end position.
TABLE 46–3. Training Progressions form a comprehensive reexamination. The purpose is

both to reassure the patients that there is no serious
1. Posture disease causing their pain and that something has not
2. Breathing been missed that could help them. Also, it is impor-
3. “Big 3” tant at this point to identify any functional deficits that
a. Quad leg reach may be realistic targets for treatment, or affective or
b. Horizontal side bridge cognitive behaviors that impede recovery. If there is
c. Trunk curlups an unresolving neurologic condition after 4–6 weeks
4. Sensory-motor training (balance boards, balance sandals) of conservative care, the patient should be referred for
5. Lower-quarter functional training (flexibility, bridges, additional investigations.
squats, lunges)
Reconditioning Reconditioning involves skilled assess-
ment and training of the patient. Methods used should
• McKenzie exercises include McKenzie techniques, stabilization train-
• Acupuncture ing, progressive strengthening, and/or cognitive–
• Epidural (for sciatica) behavioral approaches. This should be accomplished
during the subacute phase for most patients, but may
Recommended against be done earlier for those patients who are at risk of
• Sedatives, hypnotics, steroids becoming chronic. It is important to dispel the myth
• Epidural that more aggressive treatment of symptoms is re-
• Surgery for sciatica in the acute phase quired. Instead, focus should be directed to func-
• Surgery for low back pain tion/physiology rather than structure/pathology.
The report of findings following reevaluation
Reactivation Reactivation should include an educa- should focus on the importance of building activity
tional discussion about recovery goals and the means tolerance or reconditioning. The patient should be
of achieving these goals. It should include the fact that told that it is normal to have recurrences and that this
normal activities can be resumed (e.g., walking, swim- does not signify that anything is “damaged” (see side-
ming, and biking). It should also provide information bar, “Specific Reactivation Advice,” above). Patients
about simple activity modifications that may be use- should be encouraged to continue to move and do
ful to reduce biomechanical strain (e.g., hip hinge, ab- their exercises. Treatment with manipulation, medica-
dominal bracing). This step should begin on day 1 tion, injection, or surgery will not condition the mus-
in order to dispel the myth that rest is required or cles needed to enhance performance or stability.
that the spine is vulnerable. The patients should be It can be emphasized that, in many respects, backs
advised to stay as active as possible and to gradu- are like knees. Regardless of cause or treatment (even
ally increase their physical activity and that it is safe surgery), the road to recovery is through reactivation
to do so as long as pain is not peripheralizing. Also and reconditioning. This allows the patient to prevent
advise patients that hurt does not necessarily mean debilitation and to increase the body’s compensatory
harm, but is often a sign that stiff areas are being ability for normal age-related changes or deficits.
mobilized.
Referral Referral requires knowledge of assessment
ReevaluationFor those patients who recover slowly and treatment protocols. In the acute phase, referral
and enter the subacute phase, it is important to perfor laboratory or imaging tests occurs if red flags are
TABLE 46–4. Biomedical Versus Biopsychosocial Approaches
Biomedical Biopsychosocial
Emphasize anatomy, injury, and Reassurance—no sign of serious disease, low back pain is a
damage—“let pain be your guide” symptom that back is biomechanically unfit
Emphasize further tests Psychological treatment can help, but long-term results depend
on lifestyle
Focus on pain rather than activity Recovery depends on restoring function—the sooner the better
Encourage passivity and dependency Positive attitudes result in a speedier recovery
Adapted from Burton K, Waddell G. Information and advice to patients with back pain can have a positive effect. Spine 1999;24:2484–2491.
present. If such tests are positive for tumor or infec- A. Horizontal side support
tion, specialist referral is indicated. In the subacute B. Abdominal hollowing
phase, referral for rehabilitation is indicated, espe- C. Spinal flexibility
cially if yellow flags are present. D. Intrinsic muscle endurance
5. Which of the following is not representative of the
biopsychosocial model of care?
SUMMARY A. Recovery depends on restoring function
1. With the increasing use and acceptance of chi- B. Low back pain is a symptom that back is biome-
ropractic, combined with the growing interest chanically unfit
in active care for patients with low back pain, chi- C. “Let pain be your guide”
ropractors are increasingly incorporating rehabil- D. Positive attitudes result in a speedier recovery
itation techniques in their practices.
2. The biopsychosocial model is used to explain how
different patients respond to back pain. Rather ANSWERS
than viewing back pain simply as some form
of pathology, the biopsychosocial model includes 1. C.
attention directed at attitudes and attributes. 2. D.
3. The various aspects of active care include reassur- 3. B.
ance, relief of pain, reactivation, reevaluation, and 4. C.
reconditioning. 5. C.
4. There is growing evidence in the literature to
support the use of active care in patients with
low back pain. Government-sponsored evidence-
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S E C T I O N
INTRODUCTION
V
TO MANAGEMENT OF
SPECIFIC DISORDERS
This section provides core information to the student agement is greatly simplified. However, this model only
and practitioner of chiropractic regarding successful seems to apply to a minority of patients. In reality, health
case management. Chiropractic physicians are trained care is complex and patients bring a cascade of fac-
to address health matters with appropriate nonphar- tors that can influence their outcome (Fig. Intro–1).
macological and nonsurgical methods and to adapt Clinicians also bring at least three things to their in-
their approach depending on the age of the patient teraction with patients: an understanding of the rela-
and the condition being treated. Integrating diagnos- tive efficacy of treatment, the skills necessary for di-
tic acumen, a rich set of skills in physical medicine, agnosis and treatment, and knowledge to educate the
nutrition, and rehabilitation with interdisciplinary work- patient.
ing relationships (medical, psychological, surgical, so- Much is outside of the practitioner’s control. Para-
cial) should yield a highly satisfying professional expe- phrasing Sackett, a leading clinical scientist and pro-
rience providing care for patients with a broad mix of ponent of evidence-based practice, “When a patient
problems. comes to me with symptomatic incurable cancer, my
The common denominator and proving ground for pledge to them is restricted to doing my best. . . . When
all health care professionals is patient care. Regard- this ‘Level 1’ evidence is lacking, I resort to nonexperi-
less of the practitioner’s philosophical approach, beliefs, mental evidence gleaned with (research) study architec-
or scientific model of health and disease, a focus on tures at higher risk of error; my sick patient cannot wait
the patient experience should define successful clinical for better evidence.”1 When evidence is incomplete and
practice. However, health care delivery has changed and experts cannot agree on the best practices to manage a
no longer is the doctor responsible only to the patient. case, a clinician should go through the following thought
Many taskmasters may now intervene and determine process2 :
the boundaries of care. Commercial success in prac-
tice requires admission to a roller coaster ride of ever- • Review and summarize the available literature.
changing criteria for access to care, treatment pre- • Based on what is known and valid, what is logical?
certification and authorization, discussions with claims Is your conclusion or plan physiologically credible?
reviewers, and arbitrary payment of services. The ele- • Are the associated costs worth the probable out-
ments of clinical and commercial success are combined come? What does the patient think? Would you pay
under the umbrella of case management. Modern chi- for it if you had to? Would the patient?
ropractic success is nevertheless achieved on a case-
by-case basis, providing the best care possible for each
PRIMUM NO NOCERE
patient while simultaneously managing available health
care resources. Do no harm, whether physical, economical, or psycho-
To achieve this objective, society’s Holy Grail has be- logical. Patient assurance and educating people about
come the vision of evidence-based practice where ev- the long-term bright outlook and the wonder of human
ery patient is offered a treatment approach for which physiology and recovery, where appropriate, does much
there is unquestioned scientific support. When such more good than focusing on the fewer cases that dete-
unequivocal evidence is in fact available, patient man- riorate.
907
908 MANAGEMENT OF SPECIFIC DISORDERS
The Clinical Cascade
Clinical Treatment Plan Uncontrolled Clinical

Presentation 1) Treatment Event Outcomes
Effectiveness 1) Reinjury
2) Provider 2) Ergonomics
Skill 3) Work Stress
3) Ability to 4) Domestic
Educate Stress
Age Symptom Resolution

Sex Risk of Recurrence
Primary Diagnosis Complications
Condition Severity Functional Status
Clinical Stability Economic Drain
Comorbities Quality of Life
Psychosocial Patient Satisfaction
Life Style Health Care Resource Use
Culture
Financial Status
Personal Attitude FIGURE Intro–1. The clinical cas-
cade.
Plan for the usual—evidence and pathways of care been a useful teaching model at one point, it also formed
are designed for the usual case. Adapt for the unusual; a chasm in communicating with patients, policy mak-
modify treatment on an individual basis. And document ers, legislators, and third-party payors. Although the
thoroughly your rationale and justification so that stake- medical model of disease has failed to adequately ac-
holders outside of the doctor–patient relationship can count for much of a patient’s experience of spine-related
understand the basis of your recommendations and ac- disorders,3 chiropractors have also failed to convinc-
tions. ingly explain the role of subluxation in disease. As a prac-
Historically, much of chiropractic has focused on the tical matter, patients think in terms of pain, loss of func-
treatment of subluxation. While this focus may have tion, and quality of life. Generally, they do not concern
Subluxation/Functional Lesion
Health Predicament Role Mechanistic Process
Mechanical Dysfunction
1. Asymptomatic, no influence
2. Primary pathology
Local Effects Remote Effects
3. Concurrent pathology
Stress Concentration Functional

4. Secondary pathology
Inflammation Pathological
FIGURE Intro–2. Subluxation/functio-

nal lesion.
INTRODUCTION TO MANAGEMENT OF SPECIFIC DISORDERS 909
themselves with the biomechanical and physiological de- advice on examination and treatment of children in a
tails of disease mechanisms beyond those necessary to chiropractor’s office. The growing number of geriatric
resolve their complaint, prevent its recurrence, or man- patients makes Jacqueline Bougie’s Chapter 54 on is-
age its residual effects. sues that specifically affect the treatment of elderly pa-
A condition-based discussion of chiropractic prac- tients particularly relevant to clinicians. Because many
tice often engenders the internal question, “What is the chiropractors are increasingly being asked to give ad-
role of subluxation, particularly of the spine?” This ques- vice on issues of nutrition and use of supplements,
tion keys in to the central basis for chiropractic practice. Chapter 55 by Doug Andersen provides an important
Figure Intro–2 is an attempt to briefly define the various overview of the basic concepts of nutrition and dietary
components of the subluxation and their relationships. assessment.
Further discussion on this topic can be found elsewhere The next two chapters deal with the potential com-
in the literature.4–13 plications of spinal manipulation and chiropractic care.
It is also important to acknowledge the role of mind– Marion McGregor reviews the musculoskeletal com-
body interaction. The biopsychosocial model of disease, plications in Chapter 56, while Allan Terrett reviews
particularly as it affects musculoskeletal complaints, the very rare but controversial issues of neurological
has enhanced our understanding of the many factors complications, including vertebral artery dissection, in
involved in patient recovery. Although nociceptive and Chapter 57. It is fitting that Chapter 58 by Debo-
inflammatory sources of pain respond to physical and rah Kopansky-Giles, Bruce Walker, and Sira Borges,
pharmacological interventions, individual attitudes, cul- the concluding chapter in this textbook, addresses the
tural norms, and psychological overlay may greatly af- trend toward the integration of chiropractic into mul-
fect the result obtained with such treatments. Rapid tidisciplinary and hospital-based settings. This chapter
return to activity, reassurance, and encouragement are shows how far this profession has advanced in the past
generally considered the most effective methods for lim- 10 years.
iting the development of chronic sickness behavior, es- John Triano
pecially in patients with spinal pain syndromes. When
significant psychosocial risk factors exist, consultation
with a behavioral medicine professional may significantly REFERENCES
alter the patient’s quality of life and the overall success
1. Sackett DL. A science for the art of consensus.
of treatment. J Natl Cancer Inst 1997;89:1003–1005.
The first three chapters of this section deal with 2. Sox HC. Screening mammography in women
the conditions for which the majority of patients seek younger than 50 years of age. Ann Intern Med
chiropractic care. Chapter 47, by Dennis Skogsbergh 1995;122(7):550–552.
and Robert Cooperstein, addresses the problems com- 3. Haldeman S. North American Spine Society: Fail-
monly encountered in the management of patients with ure of the pathology model to predict back pain.
low back pain and radiculopathy, whereas Chapter 48, Spine 1990;15(7):718–724.
by Mark Erwin, looks specifically at the management of 4. Hansen DT, Mootz RD. Understanding, develop-
patients with thoracic spine syndromes. Then, in Chap- ing and utilizing clinical algorithms. Top Clin Chiropr
1994;1:44–57.
ter 49, Donald Murphy and Michael Freeman review
5. Lantz CA. The vertebral subluxation complex. In:
some of the principles of treatment and the unique char-
Gatterman MI, ed. Foundations of chiropractic sublux-
acteristics of neck pain with an emphasis on neck ination. St. Louis: Mosby-Year Book, 1995.
juries. This is followed by Chapter 50 by Rand Swenson, 6. Mootz RD. Chiropractic theories: Current under-
a board-certified medical neurologist and a chiroprac- standing of vertebral subluxation and manipulable
tor, and Niels Grunnet-Nilsson on the management of spinal lesions. In: Sweere JJ, ed. Chiropractic family
headaches and Chapter 51 by Rand Swenson and practice: A clinical manual. Vol. 1. Gaithersburg, MD:
Thomas Davis on peripheral nerve disorders. The more Aspen, 1992.
controversial issue of the management of nonmuscu- 7. Mootz RD. Theoretical models of chiropractic sub-
loskeletal disorders through chiropractic is then re- luxation. In: Gatterman MI, ed. Foundations of chi-
viewed in Chapter 52 by Richard Sarnat and Brian ropractic subluxation. St. Louis: Mosby-Year Book,
1995.
Budgell through a critical examination of the scientific
8. Mootz RD, Haldeman S. The evolving role of chi-
literature on the topic.
ropractic within mainstream health care. Top Clin
The next three chapters focus on specific subgroups Chiropr 1995;2:11–21.
of patients who seek chiropractic care. Chapter 53 by 9. Triano J. The mechanics of spinal manipulation. In:
Jesper Wiberg and Niels Klougart looks at some of Herzog W, ed. Clinical biomechanics of spinal manipu-
the research supporting the use of spinal manipula- lation. New York: Churchill-Livingstone, 2000:92–
tion in children and reviews specific issues and offers 190.
10. Triano J. Biomechanics of spinal manipulation. cal approach, 3rd ed. Baltimore: Lippincott Williams
Spine 2001;1:121–130. and Wilkins, 2002:109–119.
11. Triano J. Managing geriatric spine patients. In: 13. Vernon HT. Biological rationale for possible ef-
Bougie J, Morganthal P, eds. The aging body. New fects of manipulation. In: Cherkin DC, Mootz RD,
York: McGraw-Hill, 2001. eds. 98-N002. Chiropractic in the United States:
12. Triano J. Manipulative therapy in the manage- Training, Practice, and Research, Rockville, MD:
ment of pain. In: Tollison CD, Satterthwaite JR, American Health Care Policy and Research,
Tollison JW, eds. Clinical pain management: A practi- 1997.
C H A P T E R
47
THE MANAGEMENT OF LOW BACK
PAIN AND RADICULOPATHY
Dennis R. Skogsbergh and Robert Cooperstein
O U T L I N E
INTRODUCTION Pathoanatomy/Pathophysiology
LUMBAR FACET SYNDROMES Clinical Findings
Definition Laboratory Tests and Imaging
Pathoanatomy/Pathophysiology Natural/Treatment History
Clinical Findings Conservative Management
Imaging Surgical Management
Natural/Treatment History DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS
SPONDYLOLYSIS AND SPONDYLOLISTHESIS Definition
Definition Pathoanatomy/Pathophysiology
Pathoanatomy/Pathophysiology/Biomechanical Clinical Findings
Considerations Laboratory Tests and Imaging
Imaging Natural/Treatment History
Clinical Findings Conservative Treatment
Natural/Treatment History DEGENERATIVE SCOLIOSIS
Management Considerations After Aggressive Definition
Conservative Management Fails Pathoanatomy/Pathophysiology
LUMBAR INTERVERTEBRAL DISC SYNDROMES Natural/Treatment History
Definition SACROILIAC JOINT DISORDERS
Pathoanatomy/Pathophysiology Definition
Structure Pathoanatomy/Pathophysiology
Mechanism of Derangement Clinical Findings
Laboratory Testing and Imaging Natural/Treatment History
Imaging Nomenclature Laboratory Tests and Imaging
Use of Electrodiagnostic Testing Conservative Management
Clinical Findings PIRIFORMIS SYNDROME
Physical Examination Definition
Neural Tension Tests Pathoanatomy/Pathophysiology
Alteration in Jugular Venous Pressure Clinical Findings
Prone Knee Flexion Provocative Test Natural/Treatment History
Natural History Laboratory Tests and Imaging
Conservative Treatment Conservative Management
Spinal Manipulation PSOAS INSUFFICIENCY (DYSFUNCTION)
Epidural Steroid Injections SYNDROME
Surgical Management of Painful Lumbar Disc Definition
Derangements (HNP) Pathoanatomy/Pathophysiology
LUMBAR STENOSIS Clinical Findings
Definition Natural/Treatment History
911
Laboratory Tests and Imaging Natural/Treatment History

Conservative Management Laboratory Tests and Imaging
COCCYDYNIA (COCCYGODYNIA) AND TRANSVERSE AND SPINOUS PROCESS FRACTURE
COCCYGEAL SUBLUXATION Definition
Definition Pathoanatomy/Pathophysiology
Pathoanatomy/Pathophysiology Clinical Findings
Clinical Findings Natural/Treatment History
Natural/Treatment History Laboratory Tests and Imaging
Laboratory Tests and Imaging Conservative Management
Conservative Management APPLICATION AND REMARKS
FRACTURES OF THE VERTEBRAL BODY AND SUMMARY
POSTERIOR ELEMENTS QUESTIONS
Definition ANSWERS
Pathoanatomy/Pathophysiology KEY REFERENCES
Clinical Findings REFERENCES
clear that prompt return to normal activities is most

OBJECTIVES
important for achieving lasting pain relief. This re-
1. To review lumbar facet syndromes. quires early activation of the patient, departure from
2. To review spondylolisthesis and spondylolysis. passive approaches, and the prevention of chronicity.
3. To review lumbar intervertebral disc syndrome.
4. To review lumbar stenosis.
5. To review diffuse idiopathic skeletal hyperostosis. LUMBAR FACET SYNDROMES
6. To review degenerative scoliosis. Definition
7. To review sacroiliac disorders.
8. To review piriformis syndrome. Pain syndromes emanating from the lumbar articular
9. To review psoas insufficiency syndrome. facet region include a variety of problems with differ-
10. To review coccydynia. ent pathogenetic mechanisms. The first use of the term
11. To review vertebral body fracture. “facet syndrome” was by Ghormley, in 1933, where he
12. To review transverse process fracture. implied that the articular facets might be responsible
for LBP.5 In those days, the assumed clinical associa-
tion was a swayed back. While not all pain emanat-
ing from the posterior elements needs such a postural
INTRODUCTION link, there is an association of back pain with postural
Low back pain (LBP) is universal, and approximately patterns.
80% of the general population will have an episode Standard weight bearing, assessed in the sagittal
some time in their life. The good news is that most LBP plane, assumes that there is a load distribution pre-
is uncomplicated, with uneventful recovery in about ponderance on the intervertebral disc with limited
6 weeks. However, 10% of patients do not return to compression load to the facets. This requires an op-
normal function, even after 2 months.1 This group timum lordotic attitude and localization of the grav-
represents the greatest challenge to the health care ity center. Variant patterns may reinforce the devel-
provider and is a major drain on health care resources. opment of distinctive facet changes. Facet syndromes
There is considerable treatment diversity among those represent an allied family of problems ranging from
offering spine care. Many of the services and proce- facet dysfunction, capsulitis, facet impingement, pars
dures performed for LBP are both inappropriate and stress reaction, spondylolysis, and degenerative facet
ineffective. However, our understanding of lumbar disease to facet fracture.
biomechanics and pathology and the impact of spinal
manipulation is increasing. Approximately 40% of Pathoanatomy/Pathophysiology
Americans with LBP seek chiropractic care.2 Evidence Increased mechanical stress may occur under a vari-
on clinical effectiveness largely supports the use of ety of circumstances. Most are simple and uncompli-
manipulation for acute LBP and contributes to symp- cated movements for which the joint is unprepared.
tom resolution and functional restoration of chronic Factors that affect load distribution at the facet joints
spine pain.3,4 Regardless of specific treatment proce- include (a) the extent of lordosis, (b) the localization
dures employed in the treatment of back pain, it is of the weight-bearing load from the body mass above
THE MANAGEMENT OF LOW BACK PAIN AND RADICULOPATHY 913
the joint, (c) facet morphology and functional orien- likely to occur in the first 45 degrees of flexion in inter-
tation, (d) lumbar rotational deviations, (e) pelvic tor- vertebral disc herniation (IDH). Also, pain from ham-
sional and unleveling abnormalities, (f) the integrity of string spasm often subsides with stretching and hold-
the intervertebral disc and the retaining ligaments, (g) ing the maximum flexion for several seconds, whereas
the dynamic balance of motor control, and, remotely, root pain will not. Radiating pain into distal and prox-
(h) the functional integrity of the lower-extremity ki- imal aspects of the lower extremity is possible, but no
netic chain. true neurological deficit is present and the pain pat-
Uncomplicated facet and motor unit dysfunction tern is pseudoradicular.10 In some cases there may be
may be associated with a local synovial reaction (syn- confusion when facet arthrosis produces recess steno-
ovitis and capsular swelling) and reflex muscle spasm. sis, or with some synovial facet cysts.
Intraarticular synovial protrusions have been identi-
fied in the lower lumbar apophyseal joints and these Imaging
could be a source of LBP with reflex spasm.6 Hy- Conventional imaging offers little for the differen-
pertrophic synovitis has also been identified.7 Wyke tial diagnosis of most facet syndromes. Hypertrophic
found the articular capsule to be richly innervated by facet changes are indicators of advanced disease
receptor endings and showed receptor firing by cap- (Fig. 47–1). Computed tomography (CT) and magnetic
sular stretching.8 Yang was able to demonstrate that resonance imaging (MRI) provide good visualization
facetal loading is a function of the eccentricity of the of the facet anatomy (Fig. 47–2).
applied load, and he elucidated the mechanical basis
for capsular stretching and LBP.9 It has been shown Natural/Treatment History
that major intraarticular swelling increases distribu- Early resolution of the acute facet syndrome is ex-
tion of the referred pain.10 Prolonged high loading pected. This may take only a few days, but can be as
of the facets may be associated with local changes in long as 1 month, depending on severity. Acute trau-
the articular cartilage and joint capsules with progres- matic causation is usually limited to one to two lev-
sive imbrication of the articulations. Increased facet els and is typically unilateral. Recovery may be de-
loading is expected with disc degeneration and may layed in cases of comorbid complications such as facet
be asymmetrical as associated rotational deformities arthrosis. The presence of unilateral chronic low back
develop. pain with sciatic radiation but without objective neu-
rological abnormality is typical of symptomatic facet
Clinical Findings arthropathy.11 Carrera and Williams also found lum-
The patient’s posture may be normal although more bar facetal abnormalities in 57% of lower back pain
commonly there is hyperlordosis. In other cases a shal- and sciatic cases, while only 20% showed CT evi-
low lumbosacral base angle is present with a normal dence of discal protrusion. In yet another series, these
total lordosis, but a posterior shift of the center of same investigators showed the following CT changes
gravity. This latter posture, in the neutral attitude, is in 65% of the facet joints in low back pain and sciatic
equivalent to the posture of a normal individual in patients: osteophyte formation, hypertrophy of the
extension. articular processes, articular cartilage thinning, vac-
Back pain, or back and leg pain, is typically present uum joint phenomenon, and calcification of the joint
and increases with lumbar extension. Normal, pain- capsule.
free lumbar flexion is expected. There may be as- Alteration of stress distribution within the joint
sociated paraspinal tenderness over the facet artic- components may promote subsidence of tissue ir-
ulations. Segmental muscle hypertonicity is often ritability and inflammation. Treatment strategies
present. Pain referred from the lower lumbar facet should focus on limiting focal stress at the affected
joints involves only the posterior buttock and thigh joint(s) while at the same time promoting normal func-
and often does not extend below the knee. It is gener- tion. Simple manipulative procedures and continuous
ally of a drawing, cramping nature in contrast to the passive motion (CPM) are usually well suited for this.
burning pain and paresthesia in intervertebral disc Flexibility exercises should be selected to stretch the
herniation. Unilateral facet pain does not cross the paraspinal musculature and open the facet articula-
midline. Hamstring spasm contributes to this sensations, all without causing sharp pain.
tion of referred lower leg pain and also limits straight- In resistant cases, provocative testing is most use-
leg raise (SLR) and lumbar flexion. These two features ful in adapting standard manipulative procedures.12
may mimic the clinical presentation of root compres- Severe cases may require an initial period of aquather-
sion. The patient with a facetal syndrome may com- apy. If there is deconditioning, patients should
plain of pain with lumbar flexion, but flexion pain is progress to resistive exercise or even a supervised re-
usually caused by secondary reflex hamstring spasm habilitation program. Those patients who are unable
that occurs late or usually past 70 degrees. This is more to tolerate spinal motion from CPM, manipulation
FIGURE 47–1. Lumbar facet arthrosis. A. Conventional

anteroposterior projection showing marked hypertrophic
changes on the right at L5-S1 in the region of the posterior
facets. From this there is no indication as to any degree of
FIGURE 47–2. Synovial facet cyst. A. Sagittal T2-weighted MRI
stenosis of the lateral recess or associated abnormality (e.g.,
and (B) axial T2-weighted MRI. There is a large cystic mass
synovial cyst). B. Axial CT at L5-S1 showing the marked de-
on the right side adjacent to a degenerated facet articulation.
gree of degenerative change of the right facets compared to
Considerable mass effect is caused by the 1.0 × 1.0 × 1.4 cm
those on the left side with bony overgrowth and subchondral
synovial lesion. Although many are asymptomatic, they may be
cyst formation. MRI would show similar findings.
responsible for radicular symptoms and signs.
preload, or even aquatherapy may require therapeutic (c) anomalous, degenerative, or surgical abnormali-
injection or facet block to allow the appropriate pro- ties of the facets and pedicles.
cedure to be accomplished. This may require that the The overall incidence of spondylolisthesis is
manipulation be performed in conjunction with joint 3.5–7%. A significant variation exists between dif-
anesthesia (Fig. 47–3).13,14 ferent population samples. The specific incidence is
much higher in predisposed individuals, particularly
SPONDYLOLYSIS AND SPONDYLOLISTHESIS athletes (gymnasts, dancers, etc.). Spondylolisthesis
and its precursor, pars separation, is seen predomi-
Definition nately in childhood and young adulthood. The great
Spondylolysis is a separation of the isthmus (pars), majority of cases occur at L5, while 10% or less are
while spondylolisthesis is an anterior shift of one ver- seen at L4. Unilateral spondylolysis and multilevel
tebral body upon its caudad fellow. Spondylolisthe- spondylolyses and spondylolistheses are possible.
sis may result from a variety of pathogenic mecha- There is evidence for familial tendencies for the
nisms: (a) stress fracture at the pars interarticularis development of spondylolysis and spondylolisthesis.
(most common lesion)15 (b) acute pars fracture; and Whether or not there is an actual dysplastic pars, as
transmitted to the apophyseal joints. Schmitt also

demonstrated that the forces acting on the L5 pars in-
terarticularis are disproportionately large when there
is lordotic stress and, with intermittent or rhythmic
loading without a recovery phase, fatigue failure can
occur.20 Suezawa found the greatest loading of the
pars to occur with vertical loading of the hyperex-
tended spine and the resultant impingement by the
inferior facets of L4.21 Yang and King substantiated the
suspicion of a “bottoming-out” of the inferior facet tip
at the pars interarticularis of the vertebra below.9 This
represented the “pivot” point of posterior rotation of
the inferior facet and was associated with rupture of
the articular capsules.
During walking (with a lordotic attitude and
loaded with a pack, etc.) there is alternate loading from
FIGURE 47–3. Fluoroscopic depiction of needle placement and side to side. The viscoelastic disc may creep under the
facet arthrogram. Facet injection procedures are helpful diag-
action of the continuous shear force that causes al-
nostic aids as well as therapeutic measures. This procedure
ternating inferior facetal loading. The intervertebral
is especially useful in cases of resistant facet syndrome. Man-
ual procedures, including manipulation under joint anesthesia,
discs are considerably more elastic in people younger
may be performed, facilitating early rehabilitation. than age 30. Cyron and Hutton suggest that there may
be transference of substantial shear force to the infe-
rior articular facets.22 Stresses are commonly greater
suggested by some, is an issue that has not been fully and more frequent in younger age groups. Addition-
clarified. Abnormalities associated with neurulation ally, the strength of the neural arch is dependent on
and neural tube formation range from anencephaly to the completeness of the bony ring, and there may be
sacral agenesis.16 An association between spina bifida a relationship to the increased incidence of spina bi-
occulta and spondylolysis is well established, occur- fida occulta. The L5 segment, being positioned on the
ring in up to 92% of children with spondylolysis.17 steep sacral table coupled with the abrupt change in
Some cases of spondylolysis may represent a congen- the stiffness between the flexible spinal column and
itally connected formation.18 the fixed pelvis, may be more vulnerable. With weak-
ness of the multifidus (a stabilizer of intervertebral
Pathoanatomy/Pathophysiology/ shear force), the L5 arch may be subjected to a net
Biomechanical Considerations backward bending moment and be liable to fatigue.
Spondylolytic spondylolisthesis is currently con- In the case of unilateral loss of pars integrity, hy-
ceived as a stress overload (stress fracture) of the pertrophy of the opposite arch is likely to be manifest
pars interarticularis. The occurrence of stress reactions (unilateral arch hypertrophy), but this may also be
and fatigue failure is less well known at other sectors seen with any unilateral anomalous deficiency of the
of the posterior arch. This concept correlates well as vertebral arch. Unilateral spondylolysis has been asso-
a function of the hyperlordotic attitude or posterior ciated with extensive formation of osteocartilaginous
shift in the gravity center, facetal imbrication, facetal debris at the pars defect, consistent with hypertrophic
impingement, pressure erosion by articular impinge- callus or a fracture nonunion.23,24
ment, and, in due course, attenuation of the pars in- Ultimately, degenerative disc changes ensue with
terarticularis. Spondylolysis is conceived as the final interspace thinning, vacuum phenomenon, and reac-
event concluding a protracted period of recurring and tive marginal changes. There may also be buttress-
repetitious partial or microfractures at the pars. Early ing anteriorly at the promontory, and occasionally a
lesions may well heal with elongation of the isthmus, ball-and-socket formation develops.
perhaps only then to refracture if the biomechanical
process is reenacted. Static forces generated within the Imaging
pars create stress, and when the cellular mechanism Anterior displacement is commonly graded on the lat-
of repair cannot keep pace with the stress effect of eral plain film according to the Myerding classifica-
repetitive force, fatigue failure occurs. tion. The superior aspect of the subjacent segment is
In the lordotic position, the facet tips contact the divided into four equal sectors and used to calculate
laminae of subjacent segments and may bear one- the degree of translation by using the placement of
sixth of the compressive load.19 With interspace thin- the posteroinferior margin of the displaced segment
ning, up to 70% of the superimposed load may be in the respective quadrants, that is, grade I (up to 25%),
grade II (25–50%), and so on. Grade V is sometimes images commonly show the pars to be narrowed, elon-
used to signify displacement beyond the subjacent gated, sclerotic, and interrupted.27 Associated find-
level. An exact percentage of translation may be ob- ings on CT with multiplanar reconstruction include
tained by using the following formula: distance of slip discal bulge, foraminal encroachment, and encroach-
divided by the anteroposterior diameter of subjacent ment of the neural canal from soft tissue or bony cal-
segment multiplied by 100. lus formation (Fig. 47–5).28 The pars defect, and any
The oblique lumbar view (25–45 degrees) has tra- degree of stenosis, may also be visualized on MRI
ditionally been used to portray the isthmic defect, and (Fig. 47–6).
while the popularized concept of the “scotty dog” Bone scintigraphy is of value for determining
configuration needs no further elucidation, the im- whether the pars exhibit tracer accumulation sug-
portance of this visualization cannot be denied. Un- gests active stress reaction or healing. Single-photon
fortunately, oblique visualization may fail to reveal emission computed tomography (SPECT) visualiza-
spondylolysis in as many as 13% of cases.25 In those tion provides more specific localization in different
cases where the index of suspicion is high but visu- planes.
alization is inadequate, additional imaging may be
fruitful. Further clarification may come from a spot lat- Clinical Findings
eral, an anteroposterior (AP) caudal- or 30–45-degree Spondylolysis and spondylolisthesis are frequently
cephalic tilt view,25 and varied oblique projections encountered incidentally, and may not be symp-
with angulation.26 Apparent bilateral spondylolysis tomatic. This is expected in most cases.17 Spondylol-
can be purely projectional in nature. The pars defect ysis and low-grade isthmic spondylolisthesis are not
appears in a downward and outward direction (on associated with an increased risk for back problems,
the AP view) and should not be confused with the and they rarely progress in adulthood.29 However,
apophyseal joints. Bowel gas overlaying the osseous there is a small but distinct group of patients with
structure can also simulate a pars break (Fig. 47–4); pars defects who have chronic disabling pain. Symp-
and hypoplasia of the L5 body can create a false im- tomatic patients are usually young with back pain and
pression of slippage. Flexion and extension projec- no true sciatica. Many factors contribute to the overt
tions can be used to demonstrate excessive movement, syndrome, and care should be taken to elucidate the
but serial radiographic evaluation is not indicated in pain mechanism(s) and to incorporate consideration
the absence of renewed clinical manifestations. of such mechanical factors into the treatment regimen.
Computed tomographic demonstration of the de- Low back pain radiating to the leg with spasm
fect may be difficult because adjacent facet interfaces of the hamstring and paravertebral muscles, resem-
may simulate spondylolysis. When visualized, CT bling the symptoms found in the facet syndrome,
is a common presentation. Pain is accentuated by
weight-bearing and lifting movements and relieved
by rest or recumbency.
Complaints of weakness, stiffness, and instability
are not uncommon. Crepitation and abnormal inter-
segmental movement are discernible in some cases.
Extension of the spine may cause the mobile lamina
to indent the fibrocartilaginous mass with resultant
compression of a nerve root. Therefore, if pain of sci-
atic distribution is evoked by extension and relieved
by flexion, a loose and rocking lamina may be present.
In cases where there is an exaggerated lordotic config-
uration and the spinous process of L5 or L4 is quite
prominent, a transverse “furrow” may be evident on
inspection of the back.
Associated symptomatic disc prolapse is uncom-
mon. Peripheral neuralgic manifestations may be
noted, particularly in the distribution of the L5 or
S1 dermatomes. There may be associated sensory
or motor changes related to the disc protrusion or
FIGURE 47–4. Oblique view of a normal lumbar spine. The root involvement at the fibrocartilaginous mass of
overlying bowel pattern at L4 obscures visualization of the in- the isthmic lesion. Listhesis of L4 generally creates
tegrity of the pars interarticularis and creates a pseudodefect involvement of L4 or L5 roots, whereas slippage of
appearance. L5 typically involves the L5 or S1 roots. However, an
A B
FIGURE 47–5. High-grade L5 isthmic spondylolisthesis. A. Conventional radiograph showing advanced disc space loss and remod-
eling of the L5 and S1 vertebral interfaces. B. CT-myelogram with sagittal reconstruction adds information relative to the space
available for neural components in the spinal canal.
enlarged central canal resulting from the anterior slip nerve endings have been found. Eisenstein reported
may protect the patient with such a lesion. the presence of neuropeptides and immunoreactive
Arthrography and facetal injection producing sig- nerve fibers capable of nociceptive function in the
nificant pain relief suggests a substantial soft-tissue spondylolysis defect.32 Based on the anatomy, the pars
irritation that has been used as an explanation of itself appears to be capable of nociception.
some of the clinical complaints in spondylolysis.30 The
examination of biopsy specimens from the pars in- Natural/Treatment History
terarticularis shows a high density of neural tis- The management of symptomatic spondylolysis or
sues, including numerous elements consistent with spondylolisthesis with minimal displacement is con-
type IV (nociceptive) nerve endings.31 In Schneider- troversial. Most patients in whom a low-grade isth-
man’s study, histologic examination reveals extensive mic spondylolisthesis is discovered in the setting of
connective-tissue scar formation. In some cases there new onset LBP achieve symptomatic relief through a
was fibrofatty connective tissue, while other cases ex- gamut of nonoperative treatment options.33 Bouts of
hibited exuberant dense collagenous scar. No acute acute LBP are extremely common and usually are self-
or chronic infection was found. Prominent vascular limited and benign. In the few cases in which symp-
structures were present at the periphery of most spec- toms fail to resolve, it is tempting to incriminate the
imens, and small arterioles and capillaries permeated spondylolisthesis.34 The prevailing point of view in
the pars defects. Fine neural elements, including un- the literature, however, is that pain is far more likely
myelinated nerve fibers and small myelinated axons, not related to the spondylolisthesis.
have been identified and free nerve endings are noted Young patients who present with back pain where
in all specimens. Medium to large nerves are noted radiography reveals spina bifida occulta but not
in the majority of specimens, but no encapsulated spondylolysis represent a unique situation. Oakley
Strengthening of the abdominal musculature (par-

ticularly the rectus and external oblique sectors) and
reduction of the lumbosacral angle are recommended.
If the patient is constrained in a supportive device, iso-
metric abdominal exercises should be employed. An-
tilordotic postural training and instructions in proper
body mechanics and use of the strengthened part are
important for effective rehabilitation. Exercise with-
out functional biomechanical change is of little value.
The lower-extremity kinetic chain can be affected
by the hyperlordotic attitude developed in many of
these patients. It is frequently associated with undue
tightness of the iliopsoas and erector spinae, which
may be related to heel valgus and tightness of the ham-
strings and Achilles. In some cases there may also be
related rectus femoris tightness. Stretching should be
performed slowly after warmup, and sustained with
no sudden or impact loading of the musculotendi-
nous unit. Passively assisted stretching maneuvers
with active resistance can also be employed. During
the acute phase of spondylolysis, stretching of the il-
iopsoas should be avoided.
Physiotherapeutic modalities may assist in the re-
duction of inflammatory reaction, pain, and the asso-
ciated muscle spasm. Manipulation of the lumbar or
sacroiliac joints is based on the clinical determination
of painful dysfunction. Bracing should not be used
in lieu of postural training and correction, but a lum-
bosacral appliance may lend some added support to
FIGURE 47–6. T2-weighted midsagittal lumbar MRI in a pa- an unstable region.
tient with grade I L5 isthmic spondylolisthesis. There is inter- The presence of a pars defect, or even a grade I slip,
nal disc derangement with moderately advanced disc thinning. does not necessarily end an athlete’s career, even if the
Other disc levels exhibit normal-appearing alignment, interver- lesion does not heal. Athletics may be pursued, but
tebral spacing, and disc signal intensity. Segmental stability is
perhaps not always in a pain-free state. Some recent
not determined.
studies even advocate no restriction of activity and
allow full participation in sporting activities,17 but this
suggests that it may be wise to maintain observa- may cause accelerated disc degeneration.
tional control of patients with renewed pain, espe-
cially during growth spurts, for the development of Management Considerations After Aggressive
a pars defect.35 Conservative Management Fails
The spondylolytic defect that is associated with The relationship between chronic LBP and spondy-
pain of less than 6 months’ duration, particularly in lolisthesis is uncertain. Similarly, the relative bene-
the younger individual, should be treated as a frac- fits of surgery versus nonsurgical treatments, as well
ture and reduction and immobilization should be at- as the relative benefits of different surgical proce-
tempted in an antilordotic brace. Radionuclide bone dures, are also unknown. Generally, the indications
scans may remain negative in the early stage and for surgical treatment are uncontrolled pain, progres-
should not dissuade a trial of bracing if the case is sive slip, progressive spondylolisthetic scoliosis, and
thought to be acute. The more aggressive immobiliza- neurological deficiencies.37,38 Muschik et al. failed to
tion treatments have the greater percentage of favor- demonstrate clinical improvement despite showing
able results, and use of the common lumbosacral sup- improved alignment with reduction.39 Posterolateral
port is inadequate in acute spondylolysis where the fusion is associated with a high percentage of success
potential remains for healing. Steiner and Micheli de- and is considered by most surgeons to have a low risk.
scribed 67 adolescent patients who had symptomatic Good to excellent results have been demonstrated in
spondylolysis or low-grade spondylolisthesis who 68% of cases, with 80% returning to their preoperative
were treated in a Boston brace. At 2.5 years follow- occupation. Pseudoarthrosis does not always portend
up, 78% had achieved good to excellent results.36 a poor result.
Repair of the pars interarticularis defects (cable- these two components. Collagen makes up approxi-
screw constructs, bone grafting, and wire fixation)40,41 mately 70% of the dry weight of the outer annulus, but
has been considered an appropriate treatment in that less than 20% of the dry weight of the central nucleus.
subset of cases in which the pars is identified as a pain In a child, on the other hand, proteoglycans represent
generator, as determined by diagnostic injection. If the only 3% of the outer annulus and up to 50% of the
MRI shows disc desiccation, then a discogram usually nucleus.
is obtained. Pars repair usually is not considered when The disc consists of concentrically arranged tis-
there is more than 5 mm of vertebral displacement, sig- sues. The outer annulus is arranged with densely
nificant degenerative changes on radiographs or MRI, packed and highly oriented collagen fibril lamellae.
a continued habit of smoking, concordant pain on the The inner annulus is less well organized and more
discogram, or failure to reproduce pain with injection fibrocartilaginous. Between the annulus and the cen-
of the pars. The success of pars repair procedures de- tral nucleus is a transition zone. Vertebral endplates
creases with increased patient age. form the superior and inferior boundaries of the discs.
Initially, the endplates are comprised of hyaline carti-
lage until much later when they calcify.
LUMBAR INTERVERTEBRAL Every component of intervertebral disc tissue
DISC SYNDROMES changes from birth through old age, but the most ex-
Definition tensive alteration occurs in the nucleus. The number of
viable cells, concentration of proteoglycans, and water
Clinical pain syndromes directly related to the inter-
content all decline with age. Although all discs even-
vertebral disc are classified as radiculopathic or disco-
tually develop similar age-related changes, the rate
genic. These are discussed separately as degenera-
and extent of change vary considerably. Trauma may
tion/extrusion and internal disc derangement syn-
set the stage for more rapid changes.
dromes. Spondylosis, posterior facet arthrosis, and
By skeletal maturity, many peripheral blood ves-
stenotic effects, often related to and concurrent with
sels have disappeared. The outer annulus remains
intervertebral disc syndromes, are also considered
about the same relative size, but the fibrocartilagi-
separately.
nous inner layer expands largely at the expense of
the nucleus. Myxomatous degeneration develops in
Pathoanatomy/Pathophysiology
portions of the annulus with loss of the normal col-
The intervertebral discs provide stabilization of the lagen fibrillar organization. Fissures and cracks begin
spine by anchoring adjacent segments together. They to appear. The nucleus becomes firm and white with
also allow for movement, and the attenuation and dis- an increase in the diameter of the collagen fibrils, and
tribution of loads. During normal weight bearing in a fibrous plate extends across the midportion of the
a young, healthy disc, vertical stresses are exerted on nucleus. Very few notochordal cells remain. Proteo-
the cartilage endplates and loads are transferred to the glycan and water concentrations continue to slowly
nucleus pulposus, dissipating forces in an isotropic decrease.
manner to the annulus fibrosus. Between 23 and 40 years of age, there also is grad-
ual mineralization of the endplate cartilage. By age 60
Structure only a thin layer of bone separates the disc from the
The intervertebral disc (IVD) contains a sparse cellular vascular channels that were previously in direct con-
population and abundant extracellular matrix formed tact with the cartilage. Nutrient channels are slowly
by an elaborate framework of macromolecules filled obliterated through this process. These purely age-
with water. The cellular components are responsible related modifications that contribute to changes in
for synthesizing the macromolecules and maintain- disc volume and shape are also the very same fac-
ing the structural integrity of the framework. The ma- tors that increase the probability of disc herniation
ture disc lacks a significant blood supply and cellular and disc derangement syndromes.
metabolism relies on the ability of nutrients and waste
to move through the disc matrix. Both the composition Mechanism of Derangement During midlife clinical disc
and organization of the macromolecular framework symptoms and syndromes arise at a high frequency
and matrix water content are important variables and intensity. This is not surprising when one consid-
for adequate transport. Collagen and proteoglycans ers that the progressing age-related changes make the
are the primary components of the macromolecular tissues less able to recover from deformation and more
framework. Collagen provides tensile strength and vulnerable to progressive fatigue failure. Fatigue fail-
the proteoglycans, through their water bonding, af- ure of the matrix consists of fissures, cracks, myxoid
ford stiffness and resilience to compressive forces. Ma- degeneration, fragmentation of proteoglycans, and
trices differ significantly in their relative amounts of disruption of collagen fibrils.
The disc often starts on a clinical course in the is reduced locally and displaced to the immediately
teenage years with minor internal disruption, and adjacent fibers.46 Fatigue loading of a disc wedged in
with varying degrees of displacement and bulging flexion can distort the lamellae of the annulus in a
of the annulus. The risk of herniation is higher dur- manner suggestive of posterolateral radial fissures.47
ing this period. The disc still has the power to trans- When the annulus tears sufficiently to extend to the
mit loads and expand, the annulus already has tears periphery of the disc and allow the escape of nuclear
and fissures, and there is a high level of activity. In content, then it is a complete radial fissure and the disc
the young, the expansion power of the disc is high is technically ruptured, but not necessarily prolapsed.
but the annulus is strong enough to provide contain- Adams and Hutton further describe several stages
ment, whereas in the elderly, the annulus has more of gradual prolapse of a disc.44 The first stage (self-
fissures but the dehydrated nucleus is less capable of selection of the disc) represents predisposition. Discs
expansion. In cases of very advanced degeneration, with a softer and more “pulpy” nucleus and where the
the spine becomes stiffer, but is often less painful. Un- posterior annulus is much thinner than the anterior
fortunately, at this stage there may be additional pain annulus, have a natural predilection to prolapse (e.g.,
generators to contend with in the form of facet disease L5-S1 and L4-L5 where discogram shows a relative
and stenosis. posterior position of the nucleus). In stage 2, repeated
It is generally recognized that progressive degen- activities of bending and lifting gradually distort the
erative changes in the annulus nuclear complex are posterior annular lamellae. The inner lamellae become
overlaid by three phases: dysfunction (circumferential tightly curved posterolaterally. The nucleus follows
and radial tears), instability (internal disruption and this line of distortion and migrates, forming radial fis-
disc resorption), and restabilization (osteophytes and sures. The upper lumbar discs rarely pass this stage.
traction spurs). There are two basic classifications of In the third stage, the lamellae are breached. The nu-
intervertebral disc prolapse: annular protrusion (dis- clear pulp creates a narrow, perhaps tortuous, chan-
placed nuclear material that causes the outer annulus nel through the lamellae. The final barrier consists
to bulge) and nuclear extrusion (when nuclear mate- of the outermost annular lamellae and the adhering
rial escapes from the disc). posterior longitudinal ligament that the nuclear pulp
She-wei Yu correlated internal morphology of must penetrate in order to escape. This represents a
lumbar intervertebral discs with MRI findings and formidable barrier. Because the disc is unsupported
cryomicrotomy using fresh-frozen cadaveric spines dorsally, it can stretch and bulge outward in response
and classified disc tears into concentric, transverse, to the pressure of the migrating pulp, producing an an-
and radial types.42,43 Concentric tears are crescent- nular protrusion. In mature discs with a mostly fibrotic
shaped and associated with rupture of the short trans- nucleus, this may be the final stage. At stage 4 there is
verse fibers connecting the lamellae in the annulus fi- extrusion of the nuclear pulp. The pulp may appear
brosus. Transverse tears represent rupture of Sharpey at the mouth of the fissure, but quite commonly it mi-
fibers near their attachment to the vertebral rim. A ra- grates behind the final barrier and emerges/collects
dial tear is a fissure extending from the nucleus to the elsewhere. The stage 3 disc is most frequently re-
outermost surface of the annulus. For a disc to pro- sponsible for symptom reproduction when injected
lapse it needs a fissure or channel (radial tear) to the (discography). The leaking disc may occur in stage 3
periphery. or 4. The disc does not continue to leak pulp indefi-
Adams and Hutton describe two basic mecha- nitely. In stage 5, the ruptured disc achieves stability.
nisms for disc prolapse.44 The more typical mech- For instance, in fibrotic mature discs with fibrotic nu-
anism is gradual and progressive, resulting from a clear lumps, herniation is most unlikely because there
compressive force of lesser magnitude applied rep- can be no passage of the nucleus except under extreme
etitiously to a spine in flexion (e.g., frequent bend- loading circumstances. Even in less fibrotic discs, a
ing/lifting). The second mechanism is less com- 10% loss of disc fluid makes it more difficult to propa-
mon and occurs suddenly, usually associated with gate an annular tear. Therefore, nuclear extrusion and
a traumatic event, when a high compressive force is annular protrusion occur in normal and slightly de-
abruptly applied to the spine while in an unfavorable generated discs but not in severely degenerated discs.
position (forward bend together with twist).
In nondegenerated discs, the nucleus pulposus mi- Laboratory Testing and Imaging
grates posteriorly during flexion and anteriorly in High-quality conventional imaging is the initial
extension.45 Tensile stress in the annular fibers of the imaging tool for defining gross osseous morphol-
intact disc always varies, going from a maximum ogy, vertebral alignment, intervertebral spacing, and
at the inner layer to a minimum at the outer layer. intersegmental stability. However, routine radiogra-
When fibers fail at the inner layer, stress concentration phy is limited and most soft-tissue abnormalities can
A B
FIGURE 47–7. A 30-year-old male with lower back and radicular pain. A. Conventional lateral radiograph provides no information
about the disc morphology. B. Sagittal T2-weighted MRI shows two levels of disc abnormality with extrusion at L4–5.
be virtually imperceptible. This includes the morpho- always reliable for differentiating supraligamentous
logical character of the disc (Fig. 47–7). These types and subligamentous herniations.48 When there is a
of uncertainties and ambiguities may be clarified by loss of continuity with the parent disc, the term se-
various advanced imaging studies. questration is usually applied. Separated fragments of
disc material may migrate above or below the parent
Imaging Nomenclature The terminology used for the disc level.
reporting of visualized abnormalities on imaging The signal character of the protruded material sug-
studies is varied and often confusing. Diagnostic gests levels of disc hydration, which is a factor that
categories of disc abnormalities are best based on may be of predictive value as to the probability of
pathologic categories (e.g., normal, degeneration, nu- resorption. Discs with intermediate signal intensity
clear extrusion). Degeneration implies desiccation, fi- have a better chance of regression or disappearance
brotic change, disc thinning, and annular bulging of than those exhibiting lower signal intensity. In such
a diffuse nature. There also may be associated end- cases, slow change is expected over 12–18 months.
plate reactive changes and marginal osteophytic ex- Most annular fissures are not visible on MRI. Some ap-
crescences. pear bright on T2-weighted, fat saturation, and short
The term herniation has been used to describe some T1 inversion recovery (STIR) sagittal and axial images
degree of disc extension beyond the vertebral mar- as a result of local granulation tissue and edema. These
gin, but limited to a small area, usually less than 25% have been termed high-intensity zones (Fig. 47–9).
of the circumference. This may include nuclear mate- Spinal canal size varies significantly between individ-
rial as well as annulus. Such displacements may take uals, which may have significant effect on the sever-
the form of protrusion or extrusion (focal protrusion ity of clinical symptoms. Small protrusions into tight
with the base of the protrusion less than the diame- canals have more significant mass effect than those
ter of the extruded material). Figure 47–8 illustrates into normal or large canals.
several patterns of disc disruption. Whether or not Contrast administration in conjunction with the
the intervertebral disc wall contains the protrusion is MRI examination is usually limited to a search
not always clear. Furthermore, MRI criteria are not for postsurgical scar and the differentiation from
C D
FIGURE 47–8. Patterns of disc disruption. A. Central focal herniation into a normal spinal canal. B. Left paracentral and foraminal
herniation. C. Axial CT showing broad-based extension of annulus beyond the vertebral margin’s perimeter, greater than 50%. This
disc exhibited advanced degenerative thinning. Note the advanced posterior facet disease that is present bilaterally. D. MRI depiction
of a similar case with a degenerative lumbar disc protruding in a broad-based manner. E –G. Caudal migration of a disc herniation.
E . Large focal L4-L5 extrusion with caudal migration. F. Same case, axial cut at the level of the parent disc at L4-L5. Note the left
paracentral and foraminal location plus a broader-based component. G. Same case, axial cut through the inferior migration.
reherniation. Even though the use of contrast in such Electrophysiological

Use of Electrodiagnostic Testing
settings is rather routine, it often adds little diagnostic studies, such as nerve conduction, nerve root stim-
value and at times may be confusing.49 In the nonoper- ulation, and needle electrode examination, have
ated back, radial tears are enhanced with gadolinium- a spectrum of usefulness and limitation in pa-
diethylenetriamine pentaacetic acid (Gd-DTPA),50 as tients with LBP and radiculopathy. Their use should
is extradural inflammation,51 and, to a lesser degree, be guided by historical data, as well as exami-
the inflamed nerve roots.52 nation and imaging findings. The results of any
E F
G
FIGURE 47–8. (Continued )
electrodiagnostic study must be interpreted in light For instance, nerve conduction studies are often nor-
of the clinical information with an understanding mal in a single-level radiculopathy. However, the
of the pathophysiology of nerve change in radiculo- same study may be useful in a nerve entrapment or pe-
pathy. ripheral neuropathy with symptoms that mimic those
Such studies evaluate neuromuscular physiolog- of a radiculopathy. Electrodiagnostic studies may help
ical characteristics at the time of the examination. A establish or confirm a diagnosis, localize a nerve le-
normal study does not rule out nerve involvement. sion, determine the extent and timing of a nerve
A B
FIGURE 47–9. Imaging appearance of a high-intensity zone pat-

tern. A. Sagittal T2-weighted lumbar image. L4-L5 disc exhibits
low signal intensity and posterior prominence. Posteroinferiorly in
the annulus periphery there is a large zone of high signal. B. Axial
T2-weighted cut through the high-intensity zone. There is some
modest protrusion centrally. C. CT-discogram at the same level
showing internal derangement including a radial tear extending
C
to the protrusion/high-intensity zone sector.
injury, and help set the prognosis for return of muscle unequivocal and clinical findings are highly consis-
strength. tent with acute radiculopathy, EMG is rarely neces-
There appears to be confusion concerning the use sary. On the other hand, if there are equivocal find-
of electrodiagnostic testing among some clinicians ings on clinical examination or some question as to
who treat patients with LBP and radiculopathy.53 Nee- whether the radiculopathy is present, whether it is
dle electromyography (EMG) is of limited useful- acute or chronic, or the exact level or levels of nerve
ness in the first 2–3 weeks following onset of radic- root involvement, electrodiagnostic testing can be the
ular symptoms other than to establish a background only manner in which additional information can be
level of denervation. In cases where radiculopathy is obtained.
Clinical Findings primary hip and pelvis pathologies, lumbar radicu-

Attempts at diagnostic categorization of patients with lopathy, femoral neuropathy, diabetic amyotrophy,
LBP with or without limb pain are difficult. Today’s myofascial pain syndromes,55 and sacroiliac disorder.
advanced imaging and physiological evaluative stud-
ies are valuable tools, but they have shifted focus away Physical Examination
from the art of physical examination. This is unfortu- The initial physical assessment attempts to identify
nate because many normal patients demonstrate be- pain-generating tissue and to grade neurological im-
nign or incidental spinal lesions on advanced imaging. pairment. Procedures include inspection, palpation,
Imaging studies do not discriminate between symp- range-of-motion determinations, appraisal of posture
tomatic and asymptomatic lesions. and gait, neural function screening, and selective tis-
The practical clinical assessment of disc involve- sue stress tests.
ment has several functions: rule out other conditions Postural assessment may reveal a trunk list or
that may mimic a disc derangement; identify the likely pelvic shift. Trunk list is described by the direction
pain generator; grade any neurological impairment; of shift of the cephalad region. While such antalgia is
define comorbidities or complicating factors that commonly associated with disc disorders, it correlates
may influence patient management or clinical course; poorly with the topographical location of a disc lesion
and triage the patient to the appropriate treatment (i.e., central, intermediate, lateral).
strategy. Reflex, motor, and sensory testing should always
Disc derangements can result in varied combina- be performed when radiculopathy is suspected. Even
tions of pain, paresthesias, or weakness in the lum- in the presence of true root involvement, however,
bopelvic region and lower limb. Pain diagrams are some deficits may not be clinically definable. Com-
useful in documenting these complaints. The onset of binations of sensory alterations (numbness, tingling,
symptoms may be insidious or sudden, with a known and hypesthesia) and true or perceived weakness may
causative incident. Internal derangement of a disc be present. The most serious significant expression of
alone may present with pain across the lumbosacral neural compromise is loss of bowel or bladder control,
junction that radiates to the upper buttock and groin. which constitutes a medical emergency.
Extension into the posterior thigh is less common and Dermatomal pinprick sensibility testing is highly
rarely occurs below the knee (Fig. 47–10). subjective and frequently misleading, and the accu-
When intervertebral disc protrusion is present, the racy of sensory findings in identifying the level of
pattern of pain bears a relationship to its horizon- nerve compression is reportedly as low as 50%. Be-
tal location. Central protrusions tend to have LBP cause there is less dermatomal overlap along the distal
only, while lateral protrusions may cause leg pain distribution of a nerve root, these areas are targeted to
only. Intermediate patterns may have both back and help localize the level of a lesion: the lateral foot and
lower-limb involvement. Sciatic pain patterns may be small toe (S1); dorsum of the foot and web between the
referred or radicular, the latter implying nerve root first and second digit (L5); anterior thigh; and medial
origin. The distribution of limb pain versus back pain foot (L4). When sensory deficit as a result of lumbar
may be helpful in estimating the pattern of underlying disc herniation is defined, it is usually accompanied
disc pathology. Patients who present with preponder- by pain projection and motor or reflex disturbance.56
ant leg pain more often have extruded disc material The impact of nerve root compression on the motor
at surgery. system is assessed through manual isometric strength
In cases of monoradiculopathy, the level of disc testing of target muscles that are innervated in greater
herniation can be correctly predicted in 93% of cases concentration from a single nerve root (Table 47–1).
by location of the pain alone or supplemented by neu- Manual strength assessment is highly variable and
rological signs.54 When more than one nerve root be- subjective. As much as 25% of muscle strength must
comes involved, the diagnostic value of the pain pat- be lost before it is clinically detectable. When possi-
tern is significantly decreased. Radicular pain, like ble, testing with the patient’s own body weight is rec-
sensory abnormality, does not always follow a clear ommended as a more sensitive indicator of muscle
distribution. Pain projection to the first sacral nerve strength. For example, the patient is asked to per-
root distribution is the most common with all lum- form a short squat, heel walk, or toe walk. Subtle
bar disc herniations and is an unreliable indicator of strength loss may be revealed by the fatigue character-
disc herniation level. On the other hand, pain projec- istics during repeated short squats and toe/heel ris-
tion along the L5 nerve root distribution has a strong ing. Pain-induced weakness (inhibition) during mus-
predictive value for an L4-L5 disc lesion. High lum- cle testing limits the usefulness of manual strength
bar radiculopathy radiates into the groin or anterior testing. Considering the relative frequency of disc her-
thigh. The differential diagnosis includes a number of niations at L4 and L5, examiners must include strength
A B
FIGURE 47–10. Disc derangement syndrome in a 35-year-old

active male patient with preponderant back pain and minimal leg
pain. Conservative management had previously been successful,
but more recently its effect dramatically diminished. A. A con-
ventional lateral lumbar radiograph reveals little. B. Sagittal T2-
weighted lumbar MRI shows signs of internal derangement and
herniation. C. Discography at L4-L5 was concordant 10/10. The
CT-discogram exhibits grossly deranged disc morphology with cir-
cumferential and radial tear patterns. This patient refused ag-
C
gressive rehabilitation and opted instead for fusion.
TABLE 47–1. Important Muscle Group Motion and Innervation
Muscle Motion Nerve Level Key Level
Iliopsoas Hip flexion L2-L3 L2-L3

Quadriceps Knee extension L2-L4 L3-L4
Hamstrings Knee flexion L5-S1 S1
Tibialis anterior Ankle dorsiflexion L4-L5 L4-L5
Gastrocnemius/soleus Ankle plantarflexion S1-2 S1-S2
Peroneus longus Foot eversion L5-S1
Extensor hallucis longus Great toe extension L5-S1 L5
Flexor hallucis longus Great toe flexion L5-S2
assessment of the extensor hallucis longus. This is result is documented as a positive “well leg raise,” or
most important because there is no accompanying “positive cross-leg-raise sign.” This pattern is more
reflex to the L5 nerve root level and the strength of often seen with large disc extrusions or sequestra-
this muscle is the primary objective indicator of pos- tion. Severe limitation in SLR (under 30 degrees) ap-
sible L5 nerve root compression. Aronson noted that pears more common with extruded/sequestered disc
patients with upper lumbar disc derangements with fragments.60
root involvement tend to have more muscle weakness Restriction of limb elevation by severe hamstring
(63%) than patients with lower disc herniations.57 The tightness may adversely affect the validity of the SLR.
quadriceps was more frequently involved than other In addition to the lumbosacral nerve roots, a pas-
muscle groups. sive SLR also stresses the lumbopelvic and lower-limb
An asymmetrically attenuated or absent muscle anatomy (e.g., hamstrings, hip, sacroiliac joint, lum-
stretch reflex may be indicative of nerve root in- bar paraspinal muscles, and facet joints) and differ-
volvement. At the very minimum, the Achilles and ential considerations are extended to these structures.
quadriceps responses should be graded. The Achilles The reproduction or aggravation of back pain without
response correlates to the S1 nerve root, while the radicular pain on straight-leg raising should not be
quadriceps response correlates to the L4 nerve root considered a positive test as it may be doing no more
level. The absence of a reflex deficit, however, does than stressing irritated musculoskeletal structures.
not preclude nerve root involvement. Supine SLR places maximal tension upon the first
Selective tissue stress tests may be used to repro- sacral and fifth lumbar nerve roots. Traction upon the
duce the patient’s complaint by compression or stretch L4 nerve root is dependent upon its contribution to
of the pain-generating tissue. For instance, local, cen- the sciatic nerve. Patients with limb pain and nerve
tral lumbosacral junction pain with overpressure at root irritation as a consequence of the upper lumbar
the L4 and L5 spinous processes relates more closely levels may not experience symptomatic change with
to disc derangement than SI joint dysfunction. Nerve SLR procedures. In this situation, the femoral nerve
tension signs also fall into this category. traction test may be helpful. This procedure may be
performed with the patient prone or side lying. With
Neural Tension Tests The most commonly used phys- the patient on the affected side (neck flexed to place
ical maneuver used in the assessment of disc de- tension on the cauda equina) the painful extremity is
rangement is the straight-leg raise (SLR). The exam- gently hyperextended to approximately 15 degrees,
iner elevates the relaxed, straight leg (patient supine) followed by passive knee flexion. Pain along the an-
and notes any induced pain with emphasis on loca- teromedial thigh, groin, or hip may be indicative of
tion and pattern. This test may also be performed an upper lumbar nerve root involvement. A crossed
in a seated position. Reproduction or aggravation of femoral nerve stretch test may also be present, which
lower-limb pain or paresthesias along the distribution is the equivalent of the crossed sciatic sign.61,62
of an affected nerve root is considered a positive test Several confirmatory maneuvers may be used in
and is a strong indicator of root irritation and disc conjunction with the SLR. For example, after the SLR
involvement.58,59 is performed, the straightened limb is lowered several
SLR is also performed on the asymptomatic limb, degrees until the pain abates. Neural tension or com-
and is recommended prior to the symptomatic side pression is reintroduced by passive ankle dorsiflexion
for comparison. If a positive test occurs in the affected (Braggard test or Fajersztajn test),63,64 neck flexion, or
limb during elevation of the symptom-free side, the medial hip rotation65 (Bonnet test).
Another very useful adjunctive maneuver is the A third type begins insidiously with mild to
bowstring, or Cram, test. With the knee bent and hip moderate pain, but symptoms spontaneously resolve
flexion maintained, pressure is then applied to the within 6–12 weeks. Imaging usually reveals small,
posterior tibial nerve through manual compression in contained protrusions.
the popliteal fossa. Reproduction of back and/or leg Ito concluded that patients with noncontained her-
pain is reportedly more specific for nerve root com- niations could be treated without surgery if the patient
pression from a lumbar herniation.66 can tolerate the symptoms for the first 2 months.70 In
the same study, it was rare for patients with noncon-
Light paratracheal
Alteration in Jugular Venous Pressure
tained herniation to require surgery 4 months or more
pressure on the external jugular veins occludes ve- after the onset of symptoms. In general, with or with-
nous return, which produces engorgement of the up- out surgery, muscle weakness will progressively im-
per attachment of extradural nerves, and carries it prove over the first 4 years, but some degree of weak-
laterally.67 This maneuver may exacerbate or relieve ness may remain in less than 10% of patients; 35%
radicular pain. The patient should be advised that a of patients may continue to have sensory deficit at
feeling of head pressure might develop. Similarly, pa- 10-year follow-up. There is no pain or spinal mobility
tients with pain upon coughing or straining at the difference at 10-year follow-up between surgically
stool (Valsalva) are more likely to have extruded or and nonsurgically managed patients.71 In the absence
sequestered herniations.60 of bladder or bowel incontinence (cauda equina syn-
drome) or progressive neurological deficit, most pa-
tients are suitable for a 2–3-month trial of conservative
Prone Knee Flexion Provocative Test The patient lies management before proceeding with surgery.72
prone with the knees bilaterally hyperflexed so that Understanding of the natural history of disc de-
the heels approximate the buttocks. After maintaining rangement has narrowed the selection criteria for sur-
this position for 45–60 seconds, the knees are brought gical intervention. Patients that were once categorized
to 90 degrees and the reflexes and strength are reas candidates for surgery may now be effectively man-
assessed. A positive test is signaled by increased distal aged conservatively with equal, or better, outcomes.
weakness or reflex attenuation. This maneuver may be
more applicable to cases of suspected central spinal Conservative Treatment Notwithstanding the generally
stenosis.68 favorable outcome of disc herniations, clinicians must
give consideration to the goals of treatment (e.g., pre-
Natural History vent recurrence, expedite the natural history, provide
Varied patterns of improvement have been identified pain relief, reduce the potential for surgery, improve
with time frames for clinical and symptomatic resolu- quality of life, and limit the loss of productivity). The
tion in patients with disc herniation.69 most important predisposing factors to symptom de-
The first pattern is acute in onset with severe pain, terioration are working in a forward bent position and
often with a combination of lower back and lower limb sedentary activity without the opportunity to stand.73
pain that usually lasts for 1–2 weeks with or with- Good postural habits must be understood and prac-
out treatment. A relatively painless mild neurological ticed by the patient. There are an impressive array
deficit may remain that resolves over the following 6– of conservative treatment options observed across the
12 weeks. In a subset of this same onset pattern there professions providing spine care. Strategies may be
are a small group of patients in whom the pain and subdivided into pharmacological, physical, and min-
neurological deficit do not abate. These are frequently imally invasive approaches (Table 47–2).
associated with a sequestered fragment. Abolished Regardless of how management is balanced with
tendon stretch reflexes may not return to normal. complementary procedures, the principles of central-
A second pattern begins insidiously with moder- ization, stabilization, and mobilization remain fun-
ate severity and remains constant until treated. Mod- damental. This is especially so in those cases with
erate neurological findings, such as an absent tendon radiculopathy. Peripheralization means increased dis-
stretch reflex and more than one grade of motor loss, tal extremity symptoms. Centralization is the oppo-
are typical. Effective treatment may require several site, with leg symptoms receding proximally. The lat-
months and the recurrence rate is high. This pattern ter is the desired effect of treatment. Symptoms may
corresponds to small extrusions or herniations that intensify, improve, or remain the same as centraliza-
are contained. Complete resolution is expected within tion occurs. Activities that cause the increase of pe-
3–6 months with a gradual improvement of motor ripheral symptoms should be avoided.
strength. More severe neurological loss may require The process of centralization is a valuable tool dur-
as long as 1 year to achieve full, or occasionally paring both assessment and treatment. Noncentralizers
tial, recovery. have a tendency toward chronicity and continue to
TABLE 47–2. Conservative Treatment Options for Disc Derangement Syndromes
Pharmacological Physical Treatment Minimally Invasive
Nonsteroidal antiinflammatory Positional release Epidural steroids

drugs Extension protocols Selective nerve root block
Oral steroids Flexion protocols Intradiscal electrothermal therapy/
Nonnarcotic analgesics Manipulation/mobilization laser ablation
Narcotic analgesics Mechanical-assisted manual Nucleoplasty
Anticonvulsants techniques
Exercise programs
Physiotherapeutic modalities
Traction
Bracing
Bed rest
report pain, have extended activity interference or excellent outcomes, with 83% returning to full work
downtime at home, and continue to use health care rating.77
resources.74 Kopp found that 97% of patients who
were treated nonoperatively for an acute lumbar her- Spinal Manipulation This includes various manual pro-
niation were able to achieve extension within 3 days, cedures, such as unloaded spinal motion, manu-
but only 6% of those failing conservative care achieved ally assisted passive motion, and traditional manip-
lumbar extension.75 On long-term follow-up, the ex- ulation. The last type includes both standard static
tension sign effectively predicted a favorable response high-velocity low-amplitude (HVLA) thrusting and
to nonoperative therapy in 91% of cases.76 dynamic motion-assisted HVLA thrusting. Some of
Movement patterns for static or dynamic positions these techniques require specially equipped tables
should be based on the response (subjective com- that assist in delivering the treatment force. A vari-
plaints) to various loading positions and not on the ety of manipulative procedures have been described
pathoanatomical features of the disc. Some increase in the literature, but irrespective of the technique used
in back pain with a position of extension, for instance, the practitioner must first identify a clinically signif-
is not significant if centralization occurs. The course icant functional spinal lesion. This lesion may be at
of positional treatment is dynamic and may change the level of the disc herniation, at an adjacent motor
from session to session. segment, or in a remote location.
Loading patterns may include single movements, Side-posture lumbar adjusting techniques may
repetitive movements (e.g., continuous passive mo- produce significant rotational forces into the lumbar
tion), or sustained static postures. Mechanical assis- spine, whereas sacroiliac joint techniques may be
tance devices also may be used. Movements should al- applied with little rotatory force. Axial rotation with
ways be accomplished without activation of the lum- compressive disc loading has been implicated as a risk
bar extensors. When a response pattern is understood, for annular tear, raising the question as to the amount
the patient may carry the strategy over to home-based of rotation that occurs during manipulation. The ori-
replication. Low-load exercises should be integrated entation of the posterior facets prevents the rotation
as soon as tolerable; walking is recommended im- necessary for annular injury,78 provided that the spine
mediately. Core stabilizer muscle activation should is not placed into significant flexion. The work of
also be initiated immediately to prevent loss of sta- Adams and Hutton maintains that rotation is limited
bilization control. As core stability is gained, progres- to 2–3 degrees, barring facet fracture.79 In some cases
sive functional perturbations are added to challenge of severe disc degeneration, up to 7.7 degrees of rota-
core stability. Finally, endurance training is completed tion may be possible.80 Cassidy has questioned how
to restore functional capacity. A cohort retrospective the small amounts of rotation induced by side-posture
study of patients with lumbar disc herniation and manipulation could damage or irritate a healthy disc.
radiculopathy treated by back school and stabiliza- Observations of 14 patients with herniated nucleus
tion training demonstrated good to excellent out- pulposus (HNP) receiving a 2–3 week regimen of
comes in 90%, and a return to work rate of 92%. daily side-posture manipulation demonstrated that
Of patients with neurological loss, extruded frag- 13 (93%) obtained significant clinical improvement
ments, and seeking a second opinion, 87% had good to and relief of pain. The appearance of the disc
herniation on CT did not change following Using the SLR and lumbar range of motion as
manipulation.81 No studies have demonstrated objective outcomes, Nwuga compared the results
that a lumbar manipulation has the capacity to injure of manipulation versus conventional therapy for
healthy discs. patients with myelographic and electrodiagnostically
Debate continues regarding the appropriateness confirmed lumbar disc herniations. The manipulation
of delivering an HVLA thrust in patients with lum- group received side-posture oscillatory mobilization,
bar disc herniation.69 Lumbar radiculopathy with disc while the conventional group received diathermy,
extrusion, however, is not a categorical contraindi- isometric exercises, and lifting/postural education.
cation to HVLA manipulation. Suspicion of cauda In all parameters, the manipulation group exceeded
equina syndrome or progressive neurological deficit the controls: The mean improvement in SLR was
warrants surgical consultation to avoid irreversible or 39 degrees versus 4 degrees, while total flexion and
progressive neurological deficits. Slogsberg cautions extension improvements was 34 degrees versus
that spinal manipulation should not be uncondition- 13 degrees.87 In another study, outcome comparison
ally accepted as a safe and effective treatment in all between spinal manipulation and chemonucle-
cases of lumbar disc herniation. Consideration must olysis for lumbar HNP favored manipulation.
be given to the biomechanics of manipulation as they Although equal 12-month outcomes were achieved,
apply to the individual patient’s condition.82 Triano manipulation/flexion–distraction provided better
contends that skilled manipulative procedures can short-term relief and disability benefit.88 Additional
be performed safely and successfully in these types case series suggest a positive outcome following
of cases, using clinical judgment following provoca- “flexion–distraction” therapy in patients with lumbar
tive testing procedures of patient tolerance.12 The is- disc herniations.84,89−91
sue appears to be the selection of cases for manipu- Manipulation also may be performed under gen-
lation and the skillful administration of manipulation eral anesthesia. Manipulation under general anesthe-
in that same case. Before administering any manipula- sia (MUA) has been administered for lumbar HNP
tive force, graded premanipulative stressing may be of since 1964. Immediate pre- and postmanipulation un-
value. Low-grade oscillatory stresses within the func- der anesthesia myelograms were performed in the
tional boundaries of the joint can help determine pa- early studies. More than 50% of patients reportedly
tient tolerance to the procedure. If the patient is intol- experienced immediate sciatic pain reduction. Signif-
erant of the procedure, or if peripheralization of pain icant improvements were observed in deep tendon
occurs, modifications should be made and premanip- reflexes, sensory changes, and SLR. Approximately
ulative tolerance reassessed. With proper positioning, 30% of patients with positive myelograms were
HVLA manipulative force focused on a specific spinal improved following manipulation. During surgery,
segment is usually possible. patients were also placed in a side-posture manipu-
The mechanism by which manipulation might relation position. Neither the nerve root nor the disc
duce a disc herniation remains unclear. For those pa- protrusion moved perceptibly, but the laminae moved
tients with active pain generators at articular com- apart by as much as 5 mm, markedly stretching the
ponents, reduced pain following manipulation likely lower fibers of the ligamentum flavum and the su-
relates to the restoration of optimal joint function, al- perior lateral joint capsule.92 Mensor administered
tering local tissue stress, and the reduction of local rotary lumbar mobilizations under anesthesia as one
swelling. component in the management of patients clinically
There are a number of case reports that detail suc- diagnosed with disc herniations. Satisfactory results
cessful relief of radicular pain following spinal ma- were reported by 52% of patients, excellent results
nipulative procedures, or treatment including spinal were reported by 27%, and 24% reported results as
manipulation.83,84 In an a priori analysis of patients good.93 Unfortunately, in many of these early studies
treated at a chiropractic care clinic, 44 of 3531 pa- more complications from lumbar manipulation were
tients satisfied the clinical diagnostic criteria of lumbar reported when the procedure is done under anes-
disc herniation with radicular sciatica and had suffi- thesia than when performed under typical in-office
cient documentation to estimate outcome. Following conditions.94 Modern MUA techniques are much gen-
manipulation, 33 (75%) of the 44 patients reported tler than those used in the 1950s and 1960s.
improvement in their condition and demonstrated
an increase in the SLR and lumbar spine motion.85 Epidural steroid injections
Epidural Steroid Injections
Using a variety of mobilization and gentle manipu- are commonly used in an attempt to relieve back and
lation procedures, Kuo reported a 76.8% “acceptable lower-limb pain associated with disc derangements
result” following treatment of patients with radicu- with or without nerve root involvement. They are
lopathy; details of this study were not clearly usually performed in cases where the patient has
reported.86 primary leg pain or pain too severe to permit less
invasive management. Two injection routes may be

used: a direct spinal approach at the level of the disc
derangement or at the sacrococcygeal hiatus (caudal).
Injections are most safely performed under fluoro-
scopic guidance and tend to be well tolerated; only
12% of patients rated them to be significantly uncom-
fortable. Early patient satisfaction is often reported,
but satisfaction tends to decrease over time, with 17%
unsatisfied and 48–50% reporting good to excellent
satisfaction at 3 months.95 The complications of epidu-
ral steroid injections include dural tap (2.5%), tran-
sient headache (2.3%), and transient increase in pain
(1.9%). There are very few long-term adverse events
recorded.96 Systematic reviews of controlled clinical
trials of epidural injections have not shown any con-
vincing long-term positive effects.
Viton reported a statistically significant decrease FIGURE 47–11. Fluoroscopic depiction of thermal catheter
in mean Visual Analogue Scale (VAS) scores follow- placement within the disc during intradiscal electrothermal
ing periradicular corticosteroid injections for lumbar annuloplasty procedure.
radiculopathy in 90% of patients. At 90-day follow-up,
85% continued to report a significant improvement.97 controlled clinical research to warrant its widespread
Papagelopoulos reported that early pain relief may use. Patients undergoing intradiscal electrothermal
be anticipated after injections in 80% of patients, and annuloplasty typically report experiencing varying
that 68% of patients were asymptomatic at long-term levels of improvement within 2–3 months that can
follow-up.98 These techniques, however, have not yet continue until about 6 months. Improvements have
been subjected to controlled clinical trials. Any short- been measured in pain severity, sitting tolerance, anal-
term benefit may aid the patient in tolerating symp- gesic consumption, and return to work in up to 75–
toms during management.71 There is no data on the 80% of patients.99,100
long-term effect of nonoperative treatment of these
cases. The natural history would predict eventual
Surgical Management of Painful Lumbar Disc Derangements
stability of symptoms. Resistance to treatment and
(HNP) Although the natural history of disc derange-
persistent disabling pain, however, often impel the
ment favors long-term recovery, patients who un-
frustrated patient to undergo spinal surgery. For con-
dergo laminectomy/discectomy procedures report
servative management to succeed, the thrust of any
short-term (1-year) satisfaction and improved qual-
treatment strategy needs to shift strongly to stabiliza-
ity of life and function.101 Few nonsurgically treated
tion efforts.
patients experience worsened pain or require sub-
Continuous passive motion, manipulation, and
sequent surgery and 20% or more of the surgically
physiotherapeutic modalities may be beneficial early
treated patients report no improvement.102 A prospec-
on to make the patient more comfortable and to help
tive observation study suggested that lumbar dis-
control pain. As pain becomes less severe, manipu-
cectomy appears to provide patients with a greater
lation becomes less important and is useful primar-
improvement in work capacity, neurological deficits,
ily to control symptoms following exacerbation to
pain, and spinal mobility over nonsurgically managed
permit routine function and promote rehabilitation.
patients after 1 year. This improvement favored the
Aquatherapy is assistive in the early stages. Patients
surgically treated patient over 4 years, but by 10 years
improve best with progressive and extended rehabili-
there was little difference between the two groups.
tation, as well as bracing (e.g., Cybertec) during more
stressful activities.
Intradiscal electrothermal anuloplasty (IDET) has LUMBAR STENOSIS
recently been suggested as an alternative to inter-
body fusion. It has been recommended for patients Definition
with chronic LBP (>6 months) who have exhausted One of the most frequently encountered, complex, and
conservative management options, including manip- clinically important degenerative disorders in the ag-
ulation, rehabilitation, and epidural steroid injec- ing population is lumbar spinal stenosis. Stenotic ef-
tions/oral steroids, who do not have neural tension fects include any type of encroachment of the spinal
signs, and who have a positive provocative discogram canal, recesses, or intervertebral foramina, whether lo-
(Fig. 47–11).99 There has, however, been insufficient cal, segmental, or generalized, and may be caused by
any combination of bone or soft-tissue elements. The A neurological exam is performed to rule out other
clinical syndrome of stenosis represents a functional neural entrapment syndromes and to define a baseline
condition rather than a purely pathoanatomical entity. status. Normal results are seen in approximately 18%
of cases.105 Deficits in the Achilles reflex are found in
Pathoanatomy/Pathophysiology about half the cases, but this also is common in the
The most widely occurring types of lumbar steno- otherwise normal elderly patient. Motor deficits are
sis are either acquired or degenerative. Intervertebral more common in lateral recess stenosis. SLR is posi-
disc prominence posteriorly, osteophytic margination, tive in fewer than 50% of confirmed cases and is more
and hypertrophic articular facets are the most com- likely indicative of a concomitant disc extrusion with
mon degenerative intrusions into the canals. Narrow- nerve root entrapment. Valsalva maneuvers generally
ing may also result from ligamentum flavum hyper- do not influence the symptoms of either lateral recess
trophy, synovial cysts, and ligament ossification. The stenosis106 or central stenosis.107
dynamics of spinal movements and loading further
influences the volume and dimensions of the spinal Laboratory Tests and Imaging
canals. Extensive narrowing may occur with minor Conventional radiography allows for general quan-
functional ramification. tification of significant bony abnormalities, disc
interspace thinning, marginal spurring, and facet dis-
Clinical Findings ease. However, central and lateral recess changes are
Lumbar spinal stenosis often defies clear clinical iden- often missed or underestimated, and cut-off guide-
tification. Diagnostic imaging findings are not dis- lines should not be strictly applied. CT is well suited to
criminating when considered alone, and the severity exhibit the bony changes of stenosis at any site, flaval
of stenosis found on imaging studies often does not ligament thickening, hypertrophy of bone grafts, and
parallel the intensity of symptoms. In these cases, the facet cysts (Fig. 47–12A). MRI adds additional in-
history may be a powerful diagnostic tool. formation about intrinsic changes within the spinal
The most common subjective complaints associ- cord, nerve rootlets, and related soft tissues including
ated with symptomatic stenosis are LBP and pseudo- epidural fibrosis, infection, and tumors (Fig. 47–12B
claudication. Patients typically endure years of back and C). The goal of lumbar CT and MRI evaluation in
pain before the onset of claudication symptoms.103 patients with radiculopathy or myeloradiculopathy is
Those with congenital stenosis generally become to identify the presence of stenosis and determine the
symptomatic somewhat earlier (third through fifth relative contributions of each structural component
decades).103 Symptoms of degenerative joint disease, to narrowing of spinal canal dimensions or intrusion
such as backache or stiffness, characterize the spinal into the intervertebral canals at entrance, mid, or exit
complaints. Symptom patterns resulting from lateral zones.
recess stenosis may be stable or intermittent as the
result of excessive intersegmental motion. Natural/Treatment History
Vague lower-limb symptoms usually develop in- Johnsson and Rosen’s 4-year observation of patients
sidiously. Patients may complain of pain, fatigue, with symptomatic lumbar stenosis who did not re-
weakness, paresthesias, cramping, or ataxia that pro- ceive surgery reflects the best information available
gressively increase with prolonged walking or pro- on the natural history of stenosis. They found that
longed standing. Bilateral symptoms may occur with pain intensities were unchanged in 70%, while 15%
central stenosis, and unilateral radicular-like symp- improved and 15% worsened. Walking capacity was
toms are more common with recess involvement.104 unchanged in 33%, improved in 37%, and worsened
An important characteristic of neurogenic claudica- in 30%. Analgesic usage dropped from 100% to 41%
tion symptoms is relief upon forward bending or at follow-up.108 In general, it is accepted that patients
sitting. Patients with more severe stenosis tend to with mild to moderate symptomatic lumbar stenosis
have greater walking limitation and they complain can be managed conservatively. There is no evidence
of symptom aggravation by downhill walking. The that a trial of conservative care negatively affects those
primary differential diagnosis to consider is vascular patients who later require surgical intervention.109
claudication, which is most notable as pain in the gas- Generally, surgery is reserved for those patients with
trocnemius. severe, intolerable symptoms (leg and/or back pain)
The physical examination for the suspected lum- who demonstrate functionally significant or progres-
bar stenosis patient should include peripheral vascu- sive neurological impairment.109
lar status; abdominal examination; spine, hip, knee,
and ankle ranges of motion; motor and reflex grad- Conservative Management
ing; neural tension testing; and a sustained standing Often a constellation of physical, behavioral, socio-
extension test. economic, and psychological factors exist and
FIGURE 47–12. Stenosis. A. Axial CT-myelogram. Patient has de-

generative spondylolisthesis, advanced posterior facet arthrosis,
and degenerative disc disease. Note the diminutive size of the
thecal sac that has been compressed by the hypertrophic and
degenerative tissues that spatially intrude into the spinal canal
from every sector. B and C. Advanced stenosis in another pa-
tient. Sagittal and axial MRI (T2-weighted) demonstrates a very
small canal (both congenital and acquired components) with disc
intrusion and facet disease.
successful management strategies must incorporate conducted a study of 145 patients, all with pain on
plans to bridge both physical and emotional factors.4 motion and neurogenic claudication, who received
Treatment goals are to restore function with pain re- inpatient treatment for 1 month with a combina-
duction or relief; decrease the use of pain medication; tion of ultrasound, diathermy, exercise, and synthetic
eliminate the need for assistive devices; and return to calcitonin.111 At follow-up, 91% were pain-free with
work and leisure activities without limitations. Suc- motion with an 89% improvement rating in walking
cess may require a multidisciplinary approach and an capacity. Based on pain, spinal functional capacity,
aggressive treatment program.110 neurogenic findings, and neurogenic claudication,
Unfortunately, all the clinical evidence published global improvement was excellent (52%), good (18%),
on the effectiveness of treatment for spinal stenosis and mild (23%). Rosomoff similarly reported im-
has relied on uncontrolled case series. Onel et al. provement in 47 of 50 lumbar stenosis patients, with
32 experiencing excellent pain relief with a nonsur- Surgical Management

gical multidisciplinary treatment directed at the soft A decision to proceed with surgical intervention
tissues.112 is influenced by several key determinants: patient/
Conservative care falls into several categories: physician goals, relative risk versus benefit, patient
patient education; stretching, strengthening, and age, and the ability to identify the appropriate region
cardiovascular-based programs; myofascial tech- upon which to operate. In the absence of severe or
niques; mobilization and manipulation; bracing; and advancing neurological compromise, surgery is not
medication including therapeutic injections. No sin- usually performed without an aggressive and com-
gle standardized treatment plan exists, but strategies prehensive trial of conservative management.
can be individualized based on the severity and du- Surgery appears to provide better short-term relief
ration of symptoms, impact on function and qual- of spinal stenosis symptoms,101 but long-term stud-
ity of life, and functional physical examination pa- ies do not support a substantial improvement over
rameters. A step-wise approach can be divided into conservatively managed patients. Slowly progressive
three independent and overlapping phases: pain con- neurological deficits may not be halted by decompres-
trol, stabilization, and conditioning.113 Any program sion, based on neurophysiological studies.109,116 Pa-
may need to be modified so that it remains effec- tients with scoliosis may do poorly with surgery.117
tive but avoids exacerbation of coexisting orthope- Reported results of surgical treatment vary widely.
dic conditions, such as osteoarthritis of the hips or Turner’s meta-analysis defined a 64% good to ex-
knees.114 cellent outcome, similar to that reported in other
Observational data show that more than 50% studies.116,118,119 Postacchini120 and Hansraj121 have re-
of patients with stenosis symptoms were improved ported higher success rates of 80% and 94%.
2 weeks following spine manipulation.115 Cassidy also Absolute indicators for surgery include loss of fe-
reported that 36% of patients with confirmed cen- cal or urinary control (cauda equina syndrome), acute
tral canal stenosis were able to return to unrestricted foot drop, and sudden severe walking restriction. Rel-
normal activities of daily living. The average du- ative indications for surgery are pain or heaviness in
ration of symptoms was 17 years and all patients the legs, such that the patient’s quality of life is poor
had failed other operative and nonoperative forms of despite an adequate nonoperative trial.122
management.
Appropriately administered manipulation en-
hances range of motion and reduces pain. Irrespec- DIFFUSE IDIOPATHIC SKELETAL
tive of the underlying mechanism, the clinical benefits HYPEROSTOSIS
from successful manipulation may be an asset during
Definition
the overall rehabilitation process. Symptom relief and
enhanced mobility often encourage hope and confi- DISH is a common, chronic, benign musculoskeletal
dence in the safety of movement and the completion disease characterized by ossification of the insertional
of rehabilitation without symptomatic recurrence or points of tendons and ligaments, including articular
abandonment of treatment.4 capsules. The etiology remains unclear. It occurs in up
The selection of an appropriate manual method to 6% of male patients at age 50, and affects men about
should be guided by procedure–patient matching.3 twice as often as women. By age 65, the frequency
The severity of the coexisting pathology, response to increases to 15% of males.
provocative joint preloading, history of previous treat-
ment, provider skill, and preference are all considered. Pathoanatomy/Pathophysiology
In cases of stenosis associated with advanced degen- Although DISH has strong ties to complex metabolic
erative joint disease or of diffuse idiopathic skeletal abnormalities,123 its exact etiology is unknown. Dys-
hyperostosis (DISH), there may be restriction of joint lipidemia, hypertriglyceridemia, hyperuricemia, ele-
motion that cannot be affected by manipulation. Man- vated insulin and growth hormone, and insulin-like
ual and mechanical assisted spinal and sacroiliac joint growth factor-1 (ILGF-1) are commonly observed.
mobilization techniques, however, may be useful in Other possible metabolites include retinoids and bone
optimizing articular mobility at functionally restricted morphogenic protein-2.124 Risk factors also include
areas, particularly above and below the area of the obesity. The ossific process may create intervertebral
stenosis. Stress demands for motion thereby may be bridging, classically anteriorly and anterolaterally.
distributed more uniformly through the lumbar spine. However, the hyperostotic changes are not limited to
Theoretically, spinal motion not only improves the ef- the spine and often involve the appendicular skeleton
ficiency of nutrient transfer to the cauda equina and (e.g., pelvis, patella, calcaneus, and olecranon). Ra-
adjacent tissues but also improves joint ranges and diographic changes are most common in the thoracic
muscle flexibility. spine and less frequent in the lumbar region.
Clinical Findings
Signs and symptoms include stiffness and nonspe-
cific aching. Insertional tendinopathy of a particularly
chronic nature may be evident. When there is signifi-
cant ossification (hyperostosis) of the posterior longi-
tudinal ligament in the upper lumbar spine, clinical
evidence for stenosis or myelopathy may appear. In-
creased stiffness related to the ossification increases
risk of damage from trauma.
Laboratory Tests and Imaging

The diagnosis of well-developed cases is usually clear
from conventional imaging studies, even in relatively
early stages before the classical criteria are met: four
contiguous levels of vertebral ossification, disc height
preservation, and no bony ankylosis of the posterior
joints (Fig. 47–13). Reduction of disc space height may
be present in cases where disc degeneration has ante-
dated the development of hyperostosis. Also, the pos-
terior facets often exhibit hyperostosis. CT and MRI
may be necessary in those cases where posterior lon-
gitudinal ligament ossification is suspected, allowing
identification of canal stenosis and direct abnormali-
ties of the spinal cord. Scrutiny for occult injury is im-
portant in posttrauma cases. Flexion–extension views,
radionuclide scanning, CT, and MRI may be helpful.
No definitive laboratory examination exists specifi-
cally for DISH, but because diabetes mellitus is seen
in up to 23% of cases, a search for diabetes is often
fruitful.
Natural/Treatment History
Mostly DISH is benign and asymptomatic and discov-
ered fortuitously as the spine is imaged for unrelated FIGURE 47–13. Lateral conventional radiograph in a patient
conditions. The progression of ossification continues with classical changes of advanced DISH. There is multilevel
into advancing age. thick hyperostosis “flowing” anterolaterally with relative preser-
vation of the disc interspaces. Involvement of the posterior lon-
gitudinal ligament and facet capsules is not seen well on con-
Conservative Treatment
ventional imaging.
The pain-generation phenomenon must be under-
stood. In a given case, this is often from an adjacent
those cases exhibiting signs of stenosis that are nonre-
articular area such as the sacroiliac joint or posterior
sponsive to conservative management.
facet, and not from the hyperostosis that is visual-
ized radiographically. General treatment concepts are
geared to functional restoration of the pain-generating DEGENERATIVE SCOLIOSIS
joints and motor control of the lumbar spine in a
manner similar to that commonly offered for other Definition
dysfunctional and degenerative conditions. Anecdo- With an aging population, clinicians are confronted
tally, continuous passive motion, range-of-motion ex- with more complex degenerative spinal conditions.
ercises, and manipulation are usually effective in ar- Degenerative scoliosis is seen in the elderly patient
eas where the motion segment is not fused and there is having degenerative disc disease and facet arthrosis.
some preservation of motion. Local therapeutic joint It may arise de novo or in the patient with preexist-
injection may be useful in symptomatic joints where ing idiopathic scoliosis. The patient complains of back
manipulation is not possible. In advanced stages with pain but may also exhibit complaints related to steno-
virtual joint ankylosis, forceful manipulation should sis. There may be progressive worsening of back, but-
be avoided. Surgical consultation is appropriate for tock, or leg discomfort. There may be weakness with
SACROILIAC JOINT DISORDERS

Definition
The SI joint has been a subject of controversy
for most of the twentieth century. Several patholo-
gies are known to occasionally affect this joint,
including degenerative joint disease, inflammatory
arthropathy, stress fracture, and infection (Fig. 47–15).
More common afflictions arise from joint dysfunction
or subluxation with abnormal movement patterns
(hypermobility or hypomobility) associated with lo-
cal and radiating pain.
The SI joint is a hybrid structure with the iliac sur-
face resembling fibrocartilage, while the sacral side is
hyaline cartilage. It is constrained by strong ligaments
posteriorly and has a fibrous capsule consistent with
other diarthrodial joints. The functional portion, lo-
cated at the level of S2-S3, is surrounded by the ar-
ticular capsule and is bathed in synovial fluid. The
innervation of the joint is derived from the L2 to S2
nerve roots.
The amount of motion that may occur is highly
FIGURE 47–14. A 60-year-old female with degenerative dis- variable among individuals. Joint stiffness is high-
ease greatest in the mid and upper lumbar region. There is est during lateral bending and lowest during axial
dextrorotatory deviation measuring 30 degrees, and pedicular twisting.126 Traumatic injury usually occurs with a
drift. vector of force acting vertically through the joint or
with axial twisting. No uniform description of SI mo-
tion exists. Figure 47–16 describes a convenient de-
scription for the axes of rotation. The diagonal axes
walking or even standing. Approximately 50% of pa-
are related to ambulation, while the horizontal axis is
tients have root compression symptoms. Curve men-
related to flexion and sitting motions. Actual motions
suration (Cobb angle) varies considerably. The great-
show wide variation of axis location, shifting verti-
est degenerative changes tend to occur at L3-L4 and
cally and horizontally, with the effect that “normal”
L4-L5 (Fig. 47–14).
motion is very difficult to characterize.12 Each side of
the pelvis has an average of 3 degrees (or, coinciden-
tally, 1–3 mm) of movement.127
Two patterns emerge: One is lumbar scoliosis hav-
ing little rotational component, and the other is a
degenerative complication of preexisting idiopathic
scoliosis with greater degrees of rotation and loss of
lordotic attitude.125
Conservative management is directed at symptomatic
relief, striving to maintain function and minimize
symptoms using all of the standard tools for the care of
degenerative spine disorders. Scoliotic deformity may
or may not progress with aging. For those patients in
whom conservative management is inadequate, surgi-
cal considerations may be necessary. The decision for
a surgical consultation should be made considering
both the current spinal status and the overall general
health of the patient. FIGURE 47–15. Advanced bilateral sacroiliac joint arthrosis.
FIGURE 47–16. Axes of sacroiliac joint rotation. Diagonal axes

relate to ambulation. Horizontal axis is related to flexion and
sitting motions.
Pain associated with ankylosing spondylitis and

other pathologies that affect the pelvis is more read-
ily understood. However the pain source from joint
dysfunction or subluxation is unclear. A hypermobile
SI joint is believed to directly produce ligamentous
and capsular pain. A hypomobile SI joint is not ef- FIGURE 47–17. Fluoroscopic depiction of a right SI joint
fectively shock absorbing, and thus transmits abnor- arthrogram.
mal stress to related structures such as the hip and
the low back. Experimental pain induced by injec- and bicycling. Pain on sit–stand maneuvers is also
tion into the posterior–superior ligaments radiates up- common.
ward into the lumbar spine. Injection irritation within Most specific tests designed to assess SI move-
the joint tends to refer pain into the buttock and leg. ment have not been validated,131−133 although such
The first arthrographic study was conducted in 1995, tests remain popular among clinicians and clinical re-
confirming the SI joint as pain-provocative and pos- searchers. Perhaps the most reliable test is the pos-
sibly accounting for as much as 30% of low back pain terior shear or thigh thrust method (Fig. 47–18). A
cases (Fig. 47–17).128
Clinical Findings
Local SI joint pain and tenderness may be associ-
ated with referral to the buttock, especially to the
groin area, which in one study was the only SI-related
pain found to be eliminated by SI joint block.128 On
the other hand, Slipmam et al. found a large variety
of pain-referral patterns, including 50% with referral
to the lower extremity,129 while according to Daum
the pain rarely extends below the knee.130 In acute
presentations, there may be a history of a fall onto the
ischial tuberosity or hip producing a shear or rotatory
injury, or slipping while pushing a heavy object, which
produces an injury through hyperextension of the
hemipelvis. In chronic presentations, it may be dif-
ficult to identify a precipitating event. Daily activi-
ties that load the pelvis asymmetrically tend to aggra- FIGURE 47–18. Posterior shear test for assessing sacroiliac
vate the symptoms, such as walking, stair climbing, joint movement.
blinded study of pregnant women reviewed by Laslett be self-limited, and are also likely to respond well to
found a sensitivity of 81% and a specificity of 80% for conservative therapy.130 Studies by Triano et al. in-
this test.134 Positive and negative predictive values cluded cases diagnosed as SI joint disorder and found
were 81% and 88%, respectively. A high interexam- that resolution for the average uncomplicated case oc-
iner agreement of 94% (K = 0.88) was also observed. curred after an average of 5–8 sessions, depending on
Among chiropractors, the standing Gillet test is the chronicity and severity (range: 1 to 20).140 Similarly,
most commonly performed test, but studies to date DonTigny reported an average of 5.9 treatments to ob-
suggest it has poor reliability. Provocative forces ap- tain optimal results.141 Commonly associated symp-
plied either to the sacrum or the ilium of a prone sub- toms of SI disorders include trochanteric bursitis, pir-
ject, as in the sacral thrust (agreement 78%, K = 0.52) iformis syndrome, and psoas insufficiency syndrome.
or cranial shear tests (agreement 84.3%, K = 0.61), ap-
pear to have better reliability. The sacral thrust is per- Laboratory Tests and Imaging
formed on a prone patient with the force on the sacral Ankylosing spondylitis and other inflammatory dis-
base. The cranial shear tests apply pressure against eases are investigated by laboratory testing (human
the sacral apex with a cranially directed load. leukocyte antigen [HLA]-B27, erythrocyte sedimen-
The gapping or distraction test is performed on a tation rate [ESR], antinuclear antibody [ANA]) and
supine patient (agreement 88.2%, K = 0.69). Force ap- radiographic examination. Rothschild, using arthro-
plied bilaterally to the anterior sacroiliac spine (ASIS) scopic evaluation of the SI joint as a gold standard, did
is thought to distract the joint and stretch the anterior not find correlation with any radiographic findings
SI ligament. If force is applied to the ASIS with one and concluded that “radiological techniques there-
hand while the other hand stabilizes the contralat- fore have major limitations for the assessment of
eral side, it is thought to test preferentially for pos- sacroiliac disease and greater reliance on clinical acu-
terior ilium rotation. Evaluation for movement char- men is required for patient categorization.”142 Im-
acteristics, muscle tone, and muscle strength has not proved visualization of the SI joint space and mar-
proven to be useful. On the other hand, palpation that gins can be obtained using oblique views. However,
reproduces pain is supported by some studies.132,133 they are rarely productive. Vacuum phenomenon and
Tenderness may be found around the posterior osteophyte formation consistent with more advanced
sacroiliac spine (PSIS), ASIS, and symphysis pubis. degeneration may be observed. MRI is perhaps the
Cibulka et al. defined SI joint dysfunction syndrome most sensitive test for identifying early degenerative
as being present when at least three of four orthopedic joint disease.
tests were positive: standing flexion, prone knee flex-
ion, supine long sitting, and sitting PSIS palpation.135 Conservative Management
Specific manual or radiographic procedures to as-
The primary consideration in deciding upon a thera-
sess SI joint alignment have not been validated to
peutic approach is whether the history, patient pro-
any greater extent than those for SI movement.133,136
file, and examination findings suggest joint restric-
Among the various line-marking procedures that
tion or hypermobility. A hypomobile SI joint may be
have been proposed, the most popular method pre-
effectively treated by mobilization or manipulation
sumes the innominate bone with the longest vertical
methods. True hypermobility is rare and may require
dimension as seen on an AP radiograph to be rela-
surgical stabilization. Muscle strengthening, move-
tively posteriorly rotated, although Cooperstein has
ment training, and temporary use of a lumbosacral
called this into question.137,138
support, trochanteric or SI strain relief belt, are use-
The most accepted method of confirming the SI
ful to stabilize and rehabilitate the joint. Exercises
joint as the pain generator in a low back pain patient
that focus on the hip adductors and external rotators,
is fluoroscopically guided intraarticular injection of
gluteals, latissimus dorsi, and transverse abdominis
a local anesthetic, preceded by a SI joint arthrogram
and abdominal rotators are usually most helpful. Pro-
(see Fig. 47–17),139 but there remains controversy over
lotherapy is a controversial procedure that attempts
this technique. However, using the SI joint block as a
to inject sclerosing agents to “tighten” the sacroiliac
gold standard for true SI joint pain, manual diagnostic
ligaments.143
procedures were not found to have a high predictive
value.129
PIRIFORMIS SYNDROME
We are aware of studies on the long-term conse- Definition
quences of treated versus untreated SI joint prob- Piriformis pain or syndrome results from spasm or
lems. Daum suggested that these problems tend to strain to the piriformis muscle. It is associated with
buttock and posterior thigh pain. Rarely, piriformis addressed. Adjusting or mobilizing the SI joint on
involvement includes sciatic nerve irritation and the involved side may reduce symptoms. Muscular
radiating leg pain. The syndrome remains controver- stretching and deep myofascial release may be use-
sial, as is often the case with diagnoses of exclusion; ful. Once pain is responding, progressive resistance
in this case, lumbar disease must be definitively ruled exercises to balance the hip flexors, extensors, and in-
out prior to the diagnosis of piriformis syndrome.144 ternal and external rotators may help stabilize and
prevent recurrence. If the symptoms are on the side of
Pathoanatomy/Pathophysiology an anatomical long leg, lifting the other leg may pro-
The SI, lumbosacral, and hip joints form a kinetic chain vide some relief. Sometimes the patient may have to
with combined function. Disorder in one may affect be referred for consideration of injections.147
the health and function of the others.145 As a primary
stabilizer of the pelvis, the chain may become trau-
matized when the low back, pelvis, or hip is injured. PSOAS INSUFFICIENCY (DYSFUNCTION)
The piriformis syndrome most often is a secondary SYNDROME
complication of other pathological conditions.
Definition
Clinical Findings Psoas insufficiency is not a widely recognized disor-
Patients usually report pain in the mid-gluteal region der but is considered to be associated with postu-
with radiation to the posterior thigh. The pain distri- ral hyperlordosis and decreased length of the psoas
bution often is superimposed on radiating patterns muscle. Thoracolumbar, lumbar, sacroiliac, anterior
from the low back, SI joint, or trochanteric bursa. Pain hip, and buttock pain may be the primary complaint.
in this region alone, or pain in these areas that is un- Adaptive sagittal postures may develop with exag-
responsive to treatment when other sites are improv- gerated thoracic kyphosis and forward head and neck
ing, should raise suspicion. Sitting cross-legged tends position.
to aggravate the pain. Local deep tenderness in the
buttock is associated with severe pain on maximal Pathoanatomy/Pathophysiology
stretching of the muscle on external rotation of the
The psoas is an important stabilizing postural mus-
hip, and tenderness over the piriformis muscle itself.
cle, showing significant myoelectric activity during
Sciatic pain associated with the piriformis syn-
relaxed standing. The psoas is a multiarticular mus-
drome can be evoked by internally rotating the leg
cle that lies in the middle of the kinetic chain that
during straight-leg raising. Pain will appear earlier
transfers load between the trunk and lower extrem-
than when raising the leg without rotation. Both re-
ity. Dysfunction (weakness and/or hypertonicity) of
sisted external rotation of the hip and stretching the
this muscle may be associated with a cascade of conse-
muscle may produce pain. A rectal examination can
quences within the chain. Bilateral shortening of the
cause exquisite tenderness of the piriformis on the af-
iliopsoas increases the lumbar lordosis with a com-
fected side.
pensatory increase in the thoracic kyphosis. Causes
Natural/Treatment History of shortening are speculative and include failure to
developmentally elongate during the rapid growth
No epidemiologic studies are available. As is often the
phase of childhood. Acquired shortening may result
case with myofascial disorders, piriformis syndrome
from prolonged and repeated use of thigh flexion on
may resolve spontaneously or be persistent. Rarely,
the pelvis, such as fetal sleeping postures and slumped
posttraumatic cases may persist for years.146
sitting positions. Unilateral shortening laterally bends
Laboratory Tests and Imaging and rotates the lumbar spine. A chronically contracted
psoas adds to the compressive forces acting on the
In stubborn cases that fail to respond to usual con- lumbar discs.
servative treatment, injection of the piriformis muscle
with an anesthetic block has been used to confirm the
diagnosis of piriformis syndrome and may be thera- Clinical Findings
peutic. Such procedures should be performed under Bachrach suggests that the diagnosis is based on the
fluoroscopic guidance after outlining the myofascial accumulation of findings involving increased lordo-
sheath with contrast media. sis, presence of SI joint syndrome, positive psoas
stretch test, quadratus lumborum myofascial pain
Conservative Management and trigger points, hamstring shortening, and piri-
The first line of defense is to ensure that any asso- formis pain.148 If unilateral psoas shortening exists,
ciated problem of the spine, pelvis, or hip has been functional scoliosis may be present. The patient may
complain of low back and/or SI joint pain on one

COCCYDYNIA (COCCYGODYNIA) AND
side and midthoracic pain on the opposite side. Ac-
COCCYGEAL SUBLUXATION
cording to Hammer, Durianova examined 30 patients
with psoas spasm and found pain in the low back, the Definition
shoulder region, SI joint, and radiation in the L5/S1 Primary or referred pain at the coccyx or sacrococ-
segments.149 There was pain on lumbar extension, cygeal joint usually follows some direct trauma to the
trunk rotation, and hip flexion, with spinal segmental pelvis. The patient should be carefully screened for
involvement at the thoracolumbar and craniocervical fracture, joint sprain, and frank dislocation.
junction. Hip extension in the prone position was de-
creased and painful. Pathoanatomy/Pathophysiology
The Thomas (Michele) test for psoas contracture is Pain at or around the sacrococcygeal joint usually is
widely used and considered by some to be the defini- the result of local trauma. It also may arise from a mus-
tive test. One knee of the supine patient is flexed and cular enthesopathy associated with gluteal tension or
brought toward the chest; if the contralateral leg flexes injury. Clinical presentation may appear to be referred
off the examination table, then the psoas contralateral pain from the lumbosacral or SI region. As the situa-
to the flexed knee side is shortened and/or hypertonic. tion becomes chronic, there may be adhesion forma-
In the Michele form of the test, the patient is seated at tion. Richards found that as many as half of his cases
the edge of the table and lies back to a supine position. had referred pain rather than primary pain. He re-
The Thomas position is assumed and the contralateral ported that many cases of coccydynia result from lum-
leg is extended. Extension of the hip to 30 degrees be- bar disc disease with initial LBP and/or sciatica.145
low horizontal without anterior innominate rotation is
suggestive. The psoas muscle may be palpably tender Clinical Findings
as it crosses under the inguinal ligament (the muscle
belly can be made to stand out by having the patient In primary coccydynia, sitting is more likely to pro-
attempt to flex the thigh against resistance) and at its voke pain, and the patient may lean to one or the other
insertion. side to ameliorate the pain; the tip of the coccyx will
likely be exquisitely tender. Lifting either leg (strad-
dle position), as in stepping motions, may aggravate
Natural/Treatment History the pain. In cases of referred coccydynia, pain during
Symptomatic flare-ups are common and generally sitting is variable. Some patients experience aggrava-
occur in a series, often precipitated by prolonged tion while changing positions, either sitting down or
sitting. Properly directed treatment should be bene- standing from a seated position, particularly in cases
ficial within a few treatment sessions. with true dislocation.150 Coughing and straining at
stool may aggravate the pain.
There is generally tenderness at the tip of the coc-
Laboratory Tests and Imaging cyx, palpated either externally or internally through
No laboratory testing or imaging is helpful in con- the rectum. Pain along the lateral margin of the sacral
firming the diagnosis of psoas insufficiency syn- apex rather than on the sacrococcygeal joint suggests
drome. muscular enthesopathy. Abolition of pain through lo-
cal injection of an anesthetic is considered by to be di-
agnostic of coccydynia. Imaging may be suggestive of
Conservative Management the diagnosis. Maigne devised a sitting versus stand-
The treatment follows from the pathomechanics of ing radiographic technique to determine coccygeal
the kinetic chain. SI and lumbar joint dysfunction range of motion (Fig. 47–19). He found flexion in ex-
must be addressed. Myofascial release to associated cess of 25 degrees to represent hypermobility.150
involved muscles including the quadratus lumbo-
rum, piriformis, and hamstring groups is also con-
sidered important. Focused stretch of the psoas mus- Little epidemiologic data is available. Some cases
cle may be critical. In addition to passive stretching, spontaneously resolve especially when secondary.
a contraction–relaxation approach may also be used. Cases of coccygeal hypermobility and luxation are less
Treating trigger points in the iliopsoas may also be likely to resolve on their own.
added to the regimen. Cyriax mentions that chronic
psoas strain may remain for years unless treated by Laboratory Tests and Imaging
friction massage below the inguinal ligament, medial An x-ray is generally necessary for evidence of a post-
to the sartorius.149 traumatic subluxation of the coccyx, although many
attachments in nonresponsive cases may disrupt the

pattern of nodule development.
FRACTURES OF THE VERTEBRAL BODY AND

POSTERIOR ELEMENTS
Definition
Bony infraction results from acute traumatic overload
of normal or pathologically weakened bone. Wide
ranges of clinical possibilities occur, from gross in-
stability and neurological devastation to temporarily
bothersome pain.
Spine fractures have been classified according to their
morphological characteristics and by mechanisms of
injury. Hyperflexion injury and anterior vertebral
compression are most common in the lumbar spine.
Fracture management depends on stability and
risk of neurological injury. The three-column model
helps predict acute fractures that may be unstable.156
FIGURE 47–19. Seated radiographic positioning for assessing
In this model, the anterior column comprises the ante-
coccygeal range of motion. rior longitudinal ligament, anterior half of a vertebral
body, and the related intervertebral disc. The middle
false positives (misaligned coccygeal joints that are column includes the posterior half of a vertebral body
not pain-provocative) are common. Maigne et al. de- with its disc and the related posterior longitudinal lig-
scribe a radiographic technique and classification sys- ament. The posterior column consists of the posterior
tem in which images in the lateral sitting position (the elements with facet articulations and the restraining
painful position) are compared with standard lateral ligaments. Fractures of the anterior column (e.g., sim-
radiographs.151,152 Advanced imaging (CT, MR, and ple compression fractures) that do not implicate the
ultrasound) can also be used. middle column are usually stable. Shearing and burst
fractures often disrupt the middle column, and these
Conservative Management are commonly unstable. Loss of the middle column,
For primary coccydynia, the sacrococcygeal joint may posterior longitudinal ligament, and annulus largely
be extended by a side-posture thrust just above the determines the mechanical stability.157 Involvement of
sacrococcygeal joint with the patient prestressed in two columns usually results in instability.
kyphosis.153 Maigne and Chatellier describe the re-
Clinical Findings
sults of a trial of three manual methods for treating
coccydynia: levator ani massage, joint mobilization, Compression fractures exhibit sudden acute pain.
and mild levator stretch. The results were best for pa- Splinting muscle spasm and pain with movement are
tients with normal mobility, less beneficial for those typical. Focal point tenderness helps localize the ab-
with hypermobility, and worst for those with an im- normal sector. Consideration of intraabdominal injury
mobile sacrococcygeal joint.154 Intrarectal adjustment should be a part of the diagnostic workup, especially
may be used to direct the terminal segments anteriorly. with multilevel thoracolumbar trauma and posterior
Several externally applied manual techniques are also element injury. Thorough neurological assessment, in-
available. Manipulation combined with injection has cluding autonomic function, superficial reflexes, and
been reported as being more successful (85% cure rate) long tract signs, is important.
than injection alone. Maigne reports successful treat-
ment of coccygeal luxation and hypermobility with Natural/Treatment History
corticosteroid injection.155 Stable fractures are often managed conservatively and
Secondary coccyodynia requires treatment of usually require little treatment. Compression frac-
the primary condition. For enthesopathy, myofas- tures usually resolve within 12 weeks. Kyphoplasty
cial release, stretching, and antiinflammatory modal- is now offered for the relief of pain in the osteoporotic
ities may be useful. Infiltration of the tendinous patient but remains controversial. Corsets may be
effective in the elderly patient. In those instances necessary to cause such fractures and concomitant in-
where there is greater than 50% anterior compression jury is possible. Further investigation often reveals
an extension brace is preferred. Neglected cases may additional spine or soft-tissue injury. Krueger et al.
be quite painful. reported 11% missed additional sites of spinal injury
A short-term period of bed rest may be helpful. when conventional radiographs were the only imag-
Aquatherapy can be instituted early on, avoiding flexing modality.158 Lumbar transverse process fracture
ion (lateral bending, as well, if there is lateral angu- has been reported to be associated with abdominal
lation). Extension strengthening can be started early organ injury in up to 57% of cases.159,160
as symptoms permit. Lifting and bending should be
avoided. In some instances, a thoracolumbosacral or- Clinical Findings
thosis is necessary. There is usually focal to general tenderness over the in-
Following healing it is important to address any volved area with associated segmental to widespread
clinical issues of facet or sacroiliac dysfunction and hypertonicity or spasm. There is aggravation by
return strength and coordination loss. Ongoing treat- movement, particularly rotation and lateral bending.
ment is usually unnecessary; rather, treatment is given
as needed on an episodic basis. Stabilization exercises Natural/Treatment History
tend to reduce recurrences. In the long term, consid- A review of 29 cases of injury among professional
eration should be given to the future development football players by Tewes et al. showed lost time
of focal instability, which might occur in cases where from sports averaged 3.5 weeks and that associated
altered stresses around the fracture site can result in abdominal injury was rare in their group of
gradual decrease in the integrity of the restraint mech- patients.161 L3 is the most common level of involve-
anisms in a delayed fashion. This is most likely with ment. Often there is no union. Transverse process frac-
burst injuries and multiple compressions where late tures cause significant pain but, unless there is as-
kyphotic angulation may occur. sociated soft-tissue or organ damage, they do well
clinically with little treatment or residual symptoms.
Laboratory Tests and Imaging
Plain radiography is the initial examination, with at- Laboratory Tests and Imaging
tention to alignment and interspacing, the posterior The fracture may be vertical across the base of the
elements, and paraspinal soft-tissue swelling. Careful process or avulsion of the tip (Fig. 47–20). Local
correlation with injury mechanism is important. In the hematoma in the psoas may efface the psoas fascial
common compression injury, slight buckling or over- plane. Bilateral fracture also is possible. The fracture
lap of the anterior vertebral cortex is frequent. Many line is often subtle in appearance, or radiographically
patterns of injury are not seen or are poorly defined obscured by feces and gas, and the initial conventional
on conventional imaging studies. For instance, seat- imaging may not be sensitive in the detection of these
belt injuries and burst fractures may be underappre- fractures, especially when there is no displacement.
ciated or overlooked. Unexplained or unreasonable Unilateral fractures may demonstrate scoliosis con-
symptoms should provoke additional diagnostic in- vex to the side of the fracture because of unopposed
vestigation. Advanced imaging helps define subtle ab-
normalities, soft-tissue damage, ligamentous restraint
loss, and estimation of neurological risk.
TRANSVERSE AND SPINOUS PROCESS

FRACTURE
Definition
There may be complete or incomplete fractures of
a transverse process, with or without displacement.
These are often considered benign on the basis of
good outcome irrespective of treatment, but associ-
ated spinal and organ injury are not uncommon.
These fractures are often related to direct lumbar
trauma (usually high energy) or indirect muscle forces FIGURE 47–20. Fracture of the right L3 transverse process
with resultant avulsion. However, significant force is (not significantly displaced).
action of the quadratus lumborum. Following base- are caused by increased mechanical stress from
line conventional imaging, CT can be used to rule out improper weight bearing or posture. Findings in-
associated spine or organ trauma (e.g., retroperitoneal clude low back pain that is worse with extension
hematoma, renal injury). and palpatory tenderness over the facets. Treat-
ment includes spinal manipulation and stretching.
Conservative Management 2. Lumbar spondylolisthesis is an anterior shift of
Short-term treatment includes initial rest and ice. In- one vertebral body, while spondylolysis is separa-
terferential current in pain and spasm modes may be tion of the isthmus (pars). Spondylolisthesis may
helpful. Circumferential support may reduce symp- result from mechanical stress overload of the pars
toms. When the acute phase subsides, the issues of caused by pars stress fracture, acute pars fracture,
spinal dysfunction may be addressed. and anomalies, such as degenerative or surgical
abnormalities of the facets and pedicles. Low back
pain radiating to the leg with spasm of the ham-
APPLICATION AND REMARKS
string and paravertebral muscles is a common pre-
In spine trauma cases, a search should be made sentation. Treatment may include bracing, exer-
for a small process fracture, especially with rota- cise, postural training, physical modalities, and
tional injuries. In the differential diagnosis of back manipulation.
pain in athletes beyond muscle strain, disc injury, 3. Lumbar intervertebral disc syndrome is caused by
and spondylolysis, consideration should be made to disruption to the structure of the intervertebral
fracture/separation of the rim apophysis, intraspon- discs from age, trauma, or degeneration. MRI is
giosal disc herniation, and facet fracture. Bone and very useful in the diagnosis of disc syndromes,
soft-tissue injuries to the facts joints may result in although many false positives do occur. Clinical
considerable pain and dysfunction, and predispose to presentation varies, but may include low back
early development of arthrosis.162 pain following trivial trauma, radiation into the
Facet fracture is also found following laminec- thigh, leg, or foot, and/or sensory disturbances
tomy, occurring when more than 50% of the bone in the lower extremities. The physical examina-
immediately above the flare of the inferior facet has tion should aim to rule out serious pathology
been resected.163 It is also a possible finding in asso- and rule in disc syndrome through provocative
ciation with radiculopathy and was detected in 25 of and neurological testing. Conservative manage-
400 (6.25%) cases by Rothman et al.164 In these types ment includes education, exercise, manipulation,
of cases, back pain occurs after a period of postoper- and physical modalities. More serious cases may
ative well-being. There usually is a new set of symp- require injections or surgery, although neither ap-
toms (pain pattern), pain on certain movements, and proach has been validated in chronic cases.
relief with nonweight bearing, which helps differen- 4. Lumbar stenosis refers to encroachment of the
tiate facet fracture from recurrent disc herniation. spinal canal, recesses, or intervertebral foram-
While the traditional model of pathophysiol- ina from degeneration, bony overgrowth, liga-
ogy has failed to fully describe spine complaints, ment thickening, or other space-occupying lesions.
there are lessons to be learned that complement our Findings include low back pain, pseudoclaudica-
understanding of the nature of spinal pathology that tion, stiffness, and lower-extremity abnormalities
we see clinically and on advanced imaging studies. with relief upon forward bending. Conservative
This understanding may be integral to treatment se- management includes patient education, exercise,
lection and outcome goal determination. myofascial techniques, mobilization, manipula-
The presentation and treatment of common and tion, and bracing. Serious cases may require in-
uncomplicated lumbar spine syndromes is reasonably jections or surgery.
distinctive. Skillful sorting of the clinical findings and 5. Diffuse idiopathic skeletal hyperostosis is marked
selection of appropriate treatment should yield excel- by ossification of the insertional points of tendons
lent outcomes in the majority of cases, and allow for and ligaments, including articular capsules. It is
the determination of those patients suitable for mul- likely a metabolic or autoimmune disorder, al-
tidisciplinary care or surgery. though the exact etiology is unknown. Findings
include nonspecific spinal ache and stiffness. Di-
agnosis is apparent with imaging. Conservative
SUMMARY
management includes exercise and manipulation
1. Lumbar facet syndromes include facet dysfunc- or mobilization.
tion, capsulitis, facet impingement, pars stress re- 6. Degenerative scoliosis occurs in the elderly from
action, spondylolysis, and degenerative facet dis- preexisting scoliosis or degenerative changes in-
ease as a result of facet fracture. These syndromes ducing scoliosis. Conservative management is
focused toward controlling symptoms. Serious 2. What are the clinical characteristics of the disc de-
cases may require surgery. rangement syndrome?
7. Sacroiliac disorders occurs as a result of hyper- 3. What are the conservative care strategies for lum-
or hypomobility of the sacroiliac joint. Findings bar spine stenosis?
include localized sacroiliac joint pain and ten- 4. What is the optimal treatment for spondylolysis in
derness with possible referral to the buttock and the adolescent?
groin areas. Several provocative tests may con- 5. What is the basic mechanism of progressive disc
firm this diagnosis. Conservative management in- prolapse?
cludes mobilization or manipulation for a hypo-
mobile joint and exercise or supportive taping or
bracing.
8. Piriformis syndrome occurs because of acute or
chronic tightening, shortening, or dysfunction of ANSWERS
the piriformis muscle. Findings include low back
pain, pain in the mid-gluteal region, and possi- 1. Electrophysiological testing may provide informa-
ble pain radiation to the posterior thigh. Pain re- tion relative to location and severity of the le-
lief following injection may confirm this diagnosis. sion; distinguish between acute versus chronic in-
Conservative management includes lumbosacral volvement; and suggest other possible diagnoses
mobilization, manipulation, exercise, and deep (e.g., metabolic polyneuritis, peripheral entrap-
myofascial therapy. ment neuropathies, myoneural junction disease).
9. Psoas insufficiency syndrome is caused by chronic 2. Typically, the patient has had a history of chronic
shortening of the psoas muscle with associated hy- and recurrent LBP. Conservative management has
perlordosis of the lumbar spine. Findings include been successful in the past, particularly manipu-
hyperlordosis, SI joint syndrome, positive psoas lation. Recurrences have become more frequent,
stretch test, quadratus lumborum pain and trigger and previously effective conservative methods no
points, hamstring shortening, and piriformis pain. longer achieve the same result. Back pain usu-
Conservative management includes myofascial really is greater than leg pain. Response to epidural
lease therapy, stretching, and possibly manipula- steroid injection is minimal. Conventional radio-
tion. graphs often show modest degenerative change.
10. Coccydynia is pain at the coccyx or sacrococcygeal MRI demonstrates varying degrees of degenera-
joint, usually following direct trauma to the pelvis. tion and other evidence of internal derangement.
Findings include low back pain or coccyx pain Discography reveals morphological change of in-
worse with sitting, and exquisite coccyx tender- ternal derangement and there is concordant pain.
ness. Fracture may be ruled out. Conservative Conservative treatment incorporating greater em-
management includes internal or external coccyx phasis on stabilization yields better results, but pa-
mobilization and massage. tients may become frustrated and opt for surgical
11. Vertebral body fracture occurs following trauma treatment.
and in patients with osteoporosis and degenera- 3. Three overlapping treatment phases: pain con-
tion. Imaging should be used to confirm the di- trol, spine stabilization, and conditioning. Spe-
agnosis. Fractures of the middle column are usu- cific categories of treatment possibilities include
ally unstable and require surgical consultation. patient education; stretching and strengthen-
Findings include sudden, acute pain and muscle ing; cardiovascular-based techniques; myofascial
spasm. Conservative management of stable frac- procedures; mobilization and manipulation; and
ture includes rest and stabilization exercises. bracing. From these an individualized plan may
12. Transverse process fracture typically occurs fol- be derived based on the severity and duration of
lowing acute trauma to the lumbar area and is of- symptoms and the functional physical examina-
ten undiagnosed. Findings include pain, tender- tion parameters.
ness, and spasm lateral to the spine. Conserva- 4. The spondylolytic defect associated with pain of
tive management includes rest, physical modali- less than 6 months’ duration in an adolescent
ties, and possible bracing. should be treated primarily as a fracture, in an an-
tilordotic brace. For those patients in whom the po-
tential for healing of the stress fracture no longer
exists, there are a gamut of nonoperative treat-
ment options, including spine stabilization, mus-
QUESTIONS
cle stretching and elongation, physiotherapeutic
1. What is the expected usefulness of electrophysio- modalities, and manipulation, as indicated by spe-
logical testing in a lumbar radicular syndrome? cific findings in the individual case.
5. Disc prolapse begins with force applied repeti- 7. Savitz MH, Katz SS, Goldstein H, et al. Hyper-
tively to the spine in flexion. In the nondegener- trophic synovitis of the lumbar facet joint in two
ated disc the nucleus migrates posteriorly gradu- cases of herniated intervertebral disc. Mt Sinai J Med
ally and progressively deforming the inner anular 1982;49(5):434–437.
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C H A P T E R
48
THORACIC SPINAL PAIN SYNDROMES
W. Mark Erwin
O U T L I N E
INTRODUCTION Conservative Management
BACKGROUND OF THORACIC SPINE THORACIC DISC SYNDROMES
PAIN MECHANISMS Definition
Unique Regional Anatomy of the Thoracic Spine Pathoanatomy/Pathophysiology
Mechanoreceptors and Thoracic Spinal Pain Clinical Findings/Diagnostic Tests
Tachykinins and Mechanical Spinal Pain Laboratory Tests and Imaging
Sensorimotor Modulation and Spinal Pain Natural/Treatment History
Specific Thoracic Spine Syndromes Conservative Management
THORACIC SUBLUXATION/JOINT DYSFUNCTION SCOLIOSIS
Definition Definition
Pathoanatomy/Pathophysiology Pathoanatomy/Pathophysiology
Clinical Findings Clinical Findings/Diagnostic Tests
Laboratory Tests and Imaging Laboratory Tests and Imaging
Natural/Treatment History Natural/Treatment History
Conservative Management Conservative Management
THORACIC FACET JOINT PAIN MUSCULAR SYNDROMES
Definition Definitions
Pathoanatomy/Pathophysiology Pathoanatomy/Pathophysiology
Clinical Findings/Diagnostic Tests Clinical Findings/Diagnostic Tests
Laboratory Tests and Imaging Laboratory Tests and Imaging
Natural/Treatment History Natural/Treatment History
Conservative Management Conservative Management
COSTOVERTEBRAL/COSTOTRANSVERSE CONCLUSION
JOINT PAIN SUMMARY
Definition QUESTIONS
Pathoanatomy/Pathophysiology ANSWERS
Clinical Findings/Diagnostic Tests KEY REFERENCES
Laboratory Tests and Imaging REFERENCES
tive capacity of the articulations within the tho-

OBJECTIVES racic spine.
1. To review the unique anatomy of the thorax that 3. To discuss the functional and pathoanatomical
confounds the diagnosis of the source of thoracic sources of thoracic spine pain and their diagno-
pain. sis, pathomechanics, and conservative manage-
2. To review the modern information on the nocicep- ment.
951
which to deduce the cause of the patient’s “back

INTRODUCTION
pain.”
Pain in the region of the thoracic spine represents a di- There are long paravertebral muscles that span the
agnostic and treatment challenge. Often appearing as transition areas between the thorax and neck above,
localized somatic pain, symptoms must be interpreted as well as the low back and abdomen below. As such,
with the consideration that pain may be referred from the thorax serves as a base of support for the neck
other tissues in the neck, shoulder, pulmonary, or sub- and upper extremities. It, in turn, is supported by
diaphragmatic structures. The interscapular region the lower torso and pelvis. These muscular elements
can pose significant diagnostic difficulties of its own, link the movements and supportive systems, creat-
particularly in the event of concurrent pain referred ing a myofascial “figure-of-eight” sling that transmits
to the chest or arm. Interscapular pain with or with- propulsive loads upward and workloads downward.
out associated anterior chest pain and dyspnea may Furthermore, the gradual change in facet orientation
have a negative electrocardiogram (ECG) and nega- from the cervical spine into the thoracic spine is at
tive chest and spine radiographs despite dramatic pa- stark odds with the sudden thoracolumbar transition,
tient disability.1,2 Atypical chest pain, with and with- which occurs in only one segment, where the coro-
out back pain, has been reported since the 1940s and nally oriented thoracic joints become sagittally ori-
has been associated with a number of pulmonary and ented lumbar joints. Such a shift presents a complex
cardiac pathologies and/or perhaps musculoskeletal system of interdependent biomechanics, load sharing,
dysfunction of the thoracic spine.3 A central tenet of and vastly different ranges of motion for the affected
mechanical spinal pain, regardless of the location, is regions.
the ability to reproduce the patient’s complaint by The costovertebral joint is a unique feature of the
motion and/or palpation of the affected region. If thorax (Fig. 48–1). It is a likely, although often over-
movement reproduces the patient’s symptoms, then looked, source of chest, upper back, and arm pain.
the problem is likely a mechanical one and should be Failure to recognize this potential source of pain may
evaluated in that light. If movement cannot reproduce lead to fruitless, costly investigations and unnecessary
the symptoms, thoracic pain should be considered to patient suffering.1
have a pathologic basis until proven otherwise. Fail- A review of the differential diagnosis for the full
ure to diagnose the more serious causes of chest, up- spectrum of causes for thoracic pain is beyond the
per back, and arm pain could result in potentially fatal scope of this discussion. The clinician should maintain
outcomes. a high level of suspicion for visceral disease because
This chapter reviews common thoracic spine con- in rare instances, ominous pathologies may masquer-
ditions to help the practitioner learn to differentiate ade as mechanical spine pain. The clinical examina-
musculoskeletal from pathologic pain patterns and tion may require more sophisticated imaging and lab-
enhance his or her treatment approach to the thoracic oratory evaluation, particularly when back pain is
spine. accompanied by anterior chest, abdominal, neck, or
arm pain. Mootz and Talmage4 provide an excellent
review of assessment strategies for the differential di-
BACKGROUND OF THORACIC SPINE PAIN agnosis of thoracic spine.
MECHANISMS The first thoracic vertebra, T1, is very much akin
to its more cephalad vertebral cousin, C7, in that it
Unique Regional Anatomy of the Thoracic Spine has Luschka joints and facets for both C7 and T2. It
Much less is known about the mechanisms of tho-
racic spine pain generation than for other spinal re-
gions and joints. Knowledge from the cervical and
lumbar spine is therefore adapted to focus on the Costocentral Joint Radiate Ligament
unique features of the thorax. The thoracic spine is (Costovertebral)
composed of 12 thoracic vertebrae, 12 intervertebral
discs, 12 pairs of ribs, and the soft tissues of the thorax. Costotransverse
Ligament
The thoracic cage encloses all pulmonary and some
subdiaphragmatic organs, vessels, and nerves. Nerve
and vascular connections from the thorax supply the
Lateral Costotransverse
neck. Similarly, venous connections from the neck Ligament
drain into the thorax. Peripheral nerves exit the neck
and traverse the upper thorax to supply the ex- FIGURE 48–1. Schematic cross section of a thoracic seg-
tremities. The result is that the thoracic cage repre- ment and its rib attachments. (Reproduced with permission from
sents a complex and often challenging region from Mediclips.)
THORACIC SPINAL PAIN SYNDROMES 953
is the first vertebra to have another pair of facets that efferent nerve fibers. The existence of the Kuntz nerve
articulate with the first rib. The structure of the tho- was also verified in the Groen study.18 The Kuntz
racic spine is such that it resists flexion and serves to nerve is a branch from the second intercostal nerve
protect the pulmonary and, to a degree, abdominal to the first thoracic spinal nerve that provides sym-
viscera. The discs of the thoracic spine are somewhat pathetic innervation, via the brachial plexus, to the
smaller in all dimensions than those in the lumbar upper limb. It may be through this innervation that
spine, although they are otherwise quite similar. A patients with costovertebral pain complain of vague
unique characteristic of the thoracic discs is the lig- arm pain and symptoms typical of sympathetic stim-
amentous attachment with the costovertebral joints. ulation such as excessive sweating and tachycardia.
The disc annulus is continuous with the radiate lig- Groen et al.18 failed to detect fine nerve endings em-
ament, which stabilizes the rib head to the vertebral bedded within the capsule of the joint. Because termi-
body. This ligament contains an abundant supply of nal nerve specialization reportedly does not mature
nerves that are mechanoreceptive and nociceptive in until the sixth to seventh gestational month, they sug-
nature. gest that the absence of capsular nerve endings in their
The unique contribution of the ribs to thoracic sample may have been a function of fetal age.
spine pain syndromes continues to be somewhat of a Wyke reported that costovertebral receptors con-
mystery. The International Association for the Study tribute to the reflex regulation of both postural and
of Pain (IASP)5 has developed a taxonomy with which respiratory muscle activity in the paraspinal and in-
to classify painful syndromes from ablation of pain tercostal muscles.16,17 McClain has demonstrated an
after specific joint and tissue anesthetic injection pro- abundance of mechanoreceptors within the capsule
cedures. The costotransverse and thoracic facet joints of cervical and lumbar facet joints and has proposed
have been found to be potential sources of pain, al- a mechanoreceptor-mediated response to pain and
though the mechanisms of pain originating from the mechanical stimulation of these joints.20 Shannon21
costovertebral joint are unknown.1,3,6–8 showed that purposeful manipulation of the costover-
tebral joints (i.e., experimental, deliberate movement
Mechanoreceptors and Thoracic Spinal Pain of the joints) exerted a mechanoreceptor-mediated in-
Numerous authors have validated the capacity of the fluence on respiratory patterns. Shannon also con-
spinal facet joints to cause pain by both provocative firmed that the receptors are buried within the joint
injection of contrast media to distend the joint cap- capsule and receptive to both mechanical and painful
sules and by relieving the patient’s pain by either anes- stimulation.
thetic injection or by percutaneous denervation of the Mechanoreceptors may be unmyelinated free
joints.9–15 Chua and Bogduk9 have reported that the nerve endings or may represent small bulbous ex-
thoracic facet joints are innervated by medial branches pansions of terminal nerve endings. They have been
of the associated segmental dorsal rami. In a study found in the disc annulus, in the zygapophyseal joints,
of 84 medial branches examined from four human and in some ligaments of the lumbar, thoracic, and cer-
cadavers, they found that these rami pass the supero- vical spines. Mechanoreceptors modulate protective
lateral aspect of the transverse processes and then muscular reflexes important in joint function and sta-
pass medially and inferiorly across the posterior of the bility and certainly play a key role in the development
transverse processes to ramify within the multifidus of spinal pain.22–25 Sensitized mechanoreceptors, such
muscle. Each facet joint is innervated by its respective as in the case of inflammation, take on nociceptive
segmental dorsal rami, which also supply the facet qualities. They are able to modulate reactive mus-
joints of the vertebrae immediately above and below. cle function at much lower thresholds and are impli-
Wyke reported the presence of free nerve endings cated in the development of reflexive muscle activity
in the capsule of the costovertebral joint in cats and de- and spasm.26,27 Minaki et al.25 examined somatosen-
scribed the typical mechanoreceptor function of simi- sory afferent units in the rabbit lumbar spine segmen-
lar joints found elsewhere in the spine.16,17 Groen et al. tal muscles, facet joints, and intervertebral discs and
used the acetylcholinesterase in toto method to study reported group III high-threshold mechanoreceptors
the thoracic sympathetic trunk in the fetus and found within segmental paraspinal muscles at or near their
at least four to five nerves from three categories.18 insertion onto articular processes and vertebral bod-
One category provides an extensive network of small ies. Activation of these mechanoreceptors by mechan-
nerves that form a plexus of nerves almost exclusively ical loading or inflammation may result in the devel-
supplying the costovertebral joint. The presence of opment of a loop of nociceptive afferent input, reflex
a richly ramifying plexus of small nerves supplying muscular hypertonus, and pain.26,28
costovertebral joint capsules suggests an innervation In vitro experimentation shows that mechan-
with a somatosensory component in addition to the ical loading of spinal tissues known to contain
expected visceral afferent and pre- and postganglionic mechanoreceptors, such as the facet joints, muscles,
and discs, causes reflex muscle activation in the mice lacked the phenomenon of “wind-up,” lacked
rabbit.23,29 Kuslich et al.30 used progressive local anes- the normal intensity coding of nociceptive reflexes,
thesia during spine surgery and found that stimu- and did not mediate the signaling of acute pain
lation of the facet joint capsule, vertebral endplates, or hyperalgesia.37 Furthermore, they concluded that
anterior dura, and posterior longitudinal ligaments substance P plays an unknown role in the adaptive re-
resulted in a pain response only when the associated sponse to stress. Also using a mouse model, Cao et al.
nerve roots were compressed, stretched, or inflamed. disrupted the pre-protachykinin A gene, known to en-
The facet bone, fascia, normal nerve roots, disc nu- code substance P, as well as the neurokinin-1 gene,
cleus, and ligamentum flavum were not nociceptive and reported that although reception of mildly painful
to electrical stimulation. stimuli remained intact, reception of moderate to in-
Normal synovium was nonpainful in the Kuslich tense pain was significantly reduced.36 Neurogenic in-
et al. study30 despite histologic evidence of flammation associated with peripheral tachykinin A
nociceptive-sensing elements within facet and and substance P release was reported to be virtually
costovertebral joint lining. However, under ap- absent in mutant mice lacking the pre-protachykinin
propriate conditions, clinical investigation and the A gene, suggesting the intimate relationship with sub-
use of selective costovertebral joint injection using stance P and inflammatory events associated with
anesthetic and antiinflammatory compounds have joint inflammation.
verified that these joints can be potent causes of Substance P immunoreactive fibers have been
mechanical thoracic and chest wall pain.1,2 found in bone, bone marrow, and soft tissues adjacent
There is a striking uniformity of symptoms upon to bone, as well as within vessel and nerve bundles
tissue stimulation over a wide variety of spinal tis- running along muscles, ligaments, and tendons.26–28
sues including ligaments, disc, muscles, joint cap- It has been reported that substance P immunore-
sules, and periosteum. Responses such as pain active fibers are present in large numbers in the
(both local and referred), muscle spasm, and func- synovial membranes of human and rat joints and
tional impairment are classic symptoms of mechan- that tachykinin-containing sensory fibers in joints
ical spinal derangement. The evidence suggests that play important roles in neurogenic inflammatory
there is some underlying population of spinal neu- conditions.38–41 Substance P released centrally by
rons receiving convergent input from all of these tachykininergic (small diameter) C-afferent neurons
sources.31 Peripheral noxious stimulus is thought to is known to result in pain perception, modulation
contribute to a nociceptive barrage to the dorsal of flexion reflexes, and other responses of the auto-
spinal cord, whereby a “reverberating neuronal cir- nomic nervous and endocrine systems.38,39,41 Small-
cuit” develops with positive feedback central to the diameter afferent nerve fibers are frequently nocicep-
expression of mechanical spinal pain, spasm, and tive in function and a proportion of these afferents
disability.20,23,26,31−33 become responsive to otherwise innocuous stimuli in
the event of joint inflammation, probably by reduced
Tachykinins and Mechanical Spinal Pain thresholds. These afferent fibers have a characteris-
Fortier and Nixon have reported the existence of tic appearance and are readily identified with well-
immune-like reactivity to substance P within the known histological staining techniques that reveal
articular capsule and periosteum of osteoarthritic discretely identifiable fascicles of axons with termi-
metacarpophalangeal articulations in horses.34 Fur- nal “flower-spray” endings or enlarged bulbous end-
thermore, they observed an increased substance P ings, which are typical of the pacinian corpuscle in the
immune-like reactivity in areas of hypercellular infil- case of superficial pressure receptors.27 (See Figs. 48–2,
trates within osteoarthritic subchondral bone contain- 48–3, and 48–4.)
ing cystic cavitation and areas of articular remodeling.
The neurokinin-1 receptor is essential in the substance Sensorimotor Modulation and Spinal Pain
P pain pathway and is expressed by discrete pop- The thoracic spine is known to be a much more sta-
ulations of neurons throughout the central nervous ble structure than the cervical and lumbar areas as a
system.35 In fact, there are three distinctly different re- result of the protective and reinforcing aspects of the
ceptors for tachykinins: the neurokinin-1, neurokinin- rib cage. However, clinical observation of patients suf-
2, and neurokinin-3 receptors. Substance P has the fering from thoracic spinal pain has validated discrete
most affinity for the neurokinin-1 receptor, although areas of hypersensitivity and stiffness or joint dysfunc-
it can bind with neurokinin-2 and neurokinin-3 at tion that correlate with regions affected by muscular
higher concentrations.35,36 In an interesting study con- hypertonus.8,42,43 The thoracic spine has nociceptive
cerning the molecular aspects of substance P, De Felipe tissues similar to other spinal areas and is capable of
et al. disrupted the gene encoding the neurokinin-1 causing axial and referred pain, usually to the chest,
receptor in a mouse model and reported that mutant shoulder, or flank.
FIGURE 48–2. Anterior aspect of costovertebral joint capsule demonstrating a typical mechanoreceptor nerve buried deeply within
the capsule. Magnification × 20, immune-like reactivity to neurofilament protein.
FIGURE 48–3. 100 × oil immersion closeup photograph of Figure 48–2. Arrowheads depict the fine sensory nerves closely abutting
the capsule attachment to the bone. Such innervation is well positioned to impart sensory information concerning joint motion and
stress.
FIGURE 48–4. 40 × magnification of synovial meniscoid deep within a human costovertebral joint demonstrating immune-like
reactivity to substance P. Such substance P–positive neurons within intrasynovial meniscoids suggest that these tissues are to
some degree pain-sensitive and are able to generate pain signals in the event of mechanical and/or chemical irritation.
Symptoms of muscular hypertonus or spasm as the local segments. This phenomenon demonstrates
a reaction to these painful stimuli define an impor- an essential link between the sensorimotor and joint
tant aspect of the patient suffering from thoracic spinal afferent systems.42
pain. The motor system, acting primarily through the
agency of the gamma motor intrafusal fibers, reacts Specific Thoracic Spine Syndromes
characteristically to pain and/or excessive mechanical Thoracic mechanical pain associated with synovial
stimulation, probably by a convergence of afferent no- joints, such as the facet and costovertebral joints,
ciceptive input directly from injured tissue and/or forms the bulk of manipulable lesions. These syn-
from sympathetic efferent activation of primary dromes consist of disorders affecting the joint, pain-
afferents. The sum total of such neural activation generating capacity, and the associated sensorimotor
results in a stimulation of the effector mechanism structures involved with joint movement.
and the development of muscular activity.23,29,31 Such
mechanisms may modulate protective reflex mus-
cular activity, joint dysfunction, and thoracic joint THORACIC SUBLUXATION/JOINT
pain that are often relieved clinically from joint ma- DYSFUNCTION
nipulation, selective joint injection, and/or by ra-
Definition
diofrequency percutaneous rhizotomy.13,14 Perhaps
the small, segmental muscles of the spine have a The chiropractic thoracic subluxation or joint dysfunc-
sort of “sensory servomechanism” role to play in the tion is a clinical syndrome of abnormal biomechani-
crosstalk with the motor system. cal function associated with symptoms of pain, dis-
The overwhelming hypertonic action of the large comfort, stiffness, or muscle spasm. Subluxation may
multisegmental paraspinal muscles to segmental in- present as an isolated diagnosis or in conjunction with
stability and/or dysfunction in acute back pain pa- other pathology.
tients may represent a response to an aberrant load
applied to the local segmental muscles. The charac- Pathoanatomy/Pathophysiology
teristic splinting and antalgia that occur are thought The subluxation appears to be a mechanical buck-
to be an effort to stabilize and reduce the stress on ling event that results in increased local tissue stress,
whereby tissues that undergo strain beyond their in- increase mobility and strengthen the area to minimize
jury threshold become symptomatic. Symptoms may future symptomatic episodes.
be strictly local or may manifest remotely. Local in-
flammation and noninflammatory pain mechanisms THORACIC FACET JOINT PAIN
can result in central and peripheral neural sensitiza-
tion, which promotes chronicity and painful response Definition
even to normal levels of mechanical stimulus. For Pain associated with facet joints has now been well
these reasons, the clinical presentation of a patient documented in the cervical and lumbar spine. Clinical
with subluxation/joint dysfunction can be quite vari- investigation of the thoracic facet joints demonstrates
able. For further discussion of the pathomechanics of that they may also present as a source of interscapular
subluxation/joint dysfunction, readers are referred to and referred pain. Facet pain is often considered the
Section II of this text. primary source of pain associated with spinal sublux-
ation.
Clinical Findings
Patients may present with local pain and spasm iso- Pathoanatomy/Pathophysiology
lated to a single vertebral level or distributed over sev- According to Dreyfuss et al.,10 when the facet joints are
eral segments. Pain may radiate around the rib cage injected so as to distend the capsule, both local and re-
or into the shoulder girdle. In patients who have the ferred pain occurred, most intensely on the same side
less common Kuntz nerve anastomosis between T2 as the injection, and in one segment inferiorly. Of the
and the brachial plexus, arm symptoms may also ap- four subjects injected in this study, two reported sensa-
pear if the upper thoracic spine is involved. Perhaps tions of pain directed through the chest as a quarter-
the most important finding is that symptoms may be sized cylinder from the back, anteriorly toward the
reproduced with movement of the involved segment. sternum. Descriptions of pain in the lungs were typi-
cal after injections of T3-T5. Viti and Paris47 present
Laboratory Tests and Imaging a case report of a patient suffering from headache
No laboratory or diagnostic imaging tests are pathog- who completely recovered following a single thoracic
nomonic of subluxation/joint dysfunction. While nu- spine manipulation at T2-T3. The patient had previ-
merous investigations using radiographic methods ously received five nonthrust mobilizations plus typ-
have been reported, under randomized controlled ical modalities of heat with no benefit.
study, no findings have been found to correlate with In the only published randomized controlled trial
clinical symptoms44 or with response to treatment. of thoracic spine manipulation, Schiller reported a sta-
tistically significant decrease in pain and increased
Natural/Treatment History lateral flexion and right rotation motion as compared
While patients with thoracic lesions have not been to placebo.43 Decreased pain was sustained at the 1-
studied separately, the evidence on treatment history month follow-up. Although Schiller’s study was very
of patients with symptomatic episodes of subluxa- small, its results, when taken together with the pub-
tion suggests that uncomplicated cases respond fairly lished case reports, strongly support a role for the use
rapidly to appropriate treatment.45 The average total of spinal manipulation for cases of pain secondary to
number of treatment session observed is between six posterior or facet dysfunction.
and eight, depending on whether the problem is acute,
subacute, or chronic when care begins. The range of Clinical Findings/Diagnostic Tests
treatments reported by Triano et al.45 was 1 to 40. Com- Thoracic spinal pain may be inferred in the absence
plex cases confounded by presence of pathology may of “red flags” when patient history, typical pain pat-
require up to twice as much care.46 terns, palpatory findings, and favorable response to
therapeutic trials coincide. As with cases of motion
Conservative Management segment pain in other regions, one inherent difficulty
Acute management of recent injury should consider is the identification of the specific segment or joint
the presence of edema. Ice and recumbence, up to that is the likely pain generator. As in the lumbar
15 minutes per hour, may be useful in minimizing spine, interexaminer reliability of locating the lesion
swelling and controlling pain. M

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PRINCIPLES

Editor in Chief Section Editors

Associate Editor Paul D. Hooper, DC, MPH, Dipl Erg

John Triano, DC, PhD

Previous editions © 1992 by Appleton & Lange; copyright c 1980 by Appleton-Century-Crofts

I. INTRODUCTION TO CHIROPRACTIC PRINCIPLES / 1

1. History of Spinal Manipulation 5

2. A Brief History of the Chiropractic Profession 23

3. The Evolution of Vitalism and Materialism and its Impact on Philosophy

5. Communication in the Chiropractic Health Encounter:

6. International Status, Standards, and Education of the Chiropractic Profession 111

7. Integration of Chiropractic in Health Care 135

8. The Clinical Effectiveness of Spinal Manipulation for Musculoskeletal Conditions 147

9. The Treatment of Headache, Neurologic, and Non-Musculoskeletal Disorders

10. Public Health Responsibilities for Chiropractic 183

11. Professionalism and Ethics in Chiropractic 201

II. INTRODUCTION TO CHIROPRACTIC THEORY / 221

12. Sensory Innervation of the Spine 225

13. Muscle Spindles and Spinal Proprioception 249

14. Central Projections of Spinal Receptors 269

15. Peripheral Nerve Biology and Concepts of Nerve Pathophysiology 289

16. Somatoautonomic Reﬂexes 301

17. Clinical Biomechanics and Pathomechanics of the Cervical Spine 315

18. Clinical Biomechanics and Pathomechanics of the Lumbar Spine 335

19. The Theoretical Basis for Spinal Manipulation 361

20. Pathophysiology of Disc Degeneration 383

21. Pathophysiology of the Posterior Zygapophysial (FACET) Joints 401

22. The Inﬂuence of Muscles in Spinal Pain Syndromes 419

23. Biomechanics and Pathophysiology of the Sacroiliac Joint 433

24. Headaches of Spinal Origin 447

III. INTRODUCTION TO THE CLINICAL EXAMINATION / 485

26. The Clinical History 487

27. The Physical Examination 509

28. Neurologic Examination 537

29. Orthopedic Examination 561

30. Manual Examination of the Patient 593

31. The Clinical Application of Selected Examination

32. The Use of Measurement Instruments in Chiropractic Practice 629

33. Indications for and Use of X-Rays 661

34. Indications for and Use of Advanced Imaging Studies 683

35. Indications for and Use of Laboratory Tests 705

36. Documentation and Record Keeping 725

IV. INTRODUCTION TO SPECIFIC TREATMENT METHODS / 743

38. High-Velocity Low-Amplitude Manipulative Techniques 755

39. Mobilization Techniques 767

40. Low-Force and Instrument Technique 787

41. Soft Tissue Manual Techniques 805

42. Traction and Distraction Techniques 821

43. Medication-Assisted Spinal Manipulation 841

44. The Use of Physical Modalities 861

45. Acupuncture, Acupressure, and Trigger Point Techniques 875

46. The Role of Rehabilitation and Exercise in Chiropractic Practice 887

V. INTRODUCTION TO MANAGEMENT OF SPECIFIC DISORDERS / 907

47. The Management of Low Back Pain and Radiculopathy 911

48. Thoracic Spinal Pain Syndromes 951

49. Management of Neck Pain and Related Disorders 969

50. The Management of Headache 999

51. Disorders of the Peripheral Nerves 1013

52. Management of Non-Musculoskeletal Disorders 1037

53. Issues Speciﬁc in Pediatric Practice 1049

54. Issues Speciﬁc to Geriatric Practice 1079

55. Clinical Nutrition 1099

56. Musculoskeletal Complications of Chiropractic Practice 1137