SEAK Medical Training and Information for Lawyers
Chiropractic Examination and Treatment
© 2014 SEAK, Inc.
Lawyers often think of cases involving chiropractic treatment as particularly challenging. Many attorneys lack an understanding of the role that chiropractic care plays in the treatment of musculoskeletal injuries. In addition, the chiropractic profession was, and to a lesser extent still remains, steeped in controversy. The widespread use of chiropractic care in personal injury cases makes it crucial for counsel to understand chiropractic evaluation and treatment. To properly prove, explain, or defend cases involving chiropractic care, counsel needs to understand what proper chiropractic evaluation, examination, and treatment consists of. This includes the objective and subjective tests, their results, and the significance of these results.
According to the American Chiropractic Association, chiropractic is a branch of the healing arts, which is concerned with human health and disease processes. Doctors of chiropractic are physicians who consider man as an integrated being and give special attention to the physiological and biochemical aspects including structural, spinal, musculoskeletal, neurological, vascular, nutritional, emotional, and environmental relationships and are trained in diagnosis so they may treat patients effectively and make timely referral to other health care providers when appropriate.
An initial visit to a chiropractor should begin with a complete chiropractic examination. The three primary reasons for a complete chiropractic examination are to identify the patient’s health problem, to determine if the patient is a suitable candidate for manipulative therapy, to identify all previously unrecognized health problems, determine a course of management and confirm that there are no contraindications for manipulative therapy. In beginning the complete chiropractic examination, the chiropractor will first ask about the patient’s current problem.
Doctor: Tell me about your main complaint.
Patient: It’s the pain in my back. It’s right here, low back and it goes down to the bottom of my left leg. It started about two weeks ago. I was helping somebody at work. I went to help them lift up a lawn mower and put it in the back of their trunk and that’s when I felt the pain. It’s constant pain, stabbing. The only time I feel any better is when I lay back in my recliner and then it feels a little bit better.
James J. Mangraviti, Jr: After determining the current problem, the chiropractor will then illicit family history, psychosocial history, occupational history, and conduct a systems review. The initial general examination also includes assessment of the patient’s overall health. Depending on the nature of the patient’s complaints, the examining doctor may check blood pressure, temperature, the head, eyes, ears, nose, and neck, the heart, the respiratory system, and the abdomen. As the vast majority of chiropractic cases deal with the thoracic, cervical, and lumbar spine, these areas will be the focus of this video.
The thoracic spine consists of vertebrae T1 to T12. Due its anatomic structure, the thoracic spine is the least mobile part of the spinal column. The neural canal is smaller in the thoracic spine and thus there is little leeway between the thoracic disc and the spinal cord. Unilateral and bilateral pain are the most common complaints associated with the thoracic spine. During the examination of the thoracic spine, the chiropractor will inspect and observe the patient’s posture, perform regional palpation, perform range of motion testing, test muscle strength, perform provocative orthopedic maneuvers, and auscultate the lungs. The doctor will observe the patient’s posture while sitting, standing, and lying down. When observing the patient’s posture while sitting, the doctor is looking for asymmetry of the shoulders, head, and spine.
Doctor: I’m now checking for your alignment, Mr. Babitsky. Your shoulders, checking your hips, and then looking at the rotation of your head. I want you to push your head over just that way like that.
James J. Mangraviti, Jr: When observing the patient’s posture while standing, the doctor is looking for symmetry and balance of the hips, shoulders, and head. He is also looking at the position of the feet for any deficits and is checking for scoliosis.
Doctor: I’m checking the level of your head, your shoulders now, your hips, and I’m observing the movement on your feet.
James J. Mangraviti, Jr: When observing the patient’s posture while lying down, the doctor is looking for the patient’s ability to lie in an aligned plane, signs of any stress, any alleviation or increase in pain, and any transitional dizziness.
Doctor: I’m going to be checking, Mr. Babitsky, your balance today. I’m going to be observing you for scoliosis. I’m going to also be checking the vertebral artery in your neck. I’m looking for masses and tenderness. I’m looking for irregularity in the symmetry of the spine. Mr. Babitsky, would you turn your head to the right for me, please? Do you have any dizziness when you perform that?
Doctor: Would you put your head back in center, please? When I do that does that cause you any dizziness?
Doctor: Okay. Any tenderness through here, sir?
Doctor: Very good.
James J. Mangraviti, Jr: The doctor will perform static palpation to obtain additional information. Palpation involves the doctor applying manual pressure to the patient in order to obtain information concerning the patient’s tissues. Static palpation is conducted with the patient immobilized. During static palpation, the doctor is evaluating the integrity of the patient’s muscle, joints, and connective tissue and will use his hands to examine bony landmarks, muscle, and connective tissue landmarks for defects or disease.
Doctor: I’m going to be performing static palpation examination on you. I’m looking through the musculature. I’m looking to determine the connective tissue integrity. I’m also going to be observing for bony landmarks. At the C7 area that’s localized here, it should align with the bony landmarks of the sacrum and the iliac crest and the L5 and S1 vertebrae. I’m going to placing greater and greater pressure along the spine as you notice now. Let me know if there’s any areas that are particularly tender and if so, just stop me okay? You’re doing perfect. You’re doing perfect. Excellent. Excellent. Great spine.
James J. Mangraviti, Jr: During motion palpation, the patient is moving. As in static palpation, the doctor will examine the bony, muscle, and connective tissue landmarks for motion defects or disease. What is important to detect is the increase or lack of movement.
Doctor: I’m performing motion palpation now. This is just a test that I get an understanding of how your joints move. That’s an excellent response right there. I’m going to move you over this way. I’m going to move you toward the side. I’m not going to be asking you questions. This just helps me to see how the joints are moving. Perfect. Absolutely doing perfect. And the movement there. Movement forward. You just kind of relax for me. You’re doing perfect. You’re doing perfect. Little irregular through here and a little loss of segment movement. I’m just going to move you in a semicircle and then I’m going to bring you back a whole lot right there. And right there. This looks good. These joints are well lubricated. You’re moving perfectly.
James J. Mangraviti, Jr: A measure of thoracic range of motion is part of the thoracic examination. Thoracic range of motion is measured with two inclinometers. Thoracic flexion is measured with the patient seated. Inclinometer number one is placed on the sagittal plane at T1 and inclinometer number two is placed at T12. The patient is instructed to place his hands on his hips and bend forward. Both inclinations are recorded and the T12 angle is subtracted from the T1 angle to arrive at the thoracic flexion angle. Normal range of motion is 50 degrees or greater.
Doctor: Bend forward at the waist, sir.
James J. Mangraviti, Jr: To measure lateral thoracic flexion, the patient is instructed to stand and the doctor places one inclinometer flat against T1 and the second inclinometer flat against T12. The patient is asked to bend laterally to both sides. The lateral flexion angle is arrived at by subtracting the T1 angle from the T12 inclination.
Doctor: Bend at your waist, sir, to the side. Perfect. And to the opposite side. Stop and go to the left. Perfect.
James J. Mangraviti, Jr: To measure thoracic rotation, the patient is seated and is instructed to bend forward and brace himself with his arms. The inclinometers are placed at T1 and T12. The patient is then instructed to rotate his trunk to both sides. The T12 inclination is subtracted from the T1 inclination. Normal range of thoracic rotation motion is 30 degrees or greater.
Doctor: Bend forward. Rotate your shoulder right all the way over. Perfect. Come back to center. Good and to the left please. Good. And back to center. And then sit right up, please. You did perfect.
James J. Mangraviti, Jr: Muscle strength testing involves the doctor testing thoracic flexion, extension, and rotation in lateral flexion against resistance. The doctor is looking for asymmetrical weakness from side to side or weakness in one plane.
Doctor: I’m going to be checking for symmetry of muscle strength. Push forward. Perfect. Pull back. Perfect. Lean this way against. Perfect. The opposite way. Perfect. Push this way. Perfect. Push this way. Perfect. I notice no asymmetry of the muscle.
James J. Mangraviti, Jr: Provocative maneuvers can screen for disc pathology, help differentiate acute from chronic and preexisting conditions and help differentiate soft tissue injuries from mechanical injuries. Provocative maneuvers involve compression and stretching of the pain sensitive structures. Consider the following demonstration.
Doctor: These are orthopedic maneuvers are designed to reproduce your pain. If you have any discomfort where I’m compressing or placing or stretching, please let me know. Right now I’m checking the integrity of the disc bilaterally. You’re doing perfect. There is some dysfunction right in this area right here. I’m going to have you take a deep breath now and hold it and exhale. Perfect. There’s movement through here. Again, take a good deep breath. And exhale. What I’d like you to do now is bend your chin towards your chest and cough for me. Perfect. Those were excellent procedures and maneuvers to the spine.
James J. Mangraviti, Jr: The doctor may also utilize various diagnostic tests to assist him in his examination of the thoracic spine. We will now review six of these. They are: the chest expansion test, the Soto-Hall test, Adam’s sign, Beevor’s sign, Schepplemann’s sign, and McKenzie’s side glide test. The chest expansion test involves the doctor placing a tape measure around the patient’s lower rib cage. The patient is then asked to take a deep breath. The amount of expansion of the chest is noted. Usually, males can be expected to have a chest expansion of at least one and one half inches. In females, one inch. Limited expansion indicates an ankylosing condition.
Doctor: I’m performing the chest expansion test. It’s 36. I’m going to have you take a deep breath, as deep a breath as you can. And that’s 38 and a half. That’s a normal test.
James J. Mangraviti, Jr: The Soto-Hall test is performed with the patient supine. The doctor places his hand on the back of the patient’s head and assists him in moving his chin to his chest. If the patient complains of localized pain, this is a general indication of osseous disc or ligament pathology. When presented with positive findings in the Soto-Hall test, the doctor will normally perform additional and more specific testing.
Doctor: I’m going to have you lift your head forward as far as you can. If you have pain let me know.
James J. Mangraviti, Jr: When testing for Adam’s sign, the patient is standing with the doctor behind him. The patient is then asked to bend forward at the hips. The doctor observes the mid and lower back and looks for muscle spasm, complaints of pain, rib humping, muscular atrophy, and the distance the patient bends forward. When the patient’s lumbar curve does not reverse on bending, the doctor may suspect a scoliosis. A restriction in forward flexion may be indicative of a herniation of a disc. The failure of the lumbar curve to reverse may be due to muscle spasm or problems with the joint or ligaments. The doctor will also look for pain along the sciatic nerve, which may also be indicative of disc problems.
Doctor: This test is called Adam’s test. Bend forward at your waist as far as you can, please. I’m going to be observing for humping of the thoracic lumbar spine. I’m also going to be observing for your curvature that is abnormal in this area. It also appears that because of the pain in this right side, you may have disc involvement that’s irritating that sciatic nerve. The tests indicate to me that you have some scoliosis, some disc pathology, and as a result of that a nerve root pinching right here.
James J. Mangraviti, Jr.: Beevor’s sign is measured with the patient in a supine position. The patient is asked to hook his fingers behind his neck and raise his head towards his feet in a sit-up type movement. In normal patients, the upper portion of the upper and lower abdominal muscle contracts pulling the umbilicus up. When there is a thoracic nerve root lesion present, the umbilicus will move either superiorly, laterally, or inferiorly. Movement in a superior direction indicates a bilateral 10 to 12 thoracic nerve root lesion. Movement superiorly and laterally indicates a unilateral 10 to 12 thoracic nerve lesion. If the movement is in an inferior direction, a bilateral 7 to 10 thoracic nerve root compression on the opposite side of the movement is indicated.
Doctor: What I’d like you to do is hook your hand behind your head and try to do a sit-up. On this, I’m looking at your belly button. If it moved up, it would indicate that you’re having a problem from bilateral T7 through T10. If it moved out, it indicates that you have one side or the other of the lower. If it moved down, it indicates that the smaller part of the lower back disc is involved. None of those tests on you are positive. You did an excellent job.
James J. Mangraviti, Jr.: When testing for Schepelmann’s sign the patient is sitting and it asked to bend laterally at the waist to the left and right. If the patient complains of pain on bending, the doctor will evaluate the side of the complaint. If the patient complains of pain on the side of the bending, then intercostal neuritis is suspected. If the pain is on the non-bending side, then the doctor will suspect fibrous inflammation of the pleura or an intercostal sprain.
Doctor: This is a side-bending test that I’m going to ask you to perform. I’m looking for pain on both sides. I’m going to ask you to go the right and to the left. Please bend to the right side. Good. And go to the left side.
Patient: Right here.
Doctor: This indicates right here an intercostal inflammation. It also indicates to me that you do not have fibrous adhesions or fibrositis of the pleura.
James J. Mangraviti, Jr: McKenzie’s side glide test is performed with the patient standing and the doctor standing to the patient’s side. The doctor grasps the patient’s pelvis, pulling it towards him for 10 to 15 seconds while blocking the patient’s thoracic spine with his shoulder. The test is then repeated to the opposite side. If the symptoms increase on the affected side, the doctor may suspect that the patient’s scoliosis is contributing to the patient’s problem.
Doctor: I’m going to check you for scoliosis. I’m going to pull your pelvis over a little bit and I’m going to just check that area right there. That’s a perfect test. I’m going to again pull you in. I’m going to pull your chest over. We’re going to hold that for about another five seconds and then I should be able to feel the muscles contract and the curvature seems to be in a line. I don’t see any scoliosis.
James J. Mangraviti, Jr: Many litigants seek chiropractic care due to alleged neck pain caused by injury to the cervical spine. The cervical spine contains soft tissue structures, which include muscle, ligaments, and capsules. Most neck pain complaints result from the encroachment of space or the impairment of movement.
Doctor: How long have you had this pain in your neck?
Patient: It’s been about three weeks.
Doctor: Show me exactly where it’s at.
James J. Mangraviti, Jr: The examination of the cervical spine begins with the taking of the patient’s history. The doctor will note the duration and frequency of the pain and which actions make the pain better or worse. The cervical examination continues with a physical examination of the neck and adjacent structures. This physical examination includes inspection and observation of the neck including observing for posture, regional palpation, range of motion testing, muscle strength testing, vascular examination, and additional cervical tests. The cervical examination begins with inspection and observation of the neck and its posture.
Doctor: I’m inspecting your neck and observing its normal posture. It looks perfect.
James J. Mangraviti, Jr: The cervical examination may include palpation of both the anterior and posterior aspect of the cervical area. Anterior palpation begins with the doctor checking the patient’s sternocleidomastoid muscle by having the patient turn his head from side to side. The doctor pinches the muscle on the side of the rotation between his thumb and forefinger. The doctor is looking for inflammation, palpable bands, or tenderness. Inflammation and tenderness are frequently associated with whiplash injuries. Palpable bands can indicate a myofascial trigger point caused by overuse or trauma. The doctor will also check the carotid arteries by pressing two fingers lightly against the transverse process of the cervical vertebrae. A difference in pulses can be indicative of carotid artery stenosis or compression.
Doctor: I’m going to be examining your neck. Turn your head this way. That palpable band right there is the sternocleidomastoid. Let’s see if it’s on the other side. And it is. You know what this indicates, Steve, is that you’ve got some inflammation and tenderness in there. Generally I find when both of those areas are tender that you must have sustained a whiplash injury. I need to get in here and check also those carotid arteries. There’s an artery that runs right through here and I just kind of compress. If you get dizzy or nauseous let me know. Those are all normal tests with the exception of these sides right here.
James J. Mangraviti, Jr: On the posterior side, the doctor will check the trapezius muscle by palpating each muscle from the occiput first cervical vertebrae posterior arch downward to the side of the neck into the shoulder blade. Inflammation and tenderness may be indicative of muscle spasm due to torn muscle fibrosis or fibromyalgia. Common causes of muscle spasm are overuse, overload, or trauma.
Doctor: We’re examining now the posterior trapezius muscle group from the C1 down to the upper shoulder girdle. I feel some inflammation in this area right through here at the trapezius muscle. It seems to me that we’ve either got a torn muscle or this is a component of fibromyalgia. Many times, I find that this injury you have right here is from muscle spasm, overuse, or overload.
James J. Mangraviti, Jr: The doctor will then check the cervical intrinsic spinal muscles by moving his fingers over the muscle in a transverse fashion. Abnormal tone or tenderness may be indicative of muscle strain, myofascitis, or fibromyalgia. Common causes of cervical muscle strain are overuse, overload, or trauma. Cervical range of motion is measured with dual inclinometers. Assessing range of cervical motion is considered to be an objective way to judge impairment. Inclinometers measure angular displacement relative to gravity and thus they are the instrument of choice. To assure maximum patient compliance, the tests should be performed three times and the results should consistently fall within 5% and 10% of each other. The chiropractor will measure flexion, extension, lateral flexion, and rotation. In measuring flexion, the chiropractor will place the slave unit on the T1 vertebrae and the main unit on the top of the patient’s head. The patient is then asked to touch his chin to his chest. The patient bends his neck all the way forward. The doctor reads the angle in degrees at the limits of movement and subtracts the T1 inclination from the occipital inclination to obtain the captive cervical angle. The normal range is 60 degrees or greater from the neutral or zero position for the active movement.
Doctor: Bend forward, please. Thirty-eight degrees.
James J. Mangraviti, Jr: When measuring cervical extension, the patient is asked to extend his neck all the way back towards his shoulders. The doctor reads the angle in degrees at the limit of movement. The normal range of motion is 75 degrees or greater.
Doctor: Bend your head all the way back. Forty-six degrees.
James J. Mangraviti, Jr: When the chiropractor measures lateral flexion, the patient is asked to try to touch his shoulder to the side of his head without turning his chin. The doctor reads the angle in degrees at the limit of movement. The normal range is 45 degrees or greater.
Doctor: Bend to the right, please. Twenty-five. Back to center. And to the left sir. And thirty-six degrees.
James J. Mangraviti, Jr: When cervical rotation is measured, the patient is asked to lie down and turn his chin towards his left and right shoulder. The doctor uses only the master inclinometer. This is placed on the top of the head of the patient. The doctor then reads the angle in degrees at the limit of movement. The normal range for active movement is 80 degrees from the neutral or zero position.
Doctor: Turn your head all the way to the left, sir. Forty-three degrees. All the way to the right. And fifty-two degrees. Back to center. Perfect test.
James J. Mangraviti, Jr: The cervical exam continues with muscle strength testing. This testing may be done either manually or with instruments. Pain during muscle testing is frequently indicative of either a muscle or joint injury. On the other hand, pain with isometric contraction usually indicates a muscle injury. To determine if there is a muscle lesion, the doctor will completely immobilize the joint and ask the patient to do an isometric contraction. Pain is usually related to a muscular or muscle tendon lesion. A capsular injury will normally produce pain with both passive and active movement because the capsule is elongated. Purely muscular injury produces pain from the muscle’s contraction and elongation. Muscle weakness results in loss of movement due to the inability of the muscle to contract. Muscle strength is graded from one to five. Normal strength is graded at five. Where there is no muscle contraction, the muscle is graded zero.
Doctor: I’m going to ask you to do a muscle strength test. Bend your chin towards your chest and tell me if you have any pain.
Patient: Yes. On the right side here.
Doctor: Okay. Come back up. Push your head into me. Good.
James J. Mangraviti, Jr: The cervical examination may conclude with the doctor testing for vascular abnormalities. Three common tests to do so include: the Scalenus Anticus syndrome test, the vertebrobasilar artery functional maneuver, and the Fitzgerald compression test.
Doctor: I’m going to check your baseline of your radial pulse. Very good. On this test what I’d like you to do is turn your head over to the side. Take a deep breath. That’s an excellent test.
James J. Mangraviti, Jr: In the vertebrobasilar artery functional maneuver, the patient is also seated. The doctor palpates and auscultates the carotid subclavian arteries. The patient is asked to hold his breath and rotate and hyperextend his head to both sides. The doctor palpates and auscultates for the presence of pulsation or bruits. A positive result may indicate a compression or stenosing of the carotid or subclavian arteries.
Doctor: On this test I’m going to check the vertebrobasilar circulation. I’m going to ask that you turn your head back and extend it and take a deep breath.
James J. Mangraviti, Jr: In the Fitzgerald compression test, the doctor stands behind the patient or at his side. The doctor places his hand at the top of the patient’s head and has the patient bend his neck on both sides. The patient is then instructed to rotate his chin toward his shoulder. The doctor compresses to determine any joint swelling or instability of the articular facets. An increase in pain is indicative of facet inflammation, misalignment, or injury.
Doctor: I’m going to perform the Fitzgerald compression test. I’m looking for joint irritation. Does that bother you?
Patient: Yeah. It hurts right here.
Doctor: Does that bother you in the same place?
Patient: Same place. Same place.
James J. Mangraviti, Jr: The segment on cervical examination will now conclude with a description and demonstration of some additional cervical tests. These are: the foraminal compression test, the Jackson compression test, the extension compression test, the flexion compression test, the shoulder abduction test, the costoclavicular test, and Lhermitte’s sign. The foraminal compression test involves the doctor pressing down on the patient’s head. The test is repeated with the patient rotating his head in both directions. Pain may indicate foraminal encroachment. Radicular pain can suggest nerve root pressure or disc disease.
Doctor: What I’m going to do is check the middle of the neck for pain. Does that bother you?
Patient: Yeah. Goes right out there.
Doctor: Does that bother you?
Patient: Same thing. Same thing.
Doctor: Does that bother you?
James J. Mangraviti, Jr: In the Jackson compression test, the doctor laterally compresses the patient’s head while exerting downward pressure. Pain may indicate foraminal encroachment. Radicular pain is indicative of nerve root pain or disc disease.
Doctor: Evaluating your head for pain. Does that bother you?
Patient: Yeah, on this side here.
Doctor: Does that bother you?
James J. Mangraviti, Jr: In the extension compression test, the patient is asked to bend his head and neck backwards while the doctor applies pressure to the head. An increase in upper extremity radicular pain is indicative of a degenerating disc or pathology in the intervertebral foramina.
Doctor: On this test I’m going to bring you back and compress. Does that give you any discomfort?
Patient: Yes. The pain’s right here doctor.
James J. Mangraviti, Jr: In the flexion compression test, the patient is asked to flex his head forward while the doctor puts downward pressure on the patient’s head. An increase in cervical or radicular symptoms is indicative of a disc defect.
Doctor: I’m going to bend your head forward. Tell me if this gives you any pain.
Patient: Yeah. At the center, straight out.
James J. Mangraviti, Jr: In the shoulder abduction test, the patient is seated and instructed to abduct his arm and place it on top of his head. If the patient has a reduction or relief of pain, the doctor will suspect a herniated disc or nerve root compression at C5-C6.
Doctor: I want you to bring your hand up like this and tell me what happens.
Patient: Oh, my neck and shoulder feel better over here.
James J. Mangraviti, Jr: In the costoclavicular test, the patient is sitting and the examiner palpates the radial pulse of both arms of the patient, which are elevated above the shoulders as they patient tries to touch his chin to his chest. If the radial pulse disappears, this is indicative of compression of the neurovascular bundle between the first rib and the clavicle.
Doctor: Bend your chin towards your chest.
James J. Mangraviti, Jr: Lhermitte’s sign is tested for with the patient seated or lying down. The patient is asked to flex his head towards his chest. If the patient complains of electrical shock feelings, this is indicative of spinal cord degeneration or sever spinal cord injury.
Doctor: Pull your neck forward and tell me what happens.
James J. Mangraviti, Jr: The assessment of the lumbar spine includes initial observation, inspection of alignment and posture, palpation testing, range of motion measurement, and additional specific tests. The doctor will observe the patient’s gait when he enters the examination room. Is locomotion guarded or painful? Does the examinee put equal weight on each leg? If the doctor finds abnormal gait form, this is the first step in the diagnostic process. The complete assessment of the lumbar spine involves an evaluation of lumbar pelvic alignment and posture. The chiropractor first evaluates pelvic and hip alignment.
Doctor: I’m going to be observing now the lumbar and lumbar pelvic angle. Turn this way, please, facing that way. Observing the pelvis and the lumbar curve.
James J. Mangraviti, Jr: To assess posture, the patient is asked to assume a relaxed stance with his feet four to six inches apart. The patient should not have shoes on. The chiropractic physician looks for the symmetry of landmarks and will do a plumb line evaluation of spinal posture.
Doctor: I’m performing a posture analysis. Looking at the symmetry of the feet. Using the plumb line, seeing that there is a symmetry here. Shoulders are fine. Turn and face this way. Checking symmetry of the head, the shoulders, and the balance of the pelvis through the legs. Checking the symmetry of the shoulders. Again, seeing the asymmetry of the hips and then looking at the placement of the legs.
James J. Mangraviti, Jr: The plumb line provides a visual frame of reference for the influence of the center of gravity from each body segment. This enables the clinician to detect postural deviation, asymmetry, and suspected areas of postural stress. Patients are observed in the anterior, posterior, and lateral stances. Leg length is normally evaluated by measuring the head of the femur through the midline of the patellofemoral joint and the ankles.
Doctor: Back pain can come from leg length inequalities and I’m going to compare from side to side. That’s normal. And from the femur to the acetabular fossa. Comparing both sides. That’s normal.
James J. Mangraviti, Jr: An inequality in leg length is thought to predispose patients to low back pain, knee pain, or ankle pain called lower extremity syndrome. Either a cervical or pelvic mechanical dysfunction can cause an apparent short leg. This will resolve with proper chiropractic treatment. Palpation testing may be useful in lumbar examinations. With the patient in the seated position, the doctor will palpate the five large lumbar spinous processes with the spinal column in the flexed position. The patient is asked to bend forward and the doctor palpates with his index and forefinger. The doctor then puts pressure with his thumb on the spinous processes. The doctor is looking for spondylolisthesis, spina bifida, lumbarization, sacralization, and rigidity or springing associated with hypomobility or hypermobility.
Doctor: Bend forward. I’m going to examine each spinous process with my thumb and index finger. There are five lumbar vertebrae. What I’m looking for is the presence of a spondylolisthesis, a spinal bifida, lumbarization, sacralization, rigidity, or springing.
James J. Mangraviti, Jr: With the patient lying face down on the examining table, the doctor may also palpate the lumbar portion of the spine in a diagonal fashion. Positive findings are tenderness, inflammation, muscle spasm, or palpable bands. These may be indicative of muscle strain, fibromyalgia, myofascitis, or active trigger points.
Doctor: This is another way that I’ll perform an examination. With both my hands I’m stretching the muscles outward. I’m checking for tight muscle bands, evidence of trigger points, evidence of fibromyalgia.
James J. Mangraviti, Jr: The doctor may also palpate the quadratus lumborum from the twelfth rib to the iliac crest. Tenderness, inflammation, spasm, or palpable bands may again be indicative of muscle strain, fibromyalgia, myofascitis, or active trigger points.
Doctor: Checking this deep muscle called the quadratus lumborum. Are you sore there?
Patient: Yeah. Right there, right there.
James J. Mangraviti, Jr: Palpation of the gluteus may also be performed. Tenderness or spasm is indicative of a muscle sprain. A herniated disc with nerve root compression may cause tenderness and spasm to the affected area.
Doctor: Where does it hurt?
Patient: Right there.
Doctor: I am checking the gluteus maximus. Is that sore?
Patient: Yep, yep.
James J. Mangraviti, Jr: Finally, the doctor may palpate the sciatic nerve down the leg. If the patient complains of tenderness, burning, or referred pain, the doctor will suspect irritation of the sciatic nerve.
Doctor: I’m going to be examining your sciatic nerve root from the area that it goes to. Let me know if it’s tender in any place.
Patient: Yeah, right there.
Doctor: What about down in here?
Patient: No. That feels good.
James J. Mangraviti, Jr: As with the cervical and thoracic spine, the chiropractor will also measure lumbar range of motion. Lumbar flexion is measured with the patient standing. The doctor places one inclinometer at T12 and the other on the sacrum. The patient is asked to bend forward. The doctor measures the inclinations and then subtracts the sacral inclination from the T12 inclination. Normal range varies with age and sex from 66 degrees for a 25-year-old male to 49 degrees for males over 61.
Doctor: I’m going to have you bend forward at the waist if you would all the way.
James J. Mangraviti, Jr: Lumbar extension is also measured with the patient standing. The doctor places one inclinometer at T12 and the second on the sacrum. The patient is asked to bend backwards and the doctor reads the inclinations and subtracts the sacral measurement from the T12 measurement. Normal range again varies with age and sex from 42 degrees for a 25-year-old female to 36 degrees for a 65-year-old female.
Doctor: Bend all the way back please.
James J. Mangraviti, Jr: To measure lateral lumbar flexion, the doctor places one inclinometer at T12 and the second at the superior aspect of the sacrum. The patient is then asked to flex from side to side. The sacral inclination is subtracted from the T12 inclination. Normal range of motion again varies with age and sex from 38 degrees for a 20-year-old male to 19 degrees for a 62-year-old male.
Doctor: Bend all the way at your waist to the side left. And all the way to the right please.
James J. Mangraviti, Jr: The doctor may also use a series of lumbar diagnostic tests. These include straight leg raising, Bragard’s test, the Buckling Sign test, the Lasegue test, the femoral nerve traction, Bechterew’s test, minor sign, Kemp’s test, Goldthwait’s test, and the Nachlas test. We will now describe and demonstrate each of these diagnostic tests. Straight leg raising is performed with the patients lying on his back. The doctor raises the patient’s leg to the point of pain. When the patient complains of pain at zero degrees to 35 degrees extradural involvement is suspected. At 35 to 60 degrees, disc involvement is suspected and at 70 to 90 degrees, lumbar joint pain is suspected.
Doctor: What I’m going to do is perform a straight leg raise. I’m going to stretch the sciatic nerve. Does that hurt anywhere?
Patient: Right there.
James J. Mangraviti, Jr: In Bragard’s test, the patient is lying on his back and raises his foot to the point of leg pain. The doctor then dorsiflexes his foot. When pain is felt with the foot flexed at 35 to 70 degrees, irritation of the sciatic nerve is suspected from a disc lesion.
Doctor: This is called the Bragard’s test. Tell me if you feel any pain first.
Patient: Yep. Right there.
Doctor: Okay. I’m going to lower it down. Do you feel any pain?
Patient: Oh yeah. That brings it back.
James J. Mangraviti, Jr: The buckling side test is a variation of straight leg raising. If, when the doctor raises the leg, the patient’s knee buckles and he complains of pain, this is a positive indication of sciatic radiculopathy.
Doctor: I’m going to stretch the leg again. Tell me if you have any-
Patient: Oh yeah! Yeah. That’s it.
Doctor: What that is is a buckling sign.
James J. Mangraviti, Jr: The Lasegue test is a straight leg raising test in which the patient is lying on his back with his hip flexed while the doctor raises the patient’s leg. When the patient complains of pain when the hip is flexed and leg extended, the test is positive for sciatic radiculopathy. The test is also positive when there is no pain when the hip and leg are flexed.
Doctor: I’m going to bend your knee up like that, flexing your hip. Tell me if you have any pain when I do this and where.
Patient: All right. Back of my leg.
James J. Mangraviti, Jr: In the femoral nerve traction test, the patient is placed on his side with the affected side up. The patient is asked to flex the unaffected extremity at the hip and knee. The doctor then grasps the knee and stretches the hip. If the patient complains of pain that radiates to the anterior medial thigh, the doctor will suspect a nerve root problem at L3. Pain extending to the mid tibia will make the doctor suspect an L4 nerve root problem.
Doctor: This is the most painful side.
Doctor: Okay. Bend your knee for me. Okay. I’m going to grasp your leg and bring it up. Tell me if that hurts you.
Patient: Right there. Right there.
James J. Mangraviti, Jr: Bechterew’s test is performed with the patient seated. The patient is asked to extend both legs together and then one at a time. The patient with sciatica will normally have little trouble extending one leg at a time but will have difficulty and pain when extending both legs at the same time. This test is usually positive in disc protrusion cases.
Doctor: I want to check you for that disc protrusion in your lower back. Bring both legs out for me and tell me what you feel.
Patient: Middle of my back. Pain’s right in the middle of my back.
Doctor: Okay. Put them both down. Bring the right leg out again, please, and tell me what you feel. Good. And then bring the left leg out.
Doctor: Put it down. That test indicates you’ve got a disc protrusion.
James J. Mangraviti, Jr: Minor’s sign is a simple yet instructive test. Here, the patient is seated and asked by the doctor to stand up. The patient will generally support himself on the healthy side and keep the affected leg flexed. The patient with sciatica will support himself on the healthy side. This test is also used to detect symptom magnification in those patients who complain of pain but yet do not support their weight or flex their knee.
Doctor: It hurts right here. Doesn’t it?
Doctor: Would you stand up for me?
James J. Mangraviti, Jr: Kemp’s test can be performed with the patient sitting or standing. The patient wraps his arms around himself. The doctor then stabilizes the patient’s lumbar spine and with the other hand the doctor reaches around the patient, grasps the patient’s shoulder and bends the spine obliquely backwards. When the test is positive, the motion will increase disc tension, producing pain in the lower back from medial disc lesions.
Doctor: I’m going to check you for disc disease. I’m going to twist you around this way. Tell me if it hurts in your lower back.
Patient: Right in the middle.
Doctor: When I do it this way tell me if it hurts.
James J. Mangraviti, Jr: Goldthwait’s test is performed with the patient lying on his back. The doctor places one hand under the lumbar spine. The other is used to do a straight leg raising. If radicular pain is felt before the lumbar is moved, this is indicative of a sacroiliac joint disorder. If the pain is felt after they move, this is indicative of a posterior joint disorder. Pain during movement is indicative of a disc defect.
Doctor: I’m going to place my hand up under your back, if you would. On this test I’m going to be checking the lumbar and sacroiliac area. I’m going to be raising your leg up. Tell me what you feel, if anything.
Patient: Right in the middle.
James J. Mangraviti, Jr: During the Nachlas test, the patient is placed face down on the exam table. The doctor then takes the patient’s heel and moves it towards his buttock. Radicular pain in the thigh is indicative of a compression or irritation of the sciatic nerve.
Doctor: I’m going to be stretching your leg here. The object of this test is to tell me whether you feel pain anywhere.
Patient: Yeah. Right there.
James J. Mangraviti, Jr: The chiropractor will combine the results of his examination with any diagnostic tests such as x-rays and MRIs before forming his diagnosis. Then, and only then, will the doctor be prepared to decide on a treatment plan. After the doctor has formed a diagnosis, the decision then will be made about what treatment is appropriate. Chiropractic treatment or procedures can generally be divided into two categories, non-manual procedures and manual procedures. Chiropractors employ a whole host of non-manual procedures to treat patients holistically. The following is a list of the 20 most common therapeutic techniques employed by chiropractors. The number next to each technique is the percentage of chiropractors employing that technique. These are corrective therapy exercises, ice pack cryotherapy, bracing, nutritional counseling, bed rest, orthotics lifts, hot pack moist heat, traction, electrical stimulation, massage therapy, ultrasound, acupressure meridian therapy, casting taping, vibratory therapy, homeopathic remedies, interferential current, direct current, diathermy, infrared baker, whirlpool hydrotherapy. Some of these and other therapeutic procedures are not without controversy among healthcare professionals. Recent studies, however, have shown that chiropractic manual therapies are a cost effective alternative in the treatment of low back and neck pain. The two categories of manual therapies most often utilized by chiropractors are soft tissue procedures and joint manipulation procedures. When muscles and other structures lose function and elasticity, they impact joint function. To counteract this, chiropractors utilize techniques such as massage, active and passive muscle tightening and stretching, ischemic compression, and passive stretching. Massage is the application of pressure to a tight muscle to relax it and help relieve muscle spasm.
Doctor: I’m going to be massaging this strained muscle right through here. I’m just going to be stretching it with the palms of my hands and the surface of my hands. I’ll use my fingers now to kind of gently stretch it a little more deeper in the tissue. And you move away from the spine so that you don’t pool blood down in that area.
James J. Mangraviti, Jr: Active and passive muscle tightening and stretching involves the patient alternating between a tightened and relaxed muscle while the doctor stretches the musculature. The most common uses of this technique are for muscle strains, muscle spasm, and whiplash injuries.
Doctor: On that badly pulled muscle spasm, I’m going to take this ice and I’m going to stretch over that trapezius muscle all the way down to where it inserts into the shoulder. Doesn’t that feel good?
Doctor: Now, to help me and to help you I want you to bend your head back. I’m going to take this same ice, go in real, real tight. I want you tighten your neck now as I do that. Tighten that muscle. You’re doing perfect, perfect, perfect, perfect.
James J. Mangraviti, Jr: Ischemic compression or point pressure involves the doctor applying sustained or progressively stronger pressure on a pressure point, trigger point, or tight muscle. This typically reduces the point’s tenderness and produces a flushing and relaxation of tightness. The most common uses of point pressure are for muscle strains, whiplash injuries, and muscle spasms.
Doctor: On that bad pulled muscle right there I’m going to put my fingers in and use a lot of force. It’s going to hurt initially but it’ll start to relax. Feel it relaxing?
James J. Mangraviti, Jr: Passive stretching is also known as spray and stretch. Here the doctor uses coolant spray or ice prior to applying the stretch. The most common uses of passive stretching are for fibromyalgia, muscle strains, whiplash injuries, and muscle spasms.
Doctor: I’m applying this ice over the trapezius muscle to reduce spasm.
James J. Mangraviti, Jr: Attorneys are most familiar with the three types of joint manipulation procedures utilized by chiropractors. They are adjustments, mobilization, and manual traction distraction. The goal of adjustive intervention is the removal of structural dysfunction of joints and muscles. When a joint is opened, an audible click or pop is usually heard. In all of the adjustment techniques that we will be demonstrating, proper patient positioning plays a crucial role. Proper positioning will remove articulus slack, adjust joint tension and localization, and help prepare for leverage to be used during the adjustment. The six common patient postures are prone, supine, standing, sitting, knee chest, and side posture. Once both the patient and doctor are in position, the doctor must choose between 10 different chiropractic techniques. These are high velocity thrusts without recoil, high velocity thrusts with recoil, low velocity thrusts without recoil, low velocity thrusts with recoil, sustained force, blocking techniques, manually assisted mechanical thrusts, mechanically assisted manual thrusts, neurological reflex techniques, and low velocity controlled vectored force. The high velocity thrust without recoil is used mainly to treat patients with mechanical low back problems and other neural musculoskeletal problems.
Doctor: I’m going to be giving you a manipulation now to reduce some of your low back pain.
James J. Mangraviti, Jr: The manipulative thrust takes the patient beyond the normal range of motion but within the anatomical joint barriers. This is done by reducing joint inflammation. When the misaligned joint is corrected, it helps to realign the joint and reduce pain and inflammation. Manipulation restores normal joint motion, which results in a normalizing effect of the mechanoreceptors of the nervous system leading to decreased pain and diminished circulation of pro-inflammation neurotransmitters such as substance P. An audible pop or crack in the joint usually occurs as a result of this maneuver. This signifies that the procedure is successful.
Doctor: I’m going to provide a manipulation to your neck. I’m going to try to realign the joint. You’re going to feel me take this and just…
James J. Mangraviti, Jr: The high velocity thrust with recoil is used to treat recalcitrant chronic inflammation of the lower back, mid back or the neck. The doctor’s arm goes across the patient and then recoils back. This is an aggressive movement into the joint done quickly. It is usually performed only on difficult patients who have long standing problems who generally have not responded to more conservative treatment.
Doctor: This bad back pain that you’re having. I’m going to relieve some of the discomfort. Try to realign the joint. Bear with me. Again.
James J. Mangraviti, Jr: The low velocity thrust without recoil is used in patients with neuromusculoskeletal problems such as joint stiffness and soft tissue restrictions. This would involve, for example, a patient who can’t bend or turn without discomfort. The patient is taken a little beyond his passive range of motion. Through this maneuver, the doctor is realigning a minor misalignment and reducing soft tissue muscle restriction spasms. Generally, you do not expect to hear any pops when this maneuver is performed.
Doctor: I’m going to realign this misalignment. I’m going to try to reduce your pain and discomfort.
James J. Mangraviti, Jr: The low velocity thrust with recoil is used in patients with restricted joint motion and painful muscle splinting. The doctor goes in and using the transverse process of the vertebrae, holds onto, pushes, or pulls in a rapid fashion to achieve a reduction of the joint swelling that was caused by the muscle splinting. This realigns the joint.
Doctor: I’m going to provide a rather aggressive movement to realign that joint and reduce your muscle spasm.
James J. Mangraviti, Jr: The sustained force technique is used in patients with muscle contusions and joint stiffness. This is usually associated with a recoil or whiplash injury. The doctor puts his thumb or the outside of this hand on the spinous process of the vertebrae. It is angled at a 45 degree position. The doctor then presses the joint until he can feel the spasm reduced. The sustained force moves the muscle, relaxes the neck, and results in joint realignment.
Doctor: I’m going to try to reduce some of the discomfort from that whiplash that you’ve had. You’re going to feel me put a lot of pressure over that center part of your neck. You’re going to feel me apply more and more pressure. See how that joint is starting to reduce down. Can you feel the pain going away somewhat?
James J. Mangraviti, Jr: Blocking techniques are used in patients with muscle imbalance. For example, a patient having a stretch reflex in a spastic muscle. This is what is commonly referred to as a badly pulled muscle. The muscle in question is usually swollen, has no give to it, and is engorged with blood. Blocking techniques involve positioning the patient in such a way that it causes the affected muscle to relax.
Doctor: I understand you’re having a great degree of spasm in the lower back. I’m going to try to assist you by blocking this lower back. Turn you over this way. Okay. Now I want you to roll back on that. That’s elevated that spasm a little bit. How do you feel now?
Patient: That’s a little better.
Doctor: I’m going to let you lay on that for a while. Okay? And let that spasm reduce.
James J. Mangraviti, Jr: The manually assisted manual thrust is used in patients with neuromusculoskeletal problems such as painful joint, ligamentous pain, tendon pain, cartilaginous pain, and muscle and tendon dysfunction. The doctor rotates the person’s vertebrae joint on both sides to realign the joint. This reduces the tension on the ligament, the tendon, and the cartilage.
Doctor: How does that feel?
Patient: Feels better.
James J. Mangraviti, Jr: Neurological reflex techniques are utilized in patients with mild muscle spasm. The doctor stretches the painful muscle until he can get the patient in an upright, comfortable position. Bed rest or low velocity thrust without recoil to realign the minor misalignment follows.
Doctor: What I’m going to do now to reduce some of this spasm is use a neurological reflex procedure. I’m going to start pushing against this spasm and it’s going to have some reflexes that will actually let you relax a little bit and get some greater movement in there. You’re starting to do perfect. You’re coming upright. I’m going to start really compressing that nerve and reflex arc through there. How do you feel now, sir?
Patient: Feels better.
James J. Mangraviti, Jr: The low velocity controlled vectored force technique is used in patients who hit their head against a windshield or a blunt object and have neck pain. This is a gradual realignment, which is done over a week or several weeks. The doctor uses his thumbs held together and gently pushes the vertebrae in the painful area to realign the curve of the neck into its normal C-shaped appearance. This helps reduce pain and restores movement. The degree of inflammation and injury in the joint may commonly prevent immediate rehabilitation.
Doctor: This manipulation that I’m going to provide now is designed to move and restore the normal curvature of your spine. You hit the windshield and it bent your neck back and your neck is in spasm. What I’m going to do now is start more pressure along that joint. Do you feel that relieving some of your discomfort?
James J. Mangraviti, Jr: Mobilization is the second joint manipulation procedure used by chiropractors. Mobilization involves passive movement through the physiological joint range. The purpose is to increase range of motion within a restricted joint. Basically, it is a technique used to stretch joints instead of realigning them. The patient may have lost his normal ability to move and is stiff. Wherever there is a joint this can occur. The cause is commonly violent trauma, repetitive overdoes syndrome, or osteoarthritis, which occurs during the aging process. This mobilization helps reestablish normal joint movement.
Doctor: I’m going to provide some mobilization to reduce some of that stiffness from osteoarthritis in your mid back. See how that’s freeing up the joint a little more? Do you feel better?
Patient: Yes, it feels better.
James J. Mangraviti, Jr: A third joint manipulation procedure used by chiropractors is manual traction distraction. Here, the doctor uses a pulling force to induce distraction of the lumbar spinal motion segments or extension distraction of the lumbar spine. The doctor uses the palm of his hand as a gripping mechanism. He applies a traction movement to the spinous process while the patient is on a specialized manipulation table. The patient is lying on his stomach with his hands above his head grasping onto bars. The patient’s feet are immobilized with a strap to prepare his body for traction. When the patient is in a position where he doesn’t feel any pain in the disc, then the doctor takes his palm and stretches the spinous process, relieving the swelling and inflammation from a swollen or herniated disc. This is a pumping maneuver to pump fluid from a swollen disc up into the center of the vertebrae above it so there is an exchange of nutrients. This is a recognized high risk procedure and is commonly done as a last resort before disc surgery at the direction of the patient’s orthopedic surgeon or neurosurgeon.
Doctor: Do you feel comfortable?
Doctor: I’m going to start the procedure. Let me know if you’re at the greatest point of pain and then I’m going to hold it. Tell me when it’s at the greatest point of pain.
Patient: Right there.
Doctor: Okay. Now what I’m going to do is just kind of milk the joint with my hand very, very gently. I’m going to do this until you start to feel some pain reduction in either your lower back or the pain down into your leg. The side of the disc that’s been compressed now I’m going to open it up. You should start to feel some discomfort relief now. Do you feel that?
Patient: Yes I feel it.
Patient: It’s a little better.
Doctor: Okay. Now what I’m going to do is traction or pump the joint a little bit more. You’re doing perfect on this procedure. Feel that reducing your back pain?
James J. Mangraviti, Jr: We will now demonstrate and explain the appropriate adjustments for the most common conditions chiropractors treat. The most common conditions for the cervical spine are joint swelling, crepitation, muscle contusion, painful splinting, fibrocystitis, lymph stasis, ligament pain, traumatic myositis, tendon injury, tendonitis, peripheral nerve injury, osteoarthritis, disc protrusion, reconditioning, and hypomobility. Body mobilization C3-C5 with occiput stabilization is used for reducing muscle contraction headaches. This is a high velocity maneuver in which the doctor provides a quick lateral posterior to anterior thrust. This maneuver results in relaxation of the muscle contraction by aligning the joint.
Doctor: I’m going to grasp the back of your head, your skull. I’m going to provide a manipulation to realign that segment at the middle part of your neck. You’re going to feel a rapid movement. How do you feel now?
James J. Mangraviti, Jr: Atlas axis manipulation is used for neck pain, stiff neck, and osteoarthritis. This is a high velocity recoil maneuver in which the doctor uses his hand on the side of the neck near the base of the skull to free up fixation or ankylosis. This results in mobilization of a fixed joint.
Doctor: I’m going to try to reduce some of this stiffness in your neck. If you would, turn your head this way, please. This is called an atlas axis maneuver.
James J. Mangraviti, Jr: Manipulation of C5-C6 is used for reducing the effects of whiplash injury, spasm pain, and splinting. This is a sustained thrust maneuver in which the doctor uses the outside of his hand at the neck on the spinous process, moving with the same thrust from the back of the neck to the front of the neck. This maneuver should result in restoring the joint to normal position and reestablishing normal curvature after a whiplash injury.
Doctor: I’m going to be providing manipulation now to restore that joint that’s misaligned. This is a rather quick move. Just relax, please.
James J. Mangraviti, Jr: Disc distraction mobilization is used for joint and disc injury. This is a pulling maneuver in which the doctor grasps the base of the skull while the patient is lying down, flexes the neck, and gently pulls the skull back to relieve disc and joint inflammation and pressure.
Doctor: You have a swollen disc and I’m going to be now tractioning with my hands the base of your skull. As soon as you feel this relieve your discomfort let me know. I’m going to apply more and more pressure.
Patient: That feels better now.
Doctor: Okay. I’m going to hold that now until the pain is released. How do you feel now?
Patient: Good. Feels good.
James J. Mangraviti, Jr: We will now discuss and demonstrate three common thoracic adjustments. Mobilization of a segmental flexion fixation is used for osteoarthritis, painful joint spasms, and vertebrae misalignment. The patient is asked to sit upright with his hands clasped behind his neck. The doctor takes his thumb and places it directly over the painful spinous process. The doctor then grasps his hands, pulls his arms, and pushes with his thumbs to release the patient’s discomfort. You can expect to hear an audible pop when the joint is released and moves freely.
Doctor: Because of the painful joint that’s swollen in the middle part of your neck, I’m going to apply a therapy to reduce this discomfort. How do you feel now?
James J. Mangraviti, Jr: Regional mobilization of restricted extension is used when the patient is unable to bend backward. The patient is sitting upright facing the doctor. The patient lifts and places his hands over the top of his head. The doctor then places the patient’s arms into his chest, takes both of his hands, and then pulls his back into a bending extension maneuver. You can expect to hear an audible pop and feel the patient’s stiffened back move freely.
Doctor: I’m going to have you place your hands above your head now. You’re going to lean your hand and head into my chest. This is for the stiffness right through here. I’m just going to have you relax now and we’re going to provide a maneuver.
James J. Mangraviti, Jr: Tractional mobilization is used for osteoarthritis, misalignment, and spasm. The patient is standing and is asked to put his arms around himself. The doctor pulls the elbows up and back quickly. He should hear multiple audible cracks and pops. Tractional mobilization relieves joint inflammation and spasm.
Doctor: I’m going to realign this painful joint right here. I want you to cross both hands over. I’m going to take my hands up under you. Clasp your arms. Take a deep breath for me. Bend your chin down.
James J. Mangraviti, Jr: The final three adjustments we will discuss and demonstrate are for problems of the lumbar spine. Three dimensional manual traction is used for alleviation of disc or facet injury or disease. The patient is lying on his back with his arms across his chest. The doctor lifts the patient’s knee and leg. Then the doctor gently applies pressure using the leg as a lever to pull gently to traction the back. The doctor is opening the joint in the disc to relieve pain and inflammation. One can expect to hear a pop and the patient to say that his pain is relieved.
Doctor: Due to the painful swelling in your lower back disc, I’m going to be providing traction. Tell me when it starts to relieve your discomfort.
Patient: That feels better right there.
James J. Mangraviti, Jr: Side posture lumbar manipulation with recoil is used to release joint inflammation, swelling, and fixation. The patient is placed lying on his side facing the doctor. He bends his top leg towards his abdomen as far as he can. The doctor uses his hand while bending over the patient and places one hand on the shoulder and back and briskly rotates them in a quick thrust maneuver. The doctor immediately releases the patient’s shoulder and hand after the maneuver. Side posture lumbar manipulation with recoil is a common maneuver, which is designed to reduce mechanical back pain.
Doctor: Due to this stiffness right in here, I’m going to try to realign the spine.
James J. Mangraviti, Jr: Mobilization of the lumbar sacral spine is used for osteoarthritis or stiff joints. The patient is placed lying face down. The doctor places his hand at the area of his buttocks with his palm. The doctor stands at the top of the table where the patient’s head is. He will then put his weight forward and administer a sustained thrust. Mobilization of the lumbar spine will alleviate joint and hip pain, swelling, and spasm.
Doctor: Because of the inflammation in the sacroiliac joint, I’m going to provide a manipulation to that area.
James J. Mangraviti, Jr: Lawyers have many questions about chiropractic care. Let’s ask Dr. Fitzgerald some of the more common questions. What is palpation and how is it used by chiropractors?
Dr. Fitzgerald: Palpation is the use of manual pressure from the fingertips or the thumbs to determine the shape, size, consistency, position, and motility of the tissues beneath. Palpation is the primary procedure used to detect abnormalities and is the most universally applied procedure by chiropractors to identify subluxation. The two kinds of palpatory procedures are static and motion. Static palpation is done with the patient in a stationary position and can be of two kinds. Bony, where the chiropractor applies pressure to the bony landmarks feeling for evidence of joint dysfunction and soft tissue, where the chiropractor tests for pain in the dermal and deeper tissue layers. Motion palpation is performed during flexion motion, extension motion, lateral bending, and rotation bending. The experienced chiropractor will be able, through motion palpation, to identify the problems in the range of motion and the quality of joint movement.
James J. Mangraviti, Jr: What is a vertebral subluxation and how do chiropractors objectively address the presence of vertebral subluxations?
Dr. Fitzgerald: A vertebral subluxation is the alteration of normal, biomechanical, or physiological dynamics of contiguous articular surfaces. The existence of a subluxation is determined with the help of the latest instruments and diagnostic testing including x-ray spinography, computed tomography, magnetic resonance imaging, skin temperature differential analysis including thermography, paraspinal EMG scanning, bone scans, needle electrodiagnostic procedures, and clinical laboratory tests.
James J. Mangraviti, Jr: What is percussion and how is it utilized by chiropractors?
Dr. Fitzgerald: Percussion is when the chiropractor, with the use of his hand or a reflex hammer, applies force to the patient’s spine while it is flexed forward. This accentuates the spinous process, a marked response or acute pain can indicate a fracture or other traumatic joint pathology. A mild pain can indicate irritation or dysfunction. Where pain radiates into the patient’s leg, a disc lesion may be suspected. To solidify the diagnosis and determine if manipulation is appropriate, x-rays or other diagnostic tests may need to be performed.
James J. Mangraviti, Jr: Why are chiropractic symbols so confusing?
Dr. Fitzgerald: Chiropractic symbols are confusing because chiropractic is a profession in search of a standard of practice. The lack of consistency in the profession indicates a dearth of integration or even outreach to other professions by chiropractors as a profession. Note taking is often idiosyncratic, largely hand written, or often done with computer software that does not communicate as much as it confuses the status of the patient’s care. The encrypted notation is symptomatic of an epidemic of anemic record keeping. Most chiropractors feel it is unacceptable to utilize symbols extensively in their exam, diagnosis, or daily treatment records, or patient questionnaires.
James J. Mangraviti, Jr: Why does chiropractic care always seem to involve a never ending series of treatments?
Dr. Fitzgerald: The object of chiropractic treatment is to stabilize the disease or mechanical defect to achieve maximum therapeutic benefit and reduce impairment and functional disability. Oftentimes, a series of treatment is needed because the natural history of the disease or condition requires a time specific healing process. Most chiropractors terminate treatment once the condition has stabilized, the spasm has reduced, or the patient’s complaints alleviated. Objective indications of appropriate length of treatment can be found in the AHCPR and Mercy Guidelines.
James J. Mangraviti, Jr: What contraindications are there to chiropractic manipulation?
Dr. Fitzgerald: One of the oldest adages in chiropractic is it is more important to know when not to adjust than when to adjust. The Mercy Guidelines recommend that adjustments or high velocity manipulative thrust are contraindicated when the patient has rheumatoid arthritis of involved joints, acute fractures at the manipulation site, unstable os odontoideum, active juvenile avascular necrosis at the involved levels, benign bone tumors at involved levels, malignancies at involved levels, infections of bone and joint at involved levels or a significant aneurysm over the site. Note that even in patients with an acute fracture of L1, for example, spinal manipulation is not contraindicated in other areas of the spine. The most important contraindication is an inadequate physical and spinal exam and poor training in providing manipulation.
James J. Mangraviti, Jr: What types of complications can occur from chiropractic manipulation?
Dr. Fitzgerald: Complications from chiropractic manipulation are classified as adverse effects, reactions, or accidents. While rare, the most common claims are disc problems, failure to diagnose fracture or soft tissue lesion, cerebral vascular accidents, aggravation of a prior condition.
James J. Mangraviti, Jr: This concludes our program. We hope that you have found this to be a valuable resource.