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GRAVITATIONAL ANALYSIS, COMBINED VISUALIZATION WITH STATIC AND MOTION
Over the centuries
manipulative historians have had tremendous difficulty correlating a
modern diagnosis (no matter the century) with the area of altered joint
dynamics. For this reason areas of altered joint dynamic can be divided
into two common sense classifications; The Physiological Condition” of
the joint and the “Motion Condition” of the Joint. The manipulable
lesion has of these both properties or motions which assist in
differentially diagnosis and treating the condition. For example the
“Physiological Condition” of the joint is divided into disorders which
yield rationale for diagnosis based upon the anatomy, physiology, and
known pathologies associated with degenerative changes f articulations
and associated processes and structures.
Condition” of the joint tells us where on the joint the injury
occurred, why there is pain and dysfunction, and combined with a
good history of the injury or incident, tells us how the
mechanics of injury occurred as we diagnosis and
decide medical treatment.
The “Motion Condition” of
the joint is divided into the possible motions the particular joint will
exhibit. For example, we do not expect a Diarthrosis joint to exhibit
all the motions of an Ampharthrosis Joint. Thus, when examining the
spinal joints with a motion examination we bring the joint through at
least five (5) ranges of motion, which are forward flexion, extension,
lateral flexion-rotation rotation-lateral flexion, and circumduction
(which is a combination of forward bending and lateral bending motions
(combined motion) to the right and left. While bringing the spinal
joints through the five ranges of motion, the physician holds or will
‘fix” the vertebral joint under examination. If the patient report
pain/or the physician feels “joint splitting” or “joint excursion”, we
have found the “motion condition” of the joint. When we find the
“motion condition” of the joint, it indicates the restricted motion, in
what direction the joint restriction exhibits splinting, thus indicating
the direction or vector of correction. The “motion Condition” assists
in the differential diagnoses between the physiological conditions, and
indicates in what direction the joint must be adjusted.
Location of the painful
joint restrictions and resultant areas of compensatory Pathomechanics
described, is the chiropractic diagnostic procedure known as Motion
Palpation. Motion Palpation involves biomechanics in practice clinical
application. Awareness of the facet facings and of how each vertebral
joint of a given area moves is mandatory. Inducing the motion
specifically in the correct joint area, feeling for the correct data and
correlating correctly with degree of altered joint dynamics indicates
where and why and how often the joint splint or
excursion must receive treatment. Of course, you would write what
joints are to be adjusted. Further, the examination indicates whether a
correction of the altered joint dynamics occurred with manual medicine.
Throughout this section,
you will study lesion consistent for palpation, gravitational analysis
for body mechanics during weight bearing situations, motion palpation
and end feel analysis.
The cause of a muscular
joint split or restriction is usually due to a contracting head of a
muscle, a contracting muscular fasciculation within a muscle or an
entire muscle pulling the vertebra into joint splinting dynamics
represented by the joint restricted in rotation, lateral flexion
extension, flexion, or a combination of planes. Of course, there is
regional general spasticity. Note these findings if they are present.
This denotes and early acute phased of injury, or chronic condition with
Upper and/or Lower Motor Neuron Disease. Generally, if an entire muscle
contracts into spasticity neighboring and even distant vertebrae are
affected. Influences which cause muscular spasticity are numerous and
some follow: Atmospheric changes of heat and cold (Bells palsy,
Torticollis etc) vasomotor spasm, visceral reflexes, toxic metabolites
in the blood and tissues, fatigue, postural stresses and strains,
postural defects (Kyphosis, Lordosis) lateral curvatures (scoliosis),
infections, inflammation, pathologic changes in nervous system or
somatic tissues. Stretch/strain/sprain or overexertion and poor diet are
causes of muscular spasticity.
The cause of a ligamentous
restriction is usually due to ligamentous thickening or thinning of the
fibrous tissue. The etiology is usually mechanical irritation and or
inflammation and congestion. The result is a restricted (joint splint)
joint or relaxed (hypermobile) joint. The restricted joint is
characterized by an approximation of all the bony parts with a thinning
of the intervertebral disc and a thickening of the ligament about the
joint. Later, when you review the Huston Conference Listings these
conditions are known as Kinetic Intersegmental alterations.
elasticity of the interarticular fibrocartilage and a thinning of the
ligaments about the joint characterize the hypermobile joint. In order
for a joint to translate into excursion dynamics the ligamentous,
holding structures would have had to undergo deformation and creep.
Thus, the joint is lessened and its integrity has been compromised and
is in jeopardy. Etiologies for deformation of ligamentous holding
structures are trauma but also rheumatoid arthritis, and various
FUNCTIONAL PROPERTIES OF TENDON
Tendon organs are
relatively insensitive to passive “stretch” because they lie in series
with a compliant, contractile element that absorbs most of the stretch
and prevents elongation of the tendinous region. Changes in the muscle
length then affect tendon organs very little, and their receptors
provide no information about length. When a muscle contracts as in
isotonic exercise, the tendon organs within it discharge in proportion o
the tension that is developed. If the contraction merely shortens the
muscle without developing very much tension, the tendon organs are
weakly excited. If contraction would occur when the muscle is
lengthened and the ends are “fixed”, the shortening of the contractile
part of the muscle necessarily lengthens the noncontractile area where
tendon organs are located and vigorous firing will occur. Sometimes a
particular tension may be developed at various muscle lengths. Because
of their location, tendon organs measure this tension regardless of
When a stimulus is
appropriate the tendon organ is an extremely sensitive receptor.
Systematic testing of all the motor units in the Soleus muscle was
performed and it was found that about 15 different units will each cause
firing of a single tendon organ. Histological studies have shown that 3
to 25 muscle fibers insert on each tendon organ. Thus, a motor unit in
the Soleus that has averaged 180 fibers contributes only one or two of
them to a tendon organ. A tendon organ samples the local tensions in a
muscle by monitoring a small faction of the muscle fibers of a large
number of functional motor units. Response of a tendon organ is
determined by the number of active motor units inserting on it and the
tension developed by each of the contributing fibers. It is known that
a single muscle fiber producing 0.1 gm of tension is sufficient to cause
the receptor to fire at 25/sec. Thus, tendon organs have great
sensitivity and must be active whenever muscle are contracting and doing
(important reference in hyper flexion/hyperextension injuries as well as
FUNCTIONAL PROPERTIES OF
Ligaments act as the
holding structures of the somatic tissues. Often times it is their task
to hold vital structures from being touched by bony processes during
movement, and often times they may guide and/or assist in the motions of
When ligaments are damaged
may things can occur. They can elongate and thin with subsequent
atrophy and necrosis generally associated with deformation of the
ligament and subsequent creeps due to elongation with improper healing.
Ligaments can also thicken and swell due to irritation and edematous
Even the juxtaarticular
epiphyseal or apophysial insertions of ligaments can be damaged in
extension injuries. However, the body has provided excellent protection
for the insertions of ligaments into the osseous tissues. There is an
interposition of cartilage tissue between the ligament and the bone.
This subsequently reduces the chances of mechanical strain on the zone
of ligamentous insertions by preventing the ligamentous insertions from
being able to kink and twist. Thus, the fibrous interposition of
cartilage acts as an anchor to the ligamentous insertions.
If an excessive extension
injury occurs and the ligamentous juxtaarticular epiphyseal or
apophysial insertions are stretched and strained, than there may be the
process of deformation due to necrosis. This occurs in the following
steps. First, there is a deposition of lipids, and calcium salts by
hyalinization. This is usually followed by necroses and degeneration
and thinning. Often times an altered healing process also occurs.
Multipontential connective tissue cells degrade the degenerated portions
of the ligamentous tissues and scar formation of the tissues occurs.
The finale to this form of repair is generally a transformation of cells
to osteoblasts and bone formation occurs. This explains how traction
spur occur at insertions of ligaments and even tendons and how
osteoarthrotic Osteophytosis in the articular cartilage forms. This
fibroostosis or fibrous tissue becoming osseous tissue is noted upon the
radiograph a horizontal process if osteophytes, or a spur or pin or
This fibroostosis is of
primary concern to the Chiropractic physician because complete
ligamentous ossifications can occur secondary to some traumatic
incidents, permanent overloading as in the obsess or patients who
repetitively lift weights in excess of their physical conditions. If
these ligaments are not stretched with corrective manual medicine than
the mechanical impairment can again cause regressive pathological
changes in neighboring soft tissues and contiguous bursa. Repetitive
irritation may then cause friction and reactive inflammation, infection,
edema and congestion. This may irritate nervous tissues and cause
radicular complaints. When ever a fibroostosis is found than it must be
assumed that their may other etiologies other than trauma. Thus,
referral to a medical physician or a battery of lab test would be in
order to rule out bacterial or viral invasions of the tissues.
However often times the
fibroostosis is due to aging or trauma and may manifest itself with
calcium deposits in the ligaments, tendons, and ever bursas. Notorious
is the calcium deposits in the shoulders of the aged after some
traumatic incident. Various names for these deposits have been noted in
the medical literature such as calcareous tendonitis, calcareous
peritendinitis, calcareous bursitis, periarthritis and periarthropathy
where the calcium deposits occur not only in the ligaments, tendons,
tendon sheaths and tendon bursa but as well as the fibrous joint
capsules. Often ties these conditions are asymptomatic. However may
times they cause extreme limitation of joint motion, swelling, and even
severe pain. These calcium deposits may cause an inflammation and
reaction, which may spread down the course of the tissues. As in the
case of the shoulder, immediate shoulder adjustive procedures to break
up the fibrous adhesions and calcific densities will assure a return to
normal motion. These procedures should always be preceded by specific
physiologic therapeutics such as interferential and ultrasound for
hyperemic, antispasmodic, analgesic and nerve root sedation effects.
During acute stages of secondary reaction due to trauma use cryotherapy.
Many Physicians have
written about Motion Palpation over the years and it is this examiners
opinion that absent a combined Gravitational Analysis, combined with
Static and Motion Palpation and then Joint End Feel Analysis, Motion
Palpation alone yields equivocal results. However, an Examination,
which is a complete series of progressive joint analysis through joint
weight barring, static palpation and motion palpation, forms the motion
examination. Finally, the lesions discovered during the motion
examinations are consistent with lesions reviewed radiographically or
through imaging, consistent with the lesions noted upon active motion
palpation and finally consistent with the lesions treated by modern
scientific manual medicine.
It has been
established that the spinal column offers an intricate lever system
associated with the prime movers or the muscles as well as the primary
and secondary stabilizers the ligaments, tendons and other bones. This
biomechanical system allows the biped to move about efficiently under
the force of gravity. As the earth’s gravitational field tries to
accelerate the biped toward the center of the earth, our somatic
structures apply the correct force for the erect plantigrade posture or
a greater force for sustained motion.
Often times if the body is
unable to balance the centers of gravity with the force of gravity,
postural stresses, or strains with associated reflex tensions may
occur. If these manifestations are not corrected by homeostasis or
other means a vicious cycle of pain and discomfort may result. One
method of determining which joins have altered dynamics is through the
Motion Examination. This begins with a Gravitational analysis obtained
by comparing the biped with the gravity line either visualized or
conceptualized. A superiorly anchored cord that is fixed inferiorly,
called a plumb line, represents the gravity line. When the patient is
placed against the plumb line in the lateral position the line should
intersect the following anatomical landmarks:
A point which is slightly posterior to the
apex of the coronal suture
A point, which intersects the external
A point, which intersects most of the bodies
of the cervical vertebrae.
A point, which intersects the shoulder joint.
A point, which intersects the bodies of the
A point, which is slightly posterior to the
axis of the Acetabulum.
A point, which is slightly anterior to the
axis of the knee joint.
A point, which is slightly anterior to the
When the biped is compared
in the anterior-posterior position, the line should project at the
mid-line of the body.
IN-DEPTH COMBINED GRAVITATIONAL
VISUALIZATION AND PALPATION
After the physician has
compared the eight gravity intersect points he may begin his in-depth
gravitational analysis. This is done in the following manner;
The physician will observe the alignment of
the occiput. This is done by digital palpation of the inferior edge of
each mastoid process, and comparing them to one of your palpation hands
which is pivoted to a horizontal position. It has been determined with
palpation and visual observation whether the occiput is level with the
horizontal or if one mastoid is high. For example if the right is
elevated note the mastoid is high on the right.
The physician will note if one side of the
face shows more than the other. This may indicate a rotational
malposition. If the occiput palpated high on the right and the left
side of the face showed more than the contralateral side the notation
would be listed as RIGHT POSTERIOR SUPERIOR OCCIPUT.
Palpate down the upper trapezius for a
difference in muscle tonus, temperature differential, skin texture,
differential in oiliness or dryness and note the findings. Compare your
findings with your knowledge of Myotome, dermatome and neurological
relationships for determination of which vertebral segments would
theoretically be in a state of altered joint dynamics.
Once you have palpated the Acromion processes,
pivot your hands out laterally. Observe the shoulder height. Make sure
to note if one shoulder is elevated.
Observe and palpate the scapulae. Indicate
your finding sin the following manner
Right (left or negative) downward rotation
with concomitant shoulder change.
Unilateral scapulae elevation or depression
with concomitant shoulder change.
Right (left or negative) upper scapula
rotation with concomitant shoulder change.
Unilateral abduction or bilateral abduction of
Unilateral or bilateral scapulae adduction.
Vertebral winging or protrusion of medial
border of either scapulae.
Contact the i9liac crest bilaterally,
beginning at the inferior and pressing the soft tissues as your hands
translate superiorly and laterally and observe heights. Indicate right
or left iliac crest elevation.
To contact the inferior border of the
Posterior superior iliac spine come from the inferior and move
superiorly. Determine if one has moved posteriorly, inferiorly and
medialward. If the PSIS palpates more prominent make a note of it. If
the PSIS palpates anterior, superior and laterally (or medialward) make
a note of it. For the Chiropractic Physician, communication between
Biomechanical Experts or DC’s is mandatory and code your notes a RPIN,
LPIN,LPEX, LAIN, RAIN, LAEX, RAEX. For example the RPIN equates to the
right PSI moving posteriorly and inferiorly. LAEX equates to the left
PSIS moving anteriorly and externally.
THE VETEBRAL COLUMN
This procedure is best accomplished with a skin pencil for
the novas with these procedures. Compare the patient’s spine with the
gravity line. Observe the following:
Scoliotic deviations in the neutral
plantigrade posture. Next have the patient flex forward in Adams
position and note if the scoliosis diminishes (determine functional from
Palpate for differences in the patients
paravertebral musculature. Check for any prominent areas and/or
differences in texture or temperature. Also feel for prominent AP’s,
SP’s. Tp’s or MP’s.
Note relative abduction or adduction and the
Note the hands for medial or lateral rotation,
which may indicate shoulder rotation and/or Pronation-Supination of the
Observe the patient for translation through
the coronal plane. If one limb appears abducted, the other often times
Observe the Gluteal masses for symmetry and
compare bilaterally for muscle tone.
Observe the patients knees for genu valgum
(knock knee), or genu varum (Bow legged).
Observe the legs for differences in muscle
mass or symmetry.
Observe the ankles for inversion or Eversion
as well as Pronation and Supination.
Observe for loss of arch of foot as well as
deformation of the greater toe.
B.J. Palmer DC stated
“Palpation is the method of feeling, pressing or exploring with the
fingers. Vertebral palpation is the application of the principles of
palpation to the vertebral region; or it is a method of feeling, pressing
upon or exploring the region over the vertebrae or the purpose of
detecting irregularities or abnormalities in the form of subluxation,
curvatures….” Dorland’s dictionary states “Palpation is the act of
feeling with the hand; the application of the fingers with light
pressure to the surface of the body for the purpose of determining the
consistency of the parts beneath in physical diagnosis.” Actually
palpation is limited by the knowledge of the physicians and physicians
limited in palpation must never attempt to correct altered joint
Historians point out that
the middle finger of each hand has been distinguished with the title the
“Chiropractic Index Finger” distinguishing it from the first finger.
This finger has the greatest strength it is manly utilized for gripping
action and not that of tactile application. However with training this
finger develops great sensitivity due to the fact that brain centers
have been previously untrained and are impressionable. In the 1970’s
when I matriculated through the Los Angeles College of Chiropractic one
method of palpation training was to place a hair on a peace of paper.
Next they took another piece of paper and placed it upon the first. The
hair was palpated. Once this level was mastered another peace of paper
was placed upon the first. Some have palpated a strand of human hair
under no less than 30 pieces of typing paper. I was one of many.
Very light touch, light
touch; touch, and pressure are the taxonomy for communicating relative
tissue depths reached. In very light touch, or in fact passing the hand
a few millimeters above the skins surface may provide information on
surface temperature. Light touch may reveal skin humidity, and the
sebaceous and sudorific condition and activity of the skin. Mild
pressure may reveal the tone, plasticity and turgor of the skin. Slight
pressure reveals the superficial muscle groups and at times determines
their tone, turgor, and metabolic (Toxic metabolites) status. Moderate
pressure may also be utilized for abdominal exploration and
determination of organ size, shape, and correct location. Deeper
penetration pressures may allow firm, easy and gentle contact with
bone. Knowledgeable palpation assures purposeful palpation, which will
reveal vital information.
Actual palpation is
conducted with the bulb of the finger and not the tips. When palpating
a patient’s spine take the index and middle fingers and slide one at a
time downward not jumping or losing Cutaneous contact between finger and
skin. The following are landmarks for palpating the spine.
External Occipital Protuberance – EOP
Cervical second vertebra is the first big
posterior bone, and is bifid. Upon motion examination in flexion of the
head the spine moves posterior.
Cervical third vertebra has the smallest
spinous process of the spine, and also moves posterior upon head
flexion. Cervical fourth and fifth also move posteriorly upon head
Cervical sixth vertebra is found by motion
examination. Flex the head and neck forward. Find cervical six by
counting down from cervical two. Once found note at extending the head
upon the neck and upon the shoulders allows cervical six to disappear.
In clinical practice the contact finger would be placed approximately
upon cervical six and the head extended to define cervical six.
Thoracic first vertebra is known as vertebra
prominence in 40% of the population. On X-ray examination thoracic
first spinous process points caudad more caudad than the cervical
Thoracic third is found at the level of the
Thoracic fourth is the widest and longest
spinous process and the last to have an oblique angle.
Thoracic fifth is the first spinous generally
to angle inferiorly.
Thoracic sixth found in the prone position, is
at the level of the infrascapular line.
Thoracic seven is found at the level of the
infrascapular line in the plantigrade posture, ad thoracic eight is
found at the infrascapular line in the seated position.
Thoracic nine and ten are parallel in
configuration and generally palpate as one. Their angulations are more
perpendicular to the axis of the spine.
Thoracic eleven is a motion vertebrae
exhibiting great joint flexibility.
Thoracic twelve is known as a transitional
vertebra because it appears as if it is a lumbar vertebra. It also
forms attachment bigger but shorter than a thoracic. However is a
little smaller but longer than a lumbar spinous.
Lumbar third is considered the apex of a
lumbar curvature whose curve is within normal biomechanical limits.
Lumbar fourth spinous is at the level of a
line drawn from the superior crest of the Ilium.
Lumbar fifth is the last movable segment of
the spinal vertebrae.
Sacral two’s tubercle is at the level of the
posterior superior spine.
The coccyx is the last moveable segment of the
The body of a vertebra can be found by
palpating the spinous and moving the finger cephalad and around.
Transverse process of the cervical spine can
be palpated by feeling just lateral t the spinous a finger girth or on
the side of the neck.
The thoracic first body is at the level of the
Interspinous space above thoracic first spinous.
Thoracic fifth through eight palpate two
Interspinous spaces above and move lateral.
Thoracic nine through twelve palpate one
Interspinous space above and lateral.
Mamillary processes are best interpreted in
the prone position. Palpate one Interspinous space above and lateral,
and about the width of two fingers. Lumbar fifth is an exception to
The facets of Michaelis should be noted.
These are the soft tissue indentations in the lumbar region.
Visualize the foramen magnum correlating its
level with the hard palate.
Palpate cervical third vertebra and the hyoid
bone at the same approximate level.
Palpate cervical fourth and fifth and the
thyroid cartilage at the same level.
Correlate cervical sixth with palpation and
visualization of topographical landmarks such as the beginning of the
trachea, end of the larynx, beginning of esophagus, end of pharynx, and
Cervical seven correlated with the level of
the isthmus of the thyroid gland, and the highest pint of the thoracic
Thoracic first is correlated with the level of
the apex of the lungs.
Thoracic fourth is correlated with the sternal
angle, 2nd costal cartilage, end of ascending aorta, end of
trachea, and limits of superior mediastium from inferior mediastium.
Thoracic fifth to the thoracic seventh are
correlated with the thoracic duct as it crosses posterior to the
esophagus from the right below to the left above.
Thoracic seven is also at the level of the
inferior angle of the scapula in the standing posture.
Thoracic eight is correlated with the inferior
vena cava as it passes through the diaphragm.
Thoracic nine is correlated with the
Thoracic ten is correlated with the level of
the esophageal hiatus in the diaphragm.
Transverse process of atlas of cervical one
inferior and slightly anterior to the mastoid process.
Cervical seven is the second most prominent
spinous process in this region of the spine.
Thoracic second opposite jugular notch.
Thoracic fifth opposite the angle of Louis (sternal
Thoracic ten opposite the xiphoid process.
Lumbar thi8rd disc correlated with the level
of the umbilicus.
Sciatic notch is correlated as two inches
inferior and one-inch lateral to the PSIS also known as the PSS.
Ischial tuberosity is correlated as two inches
inferior to the apex of the coccyx and on a vertical line through the
The most important of the
latter would be used as ready references due to their nature. These
again follow: To find C6 it disappears upon extension. Thoracic seven
in the plantigrade posture can be found by palpating the tips of the
scapulae. To verify a thoracic or lumbar location palpate the 12th
rib to the 12 thoracic vertebrae and count to vertebra in question.
Crests of the Ilium across from the L4 spinous.
To palpate the sacroiliac
joints slide the thumbs caudad until you feel a slight notch or hook on
the Ilium in the sacral area. Visualize the fossae of Michanelis where
the depressions of the skin are due to the bony prominences. Motions of
the SI joint are related by the PSIS. The PSIS can go in a postero-inferior
motion, an antero-superior motion, an internal motion, and an external
motion. Postero-inferior is coded PI. Antero-superior as AS. Internal
deviation as IN. External deviation as EX. When you static palpate
this area note if the PIS are relatively PI, AS, IN, EX, PIIN, PIEX,
ASIN, or ASEX re within normal limits of symmetry. However many
physicians assume that it is understood that when the PSIS moves
posteriorly it moves inferiorly and when it moves Anteriorly it moves
superiorly. Chiropractic Physicians code the motion to denote which
PSIS is under discussion. This diversified coding would be as follows:
RPI, LPI, RAS, LAS, RIN, LIN, REX, LEX, RPIN, LPIN, RPEX, LPEX, RAIN,
LAIN, RAEX, LAEX.
Palpation for the Greater
Trochanter of the femur begins by palpating the lateral aspect of the
iliac crests. Palpate caudally about 5 or 6 inches to locate the
greater Trochanter. In chapter 11 you will correlate this location with
sciatic distribution manifestations. This is due to the fact that the
Piriformis muscle originates from the anterior aspect of the sacrum (see
Chapter on Origins and insertions) through the sciatic notch and inserts
on the greater Trochanter. Its function is external rotation of the
thigh. It lies over the sciatic nerve and the nerve pierces it in many
Palpation of the
Transverse process of the Atlas begins by palpating the mastoid
process. Palpate caudally by coming off the mastoid and moving
inferiorly along the sternocleidomastoidius muscle to its belly. The
transverse process palpates as a tight area in the muscle as if it felt
dull and abut twice the size of the eraser end of a pencil.
Finally palpation of the
lamina pedicle junction of the cervical spines is located one finger
width lateral to the spinous process.
THE MOTION EXAMINATION LESIONS
For many generation’s
various health care practitioners have utilized some form of manual
manipulative medicine to alleviate the joint related ailments of
mankind. Hypocrites in 490 BX utilized a crude form of traction as
described in “On Setting Joints By Leverage” and “Manipulation and Its
Importance to Good Health, “ just two of the many books he wrote.1
Doctors of Chiropractic,
the primary proponent of manipulative procedures used today, introduced
for the first time in the written scientific literature a “short
leveraged manipulation of joints using the spinous, transverse and other
vertebral processes as levers” to relieve ailments of their patients.
Today, manipulative medicine is being utilized and investigated by
scientific bodies worldwide.
The question remains,
once a quality examination has been performed, and it has been
determined manipulative medicine may be the prudent choice of
treatments, how can we figure out where to manipulate, and whether any
correction has occurred? Of primary importance to physicians interested
in manual manipulative medicine are the “Motion Examinations”. As noted
the Motion Examination combines all moving forms of palpation including
Motion Palpation. The Motion Examination is the system of modern
biomechanical based methods used in determining when and where a spinal
adjustment (Short radius manipulation to a joint) is indicated, or a
mobilization is indicated.
Often times if the biped
is unable to balance body centers of gravity with the force of gravity
and external loads, postural stresses, or strains with associated reflex
tensions, pains and suffering may occur. Further, many conditions
presented for manipulative medicine are due to some incident where the
joints of the body may have been overworked, jammed or stretched,
strained, and/or sprained and possibly deformed. This “jamming’ (Joint
Compression), overexertion (injury to the joint during or within its
physiological range of motion), or extension (injury to the joints
beyond their physiological range of normal motion) may produce an “area
of altered joint dynamics” via altered mechanics.2
This may be represented
upon examination by a “restricted joint or ‘joint splint” (hypomobile,
fixed translation, subluxation, restricted somatic dysfunction) or an
area of excessive joint play or motion known a hypermobile (hypermobile
somatic joint dysfunction, hypermobility, vertebral translation,
subluxation, or vertebral excursion).
A “joint restriction” is
defined as an isolated joint complex that demonstrated restricted
movement upon motion examinations and may have pain that can be minimal
to severe in nature, and is the consequence of a biomechanical or
pathomechanical change. The joint restriction palpates upon motion
palpation for example as a living, rubber like resistance increasing
during the continuum and upon reaching end motion comes to an abrupt
stop with some reflex or rebound to reduce physiological
Generally the joint
restriction phenomena is a component of a musculoligamentous
stretch/strain or sprain injury or a component of a reflex arch from
internal organ disease or even psychosomatic sequelae.1
A “hypermobile joint” is
defined as an isolated joint complex that demonstrates excessive motion
upon a motion examination, and again may have pain that is minimal,
slight, moderate, or severe, and is due to a biomechanical or
pathomechanical physiological change. The “hypermobile joint” (spinal
or extremity) palpates upon motion palpation as too much palpable motion
with a lack of restriction that seems to lose normal resistance prior to
end motion. End motion has been described as n empty feeling stopped by
a pain/discomfort response.2,
6 This is generally a component of a severe sprain with
musculoligamentous or tendinous tears, severe deformation of ligaments
with subsequent osseous creep or even a sequelae of chronic improper
When we are recording
range of motion findings looking for restrictions of motion with pain
responses we are assessing osteokinematic motion which is the movement
that occurs between bones.5
While assessing arthrokinematic movements you will note joint
play motion. Joint play movements are those accessory movements that
can be produced passively at a joint but cannot be produced actively.
When you perform a motion examination you will note those restrictions
to your applied motion noting the joint is in a closed packed position
also know as maximal congruence. When a joint is restricted in a closed
packed position and a subsequent trauma occurs to the joint conditions
such as fractures, dislocations, capsular tears and so forth can occur.5,6,7
Conversely if a joint is
in a loose-packed position, which is less stable and has more joint
play, trauma could perhaps induce strains and sprains to the associated
tissues about the joint.5,7
Thus the motion examination of a joint will denote whether the joint is
closed packed or in maximal congruence, restricted, hypermobile or with
a normal limit for motion, tension and absence of pain.
Often times these areas
of altered joint dynamics are not demonstrable on radiological imaging.
Here we say we have a joint restriction, or subluxation without
radiological imaging evidence and describe the change in body mechanics
by palpable pain responses, diminished range of motion with or without
pain responses, positive orthopedic tests, measurement for atrophy,
inability to perform a squat, note positive heal or toe walking and
normal and customary history, limited physical, orthopedic examination
of the area of complaint and neurological examination noting
consistencies and abnormalities related to your special testing such as
MRI. Then a diagnosis is rendered such as a strain, sprain, and
traumatic acceleration deceleration musculoligamentous injury. Examples
of radiological utility for alterations in joint dynamics would include
the Lines of symmetry such as Jackson’s, Chaberline’s, Ferguson’s,
Ulman’s, George’s and the like.
Specific alterations in
joint dynamics were organized into the Houston Conference Listings,
which are considered investigative, valuable and follow:
RADIOLOGICAL NOTATION OF
ALTERATIONS IN JOINT (CHIROPRACTIC LESIONS) DYNAMICS:
Static Intersegmental Displacement:
Lateral Flexion Malposition
Altered Interosseous spacing
Osseous foraminal encroachments
Kinetic Intersegmental Alterations in Joint
Sectional or Block Alterations in Joint
Scoliosis secondary to muscular imbalance.
Scoliosis secondary to structural asymmetries.
Decompensation of adaptational curves
Abnormalities of motion examination.
Costovertebral and costotransverse
Extremity Alterations in Joint Dynamics:
RADIOGRAPHIC ALTERATIONS IN JOINT
The Academy does not believe that
Radiographic Examination is necessary to locate and treat Manipulable
lesions. It is not necessary to irradiate each patient with a
biomechanical condition unless the study is to rule out pathology and
thus focus the care specifically.
Joint Restricted in Flexion
Motion or the Flexion Malposition.
A flexion joint “splint”
or restriction of a vertebral articulation in the position of flexion.
When a vertebra is restricted in a relative position of flexion it has
been designated a code of “FR” (flexion restriction), or “AR” (anterior
restriction) by the American Academy for Justice Through Science. In
the coordinate system, the vertebra has moved into the z-plane about the
x-axis in an anterior cylindrical motion.
Anatomical theories of the FR
The spinous process of the vertebral joint has
separated from the one below, thus approximated to the one above.
Generally the spinous would be palpated more easily then it would be
Parts of the articular surfaces are in
The body presents anteriorly at the anterior
The disc may be compressed anteriorly and
The following ligaments are thought to have
been stretched, thinned, and possibly atrophied in a worse case
scenario; Posterior longitudinal, ligamentum flava, Supraspinatous,
Interspinous and intertransverse. The anterior longitudinal ligament is
relaxed and perhaps thickened.
Due to the separation of the pedicles of the
vertebral joint splint with one below, the intervertebral foramina are
increased in size above and decreased below. Often times inflammatory
changes occurs at the foramen with a resulting deposition of connective
tissue, edema and congestion, which may alter the size of the foramen.
Fasciculi of extensor muscles of the area may
be stretched, strained and possibly deformed or atrophied.
Corresponding muscles of the flexor muscles may be contracted.
JOINT RESTRICTION IN EXTENSION
An extension joint splint
is a restriction of a vertebral articulation in the position of
extension or hyperextension. When a vertebra is restricted in a
relative position of extension or hyperextension, it is designated as
“ER” (extension restriction) or “PR” (posterior restriction). In the
coordinate system, the vertebra is moving out of the z-plane about the
x-axis in a posterior cylindrical motion.
Anatomical theories of the
The spinous process of the vertebral joint has
approximated to the one below and separated from the one above.
Parts of the articular surfaces have glided
posterior and inferior.
The body presents a slight posteriority at the
anterior inferior margin.
The disc is thought to perhaps be compressed
posteriorly and stretched somewhat anteriorly.
All the posterior ligaments are relaxed and
perhaps thickened where the anterior longitudinal ligament is stretched
perhaps thinned and possibly atrophied if a chronic restriction.
The intervertebral foramina are generally
narrowed vertically. When inflammation occurs connective tissue may
lessen in caliber.
Fasciculi of the extensor muscles of the area
are contracted while corresponding flexor muscles are stretched and
possibly atrophied if the condition is chronic or untreated. The fifth
lumbar vertebra, and the T3-T7 thoracic, vertebrae present extension
joint dynamics most commonly.
JOINT RESTRICTION IN ROTATION AND
A rotational joint splint
is a restriction of a vertebral articulation in the relative position of
rotation. When a vertebra is restricted in a right rotation it is
designated a “RR” (rotational restriction right) or “LP” (left
transverse process has moved posterior) or “PR” (spinous process has
moved posterior and to the right).
Anatomic theories of “RR”
Spinous process to the right.
Left transverse process is posterior and
approximated to the one below.
Right transverse process is anterior and
approximated to the one above.
Vertebral body relatively rotated left
posteriorly and right anteriorly.
The intervertebral disc may be compressed on
the left and spread on the right.
The IVF is narrowed vertically on the left and
widened vertically on the right.
The third right rib is slightly anterior to
adjacent ribs, separated from the fourth rib and approximated to the
The third left rib is posterior to the
adjacent ribs, approximated top the fourth, and perhaps separated form
On the right the ligamentum flava, capsular,
lateral spinal and anterior longitudinal ligaments may be stretched,
thinned and possibly atrophied. On the right, the latter ligaments are
perhaps shortened and thickened if the condition remains untreated.
On the right, the fasciculi of the multifidus,
semispinalis, and rotatores are contracted on the right, stretched and
atrophied on the left.
Rotational joint splints
occurrence in relation to spinal area is governed by the patients age.
Generally, they are most commonly found in the cervicothoracic spine.
As one reaches their fifties they are most common in the cervical spine
generally have a property of lateral flexion in their dynamic position.
LATERAL FLEXION RESTRICTION
A lateral flexion joint
splint is a vertebral articulation restricted in the position of lateral
flexion. When a vertebra is restricted in right lateral flexion
(lateral flexion has a component of rotational dynamics-coupling
motions) it is designated as a “LR” (Lateral flexion restriction). In
the coordinate system as the vertebral jot and vertebrae tilts into the
x-plane about the z-axis in a right lateral cylindrical motion.
Anatomical theories of “LR”
The intervertebral disc is thought by some
authorities to be compressed on the left, widened on the right.
A perpendicular line projected upward from the
superior vertebral end plates is inclined to the left.
Intervertebral foramen on the left narrowed
infero-posteriorly, and widened vertically on the right.
The right anterior longitudinal lateral
spinal, capsular, and ligamentum flava are stretched and possibly
atrophied. The latter ligaments on the left are perhaps shortened and
thickened absent care.
Fasciculi of the intertransverse multifidus
and rotatores are stretched and possibly atrophied on the right. The
latter fasciculi of muscles on the left perhaps become shortened and
thickened if the condition remains.
Oftentimes if a lateral
flexion joint, restriction occurs alone and not in a group or lateral
sweeping complex of vertebrae the etiology is discopathy, or
degenerative joint disease or some other arthritis o disease.
ANTERO, RETRO AND LATEROLISTHESIS
Antero or Spondylolisthesis
A defect in the pars
interarticularis allows anterior translation of the involved vertebra in
relation to the sub adjacent one. This “Anterolisthesis” of a vertebra
is known as a vertebral anterior excursion or more commonly
Spondylolisthesis. The true etiology is unknown. The foremost theory
suggests that anterior excursion is due to a fatigue fracture
superimposed on a hereditary defect or predisposition. The following
list demonstrates the wide view on the mechanism of Anterolisthesis.
Separate ossification centers (The lateral
masses, which normally have one ossification center, have two which fail
A fracture which occurs at the time of birth
An ordinary fracture of the region.
A stress or fatigue fracture.
Excursion secondary t increased lumbar
Displacement secondary to breaching of
superior and inferior articular processes.
Weakness of regional ligamentous and support
Aseptic necroses of the pars interarticularis.
Dysphasia of the pars interarticularis.
It is interesting to note
that Anterolisthesis have a high incidence below the age of six and a
half. Yet, fatigue fracture occurs after the age of six and a half.
The radiographic details of the pars are not typical of fatigue
fractures elsewhere in the body. These issues detail how incongruous a
typical fatigue fracture appears an opposed to a pars “break” or
One logical explanation
is due to the fact that the lumbar spine has a different configuration of
loading dynamics than the rest of the spine. The lumbar spine must
resist powerfully loaded shearing fore pressures while acting in its
normal function. Thus, these powerfully loaded shearing force pressures
cause a break in some cases.
Spondylolisthesis due to discopathy)
Retrolisthesis akin to
lateral listhesis are illusive to traditional medical literature.
Whether the etiology is flexion-extension strain, discopathy or disease
the retrolisthesis is a posterior excursion of the upper of two
vertebras except in the case of the sacrum. Generally, it is
accompanied by some degree of extension of a motion unit and possible
approximation of vertebral bodies due to disc narrowing. The vertebral
excursion remains restricted in posterior dynamics the body of the
vertebra is thought to cause friction and irritation of the structures
surrounding the nerve root. This may cause the reported Radiculopathies
reported by clinicians.
follows a multiplane alteration of joint dynamics. Generally a lateral
excursion is characterized by a lateral translation and excursion
accompanied by considerable vertebral rotation. Radiologic imaging
demonstrates an overreaching of the lateral margin of the vertebral body
of the superior vertebra relative to the subadjacent one. These areas
of Laterolisthesis are rare to the medical and scientific literature and
rare to clinicians.
Spacing refers to a decrease or increase in the interosseous space.
This condition is considered the most common of all the alterations in
vertebral joint dynamics commonly demonstrated by the Geriatric
The main features of a
decreased interosseous spacing are a narrowing of the vertical
intervertebral foraminal space and inferior excursion of the facets.
This narrowing is generally due to degeneration of the disc, which thus
yields an approximation of the vertebral bodies and facet
articulations. This may cause a degeneration of the intervertebral disc
resulting in increased intra discal pressures with possibility of
prolapse of the nucleus, herniation of the disc into the end plate, into
the intervertebral foramen yielding compression of the contents within
the intervertebral foramina, increased shearing force pressures upon the
posterior vertebra joints resulting in facetal imbrications and
sclerosis, in chronic cases yielding facetal degenerative arthrosis with
ebernation an even hypertrophy, resulting in alterations in vertebral
joint motion dynamics which can lead to compensation in biomechanics’ in
neighboring or even distant motor units which make up the spinal
Conversely, the main
features of an increase in interosseous spacing is a excursion of the
superior vertebra body and facets from the inferior, traction stress
forces to the annulus and the synovia of the inferior facet
articulations and jamming of the superior joint capsules, stretching of
the ligament associated with the motor units involved. This situation
is generally due to a pathological process or inflammatory swelling of
The features of foraminal
occlusion are compressive friction and irritation to the structures
within the intervertebral foramen which ay lead to nerve root swelling
and congestion within the foramen. Generally, foraminal occlusion is
due to any or a combination of the above listed static alterations in
joint dynamics, degenerative joint or disc diseases, foraminal stenosis
either acquired or idiopathic, Osteophytosis and so forth. If nerve
root irritation occurs than a radicular condition may occur.
KINETIC INTERSEGMENTAL ALTERATIONS IN JOINT DYNAMICS
JOINT RESTRICTIONS AND
The main features of the
joint splint are a motor unit, which demonstrates restricted motion.
Joint restriction may be due to muscular spasticity, thickening of the
intervertebral fibrocartilage, thickening of the ligamentous holding
structures, discogenic disease, Osteoarthritis and so forth. Patients
generally report these as a severely painful catch in the back. If the
joint is restricted in a position of altered joint dynamics, held in
this conformation, and foraminal diameters are reduced than a repetitive
stress and friction will be applied to structures within the
intervertebral foramen. This can cause swelling of the nerve root with
edema and congestion. Should this situation go untreated than a
radicular syndrome may occur. These joint restrictions can occur at
single motor units with ah hypermobile segment above, below, or in
groups of splinted segments with a hypermobile segment being distal to
the injured motor unit. Motion palpation will easily detect these
aberrations in joint mobility.
LOSE JOINT OR HYPERMOBILE JOINTS
The Lose joint is a motor
unit, which demonstrates excessive motion. It is often found as a
compensatory mechanism accompanying a joint restriction at one or more
various spinal levels. It generally means that there has been
deformation with associated creep of the ligamentous, and tendinous
attachments. These hypermobile joints may cause repetitive irritation
with excessive motion of the motor unit resulting in micro or macro
trauma to the intervertebral discs and other holding elements of the
motor unit, Periosteum, neurological root insult as well as irritation
to the musculature and blood supply. Again, motion examination will
easily detect these alterations in joint mobility and dynamics.
ABERRANT MOTION JOINT
The aberrant motion joint
has been defined to occur when one or several vertebrae move in a
manner, which is no n phase with neighboring segments during spinal
movement. In other words, the aberrant motion joint is out of phase
with the segments above and below where two motor units are involved.
Aberrant motion joints indicate that some injury either accidental or
unplanned has damaged the spinal unit above and below as well as direct
deformation and creep of the aberrant joints and their associated
holding structures yielding unstable multiple spinal units. The affects
can be encroachment of the intervertebral foramina above and below the
aberrant vertebra, increased shearing force pressures to the capsules of
both spinal units, irritation to the intervertebral disc and continuous
repetitive micro trauma to the ligamentous attachments of both motor
units with eventual degenerative joint and perhaps disc disease with
Osteophytosis, sclerosis, and ligamentous traction spur production.
SECTIONAL OR BLOCK ALTERATIONS IN
A scoliosis is a
condition in which there is a lateral deviation with torsion of a series
of vertebral bodies from the y’ plane. The scoliotic curvature is
constant in the erect position and is distinguished as functional when
it disappears in “Adams Orthopedic Position” and as structural when it
remains in Adams position.
Hypocrites in the fourth
century BC first used the term “scoliosis” to imply abnormal curvature
of the spine. He derived the term from the Greek word meaning to twist
Inspection of any type of
scoliotic spine demonstrates lateral deviation with torsion in a series
of vertebral bodies. As each vertebra varied from normal equilibrium
position to one varied in multiple planes and multiple area of altered
joint dynamics with restrictions and excursions noted.
Categories of scoliosis are
Functional, Compensatory and Structural.
Functional Scoliosis. Usually due to
unbalanced muscular loading of the spine resulting in ipsilateral
contraction of muscles. These types of patients respond remarkably to
Osteoarticular technique (manual medicine).
Compensatory Scoliosis: This classification is divided into:
A compensation for an opposite scoliosis
forming an S-shaped curve.
A compensation for a short leg-pelvic
These scoliotic patients respond excellently to
Structural Scoliosis. This scoliosis takes
its shape from a change in the vertebral bodies assuring a wedge shape.
In mild cases Osteoarticular, care is indicated in the form of manual
distraction techniques and adjustive procedures. In severe structural
scoliosis, the thoracic spine curvature with associated rib cage
deformity causes respiratory impairment with possible secondary cardiac
complication. Here manual distraction is the treatment of choice
(relative to manual medicines) to decrease intradiscal, intra-abdominal,
and intrathoracic pressure as well as opening posterior disc space,
opening foramina and decompressing nerve root structures. However,
surgical intervention may cure the patient’s ills. Differential
selection of procedures is indicated with these patients and generally
will occur only with complete cooperation between the medical forensic
chiropractors and orthodox medical (see corsets and applications;
PARAVERTEBRAL ALTERATIONS IN
This last classification
generally refers to the Costovertebral, costo-transverse and extra
spinal structures. The main features of these alterations in joint
dynamics are misalignments of the costal processes in relation to the
transverse processes and vertebral bodies. These displacements occur
independently of alterations in the vertebral motor unit. However,
these costal displacements have also been found in some cases to be
secondary to a spinal unit alteration in normal dynamics. Patients will
complain of pain upon breathing or rib excursion and the pain may
radiate along the course of the Intercostal muscles beginning at the
posterior Costovertebral joints.
These paravertebral alteration
in joint dynamics may cause repetitive stress on the capsule ligaments
and synovia with subsequent production of alterations in local spinal
unit dynamics or even affect blocks of spinal units thus changing the
spinal curves yielding irritations to the nerve roots, sympathetic
ganglia and Rami communicantes. Patients also have reported the pain
being present at the costochondral junctions at the sternum when in fact
the altered joints responsible are in the posterior articulations.
In some cases, this last
classification may refer to alterations in sacroiliac joint dynamics.
The man features of these alterations in joint dynamics are
misalignments of the sacrum in relation to the iliac bones, which are
ipsilateral in nature. When a sacral misalignment is associated with
bilateral iliac distortions it is know as a secondary displacement.
Generally, the effects of these types of displacements are a repetitive
friction and irritation to the interarticular structures as well as
extra-articular holding structures. In severe cases this may cause a
functional scoliotic pattern in the vertebra piled, a pelvic obliquity
and a short o long leg syndrome. If the displacement is severe, there
may also be a repetitive traction and irritation to the nerve roots,
which issue the intervertebral foramina of the sacrum or lumbar spine.
Dr. Henry Gillet of
Belgium originally introduced motion palpation. His primary concern was
with the physiological ranges of motion of spinal articulations. He
motion palpated for fixations which he divided in partial and complete.
He subdivided them into muscular, ligamentous, and interarticular which
actually involved the capsule. Today we know of numerous causes for
restricted vertebra such as discopathy, arthritis, contractures,
adhesions etc. Today the basis for motion palpation revolves around
nine integral notions.
Motion palpation is considered an instrument
of biomechanics in practical clinical settings. Gillet stressed that
awareness of facet facings and how a particular vertebrae of a region
Motion was to be induced specifically (in
accordance with the specificity set forth by DD Palmer) in the area
where the physician desires to test.
Relaxation of both the physician and the
patient were stressed as crucial. The patients will relax by perceiving
the physicians firm but gentle control with his/her indifferent hand
The indifferent hand contact may be modified
to the physician’s abilities and build.
If the patient is seated support the patient
on the doctor’s thigh. In the supine position the patient’s head is
cradled in the physicians fingers.
Learn to feel the motion on yourself as a
priorii to attempting it on another student or patient, or study in
quality didactic and empirical course work taught by specialists in the
Motion palpation should be conducted
unilaterally except where bilateral palpation is specifically indicated.
The active hand is designated AH and feels for
While palpating feel for joint restrictions,
loose or hypermobile joints or denote aberrant motion.
Motion palpation is
continually being refined by the various practitioners and is practiced
in many ways. Broad radius motion palpation for feeling restriction is
occasionally utilized (as it is the easiest to master, i.e. Doctors of
Physical Therapy, MD’s, DO’s) as well as
short radius motion palpation for feeling joint restriction due to
ligamentous stretch/sprain/strain or deformation with concomitant
muscular spasticity and so forth. Further an instrument has been used
to assist the physicians in the detection of lumbosacral alterations in
joint dynamics known as the Osteopathic Mc Mannis instrument, the
Chiropractic Cox Table, and others. Motion palpation on these
instruments is known as Distraction-motion palpation which some feel is
effective when lumbar discogenic diseases is suspected. Finally the
definition of motion palpation or the motion examination is a diagnostic
procedure utilized to locate areas of normal and altered joint dynamics
or subluxation. The test is also used to decide when, where, and in
what plane and adjustment is to be delivered. This test also suggests
if a vertebral correction has occurred and gives the practitioner an
indication of the anticipated duration of further manipulative care.
The following is one
method of short radius motion palpation used for the detection of
aberrant joint motions, such as a restricted joints or hypermobile
joints when examining the vertebral column. This examiner has
implemented these diagnostic procedures on over 45,000 patients
successfully, with 99% patient approval judged by actual patient
satisfaction, no stroke victims and patient end status as clinically
helpful indicated by successful clinical trials of 25 years.
Examination of the Atlanto-Occipital
Examination of flexion and extension motions:
Please place the calcaneal and digital portion of your indifferent hand
on the forehead of the patient or more superior on the head with the
thumb, palmar and digital contact (either position is deemed
appropriate). Place a broad digital one-finger contact, upon the
superior aspect of the transverse process of the atlas and the Ramus of
the mandible. Flex the patient’s Atlanto-occipital joint while feeling
the ramus approximate with the transverse process of the atlas. Next
extend the patient’s Atlanto-occipital joint while feeling the
transver3s process separate fro the ramus. If you cannot feel the
separation motion, relax and try again gently. Have another physician
place their finger next to your contact finger and have them place
pressure. Feel the pseudo-restriction. It is imperative that you learn
to feel normal limit motion before detecting aberrant motion. Feel for
a loss in resistance before en motion. Feel for a almost rubber-like
resistance increasing during the testing continuum. The latter will
equate to a joint restriction.
Please place the calcaneal and digital portion of your indifferent hand
on the forehead of the patient or more superior on the head with thumb,
palmar and digital contact. Place a broad digital one-finger contact,
upon the anterior aspect of the transverse process of the atlas and the
ramus of the mandible. Rotate the patient’s head with the indifferent
hand. At the end of the motion learn to feel the separation of the
ramus and the transverse process and feel the mastoid glide over the
transverse process. This takes practice as there is minimal (0-4
degrees) motion, which may occur at the end of cervical rotation.
Please place the calcaneal and digital portion of your indifferent hand
on the forehead of the patient or more superior on the head with thumb,
palmar and digital contact. Place a specific digital contact superior
to the transverse process of the atlas, jut inferior to the mastoid.
Next laterally flex the head gently to one side and then the other.
Feel the transverse process and mastoid separate and then approximate.
Reproduce this finding until you have confidence. However, remember the
test is conducted gently in a relaxed manner.
Please take a palmar digital contact on the vertex of the patient’s
skull. Place a broad digital one-finger contact (active hand) upon the
anterior aspect of the transverse process of the atlas and the ramus of
the mandible. Exert pressure on the head (while the chin goes anterior)
approaching a position known as the anterior inferior occiput. It is
important to remember that it is the occiput in motion and not the
atlas. Feel the ramus separate from the atlas, and the mastoid come
anterior and inferior to meet the atlas.
The Motion Examination of Possible Occipito-Axial
has been the experience of motion examiners that often
spasticity of the retus capitis posterior major and the longus capitis
will splint the Occipito-Axial region causing a painful restriction.
Please palpate within the space between the occiput and the axis
spinous Flex the head forward and “feel” the occiput move away from the
spinous process. If there is regional splinting due to longus capitis
spasticity the occiput will remain restricted in motion.
The Motion Examination of the Atlanto-Axial
Rotation Examination of the Atlanto-Axial
joint is an extremely important procedure since rotation is a primary
motion is joint. Remember that the motion occurs around the odontoid
or dens. In this examination the contact is still the original as
designated by Dr. Gillet; the three finger contact of the Atlanto-Axial
articulation. Please place the first, second and third digits on the
occipital notch, posterior tubercle of the atlas (if palpable) and the
spinous of the axis. Fix your fingers firmly but gently on the contact
points and rotate the patient’s Atlanto-Axial articulation feeling for
restriction to motion. Further if the spinous is carried or dragged
with the occiput and atlas joint restriction is definitely suspected.
Gently reproduce the test after a minute to confirm results. Always
note the direction of splinting (joint rotates well to the left but is
restricted form right rotation indicating the vector of correction).
Lateral Flexion motion examination is
many ways. The following is known as the preferred method of lateral
flexion of the Atlanto-Axial articulation. Please place the index
fingers of “both” hands together and spinous process area between the
index fingers. Place extended thumbs upon the neck. Laterally flex the
joint and then return to neutral and feel the spinous move away fro your
contact (the spinous process is moving in an arc motion) on the
contralateral side and follow your ipsilateral index finger. With joint
splinting you will note the restriction to the spinous motion. In a
hypermobile joint you will note joint instability in the articulation.
The Flexion and Extension Motion Examination:
Please place the index fingers of both hands together about the spinous
process area actually contracting the lamina pedicle junction, with the
spinous process area between the index fingers. Place extended thumbs
upon the neck. Flex and then extend the head upon the neck feeling the
C1 spinous move from C2. When both move congruently consider joint
restriction. Note the motion relationship between the C1 and C2 motion
considering restricted motions or excessive motions.
The Motion Examination of Cervical Vertebra
two through Seven (This procedure can be used with the patient in the
seated or supine position. When the patient is supine the physician
will sit or stand facing the patient’s head with your hands comfortably
under the neck.)
The Flexion and Extension Motion Examination
the cervical spine, flexion motion and extension motion occur
concomitant with changes in facet orientation or facet gliding if you
will. In flexion motion the superior articular process glides forward
on top of the inferior one and the spinous processes separate
posteriorly. The bodies approximate anteriorly, causing an approximate
wedging of the intervertebral disc and a shift of intradiscal
Please place the laymen’s index fingers of both hands together and
spinous process area and lamina pedicle junction area, under your
extended fingers. Then place extended thumbs upon the neck. Flex and
extend the cervical vertebra level under examination and feel for the
separations and approximations of the spinous processes. Expect a
larger range of motion in the lower cervicals than the upper cervical
vertebrae. With this method of motion examination also known as the
angel wing technique, one can palpate for spinous separation and
cephalad-caudad lamina-pedicle junction separation as well as articular
processes separation. If separation is inhibited or restricted
spasticity of the musculature is suspected. Please remember that you
must know how a normal non-restricted spine palpates before you make an
educated didactic and empirically trained decision. Absent proper
clinical training, physicians tend to derive erroneous information.
Thus practice on normals first.
Normal Lovett negative motion is noted in the cervical spine where
rotation and lateral flexion are coupled motions or motions, which occur
concomitantly. As the vertebrae are laterally flexed, the bodies rotate
to the same side and the spinous processes move into the convexity or to
the contralateral side.
Please place the laymen’s index fingers of both hands together and the
spinous process area between the distal interphalangeal joint and the
lamina pedicle junction area just before the distal interphalangeal
joint. Gently rotate the head and feel the stair case effect, with the
articular process going superior and anterior contralateral to the side
of rotation. A restriction will palpate as if there are more steps on
one side than the other or will present as complete restriction
splinting with no motion. To complete the rotation portion of the lower
cervical spine and isolate inter and intra motion unit restriction, you
must perform three distinct gentle motions. Please gently extend the
cervical spine. Net gently lateral flex the neck until you feel
limitation of motion. These first two motion actions will specifically
restrict motion to the motion units under examination. Last rotate the
neck feeling for the restriction. Please note vertebral motion unit
level of restriction and direction that the splint limits motion.
complete rotation examination of the lower cervical spine and isolate
inter and intra motion unit restriction, you must perform three distinct
gentle motions. Please gently extend the cervical spine. Next gently
lateral flex the neck until you feel limitation of motion. These first
two motion actions will specifically restrict motion to the motion units
under examination. Last rotate the neck feeling for the restriction.
Please note vertebral motion unit level of restriction and direction
that the splint limits motion.
Lateral Flexion Motion Examination
contact points are the same as in the rotation examination just
presented. Please laterally flex the cervical spine, feeling the
articular process on the ipsilateral side moving inferior and posterior
and feeling the articular process area on the contralateral side move
superior and anterior. As one laterally flexes the cervical spine move
your contact down the spine contacting each lamina pedicle junction and
articular areas one segment at a time. Feel the spinous process move
into the convexity.
Thoracic and Lumbar Spinal Motion
These procedures must be performed with the patient seated and the
physician either standing or sitting behind the patient. Standing is
the preferred method unless you are tall. The thoracic spine, mainly
due to its rib attachments, is essentially an immobile structure,
particularly in the mid to upper thoracic. As we age calcifications and
ossifications of rib attachments may occur. The lower thoracic spine
will demonstrate increases in motion as you move down it, due to the
floating ribs on the last two segments.
The thoracic vertebrae and the lumbar vertebrae are basically
palpated in a similar manner. The contact points differ as well as
ranges of motion.
The Flexion and Extension Motion Examination
During forward flexion of the thoracic spine there is an upward
gliding of the superior facet on the inferior facet. Feel as the
superior spinous approximates with the inferior spinous when the patient
is brought up from a full flexion position. The head is utilized as a
lever to move the upper thoracics during motion examination. From the
thoracic fourth vertebrae and below the arms of the patient are crossed
and utilized as a lever to progressively induce the range of motion
desired. Place your contact digit between the spinous processes and
later over the transverse processes. From T1-T3 with the cervical spine
fully flexed, please place your contact finger at the distal aspect of
the spinous and proximal interspaces. Flex the head a little further
palpating the spinous processes as they approximate. From T4 down flex
and extend the patient with your indifferent arm (flex the thoracic cage
generally performed in the seated position) and feel the spinous
processes approximate as the patient is brought up from flexion. At the
end of extension movement you should expect to feel the spinous
processes go slightly anterior. Descend down the spine and repeat with
transverse processes contact. Feel for restricted motion unit complexes
with or without neighboring joint restriction.
The Lateral Flexion Motion Examination for
the Dorsolumbar Spine.
is essential to remember that when the thoracic spine laterally flexes,
there is a concomitant rotation to the contralateral side known as
coupling motion. The patient should be seated with their arms crossed
in front. Please have the patient laterally flex their thoracic spine
with your palpating fingers on the spinous. Feel the spinous processes
move into the concavity. This is known as the Lovett positive motion.
Keep all lateral motion in the coronal plane, as the lower shoulder must
not go posterior ward. If it appears to biomechanical move posteriorly
feel for spinal joint restriction and note the side of restriction.
Exert pressure with your active contact thumb onto the spinous process
from the ipsilateral side in the thoracolumbar lateral flexion motion
examination. The indifferent hand can be around front upon the crossed
arms or upon the contralateral shoulder. As you laterally flex the
thorax on the contralateral side you will feel the spinous process move
into your thumb on the ipsilateral side. Note any joint splinting or
The Rotational Motion Examination for the
Again please have the patient in a seated position with their arms
crossed. The indifferent hand of the physician reaches around the
contralateral side of the patient and holds the proximal forearm area.
The contact point is the thumb onto the ipsilateral side of the spinous
process associated with the vertebral level in question. Rotate the
patient’s body contralaterally to the physician and feel the spinous
processes come into your hand. Feel for restrictions to normal motion
or excessive motion.
patient remains in the seated position with the contact point being the
sacral base at the lateral aspect (posterior superior iliac spine).
Flex, Extend, laterally flex and rotate the patient comparing them
bilaterally. Feel for restricted base motion.
Sacro-Iliac Motion Examination.
prudent physician will begin the examination with the patient in the
plantigrade position (standing). Have the patient flex the thigh toward
the chest while the knee is bent. When the patient has the leg-raised
place the ipsilateral thumb upon the exposed superior portion of the
PSIS. Have them drop the leg down. Hold the contact. Have the patient
then repeat the procedure for the left sacroiliac joint motion. Feel
for aberrant motion and not whether one thumb is higher than the other
or equal. Then while holding the contact have the patients sit down on
the examination table with you behind (start behind the table to begin
with) it. Then have the patient forward flex in the seated position
observing the motion of your thumbs while feeling for restriction to
motion or hypermobility (loose joint). If the PSIS have moved
inferiorly and posteriorly again it is called a PI Ilium by Doctors of
Chiropractic. If the PSIS has moved anteriorly and superiorly and is
splinted in the position it is called an AS Ilium.
have the patient lie prone on the examination table. With your
ipsilateral thumb on the same-sided PSIS grasp the ankle of the
ipsilateral leg and with the le flexed at the knee move the leg
externally and internally. Feel the PSIS joint move internally and
externally. If either joint palpates as restricted in the internal or
external configuration as compared to the opposite side or your
experienced knowledge of normals, note the joint as IN for internal
restriction or EX for external splinting.
Over the centuries
manipulative medicine historians have been divided on the priori of
importance between definitions, basic medical taxonomy and basic
communication. This has continued even though experts in manipulative
medicine achieved tremendous success reversing patients conditions a
well as achieving patient satisfaction.
Is it not a mistake for
health care practitioners with two points of view, one oriented toward
medicine which can be injested or injected and medicine applied
externally, and blindly assume neither has valid medicine absent
scientific scrutiny and investigation? Further, once interprofessional
scientific investigation and scrutiny occurs, would this not foster
cooperation through the principals of openness, and shared knowledge.
Only through a team effort of interprofessional cooperation will the
total health needs of all our citizens be fostered. “Health care is a
team effort and must not remain divided.”1
The motion condition of a
joint is divided into the possible motions the particular joint will
exhibit. For example we do not expect an Ampharthrosis joint to exhibit
all the motions of a Diarthrosis. Thus, when examining the spinal
joints, the physician will bring the joints through their possible
motion actions, which are generally forward flexion, Extension, lateral
flexion-rotation, rotation –lateral flexion, and circumduction motion
which is a combination of forward bending and lateral bending motions
(combined coupled motion) to the left and right. In other words you are
testing all planes of motion possible for the joint. If the patient
reports pain and or stiffness and/or the physician feels joint
restriction or joint translation or excursion, they have found the
motion condition of the joint. When we find the motion condition of the
joint, it indicates the restricted motion, in what direction the joint
restriction exhibits splinting, thus indicating the direction or vector
of correction needed for the adjustment (knowledgeable, purposeful short
In fact sophisticates in
the motion examination will denote expediently spondylolisthetic
excursions, from asymmetrical facets of the lower lumbar spine, from
facet syndrome and capsulitis (hindered entrance into extension with
pain) and so forth.
The “Motion Examination”
presented involves spinal biomechanics in practical clinical
application. Awareness of the facings of vertebral arch articular
junctures and of how each vertebral joint of a given area moved was
deemed mandatory. Inducing motion specifically in the correct joint
area, feeling for the correct data and correlating correctly with the
degree of altered joint dynamics indicates where, why and how often the
joint restriction or hypermobility must receive treatment. Further, a
quality motion examination indicates whether or not a condition of
altered joint dynamics has been reversed or improved. This combination
of biomechanical testing determines candidates for manual medicine,
which manipulations to utilize to correct the AJD
(e.g. Area of Altered Joint Dyanmics-Neff), the location to be
manipulated, and the vector of correction, the depth of the maneuver and
the velocity of the maneuver. This biomechanical testing will indicate
if a correction in vertebral dynamics has occurred, how many more
treatments the patient may need, or if a more radical procedure is
If we combine the
knowledge of the motion examination with the history of injury, a
quality orthopedic, neurological and physical examination as well as
special testing procedures, modern adjustment procedures an indications
for rehabilitative physiological therapeutics as well
as pharmaceuticals or surgery, (MD’s/DO's
working with DC’s within the same offices) you will gain insight into
the world of modern spinal manipulative specialties.
Neff Scott D., “Neuroanatomy of Vertebral
Joint Subluxations” Journal for the American Chiropractic Association,
S-55-S57, Vol 17, Number 4, 1980.
Neff S D, “Evolution of Forensic Science in
Manipulative Medicine”, Lecture for American Back Society, 1985.
Port C, “Ports Notes in Spinal Diagnosis”,
Published by Dr. Carol Port, Ass. Prof, LACC, pp. 39-65, 1978.
Friel John p, Dorland’s Medical Dictionary,
Twenty-fifth Edition, WB Saunders Co., p. 1122, 1974.
Warwick and Williams, Gray’s Anatomy, 35th
British Edition, WB Saunders Company pp. 400-407
Kessler RM, Hertling D, Management of Common
Musculoskeletal Disorders. Harper & Row P. 88, 1983.
Scott D. Neff, DC DABCO
DABFE FFABS FFAAJTS as a dedication to the
people of Minnesota and to the "Fountain Head" of learning for
Science and Medicine, the University of Minnesota. - 08-30-04
"Why does this magnificent applied
science which saves work and makes life
easier, bring us little happiness? The simple answer runs, because we
have not yet learned to make sensible use of it." Albert Einstein 1931
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