Specific Chiropractic Assessment of the NMS System. Concepts in Spinal Manipulative Therapy. Self-Serving Resource. More Self-Serving Resources

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1 Annual Chiropractic Educational Symposium (ACES) D'Youville Chiropractic Department 10-Year Anniversary Celebration Concepts in Spinal Manipulative Therapy Compiled and Presented by: Tom Bergmann, DC, FICC Professor, Methods Department Northwestern Health Sciences University What We Say We Do and What We Really Do May Be Two Different Things! September Introduction and Overview Outline Topic Sequence Joint Assessment Procedures Discussion of reliability and validity of joint evaluation procedures Characteristics of the HVLA Animation and Videofluoroscopy Manipulative Mechanics Discussion of current literature related to the effects of loads and stresses applied to the spine Specific examples of questionable adjustive mechanisms in the lumbar spine, cervico-thoracic junction, and pelvis Self-Serving Resource Biomechanical Principles Assessment Principles Adjustment Principles Spinal Adjustments Extremity Adjustments Non-Thrust Procedures Video Clips More Self-Serving Resources Specific Chiropractic Assessment of the NMS System How do we determine the Site of Care Augmented from WFC ACC NBCE Education Conference Toronto 2004

2 Great Variability Leads to confusion Patients Doctors Third-parties Research difficulties As a portal of entry to the health delivery system, the D.C. must be well educated to diagnose, using necessary aspects of the history and examination... Clinical Evaluation Case History Physical Examination Vital signs, Orthopedic, Neurologic Chiropractic Laboratory Tests Radiographic You go across the square, pass the nurse s residence, up the steps, Blood, Urine through the main lobby...and second door on your left. Clinical Evaluation Necessary to assess the nature and extent of the problem Responsibilities of a physician Clinical Evaluation The spinal examination sets apart chiropractic from the other areas of the healing arts. That name tag of yours will have to go - it s giving the patients ideas.

3 NO CONSENSUS on the most valid, reliable, objective and efficient means of detecting the adjustable joint lesion - Subluxation. Review of s used by chiropractors to determine the site for applying manipulation Triano JJ, Budgell B, Bagnulo A, Roffey B, Bergmann T, Cooperstein R, Gleberzon B, Good C, Perron J, Tepe R. Chiropractic & Manual Therapies 2013, 21:36 Evaluate the literature on the validity and reliability of the more common s used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation. P.A.R.T.S. The stronger and more favorable evidence is for those procedures which take a direct measure of the presumptive site of care s involving pain provocation upon palpation or localized tissue examination Lack of support by the available evidence included procedures which involve some indirect assessment for identifying the manipulable lesion of the spine such as skin conductance or thermography Evaluation Pain provocation Asymmetry Tenderness Orthopedic maneuver Posture Summary Localizes region/tissues of involvement Pain with movement localizes region/tissue of involvement Antalgia, kyphosis, lordosis, scoliosis Quality of evidence Recommend ation Localizing to site of care Unfavorable Stiffness, Palpatory manual Passive physiologic/ accessory motion, joint springing, overpressure Unclear

4 Evaluation Summary Quality of evidence Recommend ation Evaluation Summary Quality of evidence Recommend ation Asymmetry Stiffness, Instrumented Palpation, Static Questions of generalizability Identifying major anatomical landmarks Low with limitations with limitations Manual Muscle Testing Strength grading to localize root involvement Moderate Non-pathologic altered function Moderate Unfavorable Localizing to site of care Unclear Range of motion Sectional Localization to region Leg Length Inequality Pelvic assessment; dependent with limitations Palpation, Motion Enhanced if pain provocation present with limitations Evaluation Summary Quality of evidence Recommend ation Evaluation Summary Quality of evidence Recommend ation Tissue temperature texture tone Specialized Tests Current Perception Threshold Galvanic skin response Thermography/ thermometry of the lower limb in confirming frank sciatica Paraspinal skin temperature to locate site of care Texture-skin rolling Frank neuropathy with sensory deficit Moderate Unfavorable Localizing to site of care Moderate Unfavorable Specialized Tests Integrated P.A.R.T.S. Montages Surface EMG Diagnostic imaging Galvanic skin response Flexion-relaxation phenomenon to target lumbar region care Localizing to site of Moderate Unfavorable care Localizing to site of Unfavorable Localizing to site of care Moderate Unfavorable Localizing to site of care beyond individual component contributions Moderate Unclear The most comprehensive review of the literature, to date, in relation to the diagnostic s used for locating the site of care at which to apply manipulation treatment s. Applying assessment tools to the literature found high quality evidence for the majority of the P.A.R.T.S. constructs. Reliability Studies Lit. Rev. STUDY WHO R COMMENTS E A R Hestboek 2000 DC X X Looked at many evaluative tools MP lumbar, MP SIJs, leg length, SOT, palpatory pain. Only studies focusing on pain had consistently reliability values Huijbregts 2002 PT X X Looked at multi-professional approaches to spinal motion evaluation. Intra- varies from less than chance to generally moderate or substantial; Inter- only rarely exceeds poor to fair; ratings that include presence or absence of pain yield higher agreement. Seffinger 2003 DO DC MD PhD X X Look at content validity and reliability of spinal palpation procedures from DC, PT, MD, and DO literature. Provides a summary of each paper. No overall conclusions provided. van Trijffel 2005 MD X Assessment of motion segments C1 C2 and C2 C3 almost consistently reached at least fair reliability. Overall, inter-examiner reliability was poor to fair. Most studies were found to be of poor ological quality.

5 Reliability Studies Lit. Rev. STUDY WHO R A Stochkendahl 2006 E R COMMENTS DC PhD X X Looked at many evaluative tools MP, static palpation, osseous pain, soft tissue pain, soft tissue changes, global movement FS. Acceptable (strong) for palpation for pain inter- and intra-, global assessment intra-. No evidence or conflicting evidence for static palpation. Motion palpation good intra- not acceptable inter-. Haneline 2008 DC X X Reviewed different forms of MP (excursion vs end feel) to determine whether a difference in reported reliability was observed when the of MP varied. Not statistically significant. Haneline 2009 DC X X Very thorough review of spinal and SI MP. Provides a summary of each paper. No overall conclusions provided. No single evaluative tool should be used or relied upon to make clinical decisions. Complexity of the NMS System Need a Standardized Approach Diminish Confusion Comparisons for Effectiveness and Efficiency SINGLE TOOL MULTIDIMENSIONAL INDEX of segmental abnormality P.A.R.T.S. ASSESSMENT Where did this come from? Book chapter ART + P Papers, Presentations and Books ACA et al looking for x-ray replacement in Medicare In 2000, PART became the clinical assessment procedure for determining the clinical necessity for chiropractic care

6 P. A. R. T. S. Pain / tenderness P = Pain, tenderness A = Asymmetry R = Range of motion T = Tissue tone, texture, temperature S = Special tests Observation, percussion, provocation, palpation Premanipulative position Location, quality, intensity Subjective vs. Objective VAS, algometer, questionnaires Spinous Percussion Does that hurt? Asymmetry / alignment Static Palpation Sectional and segmental Observation of posture Static palpation Static x-ray

7 Static X-ray Range of Motion Abnormality Sectional and segmental Active, passive, accessory joint motions Goniometers, inclinometers Motion palpation Stress x-ray Active and Passive ROM Segmental ROM Segmental ROM Segmental ROM

8 Tissue tone, texture, temperature Soft Tissue Palpation Skin, fascia, muscle, ligament Observation, palpation, instrumentation Tests for length and strength Skin Temperature Special Tests / Considerations Specific to a technique system Leg check, arm fossa test, therapy localization, etc. Surface EMG Visceral relationships Remainder of Clinical Examination Orthopedic, Neurologic, PDX, etc. Objective Findings for Subluxation Where, when and when not to treat Technique selection Should improve with treatment More than a sum of its PARTS If you can t find them you can t fix them!

9 What we think we do and what we really do May be two very different things Integrated Chiropractic Methods Not all techniques are equivalent Not all techniques do the same thing All may be beneficial Opinion TB Technique Development Various forms of technique exist Over 100 named techniques Not all adjustments are equivalent Not all adjustments do the same thing New ones started by probing and interested clinicians U.S. D.C. s Technique Usage Diversified 96.2% Activator 69.9% Thompson 61.3% Gonstead 57.2% Cox Distraction 56.5% SOT 49.6% Cranial 38.0% AK 37.6% Nimmo 33.6% Forms of Chiropractic Technique It is the responsibility of the developers and followers to establish efficacy.

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11 Cervical Adjustment digital pillar pull Characteristics of the HVLA Contact on Patient Contact Point on Doctor Joint Prestress Impulse Thrust Cineradiography of Cervical Adjustment Conclusions Science is beginning to investigate the art Support for s lacking any scientific credibility in unlikely Clinical research is finally taking place - $.