Methods for Locating Fixated/Subluxated Segments

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:     Frankp@chiro.org

	Spinal Palpation A Chiro.Org article collection Review newer studies that demonstrate the reliability of palpation findings.
	Interexaminer Reliability of Seated Motion Palpation for the Stiffest Spinal Site J Manipulative Physiol Ther. 2018 (Sep); 41 (7): 571–579 ~ FULL TEXT More than half the time (54.3%) the examiners in this study agreed on the exact segment or at least the motion segment that was stiff in a given spinal region. The MedianAED for the combined dataset was 01.1 VE. This information supports high levels of interexaminer reliability for the SSS in each region of the spine and in the combined dataset. Reliability estimates based on absolute examiner differences were relatively higher and seemed to be more trustworthy than prior estimates based on discrete analysis and analysis with κ because the assessment method more closely resembled that used by clinicians in clinical practice. The reliability seen in this study is broadly consistent with previous studies of MP using continuous analysis.
	The Reliability of Spinal Motion Palpation Determination of the Location of the Stiffest Spinal Site is Influenced by Confidence Eatings: A Secondary Analysis of Three Studies Chiropractic & Manual Therapies 2016 (Dec 20); 24: 50 ~ FULL TEXT Neither the confidence module nor the subtyping by spinal region should obscure this study’s central finding: Motion Palpation (MP) for the “stiffest spinal site” (SSS) in the combined dataset, when analyzed using continuous data and related statistical methods, is reliable and appears to identify a clinically relevant and tightly constrained location for the stiffest spinal site; and the variability of the measured interexaminer differences is low. Using a stringent criterion of agreeing on at least the motion segment including the SSS, the described continuous measures palpation protocol was reliable 60.2–77.0% of the time for the combined dataset, and was 90.2% reliable when both examiners were confident. These findings support the view of some authors who have expanded the field of examiner agreement using motion palpation to include nominated segments that are within one level of each other. [30, 41]
	The Reliability of Lumbar Motion Palpation Using Continuous Analysis and Confidence Ratings: Choosing a Relevant Index of Agreement J Can Chiropr Assoc. 2016 (Jun); 60 (2): 146–157 ~ FULL TEXT Our results raise the possibility that the present inventory of reliability studies performed in the manual therapy professions, by having used mostly discrete study designs (certainly for MP) may have underestimated clinically relevant examiner agreement, thereby unduly discouraging further research and clinician interest in such research. Moreover, depending solely on ICC calculations to assess interexaminer agreement may result in flawed conclusions, when the subject population is relatively homogeneous. Greater reliance on variance-insensitive statistical functions would mitigate against that possibility. Future studies designed to analyze subsets of the data should use enough subjects to result in credible conclusions.
	Interexaminer Reliability of a Multidimensional Battery of Tests Used to Assess for Vertebral Subluxations Chiropractic Journal of Australia 2016; 46 (1): 100–117 ~ FULL TEXT In this study, high levels of interexaminer reliability were observed in each region of the spine when a multidimensional approach to detect vertebral subluxations was used. Since the combined MedAED for vertebral subluxations was 0.6VE, it can be stated with confidence that examiners usually agreed on at least the motion segment containing the most positive vertebral subluxation test indicators, and very frequently on the same segment. Vertebral subluxation assessment, when analyzed using continuous data, indicate much higher levels of agreement than has been heretofore associated with assessing agreement using discrete data and the Kappa statistic.
	Diagnostic and Treatment Methods Used by Chiropractors: A Random Sample Survey of Canada's English-speaking Provinces J Can Chiropr Assoc. 2015 (Sep); 59 (3): 279–287 ~ FULL TEXT Differential diagnosis is a standard part of the assessment of new chiropractic patients in English-speaking Canadian provinces and this is most commonly done using orthopaedic tests, palpation, history-taking, range of motion testing and neurological examination. The clinical tests/procedures used most commonly by these DCs to determine where to apply joint manipulation are palpation and painful joint findings. These methods are consistent with the current scientific literature. Chiropractic patients in Canada’s English-speaking provinces are treated with a combination of manual joint manipulation/mobilization, exercise, posture/ergonomic advice and soft-tissue therapies. These treatment methods are consistent with earlier analyses of Canadian DCs, but the data do suggest that chiropractors in Canada are increasingly using soft-tissue therapies as part of their therapeutic regimen.
	Validity of Palpation of the C1 Transverse Process: Comparison with a Radiographic Reference Standard J Can Chiropr Assoc 2015 (Jun); 59 (2): 91–100 ~ FULL TEXT Manual palpation of the C1 TVP can be very accurate and likely to direct a manual therapist or other health professional to the intended diagnostic or therapeutic target. This work is relevant to manual therapists, anesthetists, surgeons, and other health professionals.
	Review Of Methods Used By Chiropractors To Determine The Site For Applying Manipulation Chiropractic & Manual Therapies 2013 (Oct 21); 21 (1): 36 ~ FULL TEXT A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care-methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine-such as skin conductance or thermography-tend not to be supported by the available evidence.
	Frequency of Use of Diagnostic and Manual Therapeutic Procedures of the Spine Taught at the Canadian Memorial Chiropractic College: A Preliminary Survey of Ontario Chiropractors. Part 1 - Practice Characteristics and Demographic Profiles J Can Chiropr Assoc. 2013 (Jun); 57 (2): 32–41 ~ FULL TEXT In general, the demographic profile of respondents to this survey was similar to respondents to previously published surveys. Respondents in this study were mostly male and graduates of CMCC. Most reportedly used Diversified technique and, notwithstanding the fact that is the principle technique taught to them, many field doctors continue to also use proprietary soft tissue techniques and often other chiropractic technique systems and therapeutic procedures not formally taught to them. Unlike previous studies, a relatively high number of respondents in this study reportedly used Upper Cervical techniques.
	Frequency of Use of Diagnostic and Manual Therapeutic Procedures of the Spine Currently Taught at the Canadian Memorial Chiropractic College: A Preliminary Survey of Ontario Chiropractors. Part 2 - Procedure Usage Rates J Can Chiropr Assoc. 2013 (Jun); 57 (2): 165–175 ~ FULL TEXT This study reported on the frequency of use of diagnostic and therapeutic procedures currently taught at CMCC by a group of pseudo-randomized Ontario chiropractors, most but not all of whom were CMCC graduates. The most commonly used diagnostic procedures for the cervical, thoracic, and lumbopelvic spine were joint play, static and motion palpation, neurological testing and ranges of motion. A number of other orthopaedic tests were less commonly used, and a number of tests were either rarely or not used at all, particularly in the assessment of the thoracic spine. With respect to therapeutic procedures of the spine, many mobilization and manipulative procedures are commonly used, with the exception of the ‘muscle’ manipulations of the cervical spine.
	Interexaminer Reliability of Cervical Motion Palpation Using Continuous Measures and Rater Confidence Levels J Can Chiropr Assoc. 2013 (Jun); 57 (2): 156–164 ~ FULL TEXT For the entire participant pool, ICC [2,1] = 0.61, judged "good." MAD=1.35 cm, corresponding to mean interexaminer differences of about 75% of one cervical vertebral level. Stratification by examiner confidence levels resulted in small subgroups with equivocal results. A continuous measures study methodology for assessing cervical motion palpation reliability showed more examiner concordance than was usually the case in previous studies using discrete methodology.
	Interexaminer Reliability of Thoracic Motion Palpation Using Confidence Ratings and Continuous Analysis J Chiropractic Medicine 2010 (Sep); 9 (3): 99–106 ~ FULL TEXT The confidence level of examiners has an effect on the interexaminer reliability of thoracic spine MP, such that agreement is “good” when examiners are “very confident” in their calls and not above chance levels when at least one of them is not. Looking at the data set as a whole, unstratified by degree of examiner confidence, our results resemble those of other investigators, in that the index of agreement is low. Thus, we believe using continuous measures methodology, and defining subgroups according to the confidence of the palpators, is more capable than level-by-level discrete analysis of detecting interexaminer agreement. We also believe our analytic method better reflects what motion palpators, who presumably look for maximally fixated levels within a spinal region logically related to a patient complaint, actually do.
	Motion Palpation Used as a Postmanipulation Assessment Tool for Monitoring End-Feel Improvement: A Randomized Controlled Trial of Test Responsiveness J Manipulative Physiol Ther. 2009 (Sep); 32 (7): 549–555 ~ FULL TEXT The findings of this study showed that motion palpation of end-feel assessment appears to be a responsive postmanipulation assessment tool in the cervical spine for determining whether perceived motion restriction found before treatment improves after SMT. This observation may be limited to symptomatic participants.
	Spinal Motion Palpation: A Comparison of Studies That Assessed Intersegmental End Feel vs Excursion J Manipulative Physiol Ther. 2008 (Oct); 31 (8): 616–626 ~ FULL TEXT The search strategy generated 415 citations, and 29 were harvested from reference lists. After removing articles that did not meet the inclusion criteria, 44 were considered relevant and appraised for quality. Fifteen studies focused on MP excursion, 24 focused on end feel, and 5 used both. Eight studies reported high levels of reproducibility (kappa = > or = 0.4), although 4 were not of acceptable quality, and 2 were only marginally acceptable. When only high-quality studies were considered, 3 of 24 end-feel studies reported good reliability compared with 1 of 15 excursion studies. There was no statistical support for a difference between the 2 groupings.
	Manual Examination of the Spine: A Systematic Critical Literature Review of Reproducibility J Manipulative Physiol Ther 2006 (Jul); 29 (6): 475–485 ~ FULL TEXT Palpation for pain is reproducible at a clinically acceptable level, both within the same observer and among observers. Palpation for global assessment (GA) is reproducible within the same observer but not among different observers. The level of evidence to support these conclusions is strong. The reproducibility of motion palpation (MP), soft tissue changes (STC) and static palpation (SP) is not clinically acceptable. The level of evidence is strong for interobserver reproducibility of MP and STC, whereas no evidence or conflicting evidence exists for SP and intraobserver reproducibility of STC. Results are overall robust with respect to the predefined levels of acceptable quality. However, the results are sensitive to changes in the preset level of clinically acceptable reproducibility and to the number of included studies.
	Diagnosis of Sacroiliac Joint Pain: Validity of Individual Provocation Tests and Composites of Tests Manual Therapy 2005 (Aug); 10 (3): 207–218 ~ FULL TEXT Provocation sacroiliac joint (SIJ) tests have significant diagnostic utility. Six provocation tests were selected on the basis of previously demonstrated acceptable inter-examiner reliability. Two of four positive tests (distraction, compression, thigh thrust or sacral thrust) or three or more of the full set of six tests are the best predictors of a positive intra-articular SIJ block. When all six SIJ provocation tests are negative, painful SIJ pathology may be ruled out.
	An Investigation into the Validity of Cervical Spine Motion Palpation Using Subjects with Congenital Block Vertebrae as a 'Gold Standard' BMC Musculoskelet Disord 2004 (Jun 15); 5 (1): 19 ~ FULL TEXT The results of this study indicate that even novice clinicians demonstrated the ability to correctly identify the presence or absence of known cervical spine intersegmental fixations by using specific motion palpation techniques on real patients with congenitally fused vertebrae. These congenital blocked vertebrae represent a true 'gold standard', allowing more accurate evaluation of the validity of motion palpation. The results of this study justify the clinical use of motion palpation in the diagnosis of true 'fixations' in the cervical spine.
	Efficacy of Cervical Endplay Assessment as an Indicator for Spinal Manipulation Spine (Phila Pa 1976) 2003 (Jun 1); 28 (11): 1091–1096 ~ FULL TEXT In conclusion, the manipulation indicator, manual endplay assessment, does not contribute to same-day neck pain and stiffness relief associated with spinal manipulation. The data suggest that pain modulation may not be limited to mechanisms associated with manipulation of putative motion restrictions, and that the immediate palliative effects observed may not require the specificity of manipulation site and vector presumed by some chiropractors. The randomized, placebo-controlled trial design appears safe for test efficacy studies, including extended care of neck pain with spinal manipulation. Future studies of test efficacy should include an extended treatment regimen and follow-up as well as a sham treatment group. Research into the biomechanics and neuroscience of manipulation should include investigation into nonlocal mechanisms of pain relief.
	Joint Assessment – P.A.R.T.S. Topics in Clinical Chiropractic 2000; 7 (3): 1–10 ~ FULL TEXT Doctors of chiropractic are portals of entry to the health care system for many patients seeking health care services. As such, they must maintain broad and thorough assessment/diagnostic skills. Before employing any therapy, a clinician must first determine if there is a need for treatment. Therefore, the clinical information that any primary contact provider would want, including a case history, physical examination, clinical laboratory findings, radiographic findings, and any other tests necessary to check for suspected health problems, is needed. Having gathered and interpreted this information, it must be processed in order to arrive at a sound clinical conclusion. The role of this assessment process in the chiropractic office is to determine whether the patient should receive chiropractic care only, chiropractic care in concert with other forms of health care, or a referral to another health care professional for some other form of stand-alone management such as acute, crisis care. This article suggests the need for, and possible form of, a standardized assessment procedure for use by chiropractic clinicians.
	A Proposed Vertebral Subluxation Model Reflecting Traditional Concepts and Recent Advances in Health and Science J Vertebral Subluxation Research 1996 (Aug); 1 (1): 1–12 ~ FULL TEXT Part one of an expanded vertebral subluxation model (VSM) is presented which considers information from the traditional concept of vertebral subluxation, and other models including; the chiropractic subluxation complex, the vertebral subluxation complex, and the vertebral subluxation complex model. Other components, including health assessment and etiology, are to be introduced in the second part, and appropriate research designs for studying the expanded VSM are to be presented in the third part. All three parts discuss other models as well as classical and recent research findings which support the expanded VSM.
	Most Commonly Used Methods of Detecting Spinal Subluxation and the Preferred Term for its Description: A Survey of Chiropractors in Victoria, Australia J Manipulative Physiol Ther. 1997 (Nov); 20 (9): 583–589 The response rate was 85%. The most commonly used method was static palpation (mean score 6.6 +/- 1.1). Seven other methods, including pain description of the patient, orthopedic tests, motion palpation, visual posture analysis, leg length discrepancy, neurological tests and plain static X-rays had mean scores greater than 4.0. All of these methods, as well as functional X-ray views and kinesiological muscle testing, were considered reliable, with mean reliability scores greater than 4.0. Motion palpation was regarded as the most reliable method (mean reliability score 5.9 +/- 1.2). Seventy-five different terms for describing the spinal entity were named by 440 respondents. "Subluxation" was included in the preferred term of 294 respondents (67%), 46 included "dysfunction" (11%), 35 included "fixation" (8%) and 20 included "manipulable" (4.5%).
	The Accuracy of Manual Diagnosis for Cervical Zygapophysial Joint Pain Syndromes Med J Aust. 1988 (Mar 7); 148 (5): 233–236 The manipulative therapist identified correctly all 15 patients with proven symptomatic zygapophysial joints, and specified correctly the segmental level of the symptomatic joint. None of the five patients with asymptomatic joints was misdiagnosed as having symptomatic zygapophysial joints. Thus, manual diagnosis by a trained manipulative therapist can be as accurate as can radiologically-controlled diagnostic blocks in the diagnosis of cervical zygapophysial syndromes. However, before generalized claims about the reliability of manual diagnosis can be made, further studies of this nature are required to validate intertherapist reliability and the ability of manual techniques to diagnose other spinal pain syndromes.

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Updated 11-11-2023