An intriguing question has begun to be answered relating to whether changes in intersegmental stiffness can be discerned using clinically available tools. Colloca et al [175] measured intersegmental impedance (dynamic stiffness) of lumbar vertebrae and correlated it with characteristics of vertebral height and IVD height measured from plain film radiographs. They found that there was a correlation between decreased disk height at L5–S1 and increased dynamic stiffness at the same segment. These findings were analogous to those of Kaigle et al [176] who, using a porcine model, also observed increased spine dynamic stiffness associated with degenerated disks, compared with normal controls.
Using ultrasound indentation, another noninvasive approach, Kawchuk et al [177] also found that IVD degeneration in a porcine model resulted in decreased indentation for the same applied load. This is an analogous metric as spine stiffness. The use of ultrasound indentation in this animal model had high sensitivity (75.0%), specificity (83.3%), and accuracy (77.1%), compared with other approaches (arthroscopy, MRI, and plain film radiography).
Two biomechanics studies have been performed to examine the effects of fixation (ie, a hypomobile subluxation) of the lumbar spine. Cramer et al [13] used a rat model of fixation in the lumbar spine by externally fixating the spinous processes of L4–L6 for up to 8 weeks. A principal finding due to the fixation was the development of osteophytes and degenerative articular changes of the facet joints within a few weeks. Reversal of some of the degeneration was observed for joints that were fixated for a short term (~1 week), but after 4 weeks, no reversal was observed. Little et al [178] simulated a hypomobile subluxation in intact, cadaveric human lumbar spine specimens by screwing a plate into the left anterior aspect of the L4 and L5 vertebral bodies. During physiologic motions of the fixated spine specimens for flexion, extension, and lateral bending, the motions at L4–5 were significantly decreased, whereas below and above that level, intersegmental motions were significantly increased. Correspondingly, the plane strains of the facet joint capsules were significantly decreased and increased at and above/below the site of fixation, respectively.
Diagnostic tools or outcome measures
The principal biomechanical “tool” still used by most chiropractors is palpation. As such, there has been a continued investigation into factors that change what is felt during palpation. Humans are relatively good at discriminating different magnitudes of stiffness for purely “elastic” materials. [179] However, the human spine responds as a viscoelastic system, in which the speed of force application changes the apparent stiffness. Nicholson et al [180] have shown that the relatively poor ability of clinicians to accurately estimate spine stiffness magnitudes is likely due to a 50% poorer ability to discriminate viscous components of viscoelastic systems. Latimer et al [181] found that therapists used different forces to discern spine stiffness and, hence, had different internal perceptual scales. By training therapists to use a calibrated stiffness instrument, discrimination of PA stiffness in the spine can be done with relatively high interexaminer reliability. [182] Furthermore, objective instruments have been developed that can reliably measure PA spine stiffness. [183] Perhaps, the most important aspect of using palpation to detect subluxations (ie, a “manipulable lesion”) is standardization of training. [184] When examiners are trained in a standardized fashion, they are able to obtain relatively high interexaminer reliability (? = 0.68) for detecting cervical fixations.
Stiffness of the spine is influenced by many factors. If the ribcage is constrained, then the stiffness measured at T12–L4 can be significantly increased. [185] Change in orientation of an applied load to the spinous process can have small yet significant changes in objectively measured stiffness. [186] Furthermore, because the spine is a viscoelastic system, there will be a preconditioning effect when applying loads, such that after preconditioning the spine with standard mobilization SM, there will be no measurable change in stiffness. [187] There has also begun to be a growing appreciation for the natural (and normal) variability in spine stiffness as assessed by standard ROM tests during a physical examination. Christensen and Nilsson [87] found that in asymptomatic volunteers during a 3-week period, there was an intrinsic variability in ROM of the cervical spine of ± 20°, ± 14°, and ± 12° for flexion/extension, lateral bending, and rotation, respectively. In contrast, repositioning the head to the neutral position, which is related to proprioception, is done with relatively high fidelity over the same period. [188] Asymptomatic volunteers were able to reachieve the neutral zero position of their heads with a mean difference of 2.7°, 1.0°, and 0.7° for the sagittal, horizontal, and frontal planes, respectively.
Using a case study approach, Lehman and McGill [189] observed that a single HVLA SM session in the lumbar spine caused notable changes in biomechanical factors associated with a complex task (ie, a golf swing in an experienced golfer who had chronic low back pain). In addition to changes in vertebral kinematics, they observed decreased electromyographic (EMG) responses of the associated lumbar muscles. In a subsequent study, Lehman and McGill [190] found that lumbar HVLA SM in patients with low back pain resulted in variable changes in lumbar ROM and associated muscle EMG. The largest changes were associated with patients with the greatest reported pain. In a review of the available literature. Lehman [191] reported that, currently, the best way to discriminate between normal and low back patient groups was using biomechanical tests that assessed “higher-order kinematics during complex movement tasks.” Simpler end ROM tests had poor predictive ability.
Another commonly performed clinical test is measuring leg lengths, especially in the prone position. Using a special designed table to minimize friction and allow independent loading of each leg, Jansen and Cooperstein [192] determined that the prone leg length test was reliable for detecting non–weight-bearing asymmetry in leg lengths. Nguyen et al [193] found that there was reasonable concordance (? = 0.6) in determining whether a short leg was present using the Activator protocol. Cooperstein et al [194] found that it was possible to detect a leg length difference of 1.9 mm but recommended that only differences of greater than 3.7 mm should have confidence associated with them.
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