Spinal Analysis, Patient Evaluation and Adjustive Technique

Every adjustment begins with a decision about where, which direction and how hard, and the board tests both halves of that decision: the analysis that finds the lesion and the set up that corrects it. This chapter walks from observation and palpation through listing systems to region by region adjustive set ups, then surveys the named technique systems so you can recognize what each one emphasizes. In practice, a clean set up with the right line of drive is what makes care specific, comfortable and safe.

Section 1Spinal analysis and patient evaluation

What analysis is trying to find

Spinal analysis asks, in order: is manual care appropriate at all (no red flags or contraindications), where is the lesion, and what is its character (direction of restriction, side of tenderness, tissue involved)? The answers set the segmental contact and line of drive. No single tool (history, observation, palpation, instruments, imaging) is reliable enough alone, so findings are combined.

A widely used way to document a segmental lesion is the acronym PARTS:

For federal insurance documentation, a subluxation may be demonstrated either by radiograph or by physical examination; when by examination, two of the four PART elements must be present and one of the two must be asymmetry or range of motion abnormality. Most commercial payers and peer reviewers look for the same pattern.

Observation and posture

Analysis begins with gait, guarding and how the patient sits and rises. In a lateral plumb line view the line should pass through the external auditory meatus, the acromion, the lumbar bodies, the greater trochanter and just anterior to the knee joint center and the lateral malleolus. From behind it bisects the occiput, the spinous processes and the gluteal cleft and falls midway between the knees and the heels.

Common deviations include forward head posture, rounded shoulders, increased kyphosis, hyperlordosis with anterior pelvic tilt, flat back, sway back and lateral shifts. A lateral list away from the painful side in acute low back pain classically suggests a disc herniation lateral to the nerve root; a list toward the painful side suggests a medial (axillary) herniation.

Static palpation and surface landmarks

Static palpation is palpation of the patient at rest, for bony position (spinous process alignment, transverse process prominence, interspinous spacing) and for soft tissue findings (tenderness, edema, taut bands, trigger points, skin temperature, sweating). The level of a finding is fixed with landmarks (Figure 11.1).

Motion palpation, joint play and end feel

Motion palpation assesses segmental movement as the examiner guides the patient through each range, feeling the joint gap or close. A segment that fails to move is a fixation (restriction), and the restricted direction becomes the direction of thrust in diversified care.

Joint play (Mennell) is the small accessory glide and distraction that cannot be produced voluntarily but is needed for pain free motion; its loss is joint dysfunction. End feel is the quality of resistance at the end of passive range.

Interexaminer reliability of motion palpation for a single restricted segment is low (kappa often below 0.4), while pain provocation is moderate to good. Use palpation as part of a cluster, not alone.

Instrumentation

Instruments add numbers to palpation. Goniometers measure extremity motion; dual inclinometry measures spinal motion by subtracting a lower reference reading from an upper one. Algometers record the pressure at which tenderness begins. Paraspinal thermal instruments (dual probe heat readers) look for an abrupt side to side temperature "break," used in the Gonstead system. Thermography, surface EMG and heart rate variability are used in some practices, but their validity for detecting subluxation is not established, so present them as monitoring tools. A scoliometer reading of about 7 degrees in the Adams forward bend test is a common threshold for radiographic referral.

Listing systems

A listing is a shorthand description of a misaligned segment. Two families exist and the board expects you to translate between them.

The Palmer Gonstead (spinous process) system describes the position of the segment by the direction its spinous process or body has moved relative to the segment below. In Gonstead listings every vertebra is assumed to be posterior (P), because the body moves posteriorly when the disc wedges; then comes the side to which the spinous has rotated (R or L), then whether the disc wedge is open on the side of spinous rotation (S, superior) or on the opposite side (I, inferior). A suffix sometimes names the contact: -M for a mammillary (or transverse) contact and -Sp for a spinous contact. So PRS means posterior, spinous rotated right, with the open wedge on the right; PLI-M means posterior, spinous left, open wedge on the right, adjusted with a mammillary contact.

The National system names the motion of the vertebral body in orthopedic terms (flexion, extension, lateral flexion, rotation toward the side the anterior body turns). Because the spinous and body swing oppositely, a spinous rotated right is a body rotated left (Figure 11.2). Interdisciplinary reports favor these terms.

Atlas listings begin with AS (anterior superior tilt of the anterior arch, the usual finding) or AI, then the side of laterality (R or L), then the rotation of the transverse on that side (A or P). ASLA means anterior superior, lateral left, left transverse anterior. The axis is listed like lower segments (PR, PLI); pelvic listings are in Section 4.

Leg checks

Prone leg length analysis compares the heels with the knees extended and then flexed to 90 degrees. A short leg found this way is functional (from pelvic rotation, muscle tone or foot mechanics), not proof of unequal bone length. Thompson technique interprets the change between positions with the Derefield maneuver, and Activator uses leg changes during isolation tests to localize a level (Section 5).

Leg checks show fair agreement about which leg looks short, but their validity for localizing a subluxation is unproven. An anatomical inequality is measured on a standing film from femoral head heights; a heel lift for a symptomatic measured difference usually starts at about half the measured amount.

Radiographic analysis in practice

Imaging is ordered for clinical reasons, not routinely. Guidelines advise no routine imaging in the first weeks of uncomplicated neck or back pain and imaging when red flags are present (trauma, cancer history, weight loss, fever, progressive deficit, new pain after about age 50, failure to improve).

Some technique systems also mark films biomechanically: sagittal curves (Cobb or posterior tangent methods), George's line for listhesis, the lumbosacral (Ferguson) angle (about 26 to 57 degrees, average about 41), the femur head line for pelvic and leg length analysis, Gonstead pelvic listings and wedging, and the upper cervical series (lateral, nasium, vertex) used to plan an atlas vector. Flexion and extension views assess instability. Every exposure follows ALARA: collimation, filtration, no repeats and pregnancy screening.

Section 2Cervical adjustive technique

Vocabulary of a set up

Every set up is described with the same parts. Patient position (prone, supine, side posture, seated, knee chest) lets the joint be brought to tension. Doctor stance (square or fencer) puts the doctor's mass behind the thrust. The contact point is the part of the doctor's hand used (pisiform, thenar, index proximal phalanx or MCP, thumb, digital); the segmental contact point (SCP) is the patient structure contacted (spinous, lamina, articular pillar, transverse, mammillary, rib angle, PSIS). The line of drive (LOD) is the thrust direction in anatomical pairs (P to A, L to M, I to S). Tissue pull removes skin slack, pre adjustive tension reaches the elastic barrier, and the HVLA thrust may or may not cavitate.

The direction of glide available to a facet joint is set by its plane. Cervical facets lie at roughly 45 degrees to the transverse plane, thoracic facets at about 60 degrees, and lumbar facets near the sagittal plane (turning more coronal at L5 to S1). The line of drive follows the plane (Figure 11.3).

Upper cervical set ups

Occiput (C0 to C1). Supine, the head is cradled with a contact at the base of the occiput or mastoid, slightly laterally flexed toward and rotated away from the contact, and a short impulse is given in the restricted direction (a cephalad lift for extension restriction, L to M for lateral flexion restriction).

Atlas (C1). For a laterality listing the patient is supine and the doctor stands at the head on the side of laterality, contacting the lateral atlas transverse process or posterior arch with the index proximal phalanx or MCP. The head is rotated slightly away and laterally flexed toward the contact just enough to localize, and the drive is L to M, slightly I to S, through the atlas. For a rotational listing (transverse posterior) the contact moves to the posterior arch and the drive is P to A with a short rotational arc. Seated (chair) set ups use a digital or index contact on the transverse with the vector taken from the films.

Axis (C2). Contact the bifid spinous or lamina (index supine, thumb seated) on the side of posterior rotation; drive P to A and slightly I to S along the C2 to C3 facet plane.

Lower cervical set ups (C3 to C7)

The supine rotary break is the standard diversified lower cervical adjustment. Patient supine; doctor at the head in a fencer stance. Contact: index proximal phalanx on the articular pillar on the side of posterior body rotation; the other hand cradles the occiput. The head is rotated away (about 30 to 45 degrees, never to end range) and laterally flexed slightly toward the contact. Line of drive: P to A and slightly I to S, along the facet plane, "toward the opposite eye," with a short arc (Figure 11.4).

The lateral break moves the contact to the lateral pillar, laterally flexes the head toward it with little rotation, and drives L to M; it reduces rotational stress on the vertebral arteries. Seated cervical set ups (doctor behind) drive P to A and I to S; prone set ups with a thumb or pisiform on the spinous or lamina suit extension restrictions. At the cervicothoracic junction, the prone thumb move (thumb on the lateral C7 or T1 spinous, head rotated toward the contact, L to M) and the swimmer's position are used.

Safety and screening before cervical manipulation

Cervical manipulation needs a deliberate, mainly history based screen for cervical artery dissection: recent trauma, a sudden, severe, unusual headache or neck pain, connective tissue disease, and brainstem warning signs, the 5 Ds and 3 Ns (dizziness, diplopia, dysarthria, dysphagia, drop attacks; nausea, nystagmus, numbness) plus ataxia. Examine blood pressure, cranial nerves and coordination. Positional provocation tests have poor sensitivity and are not a reliable screen (Chapter 12).

Upper cervical instability (rheumatoid arthritis, Down syndrome, ankylosing spondylitis, recent trauma, os odontoideum) contraindicates upper cervical thrust until flexion and extension films exclude it; an atlantodental interval over 3 mm in adults or 5 mm in children is abnormal.

Section 3Thoracic, costal and lumbar adjustive technique

Prone thoracic set ups

The thoracic spine is stiffened by the rib cage, so many restrictions are in extension or rotation and respond to short lever posterior to anterior thrusts. Breathing is part of the technique: the thrust is timed to the end of the patient's exhalation, when the paraspinal muscles are most relaxed and the chest is least resistant. A drop piece or a soft chest piece reduces the force needed and protects the anterior chest.

Bilateral transverse. Patient prone; doctor at the side in a square or fencer stance; both pisiforms on the transverse processes of one vertebra, elbows nearly locked; line of drive P to A, often slightly I to S along the facet planes. A crossed bilateral variant crosses the hands for a rotational or distractive thrust (Figure 11.5).

Unilateral transverse contacts (reinforced pisiform on the posterior transverse, P to A) correct rotation; spinous contacts (thenar or knife edge) treat extension restriction.

Supine and seated thoracic set ups

The anterior thoracic (supine) set up: the patient crosses the arms, hands to opposite shoulders, elbows stacked. The doctor rolls the patient toward the doctor, places a closed fist, flat palm or pistol grip (thenar on one transverse, flexed fingers on the other) under the segment, rolls the patient back, and thrusts through the elbows A to P and slightly cephalad at the end of exhalation. Hands behind the neck reach the upper thoracics.

Seated and standing lift set ups are less specific and are avoided in osteoporosis because the long lever loads the anterior bodies and ribs.

Costal (rib) technique

Typical ribs (2 to 9) articulate with two vertebral bodies (costovertebral) and with their own transverse process (costotransverse, ribs 1 to 10). Upper ribs move like a pump handle (anteroposterior expansion) and ribs 7 to 10 like a bucket handle (transverse expansion); ribs 11 and 12 move like calipers (Figure 11.6).

Rib dysfunction is named positionally (posterior rib angle, elevated first rib) or by motion: an inhalation restriction (held down) or an exhalation restriction (held up). In a group, treat the top rib of an inhalation group and the bottom rib of an exhalation group first.

Posterior rib: prone, pisiform or thumb on the rib angle, P to A with a lateral to medial component along the rib, at exhalation. Elevated first rib: patient seated, doctor behind, index MCP on the superior first rib under the anterior edge of the trapezius, head laterally flexed toward and rotated slightly away from the contact (slackening the scalenes); drive superior to inferior, slightly medial and anterior, toward the opposite hip.

Lumbar side posture: the lumbar roll

Side posture is the workhorse of lumbar and pelvic adjusting. The patient lies on one side, bottom leg straight, top hip and knee flexed with the foot behind the bottom knee, bottom shoulder drawn forward. The doctor faces the patient in a fencer stance, the cephalad hand stabilizing the shoulder and the thigh on the patient's flexed knee. Tension is localized by rotating the thorax back and rolling the pelvis forward until the target segment begins to move.

A mammillary push contacts the up side mammillary process (P to A with a body drop through the thigh); a spinous push contacts the up side of the spinous (L to M toward the table); a spinous pull hooks the down side of the spinous toward the ceiling. Gonstead places the open side of the disc wedge up: spinous contact for S listings, mammillary for I-M listings (Figure 11.7).

Because lumbar facets are near sagittal, side posture mainly gaps the up side facet. Rotation loads the disc, so reduce it (or use flexion distraction or prone drop) when rotation reproduces leg pain. Cauda equina signs are an emergency and an absolute contraindication.

Section 4Pelvic and extremity adjustive technique

Sacroiliac joint and pelvic listings

The sacroiliac joint moves only a few degrees and millimeters and is stabilized by strong ligaments and by "force closure" from the gluteus maximus, biceps femoris and thoracolumbar fascia. Motion palpation (the Gillet or stork test) and pain provocation tests (distraction, compression, thigh thrust, Gaenslen, sacral thrust) are combined; three or more positive provocation tests best implicate the joint.

The innominate (ilium) is listed in the Gonstead and Palmer systems by how it has rotated relative to the sacrum:

The PI correction drives the PSIS forward and up (anterior rotation); the AS correction pushes the ischium forward, rotating the ilium posteriorly because the tuberosity lies below the joint axis. Pelvic drop pieces and SOT blocks (Section 5) are lower force alternatives for pregnancy, osteoporosis and acute pain.

Coccyx and pubic symphysis

Coccydynia often follows a fall or childbirth; the coccyx is commonly flexed or deviated. Exclude fracture, infection, pilonidal disease and tumor (such as chordoma). The external technique (prone, gentle contact at the side or tip, traction or L to M impulse) is usual; the internal technique (gloved finger per rectum mobilizing the coccyx posteriorly) requires written consent, a chaperone and confirmation of scope.

A pubic shear is usually corrected with muscle energy (resisted adduction with the knees apart) rather than force.

Principles of extremity adjusting

Extremity adjusting restores lost joint play: position the joint loose packed, take up slack, thrust a short distance in the restricted glide. The glide follows the convex concave rule (Figure 11.8): a convex surface moving on a concave one glides opposite to the bone's motion; a concave surface glides the same way.

Shoulder and elbow

Shoulder. Loss of abduction: inferior glide (contact superior humerus lateral to the acromion, S to I). Loss of flexion and internal rotation: A to P glide of the humeral head, supine. Loss of extension and external rotation: P to A glide, prone. Distraction precedes these; AC, SC and scapulothoracic mobilizations complete the region. Do not thrust an acute dislocation, fracture, high grade AC separation or empty end feel.

Elbow. A posterior radial head (lost supination and extension) is adjusted with a thumb on the posterior head while the elbow is taken into extension and supination, P to A; an anterior radial head (lost flexion) is flexed over an anterior contact. Pulled elbow in a child of about 1 to 4 years (radial head slipped under the annular ligament after traction) is reduced by supination then flexion, or hyperpronation, once fracture is excluded.

Wrist and hand. For a dorsal carpal, the doctor's thumbs stack on the dorsal bone with the forearm pronated; traction then a quick whip into slight flexion drives dorsal to palmar. The lunate is the most commonly dislocated carpal (volar, threatening the median nerve) and the scaphoid the most commonly fractured; snuffbox tenderness after a fall needs immobilization and imaging. Acute dislocations are referred. Fingers respond to long axis distraction.

Hip, knee, ankle and foot

Hip. The core maneuver is long axis distraction: supine, grasp above the ankle, hip in slight flexion, abduction and external rotation, take up traction and tug. Posterior glide improves flexion and internal rotation; anterior glide (prone) improves extension. Do not thrust an arthroplasty, avascular necrosis, fracture, septic hip, slipped capital femoral epiphysis (obese adolescent, limp, knee pain) or Legg Calve Perthes disease (boy aged about 4 to 10).

Knee. Anterior tibial glide restores extension; posterior glide restores flexion. For a posterior fibular head, the patient lies with the knee flexed, the doctor's index MCP sits behind the fibular head, and the knee is flexed briskly over it, driving the head anteriorly. Stay on the head, not the neck, where the common fibular nerve lies. The patella is mobilized, not thrust.

Ankle and foot. The ankle tug (supine, fingers interlaced over the dorsum cradling the talus, slight dorsiflexion, long axis tug) treats an anterior talus, which needs posterior talar glide to restore dorsiflexion. The cuboid whip (prone, knee flexed, thumbs on the plantar cuboid, foot whipped into plantarflexion while thrusting plantar to dorsal) treats cuboid syndrome after inversion sprain. Apply the Ottawa rules first.

Section 5Technique systems and instrument adjusting

Sorting the techniques

Named techniques differ in how the lesion is found (palpation, leg checks, films, muscle tests), how force is delivered (manual thrust, drop table, instrument, blocks, traction, soft tissue) and what lesion model they hold. Practice surveys show Diversified used by the large majority, followed by extremity adjusting, Activator, Gonstead, Thompson, soft tissue methods and flexion distraction; most doctors blend several. The Maitland grades describe the continuum of manual force (Figure 11.9).

Diversified

Diversified is the eclectic HVLA approach of Sections 2 to 4. Analysis uses history, examination, static and motion palpation and imaging when indicated; the lesion model is joint dysfunction, and the thrust goes in the direction of restriction. Most trials of spinal manipulation used diversified style HVLA, giving it the largest evidence base.

Gonstead

Gonstead treats the intervertebral disc as the foundation of the segment, so every listing starts with P. Five criteria guide analysis: visualization, instrumentation (dual probe thermal reader), static palpation, motion palpation and standing full spine or sectional films marked for wedging and pelvic listings. Only segments meeting the criteria are adjusted, with specific short lever contacts and minimal rotation on a cervical chair, knee chest table, pelvic bench or hi lo table.

Thompson terminal point (drop)

Thompson terminal point uses a table with segmental drop pieces. The piece under the segment is cocked and tensioned so that a quick shallow thrust lets it fall a short distance; the drop moves the joint with less force. Analysis uses the prone leg check, the Derefield maneuver and the cervical syndrome test (a leg length change on head rotation points to the upper cervicals). Pelvic listings use PI, AS, In and Ex.

Activator and other instrument adjusting

Activator uses a hand held, spring loaded instrument delivering a low force impulse in a few milliseconds, without rotation. Analysis compares prone leg length with knees extended (position 1) and flexed (position 2) and uses isolation tests (a small patient movement that changes leg length) to localize levels, proceeding from the pelvis upward. Low back pain trials show outcomes broadly similar to manual HVLA, but the leg check's validity is unproven. It suits osteoporosis, anxious or acute patients and extremities.

Flexion distraction

Flexion distraction (Cox) uses a table whose caudal section flexes downward. With the patient prone, the doctor holds the spinous above the lesion and flexes the table in short rhythmic cycles. It lowers intradiscal pressure, increases posterior disc height and foramen area, and gaps the facets; it is used for disc herniation, stenosis, facet syndrome and spondylolisthesis. A tolerance test comes first: if leg pain increases or peripheralizes, stop or modify.

Upper cervical techniques

Upper cervical systems emphasize the atlas and axis because of their proximity to the brainstem. They share precise radiographic analysis (lateral, nasium and vertex views), a low force, specific vector and an emphasis on holding (adjusting only when indicators show the correction is lost). The Palmer HIO toggle recoil uses a pisiform on the atlas transverse (side lying or knee chest) with a very fast thrust and immediate withdrawal. Orthogonal methods calculate a three dimensional vector and deliver it by hand or with a table mounted instrument. Evidence is mainly case series and small trials; systemic claims are not established.

Sacro Occipital Technique (SOT) and related low force methods

SOT (DeJarnette) sorts patients into Category I (pelvic torsion thought to affect dural and cerebrospinal fluid dynamics), Category II (weight bearing sacroiliac sprain or instability) and Category III (lumbar disc and nerve root, often sciatica), using indicators such as leg length and the arm fossa test. Correction uses padded wedge pelvic blocks under the prone or supine pelvis, plus reflex (CMRT) and cranial procedures. The Webster technique, a pregnancy sacral analysis from this tradition, is reasonable for pelvic pain, but claims that it turns breech babies are unconfirmed by controlled trials. Logan basic uses a light thumb contact near the sacrotuberous ligament.

Applied kinesiology

Applied kinesiology (Goodheart) uses manual muscle testing as feedback: a "weak" muscle signals a structural, chemical or emotional imbalance, checked by therapy localization and challenge, and treated with reflex points, adjustments and nutrition. Standard 0 to 5 muscle testing is valid neurology, but controlled studies show AK diagnosis (nutrient needs, allergies) performs no better than chance.

Soft tissue methods

Soft tissue work treats myofascial pain and prepares joints. Trigger points are hyperirritable spots in taut bands with a referred pattern and a local twitch response (active ones hurt spontaneously, latent ones only on pressure), treated with ischemic compression (Nimmo) and stretching.

Also know post isometric relaxation (gentle 10 to 20 percent contraction, relax, take up slack), PNF stretching, strain counterstrain (hold the position of comfort about 90 seconds), myofascial release, pin and stretch, instrument assisted soft tissue mobilization and transverse friction massage (Cyriax).

Words worth knowing