Diagnostic Procedures Template

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Diagnostic Procedures Template

• NAME OF PROCEDURE
• Typically used by
• Overview
• History
• Commonly associated terms and concepts
• Mode of use
• Physiological rationale
• Evidence
• Discussion and conclusions
• References

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(No Transcript)
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Leg checking (I)

• Typically used by
• Upper Cervical techniques
• Diversified
• Pierce-Stillwagon/Thompson
• Sacro-Occipital Technique
• Activator Methods
• Directional Non-Force Technique
• Etc.
• Overview
• Functional vs. structural LLI
• LLI as direct cause of back and other somatic
  pain
• LLI as diagnositic indicator
• Pelvis
• Upper cervical
• LLI as outcome measure
• History
• Van Rumpt (DNFT) described the reactive leg
  early in history of chiropractic

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Leg checking (II)

• Commonly associated terms and concepts
• Leg length inequality (anisomelia, leg length
  discrepancy, etc.) Asymmetry in distal foot
  positions, due to anatomic or functional factors
• Leg checking a procedure, usually but not always
  manual and visual, for assessing LLI
• Anatomical short leg (or structural short leg) A
  leg which is demonstrably shorter than the other
  leg, due to fracture, deformity, or uneven growth
  rates
• Functional short leg (or physiological short leg,
  apparent short leg, etc.)A leg which is actually
  even in length with the other leg, but which
  appears shorter due to a postural imbalance that
  draws up the hip in the non-weight bearing
  position
• Supine leg check Leg checking procedure commonly
  employed by upper cervical practitioners, thought
  to identify atlas subluxation
• Prone leg check Leg checking procedure commonly
  employed by full spine practitioners, usually
  thought to identify pelvic torsion, with
  posterior innominate rotation on the short leg
  side.
• Derifield leg check A prone leg checking
  protocol involving 2 primary components (a)
  assessment of relative leg lengths with the knees
  extended compared to knees flexed to 900.
  identifying pelvic syndrome and (b) assessment
  of change in relative leg lengths as the head is
  turned in either direction, identifying cervical
  syndrome

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Leg Checking (III)

• Mode of use
• Standardized mounting procedure
• Removing unwanted degrees of freedom
• Supine, prone
• Derifield variation
• Instrumented leg checking
• Chiroslide
• Anatomer
• Modified surgical boots
• Tape measure methods
• Scanogram
• Measurement screen

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Friction-reduced table
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Chiroslide
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Anatometer
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Leg checking (IV)

• Physiological rationales

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Allis (Galeazzi) test
Knee higher ? long tibia Knee distal ? long femur
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Leg checks Evidence (I)

• Rhudy TR, Burk JM. Inter-examiner reliability of
  functional leg-length assessment. American
  Journal of Chiropractic Medicine 19903(2)63-66.
• Mannello DM. Leg length inequality. J
  Manipulative Physiol Ther 199215(9)576-590.
• Falltrick DR, Pierson DS. Precise measurement of
  functional leg length inequality and changes due
  to cervical spine rotation in pain-free subjects.
  J Manipulative Physiol Ther 198912(5)369-373.

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Leg Checks Evidence (II)

• Reliable to some extent
• Nguyen, 1999
• Bishop, 1995
• Hinson, 1998 (supine)
• Validity poorly studied, however
• Cooperstein R, Morschhauser E, Lisi A, Nick TG.
  Validity of compressive leg checking in measuring
  artificial leg-length inequality. JMPT
  200326(9)557-66.
• Cooperstein R, Morschhauser E, Lisi A.
  Cross-sectional validity of compressive leg
  checking in measuring artificially created leg
  length inequality. Journal of Chiropractic
  Medicine in press.

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Discussion and conclusions LLI

• Friberg on anatomic LLI Friberg O. Leg length
  inequality and low back pain. Clinical
  Biomechanics 19872211-219.
• Anatomic vs. structural LLI still not
  accomplished
• Reliability of leg checks better established than
  validity

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Palpation, static and motion (I)

• NAME OF PROCEDURE
• Typically used by
• all chiropractors
• Static
• Motion MPI
• Overview
• History

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Motion Palpation Institute
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Palpation (I)

• Commonly associated terms and concepts
• Misalignment
• Range of motion, active and passive
• Static and motion palpation
• Paraphysiological joint space
• Restriction
• Accessory joint movements
• Hard and soft end-feel
• Joint play

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Palpation (II)

• Mode of use
• Intersegmental motion
• Unisegmental motion
• Physiological rationale (Gillet)
• three stages of joint fixation
• muscular hypertonicity
• ligamentous shortening
• articular adhesions
• Facilitation model
• Muscle hypertonus
• Hyperalgesia
• Autonomic disturbance

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Palpation (III)

• Evidence
• Troyanovich SJ, Harrison DD. Motion Palpation
  It's time to accept the evidence. JMPT
  199821(8)568-571.
• Hestbaek L, Leboeuf-Yde C. Are chiropractic tests
  for the lumbo-pelvic spine reliable and valid? A
  systematic critical literature review. JMPT
  200023(4)258-75.
• Haas M, Groupp E, Panzer D, Partna L, Lumsden S,
  Aickin M. Efficacy of cervical endplay assessment
  as an indicator for spinal manipulation. Spine
  200328(11)1091-6 discussion 1096.
• Discussion and conclusions
• Hard to research
• Qualitative factors
• How to choose studied, plausible, not reliable
  vs, unstudied but weird

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Diagnostic Procedures Template

• NAME OF PROCEDURE
• Typically used by
• Overview
• History
• Commonly associated terms and concepts
• Mode of use
• Physiological rationale
• Evidence
• Discussion and conclusions
• References

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Line marking A case in point
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Whats wrongwith this picture?
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Dr. George Goodheart
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George GoodheartFather of AK
GEORGE GOODHEART A chiropractor by training,
Goodheart has spent the past 40 years
manipulating muscles not just to alleviate aches
and pains but also to diagnose and treat diseases

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Hugh Logan
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Logan Basic Technique
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Flexion-distraction now, Cox Distraction
Decompression Adjustment Manipulation
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The Cox table
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Activator
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Gonstead
Dr. Gonstead's reputation spread throughout the
state, the country and ultimately around the
world, as a multitude of patient's health
problems were corrected remarkably fast by his
brand of chiropractic treatment.
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Nimmo, aka Receptor-Tonus Technique
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Nimmo model
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Nimmos central concept
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Network Spinal Analysis (formerly Network
Chiropractic Technique)

• The term Network appears to have been adopted
  in 1982 when Epstein began networking multiple
  chiropractic techniques.
• The Network concept of subluxation was also
  developed in 1982
• Class A subluxation Structural in nature with
  fixation, misalignment, and nerve interference
  classic chiropractic subluxation, treatable with
  high-velocity, low-amplitude (HVLA) thrusting.
• Class B meningeal subluxation Neurological
  (facilitated) in nature (5, 9), located within
  the brain or spinal cord. Involves a
  "multisegmental facilitation of the paraspinal
  musculature due to adverse cord-brain tension and
  interference in the cord, brain, an/or dural
  sleeves" due to emotional or chemical stress on
  CNS, and vertebra displaces secondarily, as an
  adaptative feature.
• Clinical Phasing System was added in 1985, which
  in turn was organized into three specific Levels
  of Care by 1994.
• Introduction of these Levels of Care
  distinguishes NCT from NSA
• A fourth level of care was added in 2001

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NSA Phasing System

• Phase 1
• sacrum and/or occiput
• Phase 2
• C1 and/or C5
• Phase 3
• lateral pelvic or sacral sway
• Phase 4
• C2 and/or C3
• Phase 5
• C2 and sacrum, C5 with coccyx

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NSA Levels of Care
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NSA Phase Indicators
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NSA visit frequency

• Network care involves numerous patient visits.
• Visit frequency guidelines according to its
  Levels of Care model
• Basic Care, for new patients or recently
  reinjured patients that primarily addresses the
  Class B subluxations requires 6 weeks to 4
  months, 3 visits/wk 18 to 51 office visits.
• Intermediate Care, in which primarily Class A
  subluxations are addressed, requiring 3 to 6
  months, at least 2 visits/wk 26 to 52 office
  visits.
• Advanced Care, requiring at least 4 months, at
  least 2 visits/wk 34 visits.
• Therefore, the Levels of Care model predicts that
  a new patient will be seen at least 78 to 137
  times in about one year of care. At any moment
  the level 3 patient can sink back to level 1 or
  2, and start all over again going through the
  levels.

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Two types of Network
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Dr. Epstein at work
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Upper cervical family tree
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Upper cervical today