Alternative and Complementary Therapies

Clinical Use ­ gives an explanation of CDC; Research ­ has illustrations demonstrating the procedure.

CONTENTS

INTRODUCTION

CHAPTER 1. Rationale for Manipulation 

CHAPTER 2. Theory of Operation

CHAPTER 3. Clinical Use

APPENDIX I. Repeatability Testing

APPENDIX II. Intra- and Inter-Examiner Reliability Studies



INTRODUCTION

This manual describes the use of compliance measurements obtained with the Force Recording and Analysis System to image joint fixation. The Force Recording and Analysis System (FRAS) provides the clinician with an accurate and repeatable visual display of the relative compliance of discrete segments of the spinal structure of the patient. This information, along with other data collected by the clinician, such as patient history, patient complaint, X-ray analysis, etc. is used to assist in the selection of segments of the spine for manipulation. This manual provides a rationale for the use of compliance measures, illustrates the theory of operation of the FRAS system and describes the basic clinical use of the instrument. Also included are research data and tests relating to the repeatability and reliability of the instrument in the hands of clinical users.

Prior to attempting to implement any of the clinical protocol described in the manual, the clinician must read the User Manual first. This manual is supplied with the instrument and describes in detail the proper use of the controls and features of the instrument.

The information supplied in this manual and in other publications by Sense Technology Inc. is not intended to be construed as a particular technique. The information is provided to the clinician in order that they may most effectively use the instrument while adapting it to their own particular technique or style of manipulation. The use of the words "DIFFERENTIAL COMPLIANCE" does not describe a technique of manipulation but a method for objectively and accurately assessing the relative compliance of vertebral segments1.


CHAPTER 1 Rationale for Manipulation

Spinal manipulative therapy can be broadly defined as including all procedures which are used to mobilize, adjust, manipulate, apply traction, massage, stimulate, or otherwise influence the spine and paraspinal tissues with the aim of improving the patient's health. Spinal manipulative therapy has been used since ancient times and has been referred to in the writings of such authorities as Hypocrites (400 B.C.), Galen (130-120 B.C.), Avicenna (960-1037 A.D.), Ambrose Pare (1510-1590 A.D.), Percivall Pott (1715-1788 A.D.), and Sir James Paget (1844-1899 A.D.). The most noted modern proponent of spinal manipulative therapy is D. D. Palmer,2 the founder of Chiropractic. Some form of manipulation of the spine has been available and widely used by almost every society in recorded history. 

Recently there has been a marked increase in the utilization of spinal manipulative therapy in the management of patients' low back pain. In 1976, it was estimated that 90 million patient visits were made to chiropractors in the United States. By 1980, this estimate had increased to 120 million office visits per year.3 In addition to patients who are seen by chiropractors, there has been a rapid expansion of interest in spinal manipulative therapy by medical physicians, physical therapists, and osteopaths. Increasing numbers of physicians are incorporating manipulation into their practices by working more closely with other practitioners. 

Although controlled tests of spinal manipulative therapy have not always been conducted in a manner that would meet the requirements of investigators for comparison with other studies, there is a growing assessment that manipulative therapy is more effective as a treatment modality than any other conservative treatment for lower back pain. In fact, the Agency for Health Care Policy and Research of the Public Health Service of the US Department of Health and Human Services has recently issued Clinical Practice Guide Number 14 which recommends manipulation as the primary treatment for acute low back pain..

The major theories on which manipulation is based include the reduction of disc prolapse, the correction of posterior joint dysfunction, the mobilization of fixated or blocked vertebral joints, the reduction of nerve root compression, the normalization of reflex activity, and the relaxation of muscles. Increasing research into the pathology and physiology of back pain has helped consolidate many of these theories into a model which is increasingly being used to explain the mechanism of action in manipulation. Consideration of the possible effects of manipulation on the structure of the spine has led to the postulation that there exists barriers to motion within the spinal joints which can be influenced by manipulation. 

The model representing the ranges of motion for each spinal joint is presented in Figure 1. The active range of motion is that motion affected by muscles alone. This is the range of motion in which normal exercise is performed and which is limited by the leverage capacity of muscles surrounding the joint. Beyond the active range of motion is the passive range of motion where external forces are used to effect stretching beyond the active range of motion. The limit of the passive range of motion is the so-called physiologic barrier . Beyond that range is a smaller range of motion through which a joint can be moved without disrupting its ligaments. This range of motion can be entered by a quick thrust in the direction of joint movement. The limit of this range is the anatomic barrier beyond which will result in the tearing of ligaments or bony collapse.

Normal motion may be restricted in any of three ways which include muscle spasm, joint locking and bony restriction. In Figure 1B the muscles surrounding the joint are in spasm and the normal range of motion is restricted. In Figure 1C the joint has locked on one side, pulling the physiologic barrier towards the neutral position. Mechanisms for this restriction in motion include articulator synovial pinching and disc herniation. In 1D the bony structures have blocked movement through spur formation or deformity. 

In the first two instances, manipulation may restore motion to the joint through releasing the muscle spasm and/or stretching the shortened muscles. In the instance where the motion is restricted due to joint locking, the motion may be restored by a manipulative thrust into the paraphysiologic space to stretch the ligaments and open facets. Bony obstruction to movement may not be susceptible to manipulation. 

CHAPTER 2 Theory of Operation 

Identification of fixated vertebral segments has traditionally been accomplished through manual palpation of the spine and more recently through the observation of spinal motion with X-ray image intensifiers.

The Differential Compliance Methodology implemented with the Force Recording and Analysis System enables the examiner to objectively determine the relative compliance of two or more vertebral segments or to evaluate the mobility of a single spinal segment in any of its degrees of freedom. The first step of this methodology is to obtain a measure of the compliance of each vertebra or segment of the spine under evaluation. This measure is obtained by first applying a low energy impulse to each portion of the spine sequentially. Each impulse is composed of equal energy. The force of each impulse is recorded through the use of a force transducer. Because the energy contained in each impulse is the same, the resistance of the spinal structure will determine the rate of change of force and the peak force recorded. A rigidly fixed portion or joint of the spine will result in a higher peak force for the same energy impulse than a portion of the spine which is easily moved or compliant. In addition, the rate at which force rises from the initial contact to the peak force will vary. The rate of increase will be much steeper with a rigid joint versus a compliant joint. Because of differences in the muscular and connective tissues as well as the size and configuration of the bony structure of individuals, no two individuals would be expected to have the same compliance measurements. However, comparison of the compliance measurements of different segments of the spine will indicate which joints are fixated because they will have the lowest compliance. These joints or spinal segments are candidates for spinal manipulative therapy.

A constant energy impulse is provided to each of the vertebrae or spinal segments under study with the impulse head. This head is designed to transmit an equal amount of energy to the patient's spine at each force setting. It accomplishes this by first requiring the examiner to establish a preset pressure against the patient with the instrument. This preset patient pressure (or preload) is used as a set point at which the energy of the impulse is initially transmitted to the patient. Because the energy impulse is the same each time and is delivered at the same preload against the patient's spine, a highly reproducible transfer of energy is achieved. 

By attaching a force transducer to the instrument where it contacts the patient's spine, the force which results from the energy impulse given to the patient can be recorded. 

The relative compliance of the vertebral segments under examination may be determined by extracting the maximum force from each force versus time recording made at each vertebral segment. As seen in Diagram 1, the force versus time curve rises rapidly to a high peak when the impulse energy meets an unyielding or noncompliant object. The rise is slower and has a lower peak when the energy is dissipated into a more compliant or yielding surface.



Diagram 1. Force Versus Time Response of Hard and Soft Substrate To Impulse Loads of Equal Energy

FIGURE 2 Shows a multiple segment model of joint motion. The upper and lower segments exhibit normal motion while the middle segment exhibits restricted motion due to muscle restriction. Assume for the moment that these joints are three adjacent cervical vertebrae. If the compliance of these vertebrae is determined in the neutral position as shown in FIGURE 3, the result of the analysis may show little discrimination between each joint. This is because each joint exhibits nearly normal motion in the neutral position as shown in FIGURE 4. To increase the discrimination between a normal joint and one with restricted motion, the joints may be tested in different positions. For example, the cervical joints may be tested in flexion. If the joint is restricted in flexion, the result of the analysis will be similar to FIGURE 5.

After the spinal segments of interest have been challenged with the low energy impulses and the force versus time waveform have been recorded, the maximum peak force for each waveform is stored in a buffer. In order to obtain a relative measure of the compliance of the vertebral segments, each maximum is then divided by the maximum slope or peak in the buffer. This process yields a set of numbers the maximum of which is equal to one. These numbers are then displayed as a graph or as a series of bar graphs identified with the vertebral segment under examination. This display allows the clinician to identify the highest and lowest areas of compliance of the examined spine. This procedure may be repeated for the same segments of spine after adjustment to form an objective record of the effects of the adjustment on the compliance of the spinal segments.

FIGURE 6- Differential Compliance Display

CHAPTER 3 Clinical Use

The clinical use of the instrument may be divided into three phases. The first phase consists of the pre-test or evaluation of the patient's spinal compliance prior to manipulation. The second phase is the manipulation itself. The third phase consists of the post-test or assessment of the compliance of the patient's spinal system after manipulation and comparison with the pre-test compliance results. These phases may be applied repetitively until the clinician is satisfied with the results of the manipulation. The instrument has been shown to provide extremely accurate and reproducible results when the pre- and post-assessment are performed with the patient in the same position. This is especially true in the cervical and lumbar areas of the spine. Positioning, while still important, is not as critical in the thoracic area of the spine because of the support provided the vertebrae by the ribs.

As a general principle, the assessment of the spine should be performed with the structure to be assessed at the limit of passive motion. By positioning the spine in this manner, differences in resistance to motion will be most accurately measured. Application of the principle to the cervical area of the spine may be easily achieved by placing the head and neck of the patient in flexion for the pre- and post-analysis. Testing in the neutral position may reveal information of clinical significance when compared with tests performed under flexion.

The pre-analysis will provide the user with a graphical display of the relative compliance of each vertebra tested. Segments with abnormally low compliance appear as deviations of twenty percent or more from their adjacent segments. These segments are referred to as hypomobile or fixated segments and are candidates for manipulation. The display will often indicate segments of greater than normal compliance as defined by being more than twenty percent different from adjacent segments. These segments appear as low graph readings and may be compensation for restricted mobility of other segments. High compliance (low bar graph readings) may also be due to acute muscle spasm within and around one or more vertebral segments. High compliance readings which are associated with muscle spasm are also candidates for manipulation.

Cervical Analysis

Start with the patient seated on a bench or chair. This position will present the cervical area of the patient to the clinician at a comfortable height and will allow the clinician to stabilize the patient's head and neck in flexion. Place the patient's head and neck in flexion with the head facing straight ahead. Activate the cervical display. Place the tip of the 30mm dual prong extension of the impulse head just below the occipital ridge angled at approximately 45 degrees to the back of the neck. Press the impulse head smoothly against the patient while maintaining the position of the dual prong and the head will automatically provide a low energy impulse to the patient when the pre-determined preload is achieved. The instrument will record the response of the segment to the impulse loading and store it temporarily until the pre-test is complete.

Next, change the angle of the impulse head to approximately 90 degrees to the patient's neck and repeat the test procedure. Now move the dual prong attachment tips down the patient's neck to the area of C-2, hold the instrument angled at approximately 45 degrees to the patient's neck and repeat the procedure. Complete the cervical assessment by continuing this procedure until all of the included vertebrae have been tested. At this point, the instrument displays the results of the compliance assessment in the lower graph of the cervical display.

If examination of this graph reveals deviations in compliance reading from one vertebra to the next of more than twenty percent, then that area of the cervical spine is a candidate for manipulation.

Impulse Head Positioned at Occiput
Impulse Head Positioned at C-1
Impulse Head Positioned at C-2

If the manipulation is performed with the impulse head of the instrument, it should be performed with the patient's head and neck in the position in which the high readings were obtained. That is, if the high reading occurred on the vertebra in the pre-test assessment position it will be most effective to adjust the patient with the neck in that position. This is the most effective way to "unlock" motion that is restricted by either joint locking or muscle restriction.

After the manipulation, the clinician may check the results by performing a second assessment of the
compliance of the same spinal segments. Reactivating the first cervical display transfers the initial
pre-assessment to the top graph and prepares the instrument for the second or post-assessment. Repeating the steps outlined under the pre-assessment, the instrument will then display the compliance readings in the lower graph which enables the clinician to compare the pre-assessment results with the results obtained after manipulation.

If the post-assessments indicate residual differences in compliance of more than twenty percent, then the clinician may wish to repeat the manipulation for those segments that are so identified. Clinically, a good result is identified by no residual segments being greater than twenty percent different from their neighbors.

Thoracic Analysis
This analysis can be performed with the patient seated or prone. Activate the thoracic analysis section and proceed as described in the cervical analysis with the tips of the dual prong placed on the facets of the vertebrae on either side of the spinous. Palpate to determine the fourth thoracic vertebra as a starting point. The procedure is similar to that described under cervical analysis.

Lumbar Analysis
This analysis can be performed with the patient seated or prone. Activate the lumbar analysis section and proceed as described in the cervical analysis with the tips of the dual prong placed on the lamina of the vertebrae on either side of the spinous. Palpate to determine the first lumbar vertebra as a starting point. The procedure is similar to that described under Cervical Analysis.

Adjustment
Although manipulation may be performed entirely manually, or with other instruments or with the assistance of drop tables or other techniques, the Force Recording and Analysis System provides an integral impulse head for adjustment (since the use of the instrument enables very specific manipulative technique, it will be referred to as "adjustment" rather than the broader term "manipulation"). The impulse head may be used to provide multiple high velocity impulses or "toggles" to the vertebrae or joint selected for adjustment. The clinician maintains complete control of the adjustment since the instrument will apply repetitive impulses only as long as the clinician maintains pressure against the patient's body structure with the impulse head. In addition, the instrument automatically terminates the adjustment when the vertebra "stabilizes" as measured by the force impulses sent to the computer by the impulse head.

The basic principle of adjustment with the multiple toggle impulse head is to place the body structure of the patient in the same position as that in which the deviation from "normal" compliance was observed in the analysis of the structure. Returning to our model of joint motion (see FIGURE 6) it is apparent that the force of the adjustment will be most efficiently delivered close to the point at which the joint is restricted.

The dual prong tip (in some cases, the single prong tip) is placed on the vertebra or joint inter-face to be manipulated in the direction in which the greatest resistance was encountered. The instrument is then pressed smoothly against the vertebra or joint until the instrument begins to provide multiple impulses. Holding the impulse head against the patient firmly the impulses will continue until the joint stabilizes. If in the clinician's judgment, the joint was not freed by the adjustment in the first application, the treatment may be repeated. It is often the case that joint stabilization is also accompanied by change in the tone of the multiple impulses which indicates that the underlying structure has been effectively manipulated.


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1. The terms "DIFFERENTIAL COMPLIANCE", "CFI", "CFI SCAN", and "COMPUTERIZED FIXATION IMAGING" are registered trademarks of Sense Technology Inc.
   

2. Palmer, D. D.: The Science, Art, and Philosophy of Chiropractic., Portland Printing House, Portland, OR,1910.
   

3. Frymoyer, John W. ed. The Adult Spine Principles and Practice, Raven Press, NY, NY, 1991
   

4. Pierce, Walter V., President, We Care Chiropractic Research Center, Sherman College, Inman SC, personal communication.
   

5. Clemen, Michael J., D.C., Fine Tuning the Spine for Sound Results, Today's Chiropractic, July/August 1994 issue. 
   

6. "The Fundamentals of Modal Testing", Application Note 243-3, Hewlett Packard Corporation.
   

7. "Impulse Technique for Structural Frequency Response Testing Sound and Vibration", November 1977, pp.8-21.
   

8. Ibid., Hewlett Packard p. 19.
   

9. A useful overview of the adjusting instruments is provided by Osterbauer, et al. [18]
   

10. Press, William H. et. al. "Numerical Recipes in C" Second Edition, Cambridge
    University Press 1994