I've often wondered about the confusion felt by many graduating chiropractic students in regard to basic spinal palpation and their insecurity in being able to accurately diagnose and document spinal biomechanical impairment.
In an ideal world, a patient should expect a somewhat uniform and consistent examination technique and report of physical findings following a visit to any chiropractic physician. Unfortunately, as you may realize, such inter-examiner reproducibility (and reliability) seems anything but the case.
Unless things have changed a lot since my days in school, chiropractic students are exposed to a sometimes bewildering assortment of techniques, which can leave them groping for solid ground upon which to build a successful practice. A simple, basic and effective technique of spinal palpation, which I hope to outline here, can seem lost in the miasma of conflicting approaches offered to students. When you throw in the questionable practice of allegedly locating biomechanical impairment by using so-called "X-ray spinography listings" (miniscule bony landmark measurements of supposed clinical significance), the confusion is only compounded.
I hope we can all agree that the fundamental nature of our work, and what distinguishes our profession, is our ability to appreciate by palpation functional disorders of the spine, pelvis and peripheral joints. Except, perhaps, for digital motion X-ray (DMX), truly dysfunctional vertebral motion segments can only be appreciated by skilled and artful palpation. And as the name implies, these disorders are heralded by gross abnormality of movement. In almost all instances this abnormality consists of an inherent hypokinesia or restricted joint motion and some abnormality in positional relationship between joint surfaces at rest. By my observation, most spinal and pelvic biomechanical lesions are rotary (torsional) in nature. Straight flexion or extension lesions (subluxations) of the spine do occur (most commonly in the thoracic spine), but don't seem nearly as common as rotary fixations. I also find that these straight anterior or posterior spinal facet fixations commonly occur secondary to some degree of basic postural imbalance (e.g., thoracic hypo/hyperkyphosis).
After performing a comprehensive visual examination of a patient in open-back gown (a practice one disregards to their patient's detriment), I begin a cervical spine palpation with the patient seated in a comfortable chair. Erect cervical spine palpation on an exam table may work. However, in my observation, a patient is less able to relax the paraspinalis and intersegmental muscle groups in such an unsupported posture, thus preventing deeper palpation. After doing a light-touch palpatory exam to include the anterior and posterior cervical lymphatic chain and carotid arteries, I place my left hand on the patient's forehead for stabilization and lightly contact my right-hand thumb and middle finger in the fossa at each side of the neck just below the occiput. Closing my eyes to help my fingertips "see," I then work my way gently down the posterior cervical lamina/facets applying equal P-A pressure at each level, noting any imbalance in resistance to pressure or difference in resting tonus of the overlying musculature. I then repeat this procedure using more pressure and going deeper into the underlying tissue. I may even repeat this exam technique a third time, using firm pressure of the fingertip pad to elicit mild pain at a region of dysfunction. (A note of caution: If your palpation in the cervical spine is too far to each side - too lateral - you may produce sharp bony pain because of irritating the sensitive lateral transverse processes.)
It is the areas just adjacent to the spinous processes - the region of the lamina and facets - that give so much valuable information on the wellness of spinal function. From my observation, palpatory findings of inflammatory arthrosis, capsulitis, rotary-torsion joint fixation and localized guarding paraspinal myospasm are almost always only on one side of the spine, (except for straight flexion/extension lesions), with vertebral body rotation following the side of neuromuscular reflex spasm/hypertonus. This only makes sense when you think of these paraspinal and intersegmental muscles as guy wires about the spine. In fact, it is this finding of difference in resting muscular tonus from one side of the spine to the other that is of primary importance in locating spinal im-pairment. I quite often also find rotary fixation in the upper cervical spine that appears to be in opposing compensation to a lower cervical biomechanical lesion (compensatory rotation in opposition).
After noting any regions of unilateral paraspinal hypertonus, one-sided lamina/facet prominence or sharp pain to moderate probing, I begin motion palpation of the neck by again working from the occiput inferiorly to the cervico-thoracic junction. I guide the forehead gently with my left hand through flexion, extension, lateral bending, rotation and circumduction as I work my finger pads down the spine to appreciate any specific areas of impaired motion. Patients almost always will confirm areas of subluxation with some kind of response and often are surprised at how a skilled practitioner can easily locate the troubled region without their direction. I then chart my findings as the patient moves onto the exam table.
Many of us remember the technique of abdominal palpation, whereby we were taught to relax the palpating hand and finger pads and use the opposite hand for applying downward pressure. This is understandable in that the palpating hand can then concentrate in its role as "sensor," while the opposite hand is directed to apply varying degrees of pressure. By my observation, the heralding characteristic of all thoracic and lumbar biomechanical impairment is loss of springy motion and normal joint play to P-A compression. This palpatory technique makes an excellent tool for finding any regions of functional spinal distress.
I begin palpating the thoracic spine with a patient in the prone position with their arms hanging loosely down at the side. I then place the index and middle finger pads of my palpating hand over the lamina/facets, beside the spinous processes. Then, placing my opposite hand over the palpating hand, with only gentle P-A pressure, I slowly work my way downward, getting an overall assessment of the patient's inherent flexibility and limberness of motion. At the same time, I am "looking" with my fingertips for signs of paraspinal muscular hypertonus, prominence of lamina/facet, rotary torsion, posteriority or anterior recess. I repeat this examination technique a couple of times over the thoracic spine, carefully applying increasing levels of P-A pressure, only as the patient tolerates. "Springy motion" and impaired "joint play" are somewhat subjective description of the normal give and rebound of a healthy/functional spine, but once you have palpated enough normal spinal regions, loss of this motion is quite evident.
Since lumbar hyperlordosis with chronic inflammatory arthrosis of the lower lumbar facets is so common in our portly/unconditioned population, I begin lumbar palpation with a generalized P-A compression test by placing my palpating hand crossway to the spine and carefully but firmly pushing down as I work my way up from the lumbosacral region. A positive sign is, of course, sharp, lancing, low back pain without radiation, usually on both sides of the spine, extending into the upper lumbar region. Chronic hyperlordosis with reflex guarding myospasm of the large erector spinae can present a challenge to accurate lumbar palpation.
I begin by placing my palpating thumb directly over the right L5/S1 facet and then, using my other thumb for P-A pressure, try and "bounce" the facet. As in other regions, I begin gently and apply increasing levels of pressure as is tolerable to the patient. Working individually over each facet, moving up one side of the lumbar spine, then the other, will usually reveal any area of restricted joint play. A localized, overlying hard, ropy myospasm only confirms the impression of a facet biomechanical impairment in the deeper tissue.
Distinguishing sacroiliac pain from lumbar pain can be a tricky business and mistakes in diagnosis are common. Generally, sacroiliac pain is most intense upon waking and getting out of bed in the morning, and this high level of pain reproduces itself upon rising after prolonged sitting. Since excessive synovial fluid tends to build up in the posterior compartment of the S-I joint with rest, one can understand the excessive capsular stretch producing intense pain with movement after immobility. Also, sacroiliac pain does not tend to be relieved with recumbence. In fact, women with large pelvic structures may experience increased pain with side-posture sleep. This is why sacroiliac pain also tends to improve dramatically with ambulation and knee-raise exercise (dissipating the excessive fluid pressure throughout the joint space). Lumbar (or disc) pain, on the other hand, tends to be relieved after a night's sleep but increases as the day progresses. Lumbar facet pain also tends to ease significantly with recumbency, especially in a semi-fetal side posture or flat on one's back with the knees up. A thorough questioning along such lines in initial history can be very beneficial in properly directing one's attention to low back pain.
With the patient still prone, I then do static palpation of the S-I joints by simply assessing the balance and height of each PSIS prominence in relation to the sacrum. What I hope to find is equal symmetry and the ilia resting comfortably at each side of the sacral keystone. In such cases of normality, deep thumb pressure at the sacroiliac interspaces is almost completely painless. In my observation, the pelvis most commonly lesions in simple clockwise or counterclockwise rotary fashion (cephalid view). Early osteopaths and DCs of today have observed that there seems to be a large preponderance of clockwise rotary displacements in patient populations. This, too, has been my observation. Some have speculated that this is because the majority of us are right-side dominant. In such cases of clockwise rotary pelvic displacement, I find posterior-inferior prominence of the right PSIS, as compared to the left, spasm of the right gluteus medius and right S-I interspace edema and exquisite pain. Of course, sacroiliac problems may involve one or both sides. With bilateral involvement of clockwise rotary displacement of the S-I joints, I find left anterior-superior displacement of the PSIS on the left.
The hinge and glide motion of the sacroiliac joints can make for interesting motion palpation. I commonly find sacroilitis and sacroiliac biomechanical impairment in a pelvis that still exhibits some movement on repetitive standing knee-raise (marching test). However, in such cases, I also sense a "boggy" motion in S-I joint movement on the involved side. This is characterized by a sense that one joint is struggling to go through its normal range in comparison to the opposite side.
I hope this brief treatise outlining basic palpatory skills and physical findings proves useful in your daily practice. I often tell my patients that in order to tame the beast, one must first fully identify it. Thus, I encourage you to work on developing the very real and valuable art of spinal and pelvic palpation. It is the foundation for all your other good work.
Dr. John Bomar, a 1978 graduate of Palmer College of Chiropractic, practices in Arkadelphia, Ark. He is a past board member of the Arkansas Chiropractic Association and a founding board member of the Arkansas Chiropractic Educational Society. Contact Dr. Bomar with questions and/or comments regarding this article via e-mail:
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