PI Flashcards
Two Purposes of Motion Palpation?
1- Confirm instrumentation findings
2- Verify an x-ray listing
Three Uses for Motion Palpation?
Determine:
1- Which segment is subluxated
2- Listing of the subluxated segment
3- Effectiveness of the adjustment
Listing Body Rotation
1- Look at spinous rotation
2- Look at size of pedicles (wider= posterior rotation; narrower= anterior rotation)
3- Look at width of articular process (width is less on side of spinous rotation)
IN Characteristics (8)
1- Wider innominate 2- Narrower horizontal obturator foramen 3- HYPOlordosis of the lumbar spine 4- Raises femur head 5- Anterior SI joint opened 6- External foot rotation 7- Gluteal fold will be wide and flat 8- Wear on lateral heel and medial sole
EX Characteristics (8)
1- Narrower innominate 2- Wider horizontal obturator foramen 3- HYPERlordosis of the lumbar spine 4- Lowers femur head 5- Posterior SI joint opened 6- Internal foot rotation 7- Gluteal fold is narrow and peaked 8- Wear on medial heel and lateral sole
AS Characteristics (8)
1- Shorter innominate 2- Smaller vertical obturator foramen 3- HYPOlordosis of the lumbar spine 4- Raises femur head 5- Spongy edema at the posterior inferior SI joint 6- Sacrum posterior on the involved side 7- Leg will be longer 8- Gluteal fold will be higher
PI Characteristics (8)
1- Longer innominate 2- Longer vertical obturator foramen 3- HYPERlordosis of the lumbar spine 4- Lower femur head 5- Spongy edema at the posterior superior SI joint 6- Sacrum anterior on the involved side 7- Leg will be shorter 8- Gluteal fold will be lower
5 Components of the Gonstead system?
1- Symptomatology 2- Visualization 3- Static/motion palpation 4- Instrumentation 5- X-ray
Toe Out Foot Flare:
Unilateral- IN ilium or a PEX tibia (posterior rotation on side of external wedge)
Bilateral- Base posterior sacrum, knee problem, heavier kids (may outgrow it)
*wear on outside of heel
Toe In Foot Flare:
Unilateral- EX ilium, anterior talus (from inversion sprain), paralysis of extensor muscles
Bilateral- Posterior S2 tubercle, accompanied by hyperlordosis, pigeon toed, seen in children who walk too early
Antalgic Position:
(Cannot stand up straight)
- Check lumbars
- May have BP sacrum
Dishing:
Flatness in the thoracics is an anterior compensation for a posterior vertebra below
Components of Visualization (11)?
1- Head tilt/rotation 2- High shoulder 3- Low shoulder 4- Rib humping 5- Dishing 6- Loss of smooth lateral thoracic arc (stacking) 7- Scoliosis 8- Pelvic tilt 9- Buttocks/gluteals (wide/flat, narrow/peaked) 10- Foot flare 11- Antalgic position
Loss of Smooth Lateral Thoracic Curve:
Check spine by laterally flexing patient, look for loss of smooth arc
Bilateral loss- posteriority is the major component, stacking apparent
Unilateral loss- wedge part of listing on affected side is a major contributor; scoliosis will make lateral wedging harder to observe
Head Tilt/Rotation:
Head tilt is more common than rotation
Tilt- posteriorly rotated atlas will cause the head to be RAISED on that side due to shape of the superior articular facets (higher mastoid on that side)
Rotation- may be caused by overall spinal rotation or upper cervical rotation
AS Occiput:
In children, head tipped anteriorly and walks on toes
Bang heads to decrease pressure, resulting in a flattened forehead
Pelvic tilt: lower PSIS/gluteal fold, higher iliac crest
PI ilium, an anatomically short leg, or fallen arch
Pelvic tilt: higher PSIS/gluteal fold, lower iliac crest
AS ilium
Buttocks/Gluteals:
Flat: IN ilium or posterior rotated sacrum
Narrow/peaked: EX ilium or sacrum rotated posterior on opposite side
Rib Humping:
Ribs more prominent posteriorly on one side
High Shoulder:
1- Open wedge in mid thoracics on side of high shoulder
2- PS shoulder
3- Superior scapula
4- SC or AC subluxation
Shoulder Drop:
Paralysis of trapezius
Skin Changes (7):
1- Skin color (2) 2- Varicosities 3- Petechiae 4- Brown or white patches 5- Blemishes 6- Scarring 7- Hair changes
Skin Color–Redness:
In acute situations: 1- Rubbing 2- Increased vascularization 3- Swollen irritated tissue 4- Cutaneous radiation
Skin Color–Parasympathetic/red spot discoloration:
Small red spot usually seen in a parasympathetic dermatomal area (Occiput-C5 and below L5)
Caused by a chronic condition in which there is a change in the integrity of the neurological component of the tissue
Found in the upper cervical or sacral regions
Varicosities:
Chronic vascular changes in the sympathetic region, especially at VP and L5
When located at VP, may be accompanied by Dowager’s Hump (edema)
These follow a vasotome, focus on center of involved area
Petechiae:
Broken blood vessels (possible problem area)
Brown or White Patches:
Chronic neurological changes in the sympathetic area,
occur either left or right of spine because they are neurologically specific
Hair Changes:
Increased hair over sacrum and in abnormalities such as spina bifida
Decreased amount of hair over subluxation
Blemishes:
Possible problem area
Scarring:
Healing may be haphazard if nerve damage has occurred
Process of Subluxation:
1- Trauma/stress/chemical change misaligns the vertebra, shifting it into a sustained position
2- Nucleus compressed by vertebral body and exerts pressure on annulus
3- Annular fibers stretched beyond normal capacity and are torn/damaged
4- Inflammatory reaction fills disc with edema, causing disc to swell
5- Protrusion of the disc into neural canal of IVF compresses neural structures, resulting in “Nerve Pressure”
6- Nerve pressure results in nerve dysfunction
What 3 things make a true subluxation?
1- Edema
2- Fixation
3- Nerve impingement/pressure
Purposes of the dual probed instrument (4)?
1- Exact location of the subluxation
2- Intensity of nerve pressure
3- Patient progress
4- When subluxation is corrected
What is a subluxation from C2-L5?
Disorder of the disc
Whats is a subluxation in the upper cervical and SI regions?
Result of damages to interarticular ligaments (swell and produce nerve pressure)
Errors in Instrumentation (10)?
1- Gliding too fast
2- Varying glide speed
3- Uneven pressure of thermocouples
4- Too light of pressure on skin
5- Too wide a convergence of terminals in cervicals, causing air leaks
6- Not keeping terminals centered along spine
7- Not repeating the glide to bring out deflection and reduce ambient temperature
8- Not marking break at its peak
9- Marking the recession instead of the peak of the break
10- Misinterpreting skin lesions as subluxation deflections
Relation of a break to the involved vertebra, nerve, and disc?
Atlas/ Occiput- both readings are very close together, just below occiput
C2-T3- interspinous space below
T4- level of spinous
T5-T9- interspinous space above
T10-T12- level with the spinous
L1- L5- lower 1/4 of spinous
SI joint- anywhere between superior and inferior border of articulations
Components of Static Palpation (8)?
1- Contour changes 2- Spongy edema 3- Pitting edema 4- Tone 5- Texture 6- Temperature 7- Tenderness 8- High TVP
Contour Changes:
Look for when it takes place over 1-2 segments, compare side to side, increase pressure only after you pinpoint an area of change
Spongy Edema:
Occurs where nerve exits the spine except L5 where it my be farther out because of wide transverse of L5
Covers larger area than pitting edema
Found laterally, and also in thoracics under spinouses, and center of sacrum
Bilateral- transitional areas like VP and T12
Move edema ahead of finger and it should disperse with pressure
Center will be most sensitive and may cause symptoms in problem area
Pitting Edema:
Collagen breakdown of skin due to chronic inadequate nerve supply (chronic problem)
Seen in paraspinal muscles in T and L regions and usually unilateral
Bilateral- may be muscle insertion especially if T5 (rhomboid) or T12 (trapezius)
Tone:
Tissue fullness and active resistance
May be a change in cell turgor
As it becomes chronic it can lead to pitting edema
Texture:
Problem area will be smoother, silky due to suderiferous changes
Compare both sides of the spine– unilateral changes are significant
Will be sticky over the spinous process
What is the most sensitive part of the hand?
Thenar
Temperature:
Use whole hand to compare both sides of spine
Unilateral change= possible problem area
Thoracics may feel warmer near heart
High TVP:
Indicates side of body rotation
Tenderness:
Pain when pushing spinous toward the side of laterality
Tight/taut fibers- possible compensation
Tender/edematous/lax- subluxation
Errors in Motion Palpation (3)?
1- Too much force– be light!
2- The patient helps too much
3- Feeling the gross motion instead of individual movement
What causes fixation (3)?
1- Displacement of nucleus from central position
2- Edema, from damaged tissues drawing fluid into area
3- Adhesions that develop with chronic subluxation
Base Posterior Sacrum:
Vertebral arch of L5 intact
Bodies of the above vertebra are still in line
L5 disc wedged posteriorly or is parallel
What are the Stages of Disc Degeneration?
D1- Swollen disc (up to 6 months)
D2- Disc thin at posterior (2-5 years)
D3- Disc very thin at posterior (8-10 years)
D4- Total disc is thin (2/3 original height, 10-15 years)
D5- Total disc very thin (1/3 original height)
D6- Total disc extremely thin (15 years)
Gonstead methodology revolves around what?
Intervertebral disc
Dr. Gonstead based his technique off of what?
The level foundation theory
Facet Planes (T and L):
T: coronal
L: sagittal (more flexion/extension)
Vertebral Subluxation correction:
P: thrust P to A (LOC)
Body Rotation: thrust toward the center of the vertebral body through the DPL via contact point (LOC)
Lateral Wedge: torque at the last part of the thrust
C2-L5 letters of misalignment?
Posterior
R or L: spinous rotation/laterality
S or I: wedging on side of spinous rotation
Neural fibers compressed by atlas subluxation?
Spinal Vagus Superior cervical ganglion (C1-C3) Hypoglossal Spinal Accessory
What is hypermobility?
Compensation of joints below or above a subluxated vertebra, hypermobile segments are compensating for decreased mobility at the subluxated segment. Compensations can become subluxations
IN-EX or Ex-IN listings:
Both ilia are fixed and subluxated
No anterior or posterior ilia misalignments
No lumbar rotation
*** always lists left ilia FIRST, then a hyphen, and then right ilia
SASIN rule:
ASIN- adjust ilium to sacrum:
1- When standing, the leg is lengthened on the ASIN side
2 - When prone, leg remains long
*Adjust Ilium
SASIN- adjust sacrum to ilium:
1- When standing, the leg is lengthened on the ASIN side
2- When prone, leg will shorten because the sacrum will be posterior on ASIN, it has rotated up and over the gonstead elevation
*Adjust sacrum posterior on ASIN side
Upper cervical (occiput- C2) or SI joint subluxations:
1- Damage to interarticular ligaments causes them to swell and produce nerve pressure
2- Irritation from compression of the nerve causes an inflammatory reaction, which alters metabolic rate and therefore metabolic heat of nerve
3- Heat that radiates from inflammed nerve is detectable on the surface
Running the Instrument:
Occiput to T9: probes wide as possible T10-Sacrum: probes in closer Instrument held 90 deg angle to spine, equal pressure Glide up T5 to occiput- 3 sec/seg Glide down C6 to sacrum- 2 sec/ seg
What causes heat swings?
Heat swing= unilateral localized skin temp changes 1- Muscle imbalances 2- Vasomotor reflexes 3- Burns 4- Contusions 5- Sweating reflexes 6- Inflammatory skin lesions
What is the Cutaneous Axon Reflex?
The Recurrent Meningeal Nerve innervates the IVD, articular capsule, and PLL and causes a pain signal to be sent from the IVD to the DRG
Most impulses go to cord, come back from DRG and synapse in the sympathetic ganglion
Sympathetic ganglion initiates a vasodilation response, increasing the temperature causing probe readings
Requirements for a heel lift?
- Only given so a patient will hold their adjustments- not so legs will appear even
- If a patient isn’t holding their adjustments
- AD = to or greater than 7mm
- Only if any existing SI subluxations are corrected
Contraindications for a heel lift?
- Lumbar scoliosis (convexity) on side of high femur head
- Lumbar bodies have rotated to the side of the high femur head
Determining Axis body rotation:
- Dot in middle of base of odontoid
- Dot at lamina-pedicle junction, above spinous process
- Line drawn through these points, extending above and below
Alternate method: compare the relative shapes and sizes of the transverse foramina (foramina obscured on side of spinous rotation)
Determining Axis lateral wedging:
Axis Plane Line may be drawn…
- On inferior border of body
OR
- Through dots placed at the upmost borders of the arches on either side of body
OR
- Through small white opacities just above the arches (pedicles)
What is the Level Disc Theory?
In the static spine, anatomically and physiologically normal discs will allow vertebral bodies to resume their optimal relationships.
The optimal relationship between two vertebrae is found when the perimeters of their bodies are in line, and the vertical distance between the opposing surfaces of the vertebral bodies is the same at all points
Why is the full spine x-ray used?
2 films, 3 exposures Less Radiation Less film cost (processing, storage) Time Full spine contour Exact relation of adjacent segments Posture analysis Accurate count of segments Good for patient who cannot stand for long periods (acute pain, wheel chair) Much easier to read Much easier to analyze Less chance for mistakes Better for patient education
When to list sacrum?
> 7mm rotation is significant
4-6 mm if no ilia misalignment
*All vertebrae up to C2 rotated with sacrum
Signs of posteriority (12)?
1- Base Posterior sacrum 2- Posterior S2 tubercle 3- Anterior coccyx 4- Spondylolisthesis 5- Visual posteriority 6- Schmorl's node 7- Eburnation 8- Extostosis 9- Osteophytes 10- Hour-glassing 11- Stair-stepping 12- Stacking
What does the Foundation Principle say?
When alignment between the supporting structure and the object above which it supports is disrupted, their normal relationships should be re-established by moving object onto foundation instead of moving foundation under the structure above.
Exceptions: base posterior and coccyx
What might offset femur head height other than ilia misalignment?
Previous fracture
Ankle/ knee injury/ misalignment
Anatomical short leg
What is the most important goal of the adjustment?
To restore normal motion back into the joint
What is the number one rule in adjusting the spine?
To always contact the convex side of the scoliosis (not to worsen it)
What is the number two rule in adjusting the spine?
To always contact the open side of the lateral wedge except in the special L5 listings
What is true of Xray distortion?
Distortion can alter the degree in which the vertebra appears to be misaligned but does NOT alter the direction
We see __ on the film and __ on the patient
Misalignment, Subluxation
__ and __ cause the leg to appear long
AS and IN
__ and __ cause the leg to appear short
PI and EX
Where is edema located on ASIN, ASEX, PIEX, and PIIN?
ASIN- on anterior superior margin
ASEX- on posterior inferior margin
PIEX- on posterior superior margin
PIIN- on anterior inferior margin
Lateral film is used to ___
A-P film is used to ___
Lateral: determine which bone is responsible
A-P: determine how to correct it
What is the benefit of the cervical lordotic curve?
Cervical spine supports all the weight of the head- every step causes shock to the disc
Forward curve adds flexibility to the neck and absorbs jarring
Loss of forward curve- every jolt is transmitted through the spine and the discs are left to absorb all the force
What are the functions of a nerve (9)?
1- Calorific* 2- Motor* 3- Sensory* 4- Secretory 5- Excretory 6- Respiratory 7- Reproductive 8- Expansive 9- Nutritive *the 1/3 of the nerve that carries pain sensation
We repeat the glide to…
- Bring out the deflection
- Reduce ambient temperature
What is cord pressure?
1- Disc protrudes straight posterior, producing bilateral temperature alteration
2- Camber (tilt) the scope to compare the nerve above to the one below
3- Most commonly due to an upper cervical subluxation, especially atlas
4- Pointer deflects 10+ points to one side at the level of cord pressure and remains there down to sacrum
Gonstead (wall) quote?
Dr. Gonstead has said…
First- spend all the time necessary to carefully and precisely find and correct a patient’s problem. Do not be in a hurry. Check and recheck your X-ray, your palpation, instrumentation, motion palpation, and visualization.
Second- Remember that Chiropractic always works. When it does not seem to, examine your application, but do not question the principle.
Third- Be prepared when demand for Chiropractic care increases. Study the spinal column and the nervous system every chance you get.
Our future will be our results.
Where are the parasympathetic and sympathetic regions?
Parasympathetic: Occ-C5, below L5
Sympathetic: C6-L5
What does a BP sacrum feel like?
Sacrum will not go into extension and will come back against your fingers. L5 and sacrum will motion as a unit on extension
Motioning sacrum:
Bring patient back into extension at 45 degree angle
Sacrum should drop anterior and inferior on the side of lateral bend (sacrum will drop away from your hand). If not, sacrum is P-R or P-L
3 methods for evaluating ilia?
1- By rotation
2- By lateral flexion
3- By flexion and extension in a 45 degree plane
Famous Gonstead quote?
Find the subluxation, accept it where you find it, correct it, leave it alone!
What is the full spine film size and tube distance?
14” x 36” at a tube distance of 72” FFD
What is usually the case if patient findings (ie. xray and motion palpation) contradict each other?
Inadequate information or the doctor’s ill perception of the information
What is the Gonstead approach to the problem?
1- Patient symptoms
2- Diagnostic references
3- Pinpoint and establish
4- Decide priority of adjustment
What is the 3 joint complex involved in subluxation?
IVD and the pair of posterior facet joints (zygapophysial joints)
What is the allowable yearly dose for radiation workers? How much radiation is present in full spine films (A-P, lateral)?
5 rem allowed a year
2mrem of exposure
Unequal ilia features (height, width, obturator foramens) seen on xray can be indicative of what?
1- Pathological or congenital conditions
2- Poor positioning on the xray
3- Misalignment of the pelvis*
What causes the ilium to stay in its subluxated position?
Edema
The amount of EX or IN is determined by the amount of deviation of the __ from the __
Symphysis pubis from the sacral ridge
Ideal sacral angle?
35-40 degrees
A BP sacrum is seen at the __ joint while a posteriorly rotated sacrum is seen at the __ joint
BP sacrum seen at the lumbosacral joint
Posteriorly rotated sacrum seen at the SI joint
When to adjust sacrum to ilium?
When the ilium is ASIN, ASEX with AS major. Or a PIIN with IN major
When to adjust ilium to sacrum?
When the ilium is PIEX, PIIN with PI major. Or an ASEX with EX major
How does coccyx misalign? How is this determined?
Anterior (A): lateral film
Anterior and right (A-R): lateral and A-P films
Anterior and left (A-L): lateral and A-P films
For every __mm of AS/IN misalignment, the femur head will be __mm higher/lower
For every 5mm of AS/IN misalignment, the femur head will be 2mm higher
For every __mm of PI/EX misalignment, the femur head will be __mm higher/lower
For every 5mm of PI/EX misalignment, the femur head will be 2mm lower
What is the most important purpose of the disc?
To provide flexibility to the spine while maintaining the adjacent vertebrae within normal range of motion
What are the 3 joints of sacrum articulation?
1- Right SI joint
2- Left SI joint
3- Lumbosacral joint
Definition of motion palpation:
The examination of the body tissues by touching and feeling with the fingers and evaluating movement of the bones of an articulation
Listing for (-, -, -)
PLI-M or PLI
Listing for (-, -, +)
PLS or PLS-M
Listing for (-, +, +)
PRI-M or PRI
Listing for (-, +, -)
PRS or PRS-M
Subluxation is_____
a phenomenon of the anterior motor unit– AT THE DISC
What is the anterior portion of the vertebra? Posterior portion?
Anterior portion= the vertebral body (the supporting structure)
Posterior portion= lamina, spinous, articular pillars, TVP (which all direct the motion of the vertebrae)
The ____ plays a major role in the impingement of the spinal nerve, while the ____ plays a minor role in the impingement of the spinal nerve
The swelling of the disc plays a major role in the impingement of the spinal nerve, while the narrowing of the IVF plays a minor role in the impingement of the spinal nerve
The nucleus pulposus…
- has a semi fluid gel consistency
- has a great affinity for water
- is highly resistant to compression
- is the weight bearing part of the disc
- is the fulcrum on which the VB rocks
- tends to protrude posterolateral due to poor blood supply in the area and location of surrounding ligaments
The annulus fibrosus…
- is the restraining part of the disc
- its criss-cross pattern stops the vertebra from exceeding its normal ROM
- is tightly wound around the nucleus, holding it in place
When there is a wedged disc __ a level vertebra, it is most likely a subluxation
When there is a wedged disc __ a level vertebra, it is most likely a compensation
When there is a wedged disc ABOVE a level vertebra, it is most likely a subluxation
When there is a wedged disc BELOW a level vertebra, it is most likely a compensation
What are the 3 classes in which the nucleus migrates?
Protrusion–> Herniation–> Prolapse
What occurs in protrusion?
- Nuclear shift
- Annular ring bulges outward
- Annulus is still intact
- most of what we will see in our offices
What occurs in herniation?
- Nucleus has broken through the annular ring
- Annulus is still intact
What occurs in prolapse?
- Nucleus has broken through the annular ring and through the annular material
- Part of the nucleus may actually break free into the spinal canal
What protrudes the disc, the displaced nucleus or the effects of the displacement?
The effects of the displacement (ie. edema creates pressure on the nerve) protrudes the disc
Why does the nucleus migrate posterior and lateral (posterolateral)?
- Matrix of the disc is not as dense posteriorly and anteriorly
- Nucleus sits slightly more posterior
- ALL is broad and strong, while the PLL gets much narrower as it descends the spine and is weaker than the ALL
- Vascular system of the disc is degenerated much more in the postero-lateral direction
- Supporting ligamentous structures in the posterior leave a gap which is in the postero-lateral direction, which is where the nerve root is situated (in the IVF)
True or False: You should always adjust an asymptomatic spondylolisthesis or coccyx
False: NEVER, NEVER adjust an asymptomatic spondylolisthesis or an asymptomatic coccyx
50% of cervical rotation occurs at what joint?
At the atlanto-axial articulation/joint
Most flexion/extension of the cervical spine comes from what joint?
The occipital-atlantal/atlanto-occipital joint
Other names for the sacral base line?
- Horizontal plane line of the sacrum
- Sacral horizontal line
- Sacral plane line
- Sacral groove line
Scoliosis:
-Use Adams test (bend at waist) to see if structural or nonstructural (functional)
If disappears: curve is mild to moderate (less than 25 degrees), non structural (functional)
Rotatory scoliosis has prominent muscle bundle on the side of the high transverse
Raised muscles may also be evident on the side of handedness
