Monograph 4

Posttraumatic Evaluation Protocols

By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997

Copied by Chiro.Org with permission from   ACAPress

Physical Work-up Reviewed     Assessing Physical Fitness     Evaluation     Depth of Examination     Dynamic Bony Palpation     Soft-Tissue Palpation     Joint Auscultation Practical Anthropometry     Human Dimensions and Proportions     Motion Assessment Muscle Strength     Muscle and Ligament Function     Mechanical Factors Affecting Normal Muscle Contraction     Temperature Values Affecting Normal Muscle Contraction     Muscle Testing

Electrodiagnosis and Electro-myography     Electrocardiography, Thermography and Spirometry     Laboratory Profiles Posturometry     Body Balance     Equilibrium Mechanisms     Plumb Lines and Similar Devices     Bilateral Balance Scales     Potential Visceral Effects of       Balance Defects References and Bibliography

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PHYSICAL WORK-UP REVIEWED

Courson reminds us that any rehabilitation program should include returning the patient to optimal preinjury status and developing a preventive maintenance program to minimize the possibility of injury recurrence.


Assessing Physical Fitness

A reduced level of fitness predisposes injury and likely the extent of injury at both its macroscopic and microscopic aspects. For example, physical training increases the bulk of muscle fibers and increases muscle interstitial vascularity. Both factors have an influence on the effects of acute muscle strain in that (1) an untrained muscle is more apt to bleed and form a hematoma than a trained muscle, and (2) the physiologic mechanisms necessary to absorb extravasated fluid is more efficient in a trained muscle than an untrained muscle.

Many people in modern civilization spend much of their mature life at an energy level close to the resting state because of technologic advancements and modern conveniences. To what exact degree this affects human resistance to disease, longevity, adaptability, and general well-being has not been determined, although it is generally recognized to be extensive. In this context, the role of physical training has still to be accurately defined to the satisfaction of all. Williams/Sperryn look to physical fitness as an "artificial state in so far as it is specially cultivated rather than inherent in the individual." Functional status can apparently be increased more in young subjects than in the elderly.


Evaluation

People participating in vigorous occupations and sports should have a complete examination at least annually, and re-evaluation is often necessary at seasonal intervals. Re-assessment is always necessary when the patient has suffered a severe injury, illness, or surgery.

Questioning.   Because of drilled routine, doctors are well schooled in the taking of a proper case history. But with an athletic or work injury, both obvious and subtle questions often appear. How extensive was the individual's conditioning? How much time for warm-up is allowed before vigorous activity? What precautions are taken for heat exhaustion, heat stroke, concussion, overuse strains and sprains, and so forth? Does the supervisor or coach make substitution for proper evaluation immediately on the first sign of disability? How adequate is protective gear? How many associates have suffered this injury? Who, what, when, where, how, and WHY? A detailed history of past illness and injury is vital. In organized sports, an outline of the regimen of training should be a part of the history, as well as a record of performance.

Determining Disability.   The term "disability evaluation" in clinical practice roughly describes the physician's function in claims proceedings. The doctor determines the degree of functional impairment, usually in a percentage to denote an impairment in comparison with a person's entire range of activities typical with the patient's age and sex. The doctor's responsibility is to determine functional impairment only, not to determine occupational disability, as the later is the responsibility of a workersrquote compensation board. In sports care, however, "disability" has a more profound meaning that includes not only the physical factor of functional impairment but other considerations such as a player's talent, experience, position, present and future risk to a part or organ, etc.

A defect may bar a candidate from a specific occupation, sport, or position but not another, or it may be only a deterrent until it is corrected or compensated. Many famous athletes have become great in spite of a severe handicap.


Depth of Examination

Any occupational or athletic health examination has dual functions: (1) to assess health status (limits and capacities), and (2) to recognize problems that may be precipitated during common activity. These functions must be kept in mind during the examination of a laborer, professional athlete, or a weekend athlete. If there is undue risk of present injury or future permanent injury of any type under employment or sports conditioning, practice, or competition situations, the patient should be kept from participation regardless of the patient's (or another person's) objections.

The typical initial physical examination should evaluate height, weight, sitting blood pressure and pulse, temperature, eyes and vision, ears and hearing, nose, mouth and throat, chest and lungs, female breast, heart, abdomen, rectum, genitalia, feet, and spinal and overall postural mechanics. A pelvic gynecologic examination should be considered for any female athlete over the age of 20 that has not been examined within a year.

A basic orthopedic evaluation should be conducted in regard to limb circumference measurements, joint flexibility, and range of active motion for the cervical spine, shoulders, back, hips, knees, and ankles. Neurologic deep-tendon reflexes, superficial reflexes, and coordination tests should be assessed, with more sophisticated tests reserved to confirm any abnormalities found.

Laboratory work-ups should be conducted as indicated from the physical examination. However, many clinicians feel that all patients should have as minimum a blood work-up and urinalysis, and an ECG if possible. X-ray films are not considered routine procedures unless necessary to confirm suspicions. The examiner should avoid collecting information without a clear purpose.


Dynamic Bony Palpation

Healthy articulations can be moved through their planes of normal motion actively and passively without causing pain; ie, until they reach their anatomical limit. A general rule of thumb holds that pain emanating from compressed tissues will be relieved by traction and aggravated by compression. Conversely, pain arising from tensile lesions will be relieved by compression and aggravated by traction.

The Motion Barrier.   When a joint is passively tested for ranges of motions, the examiner will find an increasing resistance to motion (a "bind") or the physiologic motion barrier. When a joint is moved past this point, the attempt becomes at least uncomfortable to the patient. This point is the anatomical motion barrier.

In evaluating degrees of passive motion, joints should be moved to but not forced through the anatomical motion barrier (which may be unstable). Thus, joint motion is evaluated by passively carrying the joint(s) through ranges of movement until the motion barrier in each plane is encountered. The degrees of movement allowed should be recorded.

Joint Play.   There is a small but precise accessory movement within synovial joints (joint play) that cannot be perceived except by dynamic palpation. Although joint play is necessary for normal joint function, it is not influenced by a patient's volition. Thus, joint play is that degree of end movement allowed passively that cannot be achieved through voluntary effort. Total joint motion is the sum of the voluntary range of movement plus or minus any joint play perceived by the examiner.

Joint play occurs because normal joint surfaces do not appose tightly. There are small spaces created by articular incongruencies necessary for hydrodynamic lubrication. In addition, because synovial joint surfaces are of varying radii, movement cannot occur about a rigid axis. The capsule must allow some "play" for full motion to occur. Thus, motion palpation to detect restricted joint play is an important part of the biomechanical examination of any painful and spastic axial or appendicular joint. Pain and protective spasm result when a joint is forced (actively or passively) in the direction in which normal joint end-play is lacking. Once normal joint play is restored, the associated pain and spasm subside.

Although joint play cannot be produced by voluntary muscle contraction, volitional action is greatly influenced by normal joint play. This occurs because restricted joint play produces a painful joint that becomes involuntarily protected by secondary muscle spasm (splinting). Joint play should exist in all ranges of motion normal for a particular joint. If a joint normally functions in flexion, extension, abduction, and adduction, the integrity of joint play in all these directions should be evaluated.

It is typical, not unusual, in joint disorders that joint play is restricted in some planes but not others. The importance of freeing articular fixations (eg, by chiropractic adjustments, mobilization) is brought out by Mennell:

Normal muscle function depends on normal joint function. If joint motion is not free, the involved muscles that move it cannot function and cannot be restored to normal.

Impaired muscle function leads to impaired joint function, and impaired joint function leads to impaired muscle function. In this cycle, muscle and joint function or dysfunction cannot be separated.

Besides translatory joint play, some distraction capability normally exists. If the act of axial lengthening is impaired for some reason, articular surfaces become closely packed and motion will be restricted.

Bony Restrictions.   Bony outgrowths may be obvious (as in Heberden's nodes), but if they are near the periphery of a joint, they may be recognized physically only by the sudden arrest of an otherwise free joint motion. In true ankylosis, there is no mobility whatever and adjacent joints are often hypermobile. In many cases, roentgenography is necessary for diagnosis.

Bony outgrowths within a joint are sometimes recognized only by the sudden arrest of an otherwise free joint motion at a certain point. That is, an abrupt halt in motion usually signifies bone-to-bone contact and that further movement should not be conducted. Such an approximation will be felt before the end of normal motion when hypertrophic bone growth (eg, an osteophyte, a malunited fracture, or obstructing myositis ossificans) has developed. If force is continued beyond the point of a bony block is painless, a neuropathic arthropathy is likely but a rare finding.

Bone vs Muscle Resistance.   Striated muscle spasm is distinguished from bony outgrowth as a cause of limited joint motion by two features: (1) Bony outgrowths allow free motion to a certain point, after which motion is arrested suddenly, completely, and without great pain. (2) Muscle spasm, on the contrary, slightly checks motion from the onset. Resistance and pain gradually increase until the examiner's efforts are stopped at some point in the arc.

Joint Stiffness.   If a patient affirms that joint stiffness is common, its distribution and duration should be explored. Inquiry should also be directed to related activities and circumstances that relieve or aggravate the stiffness. Joint stiffness is often produced by edema or structural changes.

Edema around the joint capsule is found in inflammatory disorders. Edema within the capsule secondary to inflammation is worse after rest; eg, in the morning or arising after sitting for a long period. Stiffness lasting for more than half an hour points toward one of the inflammatory arthritides (in which the stiffness may last for several hours).

Stiffness from structural changes can usually be traced to cartilage degeneration or capsule tears. It is common for previous trauma or inflammation to result in adhesion formation. Stiffness resulting from degenerative diseases becomes pronounced when area muscle compensation fails to protect thinning cartilage. Here also the stiffness is more pronounced after rest, but it is quickly relieved by mild exercise.

Loose Bodies.   Suspended bodies in joint fluid are not palpable externally and are recognized only by their symptoms, roentgenography, or exploratory surgery. They are the result of trauma, degeneration, or an inflammatory process and may be singular or multiple, free or attached, and of bony, cartilaginous, or synovial origin. Deranged cartilages and loose fragments commonly occur in the temporomandibular joint, knee, and spine. They arise less frequently in the elbow, hip, and ankle joints. Keep in mind that loose-body formation is an outstanding effect of osteochondritis dissecans or osteochondromatosis. However, there are other conditions in which loose bodies arrive as a complication of a pathologic process such as breaking loose of new bone processes and cartilage in certain degenerative joint disorders (eg, osteoarthritis), the organization of clots of fibrin-forming "rice" and "melon-seed" bodies, and intra-articular fractures (especially compression fractures).

Calcareous Bodies.   Calcareous bodies are abnormal calcifications within a joint of such an age to show advanced signs of ossification in roentgenography. They normally are not true free bodies but developments within tissue attached to the joint capsule. Free bodies are demonstrated by a change in position in subsequent roentgenography. Remember that fragments of a fractured cartilage are rarely visible on films unless a degree of calcification has ensued.


Soft-Tissue Palpation

An involved joint with a closed wound should also be palpated for masses and points of tenderness that may indicate displacement, osteoarthritis, synovitis, or a torn ligament or meniscus. Soft-tissue palpation should be conducted for tenderness, masses, muscle tone, fasciculations, and spasm.

It has been estimated that from 50% to 60% of the pains and discomforts that the average ambulatory patient has is the direct or indirect result of involuntary muscle contraction. Thus, the physician is compelled to consider the relationship of muscle contraction to pain symptoms in both diagnosis and therapy.

Local Hyperthermia.   In cases of inflammation, the presence of local heat is a valuable sign. This may be noted by passing the outstretched hand rapidly over the affected part to an unaffected part and back again. Any difference in warmth from the affected area to the unaffected area signifies an increase in local temperature.

Tenderness.   Pain produced by external pressure commonly results from trigger points, traumatic lesions of sensitive subdermal tissue, or the development of a toxic accumulation or deep-seated inflammatory irritation. Mild cases of joint involvement invariably have points of maximum tenderness that correspond to those endothelial regions that are the most superficial. For example, they are elicited (1) in the ankle at the anterior surface of the joint, (2) in the knee on both sides of the patella, (3) in the wrist over the anatomical snuffbox, and (4) in the elbow over the radiohumeral joint.

Pitting on Pressure.   Pitting is a sign of liquid infiltration into the underlying tissues. Tenderness associated with pitting is indicative of inflammatory edema. While edema gives rise to a soft pitting, a degree of induration can be felt if pus is present. A suspicion of edema may be confirmed by applying thumb pressure over the area in cases of massive infiltration and index-finger pressure in cases of localized swelling. This pressure should be maintained for at least 10 seconds. A positive sign of edema is indicated by a depression in the area after the action thumb or finger is removed. The depression is often palpable with the fingertips even if it is not visible.

Fluctuation.   All swellings should be tested for fluctuation in two planes at right angles to each other if the swelling is more than an inch in diameter. If a mass fluctuates in one plane but not another, it is negative for swelling because a swelling fluctuates in both planes. Fat and muscle also transmit an impulse, but they do so in a less perfect manner than fluid.

Moderate swellings are tested for fluctuation by pressure by the tip of one forefinger placed midway between the center and outer border of the swelling while the tip of the other forefinger is placed at an equal distance on the opposite side but remains stationary. The stationary finger moves passively from the pressure exerted by the action finger on the other side. Then the procedure is reversed, with the originally passive finger becoming the active finger and vice versa. If displacement takes place in two planes at right angles to each other, there is little doubt that the swelling contains fluid.

When examining small swellings, it is often best to use two fingers of each hand. A swelling less than an inch is difficult to test for fluctuation. In this event, Paget's test can be used: pressing the mass with a fingertip. A solid swelling feels hard in the center, while a cyst feels soft in its center.

Muscle Mass.   Palpation and mensuration are used to determine extremity muscle volume. On palpation, there should be a mass that is symmetrical bilaterally. If not, a measurement should be made with a flexible tape from a bony prominence to the belly of a suspected muscle and the point marked with a skin pencil.

The circumference of the part should then be measured at that point and then compared with a contralateral measurement. The two sides should show the same circumference approximately unless there is a large degree of unilateral occupational activity. A decrease in size (eg, arm, forearm, thigh, or calf) indicates atrophy and is usually associated with some degree of hypotonicity.

Muscle Tone.   The typical feeling of a normal muscle on palpation is one of resilience. An increased perception of tone by the examiner denotes a hypertonic muscle; a decreased perception of tone, a hypotonic muscle.

Spasticity.   When contraction occurs involuntarily, the cause can usually be traced to neuropathology or a protective reflex (splinting). This splinting reaction to inhibit movement is not always beneficial, especially when the disorder becomes chronic. When muscles become acutely spastic or chronically indurated, normal movement is impaired and foci for referred pain can be established.

Both spastic and indurated muscles are characterized by circulatory stasis that is essentially the effect of compressed vessels, which leads to poor nutrition and the accumulation of metabolic debris. Palpation will often reveal tender areas that feel taut, gristly, ropy, or nodular. An area of chronically indurated muscle tissue is often found near an area of muscle that has entered a state of fatty degeneration. When located through palpation, the lesion should be differentiated from a common lipoma.

Stretch Reflex Effects in Spasticity.   A spastic resistance is essentially a stretch reflex activity whose receptors are muscle spindles scattered but parallel with muscle fibers. In common spastic disorders, the muscles relax when the part is comfortably rested with support but become spastic with volitional movements, tendon tapping, vibration, or even startling noises. Three hypotheses have been put forward by debaucher to explain the hyperactive stretch reflexes that occur in spasticity:

Loss of corticospinal inhibition leaves the alpha motor neurons with a lower firing threshold so that they readily fire in response to any impinging sensory input, including that from stretch receptors.

A hyperactive gamma efferent system puts muscle spindles in a contracted state so that there is an abnormal response to stretch stimuli.

Spinal motor neurons normally exert a primarily inhibiting presynaptic modulating influence on afferent connections just proximal of the alpha motor neurons. Damage to or dysfunction of the corticospinal pathways weakens this influence so that afferent impulses from stretch or other sensory receptors are more likely to increase the firing rate of alpha motor neurons even if the muscle spindles are not contracted.


Joint Auscultation

Joint Clicks.   The importance of atmospheric pressure and surface tension of synovial fluid in joint stability is readily heard during knuckle cracking or by the audible click accompanying a chiropractic dynamic adjustment. A loosely packed joint may be moved several degrees to demonstrate that its collateral ligaments are relaxed.

When the joint is distracted to the degree that a sound is heard, it is at this point that the articular surfaces suddenly separate and a bubble of gas forms within the joint cavity. This can often be demonstrated by roentgenography. A distraction force applied transversely in the joint is resisted by both synovial surface tension and atmospheric pressure.

The adhesiveness of synovial fluid attempts to maintain articular juxtaposition; but once it is overcome, the intra- articular pressure is suddenly reduced to a level below atmospheric pressure so that gas is audibly released from the fluid. The larger the joint, the greater the force necessary for distraction. This is not only because of the proportionately greater contributions of surface tension and atmospheric pressure but because of the stronger stabilizing muscles and ligaments.

Crepitation.   There are types of musculoskeletal crepitus that characterize a specific type of lesion: bone crepitus, joint crepitus, tenosynovitis crepitations, and traumatic pulmonary emphysematous crepitus. Bone fractures produce an audible grating when the ends of broken fragments rub against each other during movement. Crepitation from an epiphyseal separation resembles that of a broken bone but is softer in character than the crepitus from a fracture.

A fractured rib in which a fragment of bone has pierced a lung allows air from the lung to escape into the subcutaneous tissues. Crepitus may then be felt when the fingers are placed with mild pressure over the affected area. To amplify crepitation, it is often helpful to apply a stethoscope to the joint during passive motions.

Joint crepitus can be felt by placing a hand over the joint while passively moving the joint with the other hand. Fine crepitus signifies slight roughening of apposing surfaces; coarse crepitus, extensive roughening. When coarse crepitus is transmitted to the palm of the palpating hand, osteoarthritis, chronic rheumatoid arthritis, or tubercular tenosynovitis is usually involved. Intermittent crepitus of bone against bone suggests that the articular cartilage is extensively worn.

Crepitus may also be felt over an effused joint following inflammation of the tendon sheath. In traumatic tenosynovitis of the extensor tendon sheaths of the forearm, for example, test by grasping the arm above the wrist while instructing the patient to clench his fist and rapidly open his hand several times. The presence of effusion produces a palpable and/or audible transmission.


Practical Anthropometry

Anthropometry emdash the science of measurement of weight, size, and proportions of the human body (general anthropometry) and its parts (regional anthropometry)emdash has many biomechanical implications in traumatology. Physique, body composition, and body type may be considered subdivisions of anthropometry.


Human Dimensions and Proportions

Size.   Body length (height), width, and depth of parts are linear measurements. These dimensions are usually obtained by using calipers, tapes, or gird photographs. Linear measurements offer direct evidence of bony framework length. Body part depth and width influence motor activity as they affect body mass and relative size. Broad hands and feet are an aid to the lifter and swimmer, for example. Broad hands are a control advantage to the basketball handler. Large feet offer a wide base of support.

Weight.   Dead weight is the weight of the body not involved in locomotion (eg, fat, inactive muscles, viscera). Greater mass (dead weight) is a distinct disadvantage in acceleration (eg, runners), and an advantage in being difficult to move (eg, furniture movers, truck loaders, football linemen, wrestlers) or stop once in motion (eg, football backs). Endurance and acceleration are the primary concerns that resistance exercises are used to develop strength without greatly increasing muscle bulk.

Dead weight from inactive muscle mass is as useless as fat. When weight is gained strictly through an increase in muscular weight, the undesirable effects of increasing body mass are offset by the increase in strength available for movement. On the other hand, a football lineman employs his dead weight in gaining momentum (velocity X mass) and uses his fat component to absorb the shock of impact.

Mass.   Because of gravity, body weight in human movement is a significant structural-mechanical variable. Body mass is defined as body weight divided by the gravitational constant (32 ft/sec ). In many vigorous physical activities, body weight is important because of the impact force: the greater the mass, the greater the amount of force required for movement. This may be an advantage or a disadvantage, depending on objectives.

Build.   Evaluation of body proportions is helpful in determining an individual's center of gravity and body build (type). A person's common center of gravity affects motor equilibrium (kinetic and static). The center of gravity is the point of application of the gravitational (vectorial) force acting on the body; in addition to the whole body, each part or segment has its individual center of gravity. Gravitational weight of the body as a whole or its segments differs from subject to subject depending on body type, height, size, density, age, and sex. The position of a person's normal center of gravity may be slightly changed through the influence of training and conditioning, blood supply, and diet.

Physique.   Physique is one's physical structure, organization, and development; the characteristic appearance or physical power of an individual or a race. Body type greatly influences physical performance, and it is determined by weight, linear measurements, and girth dimensions. The intermediate (mesomorphic) type's streamlined physique and lean muscle mass contribute to rapid motor talents (sprinting). The stability of the heavy endomorph is seen in wrestling and football linemen. The advantages of the long-limbed ectomorph are quickly recognized in the basketball center and football end.

Leverage.   The rigid bones and mobile joints of the body along with the forces acting on them represent a system of levers and, as all levers, transmit force and motion at a distance. Contracting muscles in the body normally constitute the force, with resistance supplied by a body part's center of gravity plus any extra weight that may be in contact with the part.

Height.   During motor activity, greater height is usually related to longer limbs, which mean longer levers (eg, high jump), longer stride (eg, running), greater velocity (eg, discus, javelin), a wider arc of reach (eg, blocking), a larger target (eg, catching), and height dominance over a raised goal such as a basketball hoop or starting at a point further from the ground (eg, shot put).

Height presents a disadvantage because of the increased leverage in weight lifting, in activities requiring quick changes in direction, in lack of stability due to the higher center of gravity (eg, judo, wrestling), and in lack of long-limb manipulative balance (eg, soccer). Thus, long limbs are a disadvantage in any job or sport where equilibrium and strength are the priority, and they are an advantage where range of motion and velocity are critical.

Body Type and Career Fit.   Several studies have shown that body type and physical performance have a close correlation. There are exceptions, but they are rare at the professional level. This means that there are many people striving for high levels of physical achievement that they probably can never attain.

Some authorities believe as high as 80% of the population should never aspire to great heights in terms of purely physical performance. This underscores the fact that the techniques and achievements of champions, commonly used in calculating standards, may not be suitable for different physiques within identical events. An important element that the voluminous literature on somatyping does not include is the great variable of personal motivation.


Motion Assessment

An injury or potential risk of injury must be evaluated relative to the person as a whole. Physical activity is a complicated phenomenon involving all joints, related tissues, and remote sections of the body when movement requires more than single joint or limb action. Regardless of the size or intensity of human motion, the articulations of the limbs and pelvis constitute the basic elements involved.

Goniometry.   The objective measurement of joint motion is an important evaluative procedure in physical examination of the joints because it offers an accurate record of joint motion and the extent of disability as part of a patient's permanent record.

Inclinometry.   Because the use of a goniometer is awkward in measuring spinal motions, the use of an inclinometer is preferred. An inclinometer is a half-circle level, commonly used by carpenters. Its use is now a standard in spinal impairment evaluation.

When measurements are taken of a unilateral disabled joint, a comparison is made with the contralateral unaffected joint. Boone and associates show that, for greater continuity in procedure, the same individual should make goniometric measurements when the effects of treatment are evaluated. For reference to average percentages, refer to the ACA text, Basic Chiropractic Procedural Manual (ed 5) where goniometry and inclinometry are described for specific joints along with average measurements.


Muscle Strength

The quantity of one's muscle fibers does not vary much after birth. Exercise primarily increases muscle quality, not quantity; it allows muscle fibers to become larger, stronger, and better developed.

Muscle and Ligament Function

Muscles can contract only in the direction of the muscle fibers. Movement may take place that reduces the joint angle (concentric contraction) or increases the joint angle (eccentric contraction). A slightly stretched muscle contracts with a great amount of force, but a shortened muscle contracts with very little force. Muscle contraction consumes nutrients and oxygen and produces acids and heat (major source). Acids accumulating as a result of continued activity contribute to fatigue.

Ligaments play a much greater part in supporting loads than generally thought. Electromyographic studies in situations involving fatigue from forces acting across a joint prove that muscles play only a secondary role. This fatigue is basically a form of pain originating in ligaments rather than muscles. Thus, some researchers believe that if the muscles involved in a problem are weak to begin with, there is an immediate strain on the ligaments producing the characteristic fatigue syndrome.

Mechanical Factors Affecting Normal Muscle Contraction

MacDonald/Stanish showed that the mechanical factors governing muscle contraction are the angle of pull, the length of the muscle, and the velocity of muscle shortening. The optimum angle of pull is at a 45 degree joint angle, and a muscle fiber's contractile force is greatest during extension. Obviously, a long muscle fiber can shorten more than a short fiber. A suddenly prestretched muscle has an increased contractile capacity. Improved flexibility through static stretching exercises, which does not activate the stretch reflex, appears to reduce soft-tissue restrictions and enhance antagonist relaxation.

Temperature Values Affecting Normal Muscle Contraction

Hill showed that a muscle's speed of contraction can be increased 20% by raising body temperature 5° F, thus the benefit of adequate warm-up before strenuous physical labor or athletic participation is underscored. Reducing muscle temperature appears to increase the threshold of irritability, which causes weakened and more sluggish contractions.

Muscle Testing

Manual muscle testing is a procedure that depends greatly on the skill, knowledge, objectivity, and experience of the examiner. In fact, the major fault with this method is that evaluation rests on the subjective skill of the examiner. Thus it is important that the same examiner records initial and follow-up evaluations of the degree of "resistance" perceived. Also, muscles often test differently in various positions such as from supine to weight- bearing.

The criteria shown in Table 1 are commonly used in recording muscle strength. One muscle or group should be tested at a time, thus the subject should be requested not to recruit allied muscles during resistance. Caution is used during resistance to avoid creating cramps, stretch injuries, or excessive fatigue.

Table 1. Grade of Muscle Strength

Grading	Rating	Findings
Grade 5	100% Normal	Complete range of motion against gravity with full resistance
Grade 4	75% Good	Complete range of motion against gravity with some resistance
Grade 3	50% Fair	Complete range of motion against gravity
Grade 2	25% Poor	Complete range of motion with gravity eliminated
Grade 1	10% Trace	Evidence of slight contractility, but no joint motion
Grade 0	0% Zero	No evidence of contractility

Manually Resisted Joint Motion   . The goal of an examiner applying passive resistance to patient active motion is to reveal and isolate pain, weakness, hypermobility, hypomobility, and associated patient reactions. It is important during testing that the joint is held near mid-range, the resistance is strong enough to avoid joint motion, and, when possible, specific muscles are isolated.

If resisted motion in opposite or incompatible directions induces pain, a muscle lesion is highly unlikely; rather, a nonmuscle lesion should be suspected near the site of attachments of the involved muscle. For example, resisted motion produces pain from periosteal tears, fractures, bursitis, or when a tender structure (eg, an abscess, neuroma) is compressed by the action.

In testing muscle strength subjectively, the patient is asked to do various actions against the examiner's resistance. For example, the patient could press the thumb and middle finger of the same hand tightly together, and the examiner could try to pry the fingers apart with the patient resisting. Normally, it would be difficult for the examiner to do this. Another example is to have the patient flex or extend an arm or leg against the examiner's resistance. The strength of an involved joint is tested, compared bilaterally, and the results recorded.

The type of response a patient makes during resisted motion can add much toward an accurate diagnosis. See Table 2.

Table 2. General Interpretation of Resisted Motion Signs

Response	Probable Cause
Strong with excessive range of motion	Capsule laxity, ligamentous instability
Strong and painful in a specific direction	Minor musculotendinous lesion
Strong and painful in all directions	Neurosis
Strong with pain on repetitive resisted movements	Arterial flow deficit
Strong and unchanged pain in all directions	Referred pain syndrome
Strong, painful, and hypomobile	Guarded joint for some reason
Strong, painless, and hypomobile	Contracture, adhesion
Weak and sharply painful pathology	Fracture, dislocation, rupture, gross
Weak without aggravation of pain (painless or unchanged constant pain)	Neurogenic disorder, muscle or tendon rupture
Weak and painless in all directions	Nonmusculotendinous deficit, probable neurogenic lesion
Pain only at specific point of arc	Functional entrapment, lax joint, dislocated tendon, loose body
Pain at one range extreme	Subluxation, tissue entrapment, eroded cartilage
Painful with gross hypermobility	Severe sprain
Painless with gross hypermobility	Ruptured tissues with interrupted sensory path

Objective Muscle Testing.   For many years, the hand dynamometer and electromyograph were the only objective clinical instruments available to record the force of muscle contractions. However, recently more practical equipment has been developed. Several companies have developed more objective but relatively expensive equipment designed to measure resistive forces and display the value on a dial or digital readout display. The Digital Myograph, Cybex, Biodex, and Kin-Com are examples. With modern equipment, the strength of almost every joint motion of the body can be assessed objectively.


Electrodiagnosis and Electro-myography

Electrodiagnosis is used to grossly test the integrity of muscles and nerves. As an adjunct to the examination of the motor system, it has become a valuable tool in evaluating whether or not partial degeneration of a nerve or muscle fibers is suspected. Such tests help to determine if disease of an upper or lower motor neuron is involved, if the nerve is interrupted, and if the muscles are undergoing degeneration.

Electromyography (EMG) allows the recording of oscillations in potential variations of skeletal muscles at rest and during activity. It basically provides a tracing of electrical activity transmitted from muscle to an electrode and then to an oscilloscope. Tracings aid in determining whether a patient's illness is directly affecting the spinal cord, muscles, or peripheral nerves. EMG recordings aid the scientific basis for diagnostic conclusions and monitor the effectiveness of therapy.

Electrocardiography, Thermography, and Spirometry

An electrocardiogram (ECG or EKG) offers a graphic representation of the electrical phenomena associated with the heart beat. It does not represent the mechanical events of the heart. The recorded P, QRS, and T waves reflect the rhythmic electrical depolarization or repolarization of the myocardium that precedes or follows cardiac contractions. The electrocardiogram should therefore be employed as a supplementary technique in the study of heart disease. Only infrequently is it a diagnostic sine qua non for a clinician.

Thermography is used to measure slight variations in temperature of soft tissue in the body using infrared heat sensors. The area to be tested is usually placed on a heat- detection device or rapid-scan equipment is used to record specific temperatures, either by color changes or a direct display of temperatures.

Dudley reports that when a spinal subluxation exists, it causes unequal contraction of muscles. This unequal contraction, an effect of the subluxation, should be observable by heat- detecting equipment. Once detected, the subluxation can be traced, corrected by adjustment, and the imbalance of the nervous system arrested. He also mentions that frequent alteration of the upper dorsal heat pattern has led to other companion signs being noted. For instance, Adson's sign is always positive on the same side as the elevation of temperature of the levator scapula and some parts of the trapezius. If the patient is adjusted to remove the causative subluxation and rescanned, the temperature becomes nearly normal, thus registering improvement of muscle function and vascular normalization.

Spirometry can be helpful when a patient presents a history of pulmonary difficulty, repeated episodes of fainting, cardiac symptoms, chest injury, or certain nervous system diseases and dysfunctions that affect lung function. Most tests are performed by having the patient breathe into a spirometer to record the amount of air put through it and the rate of air passage for a specified time. The more common tests for pulmonary function are vital capacity, forced expiratory volume, and maximal voluntary ventilation.

Laboratory Profiles

Blood, urine, and other analyses should be used whenever the clinical picture warrants it. The most commonly used profiles for acute joint complaints are:

Blood sugar	Platelet count
Blood uric acid	R-A test
CBC and differential	Sedimentation rate
Coagulation profile	Urinalysis
Febrile agglutins	VD serology.
Hemoglobin level

Urine and blood cultures, vaginal smear, EMG, ECG, and thermography are often added to this list. Serum calcium, phosphorus, alkaline and acid phosphatase, and serum protein electrophoresis are useful tests in determining the origin of bone lesions. If suppuration within a joint is suspected, referral for aspiration and its analysis may be necessary.


Posturometry

The publicity chiropractors have achieved in treating Olympic and professional athletes has much to do with their training in recognizing and correcting defects in biomechanical and neurologic body balance. DCs realize that the success a person has in meeting the constant stress of gravity can have a subtle yet profound influence on the quality of health and performance.

Sitting, standing, walking, lifting, running, bending, throwing, blocking, hitting, etc, require constant voluntary loss and regain of body balance. The human body tries to maintain an upright posture with the head positioned so that the field of vision is parallel with the horizon and straight ahead. Limb motion or the addition of a load shifts an individual's center of gravity and changes body balance.

Body Balance

Weight-bearing subluxations are often the natural forerunners of balance defects brought through the effort of the spinal column, pelvis, and lower extremities to compensate for stress and thus reduce more serious effects. Balance defects may also arise from habitual faulty postures in standing, sitting, lying, as well as from activities that employ forces of the large muscles in asymmetrical action (eg, many occupations, discus, bowling).

When created, such defects lessen the ability of the spinal column to withstand shock and overstress and are the natural precursors to subluxation-fixations. Other causes for balance defects are found in the frequent occurrence of unequal lower extremities, the faulty development of vertebrae or sacrum, and the effects of sustained abnormal reflexes.

Equilibrium Mechanisms

In evaluating physical performance, the examiner should understand the basic neural mechanisms operating during stance, locomotion, and exterior loading to provide distribution of postural tension throughout the musculoskeletal system. With the head erect, the labyrinths are placed in an optimal position to act synergistically with the cervical reflexes, and these in turn react with other existing proprioceptive and exteroceptive impulses to supply a symmetrical distribution of tone in proper quantities to the postural muscles throughout the body. Thus, it is not unlikely that proprioceptive impulses combined with the interacting postural reflexes of good body mechanics play a role in the maintenance of good health and optimal performance.

Conversely, the maladjustment of neural impulses within the central nervous system produced as a result of pressure, irritation, or poor posture may be a factor in the production of poor health and hindered performance by contributing to dysfunction from the subtle yet persistent stress. It has also been well established that viscerosomatic reflexes can produce hypertonicity of skeletal muscles, thus producing subluxations and/or disturbances in body balance and function.

Plumb Lines and Similar Devices

Pioneer chiropractors frequently used a plumb line to determine postural faults visually. In recent years, M. A. Sabia developed a "Scoliometer" that measures six spinal areas to detect slight degrees of scoliosis and three measurements to detect abnormal A-P curves. Horizontal control of the instrument is maintained by a "Lev-O- Gage" that records from 0° to 45°.

Bilateral Balance Scales

Multiple scales can weigh each vertical half or quadrant of the body to evaluate upright postural weight distribution. Aiken points out that the repeated charting of bilateral weight, along with other routine analyses, offers a clue of patient response to corrective therapy. Rotational balance defects can be measured because neither the sacrum nor the spine rotates in a horizontal plane. They rotate obliquely anterior-inferior, thus causing a shifting of weight and an alteration of the center of gravity. By antagonistic rotation, the sacrum compensates for the small amount of lateral bending and rotary movements of the vertical spine.


Potential Visceral Effects of Balance Defects

The body is a unit and dysfunction anywhere may cause dysfunction anywhere else. A somatic lesion may lead to a visceral lesion, and vice versa. Regardless, a neuropathic reflex can be established and sustained long after its initial cause has been corrected. This cycle becomes more complex when we add the factor of psychic stimuli descending the long spinal tracts and interacting with the horizontal fibers at the segmental level.

With the manifold neuromechanisms possible, there is no clear symptomatic picture of balance defects because individuals vary so much in response to mechanical, chemical, and psychic insults. Some people present immediate symptoms on slight deviation, while others offer no symptoms until pathologic changes are well in progress.

Most balance faults found are within "physiologic" limits without obvious structural deformity, yet it should be appreciated that abnormal function leads to reduced performance capabilities early and to pathology later if left uncorrected. Isolated muscle weakness should be suspected especially in situations of head or pelvic tilt, trunk imbalance, scoliosis, and uneven gait or limp. Structural malalignment, muscle weakness, uneven leg length, and the degree of spinal flexibility all have influence on posture, gait, and performance.

Constitutional burdens, visceral malfunction, nutritional status, fatigue and debility, neuromuscular tension, a large variety of psychological factors, height, weight, and body type all combine to express themselves in one's posture, body balance, and physical skills.

Effects of Soft-Tissue Overstress.   In chronic balance defects, strain, fatigue, and sprain cannot be discussed in unrelated terms. Strain commonly arises when the body is forced to be used in a position that is not favorable to muscle function or when joint facets are at their physiologic limit of articulation. Thus, pull and stabilization come from ligaments rather than muscles. The result is tissue insult leading to edema, pain, and physical deformity that is referred to the structures on which the strain is imposed or the cutaneous branches of the spinal nerve root supplying the strained tissues.

Long-term muscle strain results in adaptive changes occurring in the involved joints and their ligaments to meet the needs of the malaligment. Thus, low-key chronic sprain is a part of the picture. Abnormal fatigue and reduced performance are the result of wasted energy.

Effects of Mechanical Disadvantage.   The more pronounced an abnormal spinal curve or unilateral spasticity, the greater the mechanical disadvantage to which the supporting structures are subjected. Thus, again, the process becomes a vicious cycle. Along with chronic strain and fatigue, constant overstress produces small tears in ligament and tendon attachments and facial supports. This results in a series of subperiosteal hemorrhages that later may calcify into exostoses, becoming acutely painful on further overstress. This may occur in any joint subjected to prolonged stress, but it is especially common in the spine and other weight-bearing joints.

Neuralgic Syndromes.   There appears to be some degree of intervertebral foramina insult present when spinal imbalance exists. Neuralgic pains in the thorax and legs are common. Less common, because it mimics visceral disease, is intercostal neuralgia. If originating in the cervical region and associated with hypertrophic changes, pain is often referred about the shoulders and down the arms, frequently being mistaken for angina pectoris or carpal tendon syndrome. Similar neuralgic pains in the chest walls can be mistaken for pleurisy, pleural adhesions, or pulmonary lesions. Chest auscultation, palpation, and percussion serve in the differentiation.

Vascular Syndromes.   Circulatory disturbances are rarely absent in balanced defects. The low diaphragm results in venous congestion in its failure to assist blood returning to the heart. Sagging viscera stretch mesenteric vessels and narrow their lumina. Thus, circulatory symptoms may arise throughout the body. For instance, allopathic-oriented researchers have recorded the relief of eye strain and mild myopia in children by postural correction alone.

They explain this as a relief of venous congestion in the head. In extreme cases, such impaired circulatory inefficiency may be sufficient to produce a marked fall in blood pressure and loss of consciousness. This is said to be the result of general muscle relaxation with blood pooling in venous reservoirs, especially in the abdomen, thus reducing the practical blood volume. More often it produces only dyspnea and weakness, sometimes accompanied by palpitation. Precordial pain resembling angina pectoris is not rare.

Visceral Syndromes.   Faulty posture mechanics may cause the liver to rotate anteriorly and to the right. Traction is thereby exerted on the common duct and sometimes seriously interferes with biliary drainage. Ptosis of the kidneys, especially the left kidney, results in traction on the renal veins that may obstruct venous outflow causing passive congestion and albuminuria.

Mild digestive symptoms may be present in the apparently healthy person. This can sometimes be traced to a degree of visceroptosis resulting in dysfunction of the displaced organs. Abdominal dilatation and motility disturbances are not infrequent occurrences. This is likely the outcome of stretching of the sympathetic nerves. Stretched nerves within muscle can produce transient paralysis. In addition, when the abdominal cavity becomes shortened longitudinally, the viscera become crowded as do the glands of internal secretion. Nerve ganglia may be involved as well. Thus, orthostatic albuminuria, dysmenorrhea, and constipation may sometimes be associated.

As a result of visceroptosis, a compensating lumbar lordosis, and the insult at intervertebral foramina, symptoms can be diffuse and subtle. Duodenal stasis may be attributed to increased tension on the superior mesenteric vessels. One study showed that postural correction relieved 65% of cases exhibiting a picture of duodenal obstruction and 75% of cases presenting gastric distress, nausea, and abdominal pain associated with visceroptosis.

Narrowing of the intervertebral foramen may cause severe pain that has a segmental distribution and evidenced in the skin, muscle, or parietal peritoneum. This condition is usually misleading in origin as it suggests the presence of some intra- abdominal disorder.



REFERENCES AND BIBLIOGRAPHY:

Aiken PL: Bilateral Weight Measurements: A Clinical Tool. ACA Journal of Chiropractic, April 1980.

Bennett RL: Muscle Testing: A Discussion of the Importance of Accurate Muscle Testing. Physiotherapy Review, 27:242emdash 243, 1947.

Boone DC, et al: Reliability of Goniometric Measurements. Physical Therapy, 58:1355emdash 1360.

Courson R: Role of Evaluation in the Rehabilitation Program. In Andrews RA Harrelson GL: Physical Rehabilitation of the Injured Athlete. Philadelphia, W.B. Saunders, 1991, pp 41emdash 58.

Dudley WN: Extremity Thermography and Low Back Pain. ACA Journal of Chiropractic, March 1977.

Frishberg BA: Practical Anatomy Laboratory Experiences, Biomechanics and Kinesiology in Sports. Colorado Springs, an Olympic Sports Medicine Conference sponsored by the U.S. Olympic Committee, January 1984.

Granger CV: The Clinical Discernment of Muscle Weakness. Archives of Physical Medicine, 44:430emdash 438, 1963.

Ikai M, Steinhaus AH: Some Factors Modifying the Expression of Human Strength. Journal of Applied Physiology, 16:157, 1961.

Johnson WI: Passive Gross Motion Testing. Journal of the American Osteopathic Association; Part I, 81:298-303; Part II, 81:304-308; Part III, 81:309emdash 13, 1982.

Joseph J: Electromyographic Studies on Muscle Tone and the Erect Posture in man. British Journal of Surgery, 51:616, 1964.

Kendall HO, et al: Muscle Testing and Function, ed 2. Baltimore, Williams & Wilkins, 1971.

Kraus H: Evaluation and Treatment of Muscle Function in Athletic Injury. American Journal of Surgery, Vol 98, September 1959.

MacDonald ML, Stanish WD: Neuromuscular System. In Scott WN, et al: Principles of Sports Medicine. Baltimore, Williams & Wilkins, 1984, pp 15emdash 24.

Miller TR: Evaluating Orthopedic Disability. Oradell, New Jersey, Medical Economics Company, 1979.

Schafer RC: Chiropractic Management of Sports and Recreational Injuries, ed 1. Baltimore, Williams & Wilkins, 1982.

Schafer RC: Chiropractic Physical and Spinal Diagnosis. Oklahoma City, American Chiropractic Academic Press, 1980.

Schafer RC (ed): Basic Chiropractic Procedural Manual, ed 3. Des Moines, Iowa, American Chiropractic Association, 1980.

Williams JGP, Sperryn PN (eds): Sports Medicine, ed 2. Baltimore, Williams & Wilkins, 1976.

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