Gillet's investigations found that the lumbar region is the only area of the spine (along with the lower thoracics) in which Lovett's principles are true. However, this will depend on the initial position of the vertebrae. If the region is in a lordosis (patient standing), lateral flexion produces maximum accompanying rotation. With the patient sitting and the lumbars in a "balanced medium" or even in kyphosis, the amount of rotation will be reduced to a minimum. This is an important point to remember in this chapter.


The Interview

Information gathering about the nature of patients' problems may begin as early as when they call for an appointment and attempt to describe their pain and its onset to the receptionist. Faye poses the following questions as the patient navigates around the office and he observes their ease of movement and posture: Is there difficulty straightening when rising from a chair? Can the patient sit down at all? Is he or she bent laterally to either side or to the anterior? Is there a limp or shuffle during gait? Does the patient's facial expression reflect pain? Is the patient's attitude cheerful or does it suggest obvious distress?

The interview should be conducted as quickly and efficiently as possible while still making sure that important details are covered. Listen to the patient's uninterrupted description of the chief complaints. Then, during the systems review, interview the patient in a manner designed to confirm or rule out probable diagnoses. Pertinent questions to be asked may be derived from the lists of characteristic findings of each of the syndromes discussed here and within standard differential diagnosis texts.

The nerve function of the lumbosacral plexus is shown in Table 5.1.

According to Faye, the three most common types of low back pain are

(1) the lumbar facet syndrome,

(2) the sacroiliac syndrome, and

(3) the lumbar radicular syndrome, which may be discogenic or biomechanical in origin.

Each of these types can be acute or chronic, traumatic or nontraumatic, and have varying degrees of concomitant pathomechanics. The syndromes are named according to the level of inflammation or pain-producing structures and more than likely not the area in need of adjustments. Their typical cause may be due to:

sprain/strain,
overuse,
poor posture,
disuse,
joint dysfunction (fixation/hypermobility),
development abnormality,
degenerative changes,
or various combinations of these origins. In addition, the possibility of viscerosomatic and somatosomatic reflexes should not be overlooked.

Applied Anatomical Considerations

Many of the abnormal orientations found in the lower spine can be because the facet joints of the lumbar spine are not determined until the secondary curves are firmly developed in the erect position. The stresses imposed during the development stage can easily lead to the high incidence of asymmetry.


      The Lumbar Vertebrae

Because vertebral segments increase in size and strength progressing caudally to sustain increasing weight load, the lumbar vertebra are relatively large (Fig. 5.1). The centra are kidney shaped, larger in width than from front to back, and thicker anteriorly (except L2). A line crossing horizontally at the uppermost aspect of the iliac crests normally cuts the body of L4.

Each lumbar vertebra exhibits strong stout laminae, pedicles, and spinous processes that project directly backward on a horizontal plane (Fig. 5.2). The transverse processes, which arise at the junction of the pedicles and laminae, project laterally and slightly backwards and increase in length progressing caudally. The neural ring is triangular, and the vertebral canal is larger than that of the thoracic spine but smaller than that of the cervical spine.

Lumbar articular processes are especially strong. Because the inferior articular processes face laterally and slightly anteriorly and the superior processes face medially and slightly posteriorly, rotatory ROM is somewhat restricted. Mamillary processes (rounded tubercles) project from the postero-superior border of each superior articular process (Fig. 5.3).

L5 differs from its neighbors above in that its centrum has the largest circumference and is thinner in height, its superior facets face more posteriorly, its inferior facets face more anteriorly, and it has a short rounded spinous process. While the entire lumbar spine is encased in strong ligaments that may shortened, the iliolumbar ligaments are especially vulnerable to the stress of daily living and degenerative changes, sometimes to the point of firmly anchoring L5 to the ilium and/or sacrum, unilaterally or bilaterally.

      Lumbar Intervertebral Foramina

All vertebrae normally move in the planes of their articulations, and it is at the zygapophyses that most fixations and subluxation complexes seem to originate to influence the integrity of the related IVFs. Changes in the diameter of normal IVFs are both the result and the cause of abnormal joint function that predisposes further kinetic disturbances. These disturbances tend to alter the curves of the particular region of the spine in which the structural-functional defect is found. The lumbar region is no exception.

In the lumbar region, the IVFs are shaped like a kidney bean. It requires considerable posterolateral disc protrusion to encroach the nerve exiting at the same level because the lumbar IVFs are comparatively large in this area of the spine. When disc protrusion does cause trouble, it is usually from encroachment on the laterally placed nerve root on the vertebra above.

Sunderland emphasizes that the passage of the medial branch of the lumbar dorsal ramus and its accompanying vessels through the osseofibrous tunnel and the intimate relationship of the neurovascular bundle to the capsule of the apophyseal joint represents a potential site of fixation and entrapment following pathologic changes involving the joint.

      The Nerve Roots

The segmental innervation of the lumbosacral spine supplying the major associated muscles and the related skin and tendon reflexes are shown in Table 5.2.

There are about twice as many sensory fibers than motor fibers in the lumbar roots. When the anterior nerve root is irritated, pain is felt in the peripheral distribution of the fibers affected and the pain often becomes self-perpetuating from the focal spasm produced. When the posterior root is irritated, the pain can be perceived to be in the dermatome, myotome, sclerotome, or possibly the viscerotome.

      Planes of Articulation in the Lumbar Spine (Normal and Abnormal)

Lumbar facets have moderately sloped surfaces rather than a single-plane angle as seen in the cervical and thoracic area, and they are near parallel to the vertical plane. The convex inferior facets mate with concave superior facets. From L1 to L5, the plane of the articular facets generally change from mediolateral to anteroposterior and lie in the sagittal plane.

The lumbosacral facet planes are slightly more horizontal than those above and allow greater A-P, P-A, and lateral motion but less joint locking as compared to the vertebrae above. This horizontal and anterior inclination of L5, spreading out toward the coronal plane, becomes progressively more vertical upward from L4 to L1.

An important influence on interspinal posture is that of the facet facing of each posterior intervertebral joint, with alterations of the facings most commonly occurring in the lumbar and lower cervical regions. These facings are more frequently altered between L4 and L5 than at any other level in the vertebral column.

Symmetric facets glide with little friction produced. If the facets deviate in their direction of movement, however, the unparallel articulating surfaces "scrub" upon one another, which leads to degenerative changes. Variances of the articular structures often occur even in the absence of injury at the level of abnormality. They are characterized by thickening of the covering of the facet and marginal sclerosis. This hardening process is usually followed by hypertrophy or exostosis that produces an irregular articular surface when the facet is viewed in profile in roentgenography. Coexistent with this finding, the interarticular spaces gradually become narrowed, hazy, obscured, and even obliterated on x-ray films.

Because these various facet and interarticular manifestations are from either chronic abnormal weight-bearing or specific trauma, the term arthrosis is often used today rather than the phrase posterior intervertebral osteoarthritis. Arthrosis is a more reasonable descriptor because of the implications of the suffix "itis." Although there may not be evidence of direct bony encroachment from the process of arthrosis directly into the IVFs, one must consider that the process of arthrosis does produce a general narrowing of the diameters of the IVFs and hence can predispose interference with the normal expression of nerve impulse and axoplasmic flow transmission.

When the spine is in good postural balance, facet articulation offers minimal friction. In scoliosis, the articular surfaces are no longer parallel and the result is articular friction leading to erosion, arthrosis, and impingement. This is the result of normally reciprocal articulating surfaces operating in an abnormal relationship.


Biomechanical Considerations

From the middle of the anterior surface of T12, the body's gravity line extends downward to the anterior aspect of the sacral base. Weight distribution in the lumbar region is governed chiefly by the inclination of each vertebral body. The lumbosacral articulations are slightly more horizontal than those above them, allowing for greater P-A and lateral motion and offering less joint locking during extension as compared to the vertebrae above.

The horizontal inclination of L5, spreading out toward the coronal plane, becomes progressively more vertical from L4 to L1 as the dorsolumbar articulation is approached. These changes in articular planes allow the lower back to bend and twist to accommodate gravitational force during movement. The upper lumbar joints are J-shaped when viewed from the lateral, thus their anterior aspect resists forward displacement.

The lateral center line of gravity falls on different points in the lumbar spine because of gradual changes in the angles of the inclined planes of the various articular surfaces. This tends to force each lumbar segment more inferior, medial, and anterior or posterior until gravity brings the apex of the curve back toward the balancing point. The lateral line of gravity in the pelvic area passes just anteriorly to the S2 segment.

Except for the lesser role of the pelvic basin, superimposed body weight is carried in the lower back essentially by the L5 disc and then dispersed to the sacral base, sacroiliac joints, and acetabulae. This burden on the L5 disc is forced slightly forward on the load-bearing surfaces. Defective weight bearing is usually caused by some impairment in the anterior portion of the vertebral motion unit (eg, disc deficit, anterior ligament fixation). In contrast, faults in the direction of distortions can usually be attributed to the posterior aspect of the motion unit; eg, total or partial fixations involving the apophyseal joints, pillar erosion and distortion, osseous pathology, etc. The anterior portion of the motion unit is mechanically designed for weight bearing, the posterior pillars are not. Thus, when the pillars are forced to assume the constant role of weight bearing because of some biomechanical fault altering spinal equilibrium and the distribution of load (intrinsic or extrinsic), structural failure and compensatory remodeling of the posterior elements is likely to occur eventually.


Kinematics of the Lumbar Spine

In the absence of fixation, the range of gross lumbar motion is primarily determined by the sum of individual IVD resistance to distortion, the thickness of the discs, and the angle and size of the articular surfaces. As in other regions of the spine, the movements of the lumbar spine are flexion, extension, lateral bending, and rotation. While lumbar motion is potentially greater than that of the thoracic spine because of the lack of rib restriction, facet facing and heavy ligaments check the range of rotatory motion.

A patient may be observed who replaces normal lumbar motion with exaggerated hip motion, or vice versa. If so, the ranges of motions of the restricted lumbar or hip joints should be tested. Any disorder of the hip joint itself (eg, fracture, tuberculosis, osteoarthritis, fixation) or of the hip flexor, adductor, abductor, or extensor muscles may result in limited hip motion. Compensation of hip deficits will be attempted at the nearest movable segment(s) such as the sacroiliacs, lumbars, knees, and/or ankles.

      Muscle Weakness That May Affect Lumbar Function

The trunk is held erect by the flexors and extensors of the spine and the extensors of the hip. The muscles and ligaments that hold the trunk erect are much stronger as a whole than those of the pelvis. After a long illness, for example, a patient can sit erect long before he can stand.

Extension.   Because P-A trunk motions are the most common movements used in daily living and as flexion is assisted by gravity, the spinal extensors are the most important muscles of the trunk from a biomechanical viewpoint. Muscles of the back are rarely weak unless paralysis is present. Kendall places the incidence of weak spinal erectors at less than 1% in the nonparalytic. When signs of extension weakness are evident, differentiation must be made between weak spinal extensors and weak hip extensors. A screening test can easily be done with the patient prone (Fig. 5.4).

Lateral Flexion.   Trunk raising from the lateral recumbent position exhibits the strength of trunk lateral flexors and hip abductors. A simple screening test to differentiate weakness in these groups is shown in Figure 5.5.

Flexion.   Leg raising from the supine position is a two-phase combination between strong abdominals and strong hip flexors. A screen test to differentiate weakness of the two groups is shown in Figure 5.6.

      Muscle Shortening That May Affect Lumbar Function

The postural patterns exhibited in forward flexion from the supine position can offer distinct clues to shortening of specific muscles and muscle combinations. Six typical patterns are shown in Figures 5.7 and 5.8.

      Motion at the Thoracolumbar Transitional Area

Descriptions of normal articular angles in any text are approximations. There is considerable variation from one person to another and of the transitional segment between one region of the spine and another. For example, the transitional vertebra between the thoracic and lumbar regions is usually given as T12, but it might be any vertebra from T9–L1 according to White/Panjabi.

Owing to the restricted movements in the thoracic spine as the result of the attached thoracic cage and the mobile lumbar spine in flexion below, the intervening thoracolumbar area must achieve a degree of hypermobility in all three body planes. Because of this, as is true to some extent in all spinal transitional areas, the thoracolumbar junction is more prone to overstress from both above and below because of its unusual role.

The superior facets of the transitional vertebra resemble thoracic facets and are designed primarily for rotation and lateral flexion, even though these motions are restricted somewhat by the free ribs. While the stiff thoracic spine tends to move as a whole, most rotation takes place in the lower segments that are not restricted by the rib cage. The inferior facets of the transitional vertebra are of the lumbar type; ie, designed more for flexion and extension. Although great curves can be observed in the lumbar area, most of the apparent rotation seen is from distortion of the lumbar spine's base, vertebral and pelvic tipping, and the lumbar lordosis viewed out of its normal plane (planar displacement or malposition).

      Lumbar Lateral Bending

In the lumbar spine as a whole, lateral flexion is relatively free, followed in order of mobility by extension, flexion, and minimal rotation. Significant to gross movements in the lumbar spine is the fact that all movements are to some degree three dimensional; ie, when the lumbar spine bends laterally, it tends to also rotate posteriorly on the side of convexity and assume a hyperlordotic tendency. Thus, fixation effects are also coupled.

During lateral bending in the erect position, considerable rotation accompanies the abduction of the trunk if there is a significant degree of lordosis. However, if the lumbar spine is flattened or if the lateral bending is performed in the sitting position, the amount of associated rotation is minimal but enough to be determined by Grice on kinematic stress films.

The intertransverse spaces of the normal spine open on the convex side and close on the concave side during lateral bending. In normal extension and distinct lordosis, however, the facets jam and lateral flexion is so restricted that the vertebrae must severely rotate to allow lateral flexion.

      Lumbar Flexion

During lumbar flexion and extension, there is considerably less facet gliding than seen in other areas of the spine during such motions. Widening of the anterior disc space on extension or of the posterior disc space on flexion does not occur until movement nears its full range of motion. Even then, it is far less than that seen in other areas of the spine. See Figure 5.9.

The anterior longitudinal ligaments relax during flexion, and the supraspinal and interspinal ligaments stretch. Opposite effects occur during extension. Although many disorders result in decreased flexion, paraspinal muscle spasm and total fixations are the primary suspects. [See Clinical Comment 5.1]

      DR. FAYE'S CLINICAL COMMENT #5.1

In chronic low-back pain cases, it is important to take a series of lateral lumbar radiographs: neutral, forward flexion, and backward flexion positions. An unstable motion unit will appear to be normal in the neutral view but demonstrate antero- or postero-listhesis in stress films. This sign makes for a worse prognosis and the possible necessity for spinal fusion if disc degeneration is advanced or if correcting the etiological dysfunction does not cause a tightening of the ligaments involved. I x-ray again after 4-6 months of symptom relief. Continual severely painful episodes should suggest an orthopedic consultation.

      Lumbar Extension

Gillet's studies found that lumbar flexion-extension movements are similar to those of other regions of the spine but with less forward or backward gliding. Extension is, states Gillet, also a movement that takes place in two parts with the anterior interbody space opening only after backward bending has reached its limit. This opening anteriorly is, however, a smaller movement than that which occurs in other regions of the spine.

The extent of lumbar extension is primarily controlled by the tautness of the anterior longitudinal ligament, the elasticity of the posterior ligaments, and the tonicity of rectus abdominis anteriorly and the spinal extensor muscles posteriorly. See Figure 5.10. In IVD herniation posteriorly, facet inflammation, or spondylolisthesis, pain will be increased during extension but not on flexion. This is a helpful point in differential diagnosis.

According to McKenzie, reduced lumbar extension is frequently the result of poor sitting posture and/or inadequate extension mobilization following injury in which scar tissue prevents a full range of extension. Reduced extension

(1) causes chronic stress on the soft tissues of the posterior motion unit and an increased intradiscal pressure during sitting;

(2) restricts a fully upright posture during relaxed standing, leading to a stooped appearance in stance and gait; and

(3) produces a premature fully stretched lumbar posture when arising from a forward flexed posture.

Keep in mind that the fibers of the posterior anulus are the weakest. The anterior and lateral aspects of the anulus are almost twice as thick as the posterior aspect. The anular fibers at the posterior aspect of the disc are less numerous, narrower, and more parallel to each other than at any other portion of a disc.

If a person must work habitually in a prolonged forward flexed position, periodic lumbar extension will relieve the stress of the posterior anulus and tend to shift a loose nucleus pulposus anteriorly; ie, away from the spinal cord and IVF. Many manual laborers do this stretching maneuver instinctively.

      Lumbar Rotation

Only slight rotational fixation is necessary to affect P-A, A-P, and lateral bending motions. Because the facial planes are no longer reciprocal when a fixation exists, normal motion is restricted and sets up dyskinesia.

If the axis of rotation of lumbar vertebrae were at the tips of the spinous processes, as sometimes is taught, the spinous process of L1 would be directly in line with the spinous process of L5 during rotation while the vertebral bodies rotate to a greater degree towards the direction of movement. But because the center of rotation of T12 is distinctly anterior, it must pull L1 with it during rotation. This pulls the lumbars into rotation and flexion, jamming the facets on the side moving posteriorly and opening the facets on the side swinging anteriorly. This effect in the lumbar spine continues caudally to the sacrum, which also flexes and rotates with the lumbars.

      Segmental Stability and Instability

It is obvious that each spinal segment rests on the one beneath it and that the interposed joint surfaces serve as the support base of the separate segments. The force of gravity acting on each segment must be individually neutralized if the body as a whole is to be in complete gravitational balance.

Joint stability normally depends on

(1) the size of the joint surfaces,

(2) the height of the segmental centers of gravity above the joint surface,

(3) the horizontal distance of the common gravity line to the joint's center, and

(4) the integrity of the supporting ligaments. While these facts are true in all areas of the spine, their importance are increased in the lumbar spine because of the increased weight load.

Significant Neurologic and Orthopedic Tests

Evaluating vital signs and such procedures as light touch/pain tests, muscle strength grading, range of gross motion tests, inspection, and static palpation are so standard within chiropractic physical examinations that there is no need to describe them here. This is also true for the evaluation of reflexes pertinent to low-back syndromes such as Achilles, adductor, anal, ankle clonus, Babinski's plantar, cremasteric, Giegel's, hamstring, patella, patella clonus, and quadriceps reflexes, as well as Jendrassik's maneuver, Valsalva's maneuver, and Adams' sign. Besides these standard procedures, the following orthopedic and neurologic tests are helpful in the differential diagnosis of lumbar syndromes.

Beery's Sign.   This sign is positive if a patient with a history of lower trunk discomfort and fatigue is fairly comfortable when sitting with the knees flexed but experiences discomfort in the standing position. It is typically seen in spasticity or contractures of the posterior thigh and/or leg muscles.

Bragard's Test.   If Lasegue's SLR test is positive at a given point, the leg is lowered below this point and dorsiflexion of the foot is induced. The sign is negative if pain is not increased. A positive sign is a finding in sciatic neuritis, spinal cord tumors, IVD lesions, and spinal nerve irritations. A negative sign points to muscular involvement such as tight hamstrings. Bragard's test does not stress the sacroiliac or lumbosacral articulations and is therefore negative in facet and sacroiliac syndromes.

Dejerine's Sign.   This sign constitutes aggravated symptoms of radiculitis, resulting from a space-occupying lesion within the spinal cord, during any Valsalva maneuver (eg, coughing, sneezing, abdominal straining) that would increase intrathecal pressure.

Demianoff's Test.   This is a variant of Lasegue's SLR test used by many in lumbago and IVF funiculitis with the intent of differentiating between lumbago and sciatica. When the affected limb is first extended and then flexed at the hip, the corresponding half of the body becomes lowered and with it the muscle fibers fixed to the lumbosacral segment. This act, which stretches the muscles, can induce sharp lumbar pain. Lasegue's sign is thus negative as the pain is caused by stretching the affected muscles at the posterior portion of the pelvis rather than stretching the sciatic nerve. To accomplish this test with the patient supine, the pelvis is fixed by the examiner's hand firmly placed on the ASIS, and the other hand elevates the leg on the same side. No pain results when the leg is raised to an 80° angle. When lumbago and sciatica are coexistent, Demianoff's sign is negative on the affected side but positive on the opposite side unless the pelvis is fixed. The sign is also negative in bilateral sciatica with lumbago. The fixation of the pelvis prevents stretching the sciatic nerve, and any undue pain experienced is usually associated with ischiotrochanteric groove adhesions or soft-tissue shortening.

Deyelle-May Test.   This test may be helpful in differentiating the various etiologies of sciatic pain and is particularly designed to differentiate between pain from pressure on the nerve or its roots and pain produced by other mechanisms in the lower back. Compression or tractional pressure on muscles, ligaments, tendons, or bursae may cause reflex pain that often mimics true direct nerve irritation. Reflex pain does not usually follow the pattern of a specific nerve root, is more vague, does not cause sensory disturbances in the skin, comes and goes, but may be an extremely intense ache. The procedure in the sitting position is to instruct the patient to sit still and braced by the hands in a chair. The painful leg is passively extended until it causes pain, then lowered just below this point. The leg is then held by the examiner's knees and deep palpation is applied to the sciatic nerve high in the popliteal space that has been made taut (bow string) by the maneuver. Severe pain on palpation suggests a definite sciatic syndrome as opposed to other causes of back and leg pain such as the stretching of strained muscles and tendons or the movements of sprained sublumbar articulations.

Double-Leg Raise Test.   This is a two-phase test:

(1) The patient is placed supine, and a straight-leg-raising test is performed on each limb: first on one side, and then on the other.

(2) The SLR test is then performed on both limbs simultaneously; ie, a bilateral SLR test. If pain occurs at a lower angle when both legs are raised together than when performing the monolateral SLR maneuver, the test is considered positive for a lumbosacral area lesion.

Ely's Test.   To support iliopsoas spasm suspicions, the patient is placed prone with the toes hanging over the edge of the table, legs relaxed. Either heel is approximated to the opposite buttock. After flexion of the knee, hip pain makes it impossible to perform the test if there is inflammation of the psoas muscle or its sheath. The buttock will tend to rise on the involved side. However, a positive Ely's test can also suggest rectus femoris contraction, a lumbar lesion, a contracture of the tensor fascia lata, or an osseous hip lesion.

Fajersztajn's Test.   When straight-leg raising and dorsiflexion of the foot are performed on the asymptomatic side of a sciatic patient and this produces pain on the symptomatic side, there is a positive Fajersztajn's sign, which strongly suggests a sciatic nerve root involvement such as a disc syndrome, dural root sleeve adhesions, or some other space-occupying lesion. This is sometimes called the well-leg or cross-leg straight-leg-raising test. From a biomechanical viewpoint, this test would be suggestive but not indicative.

Gaenslen's Test.   In this test, the patient is placed supine with knees, thighs, and legs acutely flexed by the patient who clasps his knees with both hands and pulls them toward the abdomen. This brings the lumbar spine firmly in contact with the table and fixes both the pelvis and lumbar spine. With the examiner standing at right angles to the patient, the patient is brought well to the side of the table and the examiner slowly hyperextends the opposite thigh by gradually increasing force by pressure of one hand on top of the patient's knee while the examiner's other hand is on the patient's flexed knee for support in fixing the lumbar spine and pelvis. Some examiners allow the hyperextended limb to fall from the table edge. The hyperextension of the hip exerts a rotating force on the corresponding half of the pelvis. The pull is made on the ilium through the Y ligament and the muscles attached to the AIISs. The test is positive if the thigh is hyperextended and pain is felt in the area of the sacroiliac joint or referred down the thigh, providing that the opposite sacroiliac joint is normal and the sacrum moves as a unit with the side of the pelvis opposite to that being tested. The test should be conducted bilaterally. A positive sign may be elicited in a sacroiliac, hip, or lower lumbar nerve root lesion. If the L4 nerve is involved, pain is usually referred anteriorly to the groin or upper thigh. If the sign is negative, a lumbosacral lesion should be first suspected. This test is usually contraindicated in the elderly.

Goldthwait's Test.   The patient is placed supine. The examiner places one hand under the lumbar spine with each fingerpad pressed firmly against the interspinous spaces. The other hand of the examiner slowly performs an SLR test. If pain occurs or is aggravated before the lumbar processes open (0° 30°), a disc or sacroiliac lesion should be suspected. Goldthwait believed that if pain occurred while the processes were opening at 30° 60°, a lumbosacral lesion was suggested; at 60° 90°, an L1–L4 disc lesion. If pain is brought on before the lumbar spine begins to move, a lesion, either arthritic or a sprain involving the sacroiliac joint, is probably present. If pain does not come on until after the lumbar spine begins to move, the disorder is more likely to have its site in the lumbosacral area or less commonly in the sacroiliac areas. The test should be repeated with the unaffected limb. A positive sign of a lumbosacral lesion is elicited if pain occurs near the same height as it did with the first limb. If the unaffected limb can be raised higher than the affected limb, it is thought to be significant of sacroiliac involvement of the affected side. White/Panjabi, however, dispute such specific indications in orthopedic maneuvers as this. There are too many variables.

Kemp's Test.   While in a seated position, the patient is supported by the examiner who reaches around the patient's shoulders and upper chest from behind. The patient is directed to lean forward to one side and then around to eventually bend obliquely backward by placing the palm on the buttock and sliding it down the back of the thigh and leg as far as possible. The maneuver is similar to that used in oblique cervical compression tests. If this compression causes or aggravates a pattern of radicular pain in the thigh and leg, the sign is positive and suggests nerve root compression. It may also suggest a strain or sprain and thus be present when the patient leans obliquely forward or at any point in motion. Not to be dismissed lightly would be the possibility of shortened contralateral paraspinal ligaments and tendons that would force erratic motion on the side of lateral flexion. [See Clinical Comment 5.2]

      DR. FAYE'S CLINICAL COMMENT #5.2

Mennell teaches a modified Kemp's maneuver that is helpful: The sitting patient leans backward against the doctor and rotates his trunk posteriorly to the point of low-back pain and/or radiation of pain to a buttock and leg. The doctor then reaches around to the opposite side and pulls the patient's ASIS posteriorly to ease the contralateral pressure on the sacroiliac joint. Pain relief confirms a sacroiliac lesion. If no relief occurs, suspicion of a lumbar facet lesion is confirmed.

Lasegue's Rebound Test.   At the conclusion of a positive sign during Lase- gue's supine SLR test, the examiner allows the limb to drop to a pillow without warning. If this rebound test causes a marked increase in pain and muscle spasm, then a disc involvement is said to be suspect. However, it would appear that any site of irritation in the lower back and pelvis would be aggravated by such a maneuver.

Lasegue's Standing Test.   The patient attempts to touch the floor with the fingers while the knees are held in extension during the standing position. Under these conditions, the knee of the affected side will flex, the heel will slightly elevate, and the body will elevate more or less to the painful side. It should be noted that this would also be true with shortened posterior thigh and calf muscles.

Lasegue's Straight-Leg-Raising (SLR) Test.   The patient lies supine with legs extended. The examiner places one hand under the heel of the affected side and the other hand is placed on the knee to prevent the knee from bending. With the limb extended, the examiner most cautiously flexes the thigh on the pelvis to the point of pain, keeping the knee straight. The patient will normally be able to have the limb extended to almost 90° without pain. If this maneuver is markedly limited by pain, the test is positive and suggests sciatica from a disc lesion, lumbosacral or sacroiliac lesion, subluxation syndrome, tight hamstring, spondylolisthetic adhesion, IVF occlusion, or a similar disorder.

Lewin-Gaenslen Test.   The patient is placed in the lateral recumbent posi- tion with the underneath lower limb flexed acutely at the hip and knee. The examiner stabilizes the uppermost hip with one hand. With the other hand, the uppermost leg is grasped near the knee and the thigh is extended on the hip. Initiated or aggravated pain suggests a sacroiliac lesion. [See Clinical Comment 5.3]

      DR. FAYE'S CLINICAL COMMENT #5.3

Grice teaches that if the hip is flexed as far as possible and the leg is not held straight, one can test for iliopsoas and quadriceps shortening. If the iliopsoas is shortened, the patient's thigh will raise and the heel will not raise from the table. If the quadricep group has shortened, the patient's lower leg will raise from the table. This test plus hamstring tests are important in assessing causes of low-back pathodynamics.


Lewin's Standing Test.   With the patient standing with the back to the exa- miner, the examiner cautiously forces first the right and then the left knee into complete extension. Then both knees are straightened at the same time. In lumbosacral, lower lumbar, sacroiliac, and gluteal disturbances, these movements will be accompanied by increased pain and the knee will snap back into flexion.

Lewin's Supine Test.   Lewin believes a positive sign in this test indicates an ankylosing dorsolumbar lesion. With the patient supine, the examiner places his arms or a strap across the patient's thighs just above the knees. The patient is directed to sit up straight without using the hands. The sign is positive if the patient is unable to do this maneuver, and during the attempt, the patient is frequently able to localize the site of pain. It is frequently associated with lumbar arthritis, lumbar fibrosis, degenerative disc thinning with protrusion, sacroiliac or lumbosacral arthritis, or sciatica.

Lindner's Test.   The patient is placed supine, and the examiner slowly flexes the patient's head forward so that the neck and thoracic spine curve forward. This test often helps to localize diffuse spinal pain. This is the passive form of Kernig's neck test and similar to the Soto-Hall test except for the examiner's position. [See Clinical Comment 5.4]

      DR. FAYE'S CLINICAL COMMENT #5.4

When a thoracolumbar adhesion tends to pull a lumbar nerve root cephalad and produce radicular symptoms, this test will be positive and produce great patient apprehension during the maneuver. Some disc cases are the effect of incomplete ruptures (anular bulges). Cephalad traction on the root changes its normal angle as it exits the IVF, producing an abnormal tensile stress on the root involved. See Breig for full explanation.

My clinical experience is that Bragard's test is not as indicative as the Lewin-Gaenslen test. Manipulation of the thoracolumbar fixation will greatly reduce the patient's discomfort within 24 hours when this pseudo disc syndrome is present.


Minor's Sign.   Sciatic radiculitis is suggested by the manner the patient with this condition rises from a sitting position. The weight is supported on the uninvolved side by holding on to the chair for firm support in arising or the patient places the hands on the knees or thighs while working into the upright position, balances on the healthy leg, places one hand on the back, and flexes the leg and extends the thigh of the affected limb. The sign is often positive in sacroiliac lesions, lumbosacral strains and sprains, fractures, disc syndromes, dystrophies and myotonias.

Milgram's Test.   The supine patient is asked to keep the knees straight and lift both legs off the table a few inches and to hold this position for as long as possible (Fig. 5.12). The test stretches the anterior abdominal and iliopsoas muscles and increases intrathecal pressure. Abnormal intrathecal pressure can be ruled out if the patient can hold this position for 20 seconds without pain. If this position cannot be held or if pain is experienced early during the test, a positive sign is offered that indicates pressure on the cord from some source (eg, cord pathology, IVD lesion).

Naffziger's Test.   This test offers a suspicion of an abnormal space- occupying mass such as a spinal tumor or disc protrusion. It is performed by having the patient sit or recline while the examiner holds digital pressure over the jugular veins for 30 45 seconds (Fig. 5.13). The patient is then instructed to cough deeply. Pain following the distribution of a nerve may suggest nerve root compression. Though more commonly used for low back involvements, thoracic and cervical root compression may also be aggravated. Local pain in the spine does not positively prove nerve compression; it may suggest the site of a strain, sprain, or another lesion. The sign is almost always positive in the presence of cord tumors, particularly spinal meningiomas. The resulting increased intrathecal pressure above the tumor or disc protrusion causes the mass to compress or pull sensory structures to produce radicular pain. The test is contraindicated in geriatrics and extreme care should be taken with anyone suspected of having atherosclerosis. The patient should always be alerted that jugular pressure may result in vertigo.

Neri's Bowing Sign.   This sign is positive when a standing patient can flex the trunk further without low back discomfort when the ipsilateral leg is flexed than when both knees are held in extension. A positive sign suggests hamstring spasm, contractures of the posterior thigh and/or leg muscles, sciatic neuritis, a lumbar IVD lesion, or a sacroiliac subluxation syndrome.

Skin Rolling Test.   This test, according to Faye, will cause increased pain over a facilitated segment in the midline. He reports that, for a reason he is not aware of, this test can be positive unilaterally in a mechanical dysfunction segment (eg, a unilateral fixation).

Yeoman's Test.   The patient is placed prone. With one hand, firm pressure is applied by the examiner over the suspected sacroiliac joint, fixing the patient's anterior pelvis to the table. With the other hand, the patient's leg is flexed on the affected side to the limit, and the thigh is hyperextended by the examiner lifting the knee off the examining table. If pain is increased in the sacroiliac area, it is significant of an anterior sacroiliac or hip lesion because of the stress on the anterior sacroiliac ligaments. Normally, no pain should be felt on this maneuver.

In addition to the tests described above, there are occasions when Babinski's sciatic, Baron's, Barre's pyramidal, Bonnet's, buckling, Duchenne's, Gower's, iliopsoas spasm, Kernig's, Lloyd's, Murphy's kidney, Pitres', Shober's, Sicard's, toe-in, Turyn's, Vanzetti's, and Westphal's signs should be sought. This is also true for the application of Astrom's, Bechterew's, belt, bent-knee pull, heel walk, iliopsoas contracture, Nachlas', O'Connell's, quadriceps flexion, Romberg's station, Smith-Peterson's, thigh hyperextension, and toe walk tests. These tests are described in comprehensive texts on physical and differential diagnosis.

      Practical Sequence

As with any clinical examination procedure, the examination of the lumbar spine should be performed in an orderly and efficient manner designed to gain the maximum amount of information while provoking the patient's condition as little as possible. One helpful method uses a tape recorder for the doctor to dictate findings as the examination is performed. This speeds up the examination and eliminates the need for the doctor or other personnel to record findings by hand. An efficient sequence of examination, states Faye, might be as follows:

1. Patient vital statistics are taken and recorded while the patient is seated on the motion palpation stool.
   

2. Full spine motion palpation.
   

3. Low-back orthopedic testing with patient sitting.
   

4. Low-back orthopedic testing with patient standing, including postural analysis, sacroiliac palpation, observation of gait, heel and toe walk, etc.
   

5. Low-back orthopedics and neurologic testing with the patient supine (eg, reflexes, pin-wheel testing, motor strength testing, etc).
   

6. Low-back orthopedic testing with the patient prone.
   

7. When the examination is complete, the doctor decides what x-ray films are necessary. When acute spasm and antalgia exist, motion studies may not reveal significant information and it may be prudent to take standard views while delaying motion studies until muscular function has normalized enough to allow intersegmental motion to occur.

It then becomes the chiropractor's task to combine the information of the patient's history, orthopedics and neurologic examination, motion palpation examination, and x-ray findings to form a diagnosis, prognosis, and treatment regimen. These routines, when practiced to proficiency and coupled with compassion and integrity, will result in great success in the understanding and management/treatment of most low-back pain syndromes.


Lumbar Fixations

      Iliolumbar Ligament Fixations

In the Belgium group's studies of fixation, they found that the 5th lumbar vertebra acts as part of the pelvis and at that level the most common ligament at fault is the iliolumbar. When these ligaments are shortened, they pull the crests of the ilia towards each other during standing, thereby forcing the ischia outward, the base of the sacrum forward, and the sacral apex backwards in the typical position that these structures assume during sitting. Gillet reports that this fixation is difficult to differentiate from that caused by the contracture and degeneration of the lower part of the quadratus lumborum. Fortunately, from a therapeutic viewpoint, the adjustment is the same, except that if the muscle is not degenerated, its hypertonicity may be reflexively produced by an articular fixation of the proximal fibulotibial articulation.

      Quadratus Lumborum Fixations

The quadratus lumborum is a large muscle that has considerable importance by itself in producing both local and reflex fixations. Physiologically, it acts as one muscle, on either side, but individual bundles of its fibers, going from the iliac crest to a vertebra, can become "contractured" and pull the spine into distortion and fixation. This muscle, states Gillet, normally produces a flexion-rotation of the lumbar spine towards the side of the contraction. This movement takes place around a normal center of flexion-rotation in such a way that the superior and inferior articular surfaces remain in contact with each other. When in fixation, however, this normal gliding does not take place. On the contrary, the movement turns around an abnormal center of rotation that is at the opposite articulation. The articulations on the side of fixation are then forced open, with the inferior articulation being pushed into the IVF and against the nerve. This, states Gillet, is the "pressure on nerves" concept in all its simplicity and is one mechanism by which sciatica on the convex side of the lumbar curve is produced.

One special type of muscular fixation occasionally found seems to be of the vertical branch of the quadratus lumborum. It is often found to be hypertonic but quickly relaxes as other specific fixations are corrected.

      Interspinous Muscle Fixations

Gillet reports that the next "ligamentous" fixation to be found as palpation moves cephalad is "that which can be considered as being pathognomonic of chronic lower back pain; ie, the lower lumbar lordosis that will not disappear when the patient is flexed forward. In its acute form, this fixation is produced by hypertonus of the interspinous muscles, but when it becomes chronic, either the muscular tissue changes into fibrous tissue, or the interspinous, supraspinous, or sacrolumbar ligaments take over and shorten. The muscular degeneration may even spread laterally over an area from 1 inch to 1-1/2 inches in width on both sides. It then must be taken care of in a special manner."

This fixation, states Gillet, forces the vertebral articulations in a position that is not physiologic; ie, the pre- and post-zygapophyses are pulled apart at their superior edges and the interarticular spaces deform into a V shape. This, according to Gillet, forms what is usually called the facet syndrome, in which the vertebrae can be said to be "displaced." In the lateral x-ray view, this fixation gives the characteristic shape of the IVD, which is wedge shaped with the anterior part widened.

      Rotatore Muscle Fixation

This muscle, states Gillet, is often found to be unilaterally hypertonic: it pulls the corresponding spinous into rotation and pulls the transverse of the vertebra below into counterrotation (Fig. 5.14). The fixation resembles that caused by the intertransverse muscle (flexion-rotation in one case and rotation-flexion in the other). Fortunately, the muscle responsible can easily be palpated. It is often important to be able to pin-point the offending muscle accurately because the contact site for the adjustment will vary accordingly. Grice, reports Faye, recommends adjusting along the long axis of the contracted muscle.

      Intertransverse Fixations

It was described in the previous chapter that thoracic interspinous fixations are often found associated with chronic low-back pain. The intertransverse muscles in the lumbar region have a similar role in the production of sciatic pain. "Contrary to the subluxation produced by the quadratus lumborum muscle," states Gillet, "[shortening of] this muscle is responsible for the pain on the side of concavity. It pulls the two transverse processes of the vertebrae together and pinches the disc and the contents of the intervertebral foramen on that side."

      Erector Spinae Fixations

Gillet's studies found that lumbar erector spinae contractures pull the region into lordosis. In rare cases, this muscle is found, bilaterally, in a type of fibrous shortening that stops the region from moving into complete kyphosis. These cases are not frequent and sometimes difficult to manage.


Motion Palpation of the Lumbar Spine

Faye recommends that the lumbar spine be routinely palpated to determine which, if any, motion units are fixated; ie, which indicate the lack of a springy end feel at the end of all ranges of motion. The patient (sitting) and the doctor (sitting obliquely behind) should assume their standard positions for spinal motion palpation.

      Flexion

Flexion is determined by interspinous separation (positive theta x). When testing for flexion freedom of the posterior aspect of the motion unit, the examiner's thumb is placed between the spinous processes while the patient's spine is passively flexed forward (Fig. 5.15). Try to center this flexion at the level of the motion unit being evaluated, and then push anterosuperiorly on the superior spinous to see if a springy end feel exists (Fig. 5.16). The degree of intersegmental flexion motion varies considerably from patient to patient, but a distinct opening of the interspinous space should be perceived between segments that are not fixated.

This test evaluates only the posterior aspect of the motion unit; ie, the perception of motion may be normal even though the anterior ligaments have degenerated and tightened considerably.

      Extension

During motion palpation for the integrity of segmental extension, two factors should be checked; ie, facetal extension and elasticity of the anterior longitudinal ligament.

Extension of the zygapophyses (negative theta x). Extension freedom of the posterior aspect of the motion unit is indirectly tested by extending the patient's spine a few degrees and then pushing the articular process of the superior segment of the motion unit anteriorly (further into extension) with your palpating thumb (Figs. 5.17 and 5.18). You should feel a subtle springy movement under your thumb signifying that the joint has closed.

This motion, which evaluates the integrity of the posterior aspect of the superior segment of the motion unit, may appear normal even though an anterior fixation exists. Although fibers of degenerated ligaments lose their elasticity and plasticity to tensile forces, they still retain a large degree of their flexibility and are able to twirl to some degree.

Extension, as determined by anterior longitudinal ligament testing in hyperextension. The examiner's thumb is placed over the spinous process of the superior segment of the motion unit being evaluated. The patient's lumbar region is slightly hyperextended by the examiner's stabilizing arm, and then a forward push is made with the examiner's palpating hand (Fig. 5.19). Once the end of the ROM is reached, check for the normal springy end feel. If the anterior ligaments have degenerated, this springy end feel will be absent and the patient will report feeling quite uncomfortable.

      Lateral Flexion

Right and left lateral flexion (positive and negative theta z). To check lumbar lateral bending to the left, the examiner's thumb is placed against the left side of the spinous process of the superior segment of the motion unit being evaluated (Fig. 5.20). As the patient is passively laterally flexed to the left with your stabilizing arm, your right thumb should push against the left aspect of the spinous process to produce a greater opening between the contralateral facets (ie, on the right, the side of convexity). See Figure 5.21. This slight movement should be perceived. Reverse your oblique position and these procedures for testing opening of the left articulation during lateral bending to the right. Again, a springy end-feel is normally sensed. A blocked resistance with a nonlingering painful discomfort indicates a fixation of significance.

      Rotation

Left (clockwise) and right (counterclockwise) rotation, as determined by P-A motion of the zygapophyses (positive and negative theta y). The examiner and patient should attain the basic starting (neutral) position. In testing the capability of the inferior facet of the superior segment of the motion unit to rotate counterclockwise on the right (slightly superiorly, anteriorly, and medially on the superior facet of the segment below), the examiner's right thumb is placed against the right inferior process of the superior segment of the motion unit (Fig. 5.22). Rotate the patient's trunk counterclockwise (anteriorly on the right, posteriorly on the left) with your stabilizing arm, and, at the end of the ROM, check for a springy end feel by pushing forward with your thumb (Fig. 5.23). It is important during this maneuver to maintain constant contact against the inferior articular process being evaluated. Reverse your oblique position and these procedures for testing the contralateral articulation.

It should be noted that intersegmental rotatory motion may appear normal (but inhibited) even though extensive anterior and/or posterior partial fixations exist. As previously explained, this is because degenerated connectivetissue fibers retain some freedom to spiral and may be flexible. However, if a unilateral total (articular) fixation exists, rotatory motion will be absent on either side of the segment.


Applied Roentgenography

Lumbar studies, states Faye, should be conducted with a 72-inch tube-film distance, 100 KVP, 12:1 ratio grid with 103 lines, rare earth screens, and fast film. Considerable roentgenographic research has been done with patients sitting on a stool, but many clinicians use a standing A-P or P-A view quite successfully. Gonadal shields should always be employed. To read these functional films accurately, the examiner must be sure the pelvis did not side slip in lateraI flexion.

Flexion-extension views are becoming more significant as investigations discover the significance of segmental instability. Motion studies with nonionizing radiation (eg, ultrasonic, magnetic) appears to be the standard of the future. The high KVP and rare earth screen combination is the best x- radiation reducer so far. The diagnosis of pathology is not the aim of a function study in dynamic chiropractic; therefore, stabilization is not used to immobilize the region.

The radiograph can show hypo- and hyper-mobility, but this finding will not recommend an articular adjusting procedure. Chronic hypermobilities seem to respond to stabilization if associated hypomobilities are corrected. More research is necessary in this area of our work. Personal observation of occasionaI cases such as those shown in MPI slides portray the return of hypermobile segments to a normal range of motion with time and correction of associated hypomobile articulations.

Flexion/extension overlay studies are extremely helpful for recording preand post-treatment changes. There are many methods recommended by different authors. Faye advises tracing the body and spinous process as it seems a more accurate method. Three colors of pointed pens that write on clear acetate sheets are also preferred. Each vertebra becomes the established reference point for the movement of the vertebra above. The neutral spine is traced first as it appears on the neutral lateral film. The clear acetate with the neutral spine traced on it in black is then used to compare flexion and extension ROMs of each motion unit.

In combined lumbar-sacroiliac disorders, the sacroiliac joints can be radiographed for pathology and anomalies. Faye uses a P-A view, stating that it gives a better picture of both sacroiliac joints. However, the professional standard is to use an A-P view. Most authorities agree that an oblique view is best for analyzing a particular sacroiliac joint.


Differential Diagnosis

Differential diagnosis is an art, not a pure science. The significance of the diagnosis depends on the perspective when the problem is approached. In our case as doctors of chiropractic, states Faye, "we need a double diagnosis. The classic diagnosis of allopathic medicine enables us to communicate with other professionals, insurance companies, etc. The chiropractic diagnosis is essentially a working knowledge of the five components of the subluxation complex."

To differentiate low-back pain, the chiropractic physician attempts to systematize, and hopefully simplify, the chiropractic diagnosis of low-back syndromes through a better understanding of the major types of low-back pain and accurate significant examination. This is not an exhaustive approach to low-back diagnosis as it is assumed that at the postgraduate level the doctor is already versed in the mechanisms of referred pain, the clinical implications of x-ray findings, recognizing pain of organic pathology, and that occasionally patients problems don't always follow a classic pattern and are subject to variation in their clinical presentation. Kirkaldy-Willis and Cassidy state: "Moreover the many different causes of back pain are not always readily apparent. With the exception of back pain from entrapment of the spinal nerve root by degenerative changes or by disc herniation, most causes of low-back pain lack objective signs and overt pathological changes. Nevertheless, these obscure causes are responsible for most of the back pain seen in clinical practice." This further emphasizes the need for an ever-increasing understanding of biochemical mechanisms, pathologic joint movement, and consequential nervous system dysfunction.

      Lumbar or Lumbosacral Facet Syndrome

The pain of lower lumbar facet syndrome is usually in the midline, presenting with an achy (sometimes sharp) pain that improves in the morning after rest and becomes worse in the evening after prolonged weight bearing. The patient's discomfort is aggravated by any maneuver causing extension of the lumbar spine such as with Kemp's, Lewin-Gaenslen's, or Ely's tests, and often relieved by forward flexion or when in the fetal position.

Faye reports that associated referred pain, usually mild to moderate, can refer to the

(1) ipsilateral iliac crest;

(2) ipsilateral buttock;

(3) ipsilateral groin, scrotum, labium occasionally; or

(4) leg, usually above the knee. There are no conclusive neurologic signs (reflexes +2, sensory negative, motor negative).

There is usually no pain on coughing or sneezing, but the skin rolling test may be positive over the level of inflammation. Faye also states that the most common sites of causation fixation are at the

(1) sacroiliac joints,

(2) thoracolumbar or lumbar joints, or

(3) the hip joints.

      Lumbar Disc and Radiculitis Syndromes: General Considerations

One early clinical concern is to differentiate inflammatory conditions from noninflammatory joint dysfunction syndromes. If a patient can point specifically to an exact joint as the source of the pain, it is likely the pain arises from that joint. If the patient moves the whole hand over a general area, then a specific joint is not usually the correct diagnosis.

Percussing the area of pain causes a sharp pain in dysfunction: an "ouch" reaction. However, more serious pathology is suggested if percussion produces a deep, throbbing, aching pain. Differentiating signs of lumbar disc protrusion, sprain, and strain are shown in Table 5.3.

With either IVD lesions or lumbar radiculities, Faye describes that the patient usually presents with an acute antalgic posture, bent either laterally or anteriorly. There may or may not have been a traumatic onset. There is pain on coughing or sneezing, and it may radiate down either leg. The leg pain extends from below the knee to the foot. There may be neurologic signs such as paresthesia, weakness of the big toe, weak foot and ankle dorsiflexion, and/or weak plantar flexion eversion. Atrophy of the affected limb is possible.

SLR, leg-lowering, and Kemp's tests will be positive. Bragard's, Minor's, and Neri's bowing tests may be positive or negative. The patient's discomfort becomes worse with activity, improves with rest; is worst in the evening; and improves in morning. The most common causative fixations are at the

(1) thoracolumbar junction,

(2) sacroiliac joints,

(3) hip joints.

      Intervertebral Disc Lesions in the Lumbar Spine

The firm diagnosis of IVD rupture can only be made during surgical inter- vention; myelography is no exception. Thus, only a tentative diagnosis of disc protrusion can be made when the conclusions are drawn from clinical signs and symptoms.

A classification of IVD syndromes is shown in Table 5.4.

In the abscence of severe trauma, disc height is a reflection of disc hydration. As dehydration increases with age and late degeneration, the nucleus tends to lose its turgor, and disc height can be used as a sign of these two factors. But this is not to say that advanced degeneration cannot be found in a disc of normal height. During roentgenographic analysis, the tip of the superior articular facet should not reach a line extending backward from the undersurface of the vertebral body above (Macnab's joint body line) if disc degeneration is absent (See Fig. 5.24).

Most exacerbating and remitting spinal pain cannot be attributed to the disc itself. Rather, involvement of the sensitive articular facets and IVF contents is much more likely.

Types of Intervertebral Disc Pathology.   One method of classifying the various types of IVD pathology is Charnley's method:

Type I:   acute sprain, usually from unexpected loading. There typically are severe pain and muscle spasm. Nonsciatic referred pain is usually associated. Rupture of some of the peripheral or central anular fibers, slight end plate fracture, and stress to the capsular or interspinous ligaments and posterior arch muscle fibers occur. Lasegue's straight-leg raising test is negative.

Type II:   a nontraumatic, idiopathic, sudden intake of fluid by the nucleus pulposus, causing irritation of the peripheral anular fibers because of the nuclear pressure being transmitted horizontally. There are back pain and muscle spasm without referred pain or sciatica. Lasegue's test is negative.

Type III:   slight abnormal bulging of some of the posterolateral fibers with slight IVF encroachment. In addition to local back pain, pain may be referred into the sacroiliac area, buttocks, hip, and posterior thigh. There is no neuromuscular deficit, and Lasegue's sign is negative.

Type IV:   herniation of part of the nucleus into the peripheral anulus that, in turn, bulges into the vertebral canal (Fig. 5.25). Local back pain increased with Valsalva's straining maneuvers, true sciatica, and a positive Lasegue's test occurs. These are signs of irritation of a nerve root.

Type V:   floating nuclear fragment. This chronic condition is sometimes associated with disc degeneration. There are episodes of back pain, with or without sciatica, depending on the position of the fragment and the magnitude of stress.

Type VI:   anchored nuclear fragment. This disorder is often the aftermath of Type V where the nucleus is fixed within the peripheral anulus or vertebral canal with probable IVF encroachment. The nerve root becomes chronically irritated from mechanical pressure, chemical irritation, autoimmune response, or a combination of these factors. True sciatica with a positive Lasegue's sign occurs. A narrowing of the IVD space is usually associated.

Type VII:   advanced disc degeneration. When a disc is not well hydrated and nourished, it is unable to serve its hydraulic function. Disc narrowing and arthrotic processes of the vertebral bodies are invariably associated. Symptoms vary from severe to none and may be chronic or intermittent.

      Lumbar Radiculitis

Signs and symptoms of lumbar radiculopathy vary somewhat depending on which root(s) are involved. See Table 5.5. In general, it can be said that painful lumbar attacks of radiculogenic erector splinting, often with brief episodes of paresis and paresthesiae, are sudden in onset and frequently bilateral as opposed to the invariably unilateral pain of a posterolateral disc protrusion. In this syndrome, the paravertebral ligaments are extremely tender, and pain is increased by rotation. Neurologic signs and Lasegue's SLR test are usually negative or unconclusive. The acute attacks of instability are often quickly relieved by rest and support. See Figure 5.26.

                 L3 Root         L4 Root         L5 Root         S1 Rootz
Feature          L2–L3 IVD       L3–L4 IVD       L4–L5 IVD       L5–S1 IVD
Ankle reflex     Normal          Normal          Normal          Diminished

Back pain        Buttocks,       Buttocks,       Buttocks,       Buttocks,
radiates to:     dorsal thigh,   dorsal thigh,   lateral calf,   mid-calf,
                 anterior knee   medial calf     dorsal foot,    plantar foot,
                                                 great toe       heel

Lasegue's        Usually         + at 80°        + at 50–60°     + at 30–40°
supine sign      negative        or more         or more         or more
(SLR)

Muscle           Quadriceps      Quadriceps      Gluteus med.,   Gluteus max.,
weakness         femoris group   iliopsoas       ant. tibialis,  hamstrings,
                                                 hallucis ext.   gastrocnemius,
                                                                 soleus

Patellar         Normal          Diminished      Normal          Normal
reflex

Sensory sign     Knee numbness   Lower medial    Numbness at     Numbness
                                 leg numbness    cleft between   inferoposterior
                                                 1st and 2nd     to lateral
                                                 toe, dorsal     maleolus, heel,
                                                 foot            dorsal calf,
                                                                 lateral foot

Adjusting Lumbar Fixations

      Flexion: Interspinous Separation Fixation

Place the patient in the lateral recumbent position with both knees and hips flexed, arms crossed, and adjust the head-piece of the adjusting table to patient comfort. This is a modification of the classic side posture adjustment position. The patient may lie on either side during the adjustment, for here we are dealing with a midline fixation.

Avoid rotating the patient's lumbars during patient placement. The patient's knees are stabilized by the doctor's thigh as he or she stands over the patient's flexed lower limbs. Once the patient is properly positioned, apply a pisiform contact on the tip of the spinous of the superior segment of the involved motion unit and direct an impulse cephalad and slightly forward to produce further flexion (kyphosis) of the superior segment on the inferior segment. See Figure 5.27.

Once lumbar interspinous soft-tissue fixations become chronic and degenerative processes are well established, they respond less to adjustments. See Figure. 5.28. Some type of stretching exercise is usually necessary to facilitate the effects of a mobilizing adjustment. One frequently used technique is to place the patient supine and flex both of the patient's knees toward the patient's chest, adding your own body weight if necessary, in an attempt to curl the patient's lumbar spine into flexion and place a slow stretch on the posterior elements. The sacral apex should be raised from the supporting surface (eg, a low therapy table). Try to direct the greatest force at the apex of the patient's lumbar lordosis. It may be necessary to place one hand under the patient's sacral apex and lift upward and cephalad to enhance this curling motion. See Figure 5.29.

With slight modifications, this stretching maneuver can be used as the primary adjustment with large patients that are difficult to manage in the lateral recumbent position. The modifications are to apply a knuckle contact with your active hand between the fixed spinous processes, lean well over the patient with your stabilizing arm across the patient's uppermost thigh, and then deliver a body drop directed against your contact finger that serves as a fulcrum.

      Extension: Zygapophyseal Fixation

Place the patient in the classic lateral recumbent position, involved side upward, with the uppermost hip and knee flexed over the underneath extended limb resting on the surface of the adjusting table. Position the patient so that the lumbar spine is lordotic (curved in moderate extension); ie, the patient's hips and shoulders are further from you than the patient's abdomen. Apply a pisiform contact on the involved articular process and direct an impulse anteriorly and slightly cephalad to produce extension (lordosis) of the superior segment on the inferior segment (Fig. 5.30). An added body drop during this adjustment is usually beneficial.

      Extension: Shortened Anterior Longitudinal Ligament, Patient Prone

Place the patient prone, raise the pelvic support of the adjusting table slightly, lower the head-piece a few notches, and relax the tension from the chest-abdomen support of the adjusting table to place the patient's lumbar spine in extension (Fig. 5.31). With the patient in this "swayback" position and pressure is applied to achieve maximum extension, it only takes a slight impulse delivered obliquely anteriorly and cephalad (using a crossed-hand double-pisiform contact against the laminae bilaterally) to stretch the anterior longitudinal ligament. See Figure 5.32.

      Extension: Shortened Anterior Longitudinal Ligament, Patient Sitting

Place the patient in the sitting neutral position, and stabilize the patient's shoulders as during motion palpation. Slightly flex the patient's lumbars to open the interspinous space so that you can obtain a firm thumb contact between the spinous processes of the involved motion unit. Return the patient's spine to the neutral and then into extension while continuously maintaining a firm contact with your thumb. Once the maximum ROM of extension is achieved, deliver an impulse with your thumb that is directed anteriorly and slightly cephalad (Fig. 5.33). Faye recommends this technic when a shortened anterior ligament fixation is found during a housecall.

Gillet and Faye report that shortening of the lumbar anterior longitudinal ligament frequently occurs at one or two motion units, tending to push one or both of the involved segments into a state of local kyphosis (Fig. 5.34). The same condition may also be found in the thoracic and cervical spine. At times, such kyphotic segments in the lumbar spine will not be the effect of a shortened anterior longitudinal ligament; rather, they may be the result of iliopsoas spasm or hypertonicity. This point should be underscored for the iliopsoas has been shown to play a major role in many low-back pain complaints.

Schafer points out that the term "shortened anterior longitudinal ligament" should not be taken literally. It is a term that has been carried over from Gillet's writings, and it is likely that something became misinterpreted during translation. Shortened ventral spinal tissues would probably be a more correct general phrase. Although the anterior longitudinal ligament may degenerate, it is such a thin structure in the lumbar spine that tightening of this ligament in itself would unlikely interfere greatly with lumbar movements. Observation during surgery reveals that more important to restricting lumbar extension would be degeneration of the strong tendons and fascia of the iliopsoas muscle (and some fibers of the retroperitoneal fascia) that firmly attach anteriorly to the vertebral bodies, IVDs, and transverse processes along with fibers from the anterior longitudinal ligament (Fig. 5.35). This ligamentous and tendinous complex should be considered clinically as a whole. It would be an unusual circumstance if degenerative processes would attack fibers of the anterior longitudinal ligament in this area of the spine and leave adjacent ligament, fascia, and tendon fibers unaffected.

      Extension: Shortened Anterior Longitudinal Ligament, Patient Standing

This adjustment can be performed in several ways. One method is similar to that described for a shortened anterior longitudinal ligament in the thoracic spine. For the lumbar region, Faye stands backwards to the patient so that his buttocks fits into the patient's lumbar lordosis, reaches backward to grip the patient's crossed arms, and flexes forward to induce distraction and extension of the patient's spine. See Figures 5.36 and 5.37. Some doctors prefer to stand sideways to the patient and place their hip against the patient's lordosis just before the lifting maneuver is performed.

As an alternative to these technics with the doctor and patient in the standing position that are designed to stretch the anterior longitudinal ligament and induce intersegmental traction, Schafer achieves the same objective with the patient supine by applying intermittent mechanical spinal traction to the patient while a small Dutchman's roll is been placed under the patient's lumbars. Choice of technic is always a matter of clinical judgment and physician preference.

      Zygapophyseal Rotatory Fixation, Patient Laterally Recumbent

Place the patient in the classic lateral recumbent position, involved side either upward or downward. Maneuver the patient's spine to apply a passive rotatory force against the site of fixation. The objective here is to induce a torque between the facets that exhibit restricted rotatory motion. With the patient positioned as described above, this can be accomplished in either of two ways depending on if the superior segment is restricted in its clockwise or counterclockwise motion (from a bird's-eye view with the patient sitting). If restricted in counterclockwise motion, the superior segment is moved in this direction against the fixation while the inferior segment is moved in the opposite (clockwise) direction. The adjustment is achieved by finger or thumb contact under the lateral aspect of the spinous process of the superior segment lifting obliquely upward and the contact over the lateral aspect of the spinous process of the inferior segment simultaneously pushing obliquely downward in line with the plane of articulation (Fig. 5.38). These counterrotations are centered at the fixated facet, and a mild added body drop will enhance this adjustment. The same effect can be achieved by stabilizing one segment and rotating the other. This latter method is the technic taught by Faye.

If the superior segment is restricted in clockwise motion, either the contacts and direction of force can be reversed or the patient can be placed on the other side. Keep in mind that restricted clockwise motion of the superior process is the same as restricted counterclockwise motion of the motion unit's inferior process, and vice versa, for facetal motion is relative to the gliding positions of the articulating surfaces.

This reciprocity of facetal motion is readily recognized in gross motions of the spine: if a patient's shoulders are stabilized and the patient's pelvis is rotated clockwise, the motions induced in the movable articulations of the patient's spine are no different than those that occur when the patient's pelvis is stabilized and the patient's shoulders are rotated counterclockwise. The same principle is true at the segmental level, for gross motions are only the sum of the actions taking place at segmental levels. For this reason, a large variety of technics can be applied in different fashions and yet achieve the same objective (the release of restricted joint motion or, conversely, the increase in joint motion freedom).

      Zygapophyseal Rotatory Fixation, Patient Sitting

If necessary for the circumstances at hand, correction of restricted rotatory motion can be achieved with the patient in the sitting position. The doctor and patient positions are the same as those used for motion palpation of segmental rotation except that a pisiform contact is used rather than a thumb contact. If counterclockwise rotation is restricted on the right, the patient is rotated into maximum counterclockwise ROM by the doctor's stabilizing arm. With the doctor's contact hand, an impulse is then directed anteriorly, slightly cephalad, and medially against the medial aspect of the right transverse process of the superior segment of the fixed motion unit.

      Zygapophyseal Rotatory Fixation, Patient Prone

The patient is placed prone, the head-piece of the adjusting table is lowered, the abdominal support is raised slightly, and the front aspect of the pelvic support is raised slightly to place the patient's spine in mild flexion to slightly open the posterior elements of the lumbar vertebrae. If the superior unit of a motion unit exhibits restricted counterclockwise motion on the right, for example, Schafer recommends applying a crossed-hand double-pisiform contact, with one contact applied against the right lamina of the superior segment and the other contact applied against the left lamina of the inferior segment of the motion unit. With elbows almost locked, the adjustment is delivered bilaterally anteriorly and cephalad (in line with the plane of articulation) with equal force to produce an intersegmental torque within the restricted articulations. See Figure 5.39.

      Restricted LateraI Lumbar Flexion, Patient Laterally Recumbent

The patient is placed in the classic lateral recumbent position, and care should be made to avoid any degree of lumbar rotation. If lateral bending is restricted on the right, the patient is positioned so that side is upward, and vice versa. Release the tension on the abdominal support, and slightly raise the front aspect of the pelvic support. Stand in front of the patient, perpendicular to the site of involvement. Reach over the patient and apply a pisiform contact deep against the lateral aspect of the spinous process of the superior segment of the involved motion unit. Apply firm pressure downward (and slightly anteriorly to avoid slipping) to produce lateral flexion under your contact, and, at the maximum ROM, deliver an impulse and mild body drop directed obliquely downward, cephalad, and anterior (in line with the place of articulation). See Figure 5.40.

Note:   It should be realized that this adjustment can only be effective if the tension on the abdominal support is released to allow free lateral flexion. If the adjustment is delivered with the patient on a firm table, as sometimes must be demonstrated, the pressure contact and downward impulse on the spinous process (the most posterior lever on the motion unit) will not produce lateral flexion, it will produce clockwise rotation of the segment; ie, as the spinous process is forced downward, the centrum will rotate in the opposite direction. The unyielding table surface will inhibit lateral flexion. The ideal contact to release a lateral flexion block would be on the lateral aspect of the contralateral articulating processes. As this is impossible without producing injury to the overlying tissues, patient and table positioning to achieve passive preadjustment lateral flexion against the fixation is almost mandatory.

      Iliolumbar Ligament Fixations

Shortening of the iliolumbar ligaments, which extend from the transverse processes of L5 to the iliac crests bilaterally, tend to pull the pelvis in the standing position into the shape it normally takes in the sitting position. This produces a low lordosis in the standing position but of a different type than that caused by lumbar interspinous ligament fixations.

Iliolumbar shortening can be relieved by placing the patient in the lateral recumbent position and applying a roll-type adjustment with contact held on the iliac crest on the side of the shortest iliolumbar ligament (Fig. 5.41). The objective is to increase the distance between ligament's origin and insertion. With the patient in the prone position and the tension on the abdominal support eased, an alternative technic can be applied by giving a short, stiff thrust against the midpoint of the shortened ligament.


Integrated Treatment Approach

Once the diagnosis is first established, it is best to consider it as the working diagnosis. This temporary diagnosis is usually confirmed or replaced in 2 3 weeks.

"The first concern therapeutically is the reduction of any inflammation and pain," states Faye. "The most effective methods of reducing inflammation, also reduces pain. I found electrotherapy and ice were more effective than ultra sonar. Restoring joint mobility also had a great pain relieving effect. In acute cases, the trauma has to be differentiated as invasive or a biomechanical insult. Thrust adjusting is contraindicated in invasive trauma. Manipulation of the area of dysfunction is indicated in trauma caused by biomechanical insult. The area of manipulation is more often not at the level of the inflammation treatment. The flow chart (refer to Fig. 2.5) helps in scheduling."

In developing an integrated treatment approach for low-back pain complaints, Faye emphasizes the inclusion of muscle testing, locating and treating associated trigger points, using a lumbar spine PNF stretching procedure, and physical therapy.

Lumbar trigger points are commonly found within each belly of the quadratus lumborum muscle; the multifidus, rotatores, and intertransversarii muscles; and the erector spinal muscles. Faye mentions that gluteus and piriformis trigger points are also commonly concomitant.

In PNF stretch of the lumbar spine, the patient sits for these stretches with arms crossed, hands on shoulders, and each range of motion is resisted for 8 seconds and than actively stretched to tolerance by the antagonist with gentle help from the doctor.

Muscles can be tested by judging the power of a contraction against resistance or by using a dynamometer such as a Cybex unit. A weak muscle or muscle group should be tested to see if it contracts when faradic current is applied. If it does, states Faye, it will recover in a few weeks. If no contraction occurs but galvanic current can cause a contraction, then from 8 to 12 months can be expected for a recovery. Faye reports that no response to galvanism means no recovery can be expected.

If physical therapy is employed in your practice, the doctor should use a modality to achieve a specific predetermined physiologic effect. The following considerations are recommended by Faye:

1. Reduce swelling and inflammation of acute condition:   ice, electrotherapy, compression, elevation.

2. Reduce pain and thus anxiety caused by pain:   electrotherapy, ice.

3. Promote healing by increasing metabolism and circulation:   heat (eg, diathermy, infrared, etc).

4. Promote healing by changing polarity of pathology area:   electrotherapy, electromagnetic field therapy.

5. Promote muscle strengthening by electrical stimulation   faradic, galvanic, Russian stimulation, tetanizing currents with proper rest phases.

6. Extinguish active or latent trigger points:   electrotherapy, ischemic compression, percussion vibration, spray-and-stretch.

7. Promote a positive feeling of getting well, which is so essential to the patient's psychology of getting well.

These notes provide a foundation for a chiropractic approach to many pelvic and lumbar spine complaints. Faye recommends that the involved segmental areas be adjusted often even though no low back pain syndrome is present. "The biomechanical model of joint function and the locomotor system as an integral unit of harmony of joints, muscles and neurobiological mechanisms is the chiropractic model of health and disease. We hope this approach stimulates your thinking and practical expertise in practicing rational chiropractic."


Motion Palpation Recumbent on a Mobile Adjusting Table

With the introduction of chiropractic adjusting tables that produce both y-axis distraction and lateral flexion, new methods of motion palpation are now possible. These innovations have been shown by Martin and associates to be as accurate in interreliability studies as our traditional methods conducted in the sitting posture.

A motorized table leaves both hands of the examiner free for palpation. Y-axis distraction can be palpated in the lumbar, thoracic, and cervical spine. In the lumbar spine, all ranges of motion can be examined while the patient is prone.

For the methods described below, the table needs to swing laterally between its abdominal and pelvic sections.

      Lumbar Rotation: Patient Prone

With this type of motion palpation, do not drop the center abdominal section because a flattened lumbar spine is easier to palpate than one that is lordotic. Unlock the lateral flexion mechanism. Position yourself on that side of the table which allows your nondominant hand to laterally flex the table. This will leave your dominant hand free to palpate.

The first step is to place your palpating thumb against the spinous process of L5 and push it away as you simultaneously pull the upper half of the table toward you. During the first few degrees of table motion, spring the L5 spinous to see if it can rotate a degree or so. The second step is to push the table back toward neutral, and hook your index and third finger over the contralateral side of L5's spinous process. Then the third step is to pull and spring the L5 spinous process toward you as you push the table a few degrees laterally away. See Figure 5.42. Repeat this process up through the thoracolumbar junction to above the T11 level.

It is important to note that the spinous processes move in the opposite direction when the spine is in the prone position; ie, the spinous processes rotate to the convexity during lateral flexion. This rotation is only a degree or so. The significant feature to evaluate is the springy elastic barrier of the joint being examined. The lack of this rotation often releases during the testing procedure. [See Clinical Comment 5.5]

      DR. FAYE'S CLINICAL COMMENT #5.5

Spinal adjusting during motorized motion is a fairly new method of restoring fixated joints to normal function. With a motorized Y-axis distraction table, less physically endowed doctors can now much more easily restore specific ranges of spinal motion. It has been shown by Eckard in a personal demonstration that up to 50% less force is necessary for some forms of lumbar and thoracic manipulation when using motorized mechanical traction. The test equipment used by Eckard contained computerized pressure gauges located underneath the sections of the table.

      Lumbar Lateral Flexion: Patient Prone

Using the same method described above, pull the upper half of the table into full lateral flexion and continue to push the spinous process being tested toward the spinal convexity. The spinous process will serve as a lever to help you determine if a springy motion is palpable at full lateral flexion. Loss of joint motion on the convex side of the lumbar curve will restrict lateral flexion. Once again,

(1) pull the table toward yourself and push the spine away by using your thumb against the spinous process of the segment being tested; then

(2) push the table away and pull the spinous process with your index and 3rd finger to see if the ipsilateral joints are opening during lateral flexion (Fig. 5.43).

      Y-Axis Translation

Palpate a potential Y-axis fixation with the abdominal piece of the motorized table dropped. The superior edge of the patient's iliac crests should be positioned in line with the top edge of the pelvic cushion. As the position of the pelvic section of the table descends at the caudad end, palpate the degree of separation within the interspinous spaces. In addition, push gently with the heel of your hand to determine if slight z-axis translation occurs (Fig. 5.44). The spinous processes should separate, and the lumbar joints should have a springy end point. You will likely find that gentle thrusts on the spine during the downward stroke of the pelvic section will often release both y-axis and z-axis restrictions.

      Flexion/Extension of Lumbar Spine: Patient Laterally Recumbent

With the patient placed on their side and the downward iliac crest on the pelvic portion of the table:

(1) Position the table's abdominal and head sec- tions to produce lumbar flexion of the patient's spine. The patient's interspinous spaces should separate and approximate as the table is pushed back into neutral.

(2) Continue pushing the table back until extension of the patient's spine occurs. The spinous processes should then close farther. Spring the joints at the end of each range of motion to see if normal zygapophyseal end play exists. See Figure 5.45.

Bachman DC, Noble HB: Helping the patient with low back pain. Modern Medicine, 46(4):34-37.

Beal MC: The sacro-iliac problem: review of anatomy, mechanics, and diagnosis. Journal of the American Osteopathic Association, vol 81, June 1982.

Bell GR, Rothman RH: The conservative treatment of sciatica. Spine, 9:54-56, 1984.

Bellamy N, Park W, Rooney P: What do we know about sacro-iliac joints? Semi- nars in Arthritis and Rheumatism, 12(3):282-305, February 1983.

Blower PW: Neurologic patterns in unilateral sciatica: a prospective study of 100 new cases. Spine, 6:175-179, 1981.

Bogduk N: The innervation of the lumbar spine. Spine, 8(3):286-291, 1983.

Bogduk N: Lumbar dorsal ramus syndrome. Medical Journal of Australia, 2:537- 541, 1980.

Brewer BJ: Low-back pain. American Family Physician, 19:114-119, 1979.

Breig A: Adverse Mechanical Tension in the C.N.S. New York, John Wiley & Sons.

Brodin H: Inhibition-facilitation technique for lumbar pain treatment. Manuell Medizin, 20:95-98, 1982.

Brunarski DJ: Functional considerations of spinal manipulative therapy. ACA Journal of Chiropractic, May 1980.

Burton AK: Back pain in osteopathic practice. Rheumatology and Rehabilitation, 20:239-246, 1981.

Burton CV: Conservative management of low back pain. Postgraduate Medicine, 70:168-183, 1981.

Cailliet R: Low Back Pain Syndrome, ed 3. Philadelphia, F.A. Davis, 1981, pp 1-21, 44-51, 53-67, 69-78.

Cailliet R: Soft Tissue Pain and Disability. Philadelphia, F.A. Davis, 1980, pp 41-54.

Calin A: Back pain: mechanical or inflammatory? American Family Physician, 20:97-100, 1979.

Carmichael SW, Burkart SL: Clinical anatomy of the lumbosacral complex. Physi- cal Therapy, 59:966-975, 1979.

Cassidy JD, Potter GE: Motion examination of the lumbar spine. Journal of Manipulative and Physiological Therapeutics, 2(3):151-158, September 1979.

Chusid JG: Correlative Neuroanatomy & Functional Neurology, ed 19. Los Altos, CA, Lange Medical, 1985, pp 150-161.

Cox HH: Sacro-iliac subluxation as a cause of backache. Surgery, Gynecology, and Obstetrics, 45:637-48, 1927.

Crock HV: Normal and pathological anatomy of the lumbar spinal nerve root canals. Journal of Bone & Joint Surgery (British), 63:487-490, 1981.

Cyriax E: Some common postural deformities and their treatment by exercise and manipulation. British Journal of Physical Medicine, June 1938.

D'Amico JC: The postural complex. Journal of the American Podiatry Associa- tion, August 1976.

Daniels L, Worthingham C: Muscle Testing: Techniques of Manual Examination, ed 4. Philadelphia, W.B. Saunders, 1980, pp 22-29, 34-35.

Dinnar U: Classification of diagnostic tests used with osteopathic manipula- tion. Journal of the American Osteopathic Association, 79(7):451-455, March 1980.

Drevet JG, Chirossel JP, Phelip X: Lumbago-lumboradiculalgia and posterior vertebral joints. Lyon Medical, 245:781-787, 1981.

Dvorak J: Neurological and biomechanical aspects of back pain. In Buerger AA, Greenman PE (eds): Empirical Approaches to the Validation of Spinal Manipu- lation. Springfield, MO, Charles C. Thomas, 1985, pp 241-262.

Ebel JN: Reflex relationships of paravertebral muscles. American Journal of Physiology, 200(5), May 1961.

Edgelow PI: Physical examination of the lumbosacral complex. Physical Therapy, 59:974-977, 1979.

Evans DC: Biomechanics of spinal injury. In Gonzna ER, Harrington IJ: Bio- mechanics of Musculoskeletal Injury. Baltimore, Williams & Wilkins, 1982, pp 204-212.

Evans DP: Backache: Its Evolution and Conservative Treatment. Baltimore, Uni- versity Park Press, 1982, pp 21-30, 40-43, 55-63, 161-165.

Evans FG: Some basic aspects of biomechanics of the spine. Archives of Physi- cal Medicine and Rehabilitation, 51:214-226, 1970.

Farfan HF, et al: The effects of torsion on the lumbar intervertebral joints: The role of torsion in the production of disc degeneration. Journal of Bone and Joint Surgery, 52A:468, 1970.

Farfan HF: Symptomatology in terms of the pathomechanics of low-back pain and sciatica. In Haldeman S (ed): Modern Developments in the Principles and Practice of Chiropractic. New York, Appleton-Century-Crofts, 1980.

Farrell JP, Twomey LT: Acute low back pain: comparison of two conservative approaches. Journal of the Australian Medical Association, 1:160-164, 1982.

Faye LJ: Chiropractic Manipulation of the Lumbar Spine [Videotape]. Los Ange- les, Dynaspine, 1987.

Faye LJ: Manipulation I [Cassette tape program]. Huntington Beach, CA, Motion Palpation Institute, 1983, 6 tapes.

Faye LJ: Spine I: Motion Palpation and Clinical Considerations of the Lumbar Spine and Pelvis. Huntington Beach, CA, Motion Palpation Institute, 1987, pp 15-20, 22-27.

Finneson BE: Low Back Pain. Philadelphia, J.B. Lippincott, 1973, pp 7-9, 93-132, 141-177, 256-287, 325-326.

Fisk JW: The Painful Neck and Back. Springfield, IL, Charles C. Thomas, 1977, pp 13-34, 91-114, 169-193.

Fosse M: A clinical study of lumbar spine movement using an external method of measurement. Brussels, Prestoprint, 1972. Anglo-European College of Chiro- practic. Thesis.

Gehweiler JA Jr, Osborne RL Jr, Becker RF: The Radiology of Vertebrae Trauma. Philadelphia, W.B. Saunders, 1980, pp 267-273, 296-299, 401-429, 446-447.

Gillet H: Evolution of a chiropractor. National Chiropractic Journal, November 1945, January 1949, December 1949, January 1951.

Gillet H, Liekens M: Belgian Chiropractic Research Notes. Huntington Beach, CA, Motion Palpation Institute, 1984, pp 8-9, 15, 17-18, 36, 133-135.

Gillet H, Liekens, M: A further study of spinal fixations. Annals of the Swiss Chiropractic Association. Geneva, IV:41, 1967.

Gitelman R: A chiropractic approach to biomechanical disorders of the lumbar spine and pelvis. In Haldeman S (ed): Modern Developments in the Principles and Practice of Chiropractic. New York, Appleton-Century-Crofts, 1980, pp 297-299, 314-320.

Gottlieb HJ, Alperson BL, Koller R, Hockersmith V: An innovative program for the restoration of patients with chronic back pain. Physical Therapy, 59:996-999, 1979.

Gowitzke BA, Gowitzke MM: Understanding the Scientific Bases of Human Movement, ed 2. Baltimore, Williams & Wilkins, 1980.

Gracovetsky S, Farfan HF, Lamy C: The mechanism of the lumbar spine. Spine, 6:249-262, 1981.

Grice AS, Fligg DB: Class notes: Spinal dynamics. Department of Biomechanics/ Kinesiology, BK202. Toronto, Canadian Memorial Chiropractic College, date not shown, pp 36-41.

Grieve GP: Common Vertebral Joint Problems. New York, Churchill Livingstone, 1981, pp 17-29, 34, 48-55, 60-62, 143-158, 198, 200.

Grynbaum BB, Belandres PV: Managing low back pain. Female Patient, 3:43-45, 1978.

Gunn CC, Milbrandt WE: Early and subtle signs in low-back sprain. Spine, 3(3):267-281, September 1978.

Hadley LA: Anatomico-Roentgenographic Studies of the Spine. Springfield, IL, Charles C. Thomas, 1981, pp 230-252, 399, 401, 404.

Hasue M, Kikuchi S, Sakuyama Y, Ito T: Anatomic study of the interrelation between lumbosacral nerve roots and their surrounding tissues. Spine, 8:50-58, 1983.

Helfet AJ, Gruebel Lee DM: Disorders of the Lumbar Spine. Philadelphia, J.B. Lippincott, 1978, pp 3-25, 27-31, 38, 42-48, 51-61, 69-82, 116, 145-161, 170-182, 219-220, 237-242.

Hoehler FK: Low back pain and its treatment by spinal manipulation: measures of flexibility and asymmetry. Rheumatology and Rehabilitation, 21:21-26, 1982.

Howe JW: Determination of lumbo-sacral facet subluxations. Roentgenological Briefs, Council on Roentgenology of the American Chiropractic Association, date not shown.

Hviid H: Erect working posture. Annals of the Swiss Chiropractors' Associa- tion, VI:71-90, 1976.

Janse J: Differentiation and interpretation of spinal pain syndromes. Notes on Correlative Techniques. Chicago, National College of Chiropractic, date not shown.

Janse J: Principles and Practice of Chiropractic. Lombard, IL, National College of Chiropractic, 1976, pp 45-46, 116, 187-196.

Jayson MIV, et al: Mobilization and manipulation for low back pain. Spine, 6:4, July-August 1981.

Jayson MIV, Sims-Williams H, Young S, Baddeley H, Collins E: Mobilization and manipulation for low-back pain. Spine, 6:409-416, 1981.

Johnston WL: The role of static and motion palpation in structural diagnosis. In Goldstein M (ed): The Research Status of Spinal Manipulative Therapy. NINCDS Monograph No. 15, DHEW Publication No. (NIH) 76-998, Stock No. 017-049-00060?7, Washington, DC, U.S. Government Printing Office, 1975.

Kanse J: The clinical biomechanism of the sacro-iliac mechanism. ACA Journal of Chiropractic, 12:S-1, January 1978.

Kapandji IA: Physiology of the Joints: Lower Limb, ed 2. New York, Churchill Livingstone, 1981, vol III, pp 54-57, 68, 74-78, 80-82, 86, 88-106, 114-118, 120.

Kirkaldy-Willis WH: Five common back disorders: How to diagnose and treat them. Geriatrics, December 1978.

Kirkaldy-Willis WH: A more precise diagnosis for low back pain. Spine, 4(2), March-April 1979.

Kirkaldy-Willis WH: The relationship of structural pathology to the nerve root. Spine, 9:49-52, 1984.

Kirkaldy-Willis WH, Wedge JH, Young-Hing K, Reilly J: PathoIogy and pathogene- sis of lumbar spondylosis and stenosis. Spine, 3(4):319-328, December 1978.

Kuo PP, Tang HF: Manipulation as a treatment of low back pain. The Journal of the Western Pacific Orthopaedic Association, 2:31-34, 1983.

Lamb DW: The neurology of spinal pain. Physical Therapy, 59:971-973, 1979.

Leavitt F, Garron DC, D'Angelo CM, McNeill TW: Low back pain in patients with and without demonstrable organic disease. Pain, 6:191-200, 1979.

LeVeau B: Williams and Lissner: Biomechanics of Human Motion. Philadelphia, W.B. Saunders, 1977.

Lewit K: Post-isometric relation in combination with other methods of muscular facilitation and inhibition. Manuell Medizin, (2:101-104, 1986.

Macnab I: Backache. Baltimore, Williams & Wilkins, 1977, pp 19-23, 44-63, 69-74, 98-104, 133-207.

Malik DD, et al: Recovery from radiculalgia by chiropractic adjustment and physical therapy. ACA Journal of Chiropractic, June 1984.

Manipulation in lumbar intervertebral disc protrusion. Chinese Medical Jour- nal, 3(1):31-36, January 1977.

Markey LP: Markey distraction technique: new protocol for doctor and patient safety, part I. The Digest of Chiropractic Economics, September-October 1985.

Markolf KL: Deformation of the thoracolumbar intervertebral joints in response to external loads. Journal of Bone and Joint Surgery, 54A:511-533, 1972.

Martin L, et al: A comparative study between loss of joint play by evaluating (1) a patient in active sitting palpation as described by L. Faye, DC, as compared to (2) passive joint play using the Hill table. Canadian Memorial Chiropractic College, Toronto, 1982. Thesis.

McAndrews JF: Spinal motion examination. ACA Journal of Chiropractic, May 1969.

McCall IW, Park WM, O'Brien JP: Induced pain referral: posterior lumbar ele- ments in normal subjects. Spine, 4(5):441-446, September/October 1979.

McGregor M, Cassidy JD: Post-surgical sacro-iliac joint syndrome. Journal of Manipulative and Physiological Therapeutics, 6(1), March 1983.

McKenzie RA: The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikane, NZ, Spinal Publications, 1981, pp 1-2, 4-5, 87-90.

McRae R: Clinical Orthopaedic Examination, ed 2. New York, Churchill Living- stone, 1983, pp 71-96.

Mensor M, Duval G: Absence of motion at the fourth and fifth lumbar interspa- ces in patients with and without low-back pain. Journal of Bone and Joint Surgery, 41-A(6):1047-1054.

Mior SA, Cassidy JD: Lateral nerve root entrapment: pathological, clinical, and manipulative considerations. The Journal of the Canadian Chiropractic Association, 26(1):13-20, March 1982.

Molloy RD: A correlation between muscle testing and chiropractic treatment. Anglo-European College of Chiropractic, 1976. Thesis.

Moore KL: Clinically Oriented Anatomy. Baltimore, Williams & Wilkins, 1980, pp 127-137, 617-618.

Morris JM: Biomechanics of the spine. Archives of Surgery, 107:418-423, 1973.

Mumenthaler M: Neurology, ed 2. Translated by EH Burrows. New York, Thieme- Stratton, 1983, pp 361-363.

Murphy KA, Cornish D: Prediction of chronicity in acute low back pain. Archives of Physical Medicine & Rehabilitation, 65:334-337, 1984.

Nachemson AL: The lumbar spine, an orthopaedic challenge. Spine, 1(1):59-68, March 1976.

Nash CL, Moe JH: A study of vertebral rotation. Journal of Bone and Joint Surgery, 51:223, 1969.

Ng SY: Sacro-iliac lumbar mechanism. ACA Journal of Chiropractic, pp 51-59. April 1983.

Offierski CM, Macnab I: Hip-spine syndrome. Spine, 8(3):316-321.

Olsen GA, Hamilton A: The lateral stability of the spine. Clinical Orthopae- dics, 65:143, 1969.

Olsen RE: Acute lumbosacral angle. Roentgenological Briefs, Council on Roent- genology of the American Chiropractic Association, date not shown.

Panjabi MM, Goel VK, Takata K: Physiologic strains in the lumbar spinal liga- ments. Spine, 7:192-203, 1982.

Park WM, McCall IW, O'Brien JP, Webb JK: Fissuring of the posterior annulus fibrosis in the lumbar spine. British Journal of Radiology, 52:382-387, 1979.

Parke WW: Applied anatomy of the spine. In Rothman RH, Simeone FA (eds): The Spine. Philadelphia, W.B. Saunders, 1975, vol I, p 27.

Pennal GF, et al: Motion study of the lumbar spine: A preliminary report. Journal of Bone and Joint Surgery, 54B:3, August 1972.

Peters RE: The facet syndrome. Journal of the Australian Chiropractors' Asso- ciation, 13:15-18, 1983.

Poole PB: Considerations of neurogenic pain. Ortho Briefs, Council on Chiro- practic Orthopedics of the American Chiropractic Association, Fall 1982.

Porter RW, Hibbert C, Wellman P: Backache and the lumbar spinal canal. Spine, 5:99-105, 1980.

Roaf R: A study of the mechanics of spinal injuries. Journal of Bone and Joint Surgery, 42B:810-823, 1960.

Rothman RH, Simeone FA: Lumbar disc disease. In Rothman RH, Simeone FA (eds): The Spine. Philadelphia, W.B. Saunders, 1975, vol II, pp 443-506.

Ruge D, Wiltse LL (eds): Spinal Disorders: Diagnosis and Treatment. Philadel- phia, Lea & Febiger, 1977.

Sandoz R: New trends in the pathogenesis of spinal disorders. Annals of the Swiss Chiropractic Association, V:93, 1971.

Sandoz R: Some reflex phenomena associated with spinal derangements and ad- justments. Annals of the Swiss Chiropractic Association, VII:45, 1981.

Schafer RC: Chiropractic Management of Sports and Recreational Injuries. Bal- timore, Williams & Wilkins, 1982, pp 283-286, 442-452

Schafer RC: Chiropractic Physical and Spinal Diagnosis. Oklahoma City, Associ- ated Chiropractic Academic Press, 1980, pp IV: 7, 10, 29; XIII:1-8, 15-19.

Schafer RC: Clinical Biomechanics: Musculoskeletal Actions and Reactions. Bal- timore, Williams & Wilkins, 1983, pp 375-388, 412-431.

Schafer RC: Physical Diagnosis: Procedures and Methodology in Chiropractic Practice. Arlington, VA, American Chiropractic Association; Chapter 20, Phy- sical Examination of the Lumbar Spine and Pelvic Girdle. In development; scheduled to be released in 1989.

Schafer RC: Symptomatology and Differential Diagnosis. Arlington, VA, 1986, pp 788-840.

Sharpless SK: Susceptibility of spinal roots to compression block. In Gold- stein M (ed): The Research Status of Spinal Manipulative Therapy. NINCDS Monograph No. 15, DHEW Publication No. (NIH) 76-998, Stock No. 017-049-- 00060-7, Washington, DC, U.S. Government Printing Office, 1975.

Simons DG, Travell JG: Myofascial origins of low back pain. Postgraduate Medi- cine, 73(2):66-108, February 1983.

Stonebrink RD: Palpation for vertebral motoricity. ACA Journal of Chiroprac- tic, February 1969.

Sunderland S: Anatomical perivertebral influences on the intervertebral fora- men. In Goldstein M (ed): The Research Status of Spinal Manipulative Therapy. NINCDS Monograph No. 15, DHEW Publication No. (NIH) 76-998, Stock No. 017- 049-00060-7, Washington, DC, U.S. Government Printing Office, 1975.

Sweere JJ: A method of physiological testing in the differential diagnosis of acute mechanical low back pain. Orthopedic Brief, ACA Council on Chiroprac- tic Orthopedics, September 1984.

Travell J: Myofascial trigger points: Clinical view. In Bonica JJ, Albe- Fessard D (eds): Advances in Pain Research and Therapy. New York, Raven Press, 1976.

Triano J: Significant lumbar dyskinesia. ACA Journal of Chiropractic, February 1980.

Turek SL: Orthopaedics: Principles and Their Application, ed 3. Philadelphia, J.B. Lippincott, 1977, pp 1322-1333, 1339-1341, 1350-1353, 1356-1358, 1362-1366, 1383-1389.

Van Dusen LG: Chiropractic Relationship to Gravitational Force. Sodus, NY, published by author, 1968, pp 87, 91, 93, 97, 103,

Voloshin A, Wosk J: An in vivo study of low back pain and shock absorption in the human locomotor system. Journal of Biomechanics, 15:21-22, 1982.

Waddell G, McCulloch JA, Kummel E, Venner RM: Nonorganic physical signs in low back pain. Spine, 5:117-125, 1980.

Wax M: Procedures in elimination of trigger points in myofascial pain syn- dromes. ACA Journal of Chiropractic, October 1962.

Weitz EM: The lateral bending sign. Spine, 6:388-397, July-August 1981.

West HG Jr: Physical and spinal examination procedures utilized in the prac- tice of chiropractic. In Haldeman S (ed): Modern Developments in the Prin- ciples and Practice of Chiropractic. New York, Appleton-Century-Crofts, 1980, p 283.

White AA, Panjabi MM: Clinical Biomechanics of the Spine. Philadelphia, J.B. Lippincott, 1978, pp 78-81, 166-178, 184, 212, 251-264, 272, 295, 292-293, 297-302.

Wigh RE: The transitional lumbosacral osseous complex. Skeletal Radiology, 8:127-131, 1982.

Wilson FC: The Musculoskeletal System: Basic Processes and Disorders, ed 2. Philadelphia, J.B. Lippincott, 1983, pp 67-69.

Wyke BD: Articular neurology and manipulative therapy. In Aspects of Manipula- tive Therapy. Proceedings of Multidisciplinary International Conference on Manipulative Therapy, Melbourne, Lincoln Institute of Health Sciences, Carl- ton, Victoria, Australia, August 1979, pp 67-72.

Yang KH, King AI: Mechanism of facet load transmission as a hypothesis for low back pain. Spine, 9:557-565, 1984