Instrumentation 2 InstrumentationRECOMMENDATIONInstrumentation is indicated for the qualitative and/or quantitative assessment of the biomechanical and physiological components of vertebral subluxation. When using instrumentation, baseline values should be determined prior to the initiation of care.
Rating: Established
Evidence: E, L
Commentary
The chiropractor uses a variety of procedures to assess the vertebral subluxation. These methods may include history taking, physical examination, imaging procedures and instrumentation. Through information gained from research and personal experience, the chiropractor generally assigns a personal value to each procedure in a particular clinical circumstance. The intent of this chapter is to describe clinical applications for the various instruments that may be used by chiropractors in examining their patients for evidence of vertebral subluxation.
Definition of instrumentation: The use of any tool or device used to obtain objective data, which can be recorded in a reproducible manner, about the condition of the patient relative to vertebral subluxation. Such instrumentation as that described below may provide information concerning the biomechanical and/or neurological aspects of vertebral subluxation.
POSTURAL ANALYSIS Sub-RecommendationPostural analysis using plumb line devices, computerized and non-computerized instruments may be used to evaluate changes in posture associated with vertebral subluxation.
Rating: Established
Evidence: E, L
Posture analysis is recommended for determining postural aberrations associated with vertebral subluxation. The findings of such examinations should be recorded in the patient record. In order to encourage standardization of reporting, it is suggested that findings be recorded in a form consistent with manufacturers' recommendations.
Posture analysis may include the use of such devices as the plumb line, scoliometer and posturometer.(1-8) Posture is often analyzed by x-ray methods(9-13) simply by visualizing the patient and making determinations based on that visualization. The procedure is often enhanced by a plumb line and other vertical and horizontal lines.
BILATERAL AND FOUR-QUADRANT WEIGHT SCALES Sub-RecommendationBilateral and four-quadrant weight scales may be used to determine the weight distribution asymmetries indicative of spinal abnormalities.
Rating: Established
Evidence: E, L
Unequal weight distribution has been shown to be indicative of spinal abnormalities.(14-18) Weight scales are a simple and effective means to determine weight distribution asymmetries.
MOIRÉ CONTOUROGRAPHY Sub-RecommendationMoiré contourography may be used to provide a photographic record of changes in body contour associated with vertebral subluxation.
Rating: Established
Evidence: E, L
Moiré contourography is a photographic technique which yields information regarding body contours and their variations for the purpose of evaluating structural abnormality. It is useful to the chiropractor because body surface asymmetries may be indicative of the presence of vertebral subluxation.(19-33)
INCLINOMETRY Inclinometry may be used as a means of measuring motion against a constant vertical component of gravity as a reference. Changes in ranges of spinal motion may be associated with vertebral subluxation.Rating: Established
Evidence: E, L
Mechanical, electronic and fluid-filled inclinometers are available.(34-38) Inclinometer measurements have been thoroughly studied regarding their ability to measure complex motions of the spine.(39-49) Inclinometers are considered superior to goniometers for assessing spinal motion.(50) Inclinometers have been shown to be accurate within 10% of those obtained by radiographic evaluation.(51) Achieving acceptable reliability is dependent upon use of standardized procedures.
GONIOMETRY Sub-RecommendationGoniometry, computer associated or not, may be used to measure joint motion. Inclinometry is superior to goniometry when standardized procedures are employed.
Rating: Established
Evidence: E, L
A goniometer is a protractor that may be held in the proximity of the area being measured to provide a means by which to determine degrees of motion.(35) Although goniometry is common, a wide range of variance has been reported, (56-59) expressing up to 10°-15° error.(60, 61)
ALGOMETRY Sub-RecommendationAlgometry may be used to measure pressure-pain threshold. Changes in sensory function associated with vertebral subluxation may produce changes in pressure-pain thresholds.
Rating: Established
Evidence: E, L
A pressure-pain threshold meter yields a measurement of when a patient feels a change from pressure to tenderness as the device produces mechanical irritation of deep somatic structures. Pressure-pain-threshold measurements produce acceptable levels of reliability.(62-66, 142-145) Algometry has been shown to be very useful in measuring changes in paraspinal tissue tenderness as the thresholds are symmetrical.(145) This renders the procedure applicable to chiropractic analysis.
CURRENT PERCEPTION THRESHOLD (CPT) TESTING Sub-RecommendationCurrent perception threshold devices may be used for the quantitative assessment of sensory nerve function. Alterations in sensory nerve function may be associated with vertebral subluxation.
Rating: Established
Evidence: E, L
The current perception threshold device is a variable voltage constant current sine wave stimulator proposed as a simple noninvasive and quantitative measure of peripheral nerve function.(67-71, 137-141) One type of current perception threshold instrument, the neurometer, has been shown to be appropriate for rapid screening for neural dysfunction.(69)
ELECTROENCEPHALOGRAPHY (EEG) Sub-RecommendationElectroencephalographic techniques including brain mapping and spectral analysis, may be used to assess the effects of vertebral subluxation and chiropractic adjustment associated with brain function.
Rating: Established
Evidence: E, L
Standard EEG and computerized EEG techniques, including spectral analysis and brain mapping, have been shown to change following chiropractic adjustments or manipulation.(72, 161, 204) Such procedures may be useful in evaluating possible effects of chiropractic care on brain function.
SOMATOSENSORY EVOKED POTENTIALS (SSEP) Sub-RecommendationSomatosensory evoked potentials may be used for localizing neurological dysfunction associated with vertebral subluxations.
Rating: Established
Evidence: E, L
Somatosensory and dermatomal evoked potentials are used for localizing neurological abnormalities in the peripheral and central conducting pathways. These findings are useful as objective indicators of the level or levels of involvement.(73-86, 154) One study reported that improved nerve root function was observed in subjects who received a high-velocity chiropractic thrust; similar changes were not observed in controls.(73)
SKIN TEMPERATURE INSTRUMENTATION Sub-RecommendationTemperature reading devices employing thermocouples, infrared thermometry, or thermography (liquid crystal, telethermography, multiple IR detector, etc.) may be used to detect temperature changes in spinal and paraspinal tissues related to vertebral subluxation.
Rating: Established
Evidence: E, L
The measurement of paraspinal cutaneous thermal asymmetries and other measurements of anomalies have been shown to be a mode of sympathetic nervous system assessment, (88, 90, 91, 93-95, 97-103, 160) which may be used as one indicator of vertebral subluxation. Demonstrable changes in thermal patterns have been observed following chiropractic adjustment.(19, 92) Thermocouple instruments have been shown to demonstrate an acceptable level of reliability and clinical utility applicable to the assessment of vertebral subluxation related temperature changes.(87, 89, 96, 104) Normative data have been collected concerning the degree of thermal asymmetry in the human body in healthy subjects.(105) These values may serve as one standard in the assessment of sympathetic nerve function and the degree of asymmetry as a quantifiable indicator of possible dysfunction.(106)
SURFACE ELECTROMYOGRAPHY Sub-RecommendationSurface electrode electromyography, using hand-held electrodes, or affixed electrodes, may be used for recording changes in the electrical activity of muscles associated with vertebral subluxations.
Rating: Established
Evidence: E, L, C
Surface electromyographic techniques using both hand-held electrodes and affixed electrodes have demonstrated an acceptable level of reliability for general clinical usage.(107-112, 114-121, 129-136, 159) Other studies have demonstrated that significant changes in muscle electrical activity occur following adjustment or spinal manipulation.(111, 113, 126, 136) Protocols and normative data for paraspinal EMG scanning in chiropractic practice have been published.(122-125, 127-128) Surface EMG techniques may be used to assess changes in paraspinal muscle activity associated with vertebral subluxation and chiropractic adjustment.
MUSCLE STRENGTH TESTING Sub-RecommendationMuscle strength testing may be used to determine bilateral differences or other differences in patient resistance. These differences may be characterized by the experienced examiner based on various technologies. Manual, mechanized and computerized muscle testing may be used to determine changes in the strength and other characteristics of muscles. These changes may be a result of alterations of function at various levels of the neuromuscular system and/or any other system related to the patient. Such changes may be associated with vertebral subluxation.
Rating: Established
Evidence: E, L
Muscle testing as a means of evaluation and diagnosis of patients within chiropractic as well as other disciplines, is well documented.(146-153, 155-158, 163-177) Muscle testing techniques may be used to assess the effect of vertebral subluxation on various aspects of muscle strength. Research has shown manual muscle testing to be sufficiently reliable for clinical practice. (148, 149, 153, 156, 169, 170, 171, 175) Studies concerning manual muscle testing have also demonstrated electromyographic differences associated with various muscle weaknesses, and differences in somatosensory evoked potentials associated with weak versus strong muscles.(146, 147) Other studies have demonstrated the clinical utility and reliability of hand-held muscle strength testing devices.(151, 152, 157, 172)
QUESTIONNAIRES Sub-RecommendationQuestionnaires may be used in the assessment of the performance of activities of daily living, pain perception, patient satisfaction, general health outcomes, patient perception outcomes, mental health outcomes, and overall quality of life, throughout a course of chiropractic care. Questionnaires provide important information, but should not be used as a substitute for physical indicators of the presence and character of vertebral subluxations.
Rating: Established
Evidence: E, L
There are a variety of questionnaires of demonstrated reliability and validity which may be used to document outcomes,(178-203) including pain and symptoms, although these are not necessary correlates of vertebral subluxation. However, correction of vertebral subluxation and reduction of the abnormal spinal and general functions associated with it may be accompanied by reduction or elimination of pain and symptoms. It must be emphasized that the clinical objective of chiropractic care is the correction of vertebral subluxations. No questionnaires exist which assess the presence or correction of vertebral subluxation. Therefore, it is inappropriate to employ questionnaires to determine the need for chiropractic care, but questionnaires are appropriate as one aspect of monitoring patient progress and the effectiveness of subluxation-based care.
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