J Can Chiropr Assoc. 2013 (Jun); 57 (2): 32–41 ~ FULL TEXT
Brian Gleberzon, DC, MHSc and Kent Stuber, BSc, DC, MSc
Chair of Department of Chiropractic Therapeutics,
CMCC, 6100 Leslie St.
Toronto, Ontario, M2H 3J1.
OBJECTIVE: The purpose of this study was to determine which diagnostic and therapeutic procedures of the spine are most commonly utilized by chiropractors practicing in Ontario, based on a list of currently taught procedures at CMCC. In Part 1 of this study (published previously), the demographics and practice patterns of the respondents were presented. Part 2 of this study (presented here) reports on the utilization rates of spinal diagnostic and therapeutic procedures by the respondents.
METHODS: The study consisted of a paper-based survey that was sent to 500 randomly selected Ontario chiropractors who responded confidentially. Survey questions inquired into demographic and practice style characteristics as well as the frequency with which spinal diagnostic and therapeutic procedures were performed.
RESULTS: There were 108 respondents to the survey, giving a response rate of 22.4%. Frequency of use of diagnostic procedures fell into three broad categories: (i) those tests that are almost always performed, (ii) those tests that are almost always performed by two-thirds to one-half of patients, and (iii) those tests that are virtually never used. By comparison, respondents utilized the same therapeutic procedures for patients care less consistently.
CONCLUSIONS: Despite a low response rate, respondents reported mostly relying on static and motion palpation, joint play, neurological tests, and ranges of motion when assessing their patients. Due to a low response rate, the results of this study may not be generalizable to all Ontario chiropractors.
KEYWORDS: Chiropractors; manual therapy; physical examination; survey
From the FULL TEXT Article:
Chiropractors are taught numerous diagnostic and therapeutic procedures during their undergraduate education and clinical internship. These procedures are principally directed towards the cervical, thoracic, lumbar and pelvic regions (the spine) and peripheral joints, although students are also taught how to assess other structures (eyes, ears, heart and so on) as well. Two previous studies sought to determine if the diagnostic and therapeutic procedures taught during the undergraduate programme at the Canadian Memorial Chiropractic College (CMCC) are required to be used by fourth year students during their internship when providing patient care under the direct supervisions of chiropractic clinicians. [1, 2]
In general, these studies reported a relatively high degree of vertical integration of procedures between the undergraduate and clinical internship with respect to the cervical, thoracic and lumbopelvic spine but a very low degree of vertical integration with respect to assessment procedures of the cranium. [1, 2] This study took those investigations one step further by attempting to ascertain if the diagnostic and therapeutic procedures currently taught to students are subsequently utilized for patient care after graduation.
The overall purposes of this study were to:
(i) characterize practice patterns and demographic information of a pseudo-random sample of Ontario chiropractors;
(ii) determine which diagnostic tests of the spine and
(iii) which therapeutic procedures of the spine were utilized by a pseudo-randomized sample of Ontarian chiropractors as well as how often (i.e. at what frequency) they were being used.
The first objective (characterization of practice patterns and demographic information) has been accepted for publication.  We present here the second and third objectives of this study; namely, which diagnostic and therapeutic procedures currently taught to chiropractic students are used by a pseudo-randomized sample of Ontario chiropractors and how often (i.e. at what frequency) these tests were being used.
The methods employed in this study have been described in detail elsewhere , and modelled after two previously published studies on this topic. [1, 2] Briefly, this study received approval from the CMCC Research Ethics Board (project #112019) and funding from the CMCC Division of Graduate Education and Research. Subjects were mailed a cover sheet and consent form, a paper-based survey and an addressed postage paid envelope to return the survey. The survey consisted of demographic questions, questions regarding practice patterns, and several tables that listed and described all of the spinal diagnostic/examination procedures and manual mobilization and spinal manipulative therapies currently taught in the college’s curriculum, ascertained by auditing courseware of technique, orthopaedic and clinical diagnosis courses. [4, 5]
A six-point scale was provided for subjects to indicate the frequency with which they perform each procedure. Response options were “never used”, “rarely used”, “sometimes used”, “often used” and “almost always used” as well as “no clinical cause to use this test”. The survey was based on previous published studies on this topic by one of the authors [1, 2], and further pre-tested on a single independent external subject.
The surveys were distributed to a systematically pseudo-randomized sample of 500 licensed Ontario chiropractors selected from the directory of the College of Chiropractors of Ontario (CCO) (the licensing body of that province). Subjects were included if they were a practicing chiropractor registered with the CCO who was involved in patient care and signed the informed consent form for participation. Confidentiality was assured and participants could respond anonymously. Descriptive statistics were employed to determine the overall frequency with which the different procedures were performed, along with determining the results of the demographic and practice pattern questions and a response rate.
The six options available to respondents used in the survey (see above) were collapsed into four categories to facilitate response pattern analysis.
These categories were:
‘Never/Rarely’ (N/R) used,
‘Sometimes’ used (ST),
‘Almost Always/Often’ (AA/O) used and
‘Haven’t Had a Patient to Use it on’ (HH-P).
Diagnostic Examination Procedures
Cervical Spine (Table 1)
All respondents (100%) reported they ‘Almost Always/Often’ (AA/O) perform cervical ranges of motion, and almost all respondents reported they perform joint play (96.3%) and static palpation (95.4%) during examination of the cervical spine. Over 80% of respondents reported AA/O performing motion palpation (84.3%) and Kemp’s test (82.4%). Roughly half of respondents indicated they AA/O perform Cervical Compression (63%), Distraction (58.3%), Jackson’s (50.9%) and Spurling’s (46.3%) tests, while the Valsalva’s and Doorbell tests were AA/O performed by slightly less than half of respondents, although the results for these tests increase substantially if combined with the responses from respondents who reported that they ‘sometimes’ perform them.
Conversely, over 85% of respondents reported they N/R performed Naffziger’s test. Houle’s test, a test that purportedly screens for patients at-risk of experiencing a vertebrobasilar stroke during cervical manipulation , was never used by 70.4% of respondents. Other tests commonly N/R used included Cervical Flexion-Rotation, L’Hermittes, Upper Limb Tension and Soto-Hall. The Rotary Chair and Dix-Hallpike tests, used to differentially diagnose dizziness as either cervicogenic vertigo or benign paroxysmal positional vertigo (BPPV) respectively, were both N/R used by 70.4% of respondents, with roughly 7% indicating that they never had opportunity or cause to perform these tests (see Table 1). Other tests commonly N/R used included EAST, Adson’s and Wright’s tests, used to diagnose Thoracic Outlet Syndrome as well as Kernig’s and Brudzinski’s tests, used to identify meningeal irritation.
The majority of respondents indicated they AA/O conduct motor (85.3%), reflex (83.3%) and sensory (75%) neurological testing. However, only 10.2% indicated they AA/O perform Hoffman’s test.
Thoracic Spine (Table 2)
A high percentage of respondents reported they ‘Almost Always/Often’ (AA/O) perform static palpation (96.2%), joint play (95.3%) and ranges of motion (93.4%) testing when assessing the thoracic spine, although only roughly two thirds perform Adam’s test. Many respondents indicated they AA/O perform a straight leg raise, motion palpation, Kemp’s, and rib springing. Other than Valsalva’s maneuver and Doorbell testing, most of the other tests on the questionnaire were never or rarely used, including Beevor’s test or Beevor’s sign, chest expansion test, Upper Limb Tension Testing, passive scapular approximation, Slump test, skin rolling, L’Hermitte’s, Soto-Hall, apparent or true leg length testing, and Kernig’s or Brudzinski’s tests. In this study, 56.1% of chiropractors reported they N/R performed chest percussion.
Lumbopelvic Spine (Table 3)
Respondents reported they ‘Almost Always/Often’ (AA/O) perform a number of tests for the lumbopelvic spine, including static palpation (99.1%), joint play (96.3%), straight leg raise (95.3%), ranges of motion (95.3%), PSIS joint challenge (91.4%), motion palpation (86.9%), gait analysis (85%), Kemp’s (82.2%), crossed straight leg raise (79.2%), and Sacral Thrust (79%).
A number of tests were reportedly used AA/O by roughly one-half to two-thirds of the respondents, including the Patrick’s FABER (Figure ), Ely’s, heel and toe walking, psoas palpation, Braggard’s, Yeomans’s, Hibb’s, Thomas test, Valsalva’s, Minor’s sign, Gillet’s (SI motion), tandem gait, and Bowstring’s.
A number of tests were N/R used, including Schober’s, Waddell’s tests, FAIR, Thigh Thrust, Gaenslen’s, spinous percussion, Ober’s, Bowstring, Distraction, and Trendelenburg test. In this study, 61.3% of respondents never assessed lower limb pulses and 49.5% of respondents never performed abdominal percussion.
With respect to neurological testing, 90.6% of respondents indicated they AA/O performed motor testing, 84% AA/O assessed reflexes, and 74.5% assessed lower limb sensation. The plantar reflex was used AA/O by 53.8% of respondents. Conversely, 84.9% of respondents N/R assessed ankle-leg index, 81.9% N/R performed Herron-Pheasant’s test and N/R assessed 53.8% muscle girth.
Cervical Spine – manual therapeutic procedures (Table 4)
The most commonly used cervical mobilization (cMOB) were long axis distraction (AA/O used by 76.2% of respondents), segmental rotation (65.7%), global lateral flexion (61.9%), segmental lateral flexion (60%), segmental extension (54.2%) and global rotation (49.5%). All listed mobilizations were used to some extent.
The cervical spinal manipulative procedures AA/O used by respondents in this study for the cervical spine were the Supine Rotary Cervical manipulation with Lateral Flexion (81%) and the Supine Rotary manipulation (74.3%). The next most commonly used procedures were the Lateral Break, Lateral Atlas, Seated and Prone cSMT. A number of other cSMT were N/R used by respondents, these were predominately the ‘muscle adjustments’.
Thoracic spine – manual therapeutic procedures (Table 5)
With respect to thoracic spine mobilizations (tMOB), respondents reported AA/O or N/R using long axis distraction (50%), iliotransverse (42.5%), iliocostal (41.5%) and seated procedures (43.4%)in almost equal numbers.
The most commonly reported thoracic spinal manipulative therapies (tSMT) used AA/O were the Anterior (80.2%), Cross-Bilateral (74.5%), Carver (71.7%), Combination (65.1%) and Modified Anterior (61.3%). The other tSMT listed (Thumb Move, Reinforced Unilateral and First Rib) were AA/O or ST used by more than half of respondents. The only tSMT N/R used by a large number of respondents was the Lateral Recumbent Rib (67.9%).
Lumbar spine – manual therapeutic procedures (Table 6)
With respect to lumbar mobilizations (L-MOB), long axis distraction was used AA/O by 61.3% of respondents and iliomammilary mobilization was used AA/O by 49.1% of respondents
The lumbal spinal manipulative procedures most frequently reported as being AA/O used by respondents in this study were the Lumbar Roll ((81.1%), followed by the Lumbar Pull (68.9%), Lumbar Push (56.5%) and ‘Bonyun’/Long Axis Distraction (54.5%). A number of other lumbar spinal manipulative therapies (L-SMT) were frequently reported as N/R, notably the Reverse Roll (84%), Seated (75.5%) and Disc Opening (61.3%) procedures.
Pelvic spine – manual therapeutic procedures (Table 7)
With respect to mobilizations of the pelvis, respondents reported to AA/O use the sacral pump, knee-chest, and iliofemoral, although it should be noted that 50% of respondents reported they N/R use the iliofemoral mobilization procedure.
The pelvic spinal manipulative procedure most frequently reported as being AA/O used by respondents in this study was the PSIS contact (‘upper SI’) spinal manipulative procedure (85.8%). Other pelvic spinal manipulative therapies (P-SMT) were AA/O used less frequently. In descending order these were Ischial contact (‘lower SI’), Prone SI, and Sacral base. Respondents reported to AA/O or N/R use the Sacral Apex manipulative procedure at almost the same frequency (roughly 39%). The Sitting Iliac Flexion procedure was N/R used by 85.8% of respondents, lateral (or side posture) pelvic therapy was N/R used by 61.3% of respondents and the Supine Iliac Flexion procedure was N/R used by 59.4% of respondents.
Three distinct categories of tests can be discerned from the results of this survey. There appears to be one group of tests that respondents to this survey ‘Almost Always’ or ‘Often’ use. These mainly consist of segmental joint play, static and motion palpation, ranges of motion and neurologic testing of the different spinal regions. Triano et al6 reported there was good evidence for some of these tests when used to identify the site of care (the clinical target of manipulation). The second category of tests identified in this survey was more condition-specific and AA/O used by roughly one half to two-thirds of respondents in this survey. For example, cervical compression tests (Kemp’s, Jackson’s or Spurling’s test) or nerve tension tests of the lumbar spine (Braggard’s or Bowstring’s test) may be required to be used on some – but not all – patients presenting to a chiropractor’s office depending on the presence of referred or radicular pain.
The third category of tests identified from the current survey are those that are ‘Never’ or ‘Rarely’ used by the majority of respondents. These include Naffzinger’s or L’Hermitte’s tests in the cervical spine, true and apparent leg length testing in the thoracic spine and Schober’s or Ankle-leg index testing in the lumbar spine.
Overall, the level of vertical integration reported by respondents in this study with respect to diagnostic and therapeutic procedures of the spine was lower than the level of vertical integration reported from clinical faculty from CMCC [1, 2], especially of the thoracic spine.
The most notable limitation of this study was its very low response rate of only 22.2%. This low response rate and the pseudo-randomized sample reduce confidence in the generalizability of our findings. Furthermore our study included graduates of CMCC and other institutions, so it is possible that those educated at institutions other than CMCC may not have been taught some of the tests and techniques in the CMCC curriculum. Our decision to use a pencil-and-paper survey distributed by mail rather than an electronic survey may have contributed to the poor response rate. Future studies could perhaps garner a higher response rate using an on-line survey.
We chose not to set parameters around what constituted ‘almost always’ versus ‘sometimes used’ or ‘often used’, instead relying on respondents to interpret what these meant. Future studies could provide definitions of these terms (ie ‘almost always’ implies the test is used on more than 90% of patients) for respondents.
This study reported on the frequency of use of diagnostic and therapeutic procedures currently taught at CMCC by a group of pseudo-randomized Ontario chiropractors, most but not all of whom were CMCC graduates. The most commonly used diagnostic procedures for the cervical, thoracic, and lumbopelvic spine were joint play, static and motion palpation, neurological testing and ranges of motion. A number of other orthopaedic tests were less commonly used, and a number of tests were either rarely or not used at all, particularly in the assessment of the thoracic spine. With respect to therapeutic procedures of the spine, many mobilization and manipulative procedures are commonly used, with the exception of the ‘muscle’ manipulations of the cervical spine.
The authors declare that there are no disclaimers or conflicts in the preparation of this manuscript.
Funding for postage for this study was provided by the Division of Graduate Education & Research, Canadian Memorial Chiropractic College
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