FROM: Topics in Clinical Chiropractic 2000; 7 (3): 1–10 ~ FULL TEXT
Thomas F. Bergmann, DC, Bradley A. Finer, DC, DACAN
Professor, Clinical Science Division
Northwestern Health Sciences University
College of Chiropractic
Purpose: An approach to systematically perform clinical work-up for chiropractic subluxation is proposed. Literature on assessment approaches is reviewed and a discussion is presented.
Method: A qualitative review of clinical and scientific literature related to assessment methodologies for subluxation was performed.
Summary: Variation in assessment techniques exists for identification of spinal and other articular joint dysfunction. Useful scientific data also are limited to only a few approaches, and there is a need for a more systematic assessment approach profession wide.
Key words: Articular range of motion, chiropractic, Medicare, palpation, physical examination, subluxation
From the FULL TEXT Article
Doctors of chiropractic are portals of entry to the health care system for many patients seeking health care services. As such, they must maintain broad and thorough assessment/diagnostic skills. Before employing any therapy, a clinician must first determine if there is a need for treatment. Therefore, the clinical information that any primary contact provider would want, including a case history, physical examination, clinical laboratory findings, radiographic findings, and any other tests necessary to check for suspected health problems, is needed. Having gathered and interpreted this information, it must be processed in order to arrive at a sound clinical conclusion. The role of this assessment process in the chiropractic office is to determine whether the patient should receive chiropractic care only, chiropractic care in concert with other forms of health care, or a referral to another health care professional for some other form of stand-alone management such as acute, crisis care. This article suggests the need for, and possible form of, a standardized assessment procedure for use by chiropractic clinicians.
Most patients seeking the services of health care professionals, including doctors of chiropractic, present with problems or complaints. It is therefore necessary to identify the nature and extent of the patient's problem before initiating treatment. A comprehensive examination is a critical step in the management of patients with musculoskeletal problems. The role of the evaluative process is to differentiate a particular pathologic process from other possible causes of the presenting signs and symptoms. It also aids the clinician in clarifying the nature and extent of the lesion and to establish a basis on which to judge progress. This information allows a clinician to develop and implement indicated treatment procedures and determine their effectiveness.
While the chiropractic examination considers all aspects, it especially emphasizes the assessment of the spinal column and the nervous system. The chiropractic articular spinal examination is unparalleled in the healing arts. As the most specialized and significant therapy used by the doctor of chiropractic involves the adjustment of the articulations of the human body, the articular examination becomes the focal point of the patient's evaluation. There remains, however, a great deal of controversy among chiropractors, as well as other practitioners of manual therapy, as to the most valid, objective, and efficient means of detecting joint dysfunction.
The fundamental malady treated by doctors of chiropractic is the joint dysfunction commonly referred to as subluxation, vertebral subluxation complex (VSC), or vertebral subluxation syndrome (VSS). The traditional chiropractic portion of physical examination identifies the subluxation. The balance of the examination portion can be considered to focus on identification of pathophysiologic problems that may be associated with the subluxation. The identification of other findings will serve as a modifier or qualifier to the subluxation. Identifying the various attributes of subluxation may help clarify why one patient responds quickly to treatment while another responds slowly or not at all. The evaluation data also may serve as a means for deciding which form of manual therapy is best suited for the particular patient. Because a subluxation is considered an abnormal change in the normal function of the joint, specific criteria should be used to identify it. A plethora of technique procedures is available to the chiropractic practitioner. The literature identifies more than 100 individual named techniques.  Most of the chiropractic technique systems were started by interested and probing doctors who noticed regularity in their results. These approaches typically developed into systems of assessment and treatment. The fallacy of many of the system approaches is that the evaluation procedures that are linked to the manipulative procedures are often singular and very simplistic. These systems are often alluring because the assessment normally takes only a short period of time and the indicated therapy is directly determined.
In addition, little mental energy needs be expended. However, because the human body is a very complex and integrated organism, relying on a single evaluative tool to determine the specific therapeutic intervention is not considered sound clinical practice. Figures 1 and 2 demonstrate the evaluative sequence to consider when addressing patients with neck and low back pain, respectively. Furthermore, confusion abounds when patients go from one practitioner to another, being evaluated and treated in significantly different ways. Third-party payers and legal professionals have difficulty determining what is being treated. Finally, communication between practitioners is difficult because of the number of evaluative procedures.
Therefore, the chiropractic profession could benefit from greater standardization of the approach to the evaluation of joint structure and function leading to the identification of subluxation. A standard approach will allow for comparisons regarding effectiveness and efficiency of different treatment methods. Standardization will also help to diminish the confusion that occurs when patients see different chiropractors. It is quite likely, however, that the detection of joint dysfunction/subluxation may never be a precise science. Any method of joint dysfunction detection is susceptible to false positive, false negative, and equivocal findings. More research must be done to demonstrate that the techniques chiropractors use to identify a subluxation are reliable and valid and provide information for further refinement of accurate, efficient, and effective methods. However, in the absence of such research, clinicians still need a rational approach to assessment, based on best available information, sound judgment, and clinical experience.
THE PARTS EVALUATION
Structural evaluation of joint dysfunction will be viewed in terms of a multidimensional index of segmental abnormality. However, the examination of musculoskeletal system is not done in isolation, but within the context of the history and physical examination of the patient. The methods used in articular examination are the same as those used in other aspects of the evaluation process (ie, observation, palpation, percussion, and auscultation). Practitioners using various forms of manual therapy must use all of their senses to decide where and how to treat the patient, making the examination much more than history taking and performing orthopaedic tests. 
Given the complexity of the musculoskeletal system and the relative inconclusiveness in published studies that attempt to evaluate the reliability and validity of single assessment procedures, an approach to the examination that employs multiple evaluative procedures is worth consideration. The accumulation of examination data determines if there is a preponderance of evidence indicating the specific diagnosis of subluxation. The proposed multidimensional index for spinal evaluation is derived from the acronym PARTS. It comprises a five-part assessment that provides a wide variety of data, and thus builds, in a systematic way, upon the concept of employing multiple evaluative procedures. Although the individual components are objective and used daily by most chiropractors, this information is unfortunately not commonly recorded in any systematic fashion. The five diagnostic criteria for subluxation that constitute PARTS are listed in Table 1.
P – Pain/tenderness
A – Asymmetry/alignment
R – Range of motion abnormality
T – Tone/texture/temperature of soft tissues
S – Special tests
Findings of pain and tenderness are identified through
observation, percussion, provocation, and palpation. The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Many musculoskeletal disorders
are made evident principally by pain. The patient's description and location of pain may be obtained verbally, physically,
or by a pain drawing. The location and intensity of tenderness
produced by palpation of osseous and soft tissues should be
noted. Furthermore, changes in pain intensity should be objectified through the use of a visual analog scale (VAS), algometer, or pain questionnaire. The production of palpatory pain
over osseous and soft tissues has been found to have high
degrees of inter- and intra-examiner reliability. [3–5] However,
validity studies have not been done.
Pain is the usual reason that individuals seek the services of
a physician, and it is considered a subjective finding. There is
a general contention that subjective findings have less significance than findings that are "objective." However, many so-called objective tests rely on the patient's report of pain. For
example, the straight leg raise test is considered an objective
test, however, it is the patient report ofleg pain that constitutes
a positive test. This is no different from applying pressure over
osseous or soft tissue structures and having the patient report
the presence or absence of pain. Therefore, the use of provocative tests to localize a painful area is a useful means for
identifying musculoskeletal problems, including subluxation.
These manual physical maneuvers are designed to reproduce
the patient symptoms or verify the location of pain, thereby
supporting the local presence of a dysfunctional process.
Typically, these tests stretch, compress, or distract specific
anatomic structures while the doctor solicits a report of pain
by the patient. When patients experience pain due to one of
these mechanical tests, there is likely to be a local mechanical
component contributing to their condition.
Unfortunately, a frequent clinical difficulty arises because
the site of pain does not always correspond well with the site
of lesion. The patient often describes radiating patterns of
pain, cutaneous patterns of hyperalgesia/hypalgesia, or tenderness to palpation at sites distant from the site of pathophysiology. These patterns may correspond to known patterns of myotomes, dermatomes, and sclerotomes. Dermatomal
pain will usually be sharp, shooting, superficial, and well
localized. Sclerotomal pain is typically deep, dull, aching, and
poorly localized. Charts are available depicting these various
patterns of peripheral pain. 
Asymmetric qualities on a sectional or segmental level are
noted. It includes observation of posture and gait, as well as
palpation for misalignment of joint structures. Findings of
asymmetry are identified through observation (posture and
gait analysis), static palpation, and static X-ray analysis.
Static palpation is performed with the patient in a stationary
position, and it is often further subdivided into bony and soft
The major goal of bony palpation is to locate bony landmarks and assess contour for any joint malpositions, anomalies, or tenderness. Typically, the palmar surfaces of the fingers or thumbs are used because they are richly endowed
with sensory receptors. Light pressure is used for superficial
structures, gently increasing pressure for deeper landmarks.
During spinal palpation, the pelvic, lumbar, and thoracic
regions are customarily evaluated with the patient in the prone
position and the patient's cervical spine in the sitting or supine
position. The spinous processes (SPs), transverse processes
(TPs) in the thoracic spine, articular pillars (APs) in the
cervical spine, and mammillary processes (MPs) in the lumbar spine are palpated for tenderness and compared for contour and alignment. Individual motion segments are often located relative to these bony landmarks. It is important to
appreciate the anatomic relationship of the lateral processes
(TPs, MPs, APs) to the corresponding spinous processes.
Rotational and lateral flexionmal positions are usually determined by the relationship of the lateral processes, while
flexion and extension malpositions are usually determined by
the spinous processes. Misaligned articular structures do
suggest joint subluxation/dysfunction, but appareht joint
malpositions may result from anomaly or compensation without dysfunction. Spinal landmarks, especially the spinous
process, are prone to congenital or developmental malformation. Disrelationship between adjacent spinous process can be
misinterpreted when a physical malformation exists. Therefore, static palpation using the SPs should not be relied on to
identify true misalignment in rotation or lateral flexion. Furthermore, the spine functions as a kinetic chain, and disease or
dysfunction at one level may force adaptational alterations in neutral alignment at adjacent levels. These sites of compensatory change may palpate as being malpositioned (out of ideal neutral alignment) yet have normal and pain-free function.
Radiographic assessment and determination of joint subluxation have been integral parts of chiropractic evaluation
since the early 1900s. [7–9] Relative to the assessment of biomechanical relationships, the primary focus has been on the
measurement and description (listing) of spinal joint
malpositions. To that end, the profession and many of its
individual technique innovators have developed specific radiographic measurement techniques (spinography) to quantify and classify spinal malpositions and subluxations. [10–16] Proponents of radiographic evaluation for the detection of
spinal subluxations claim that the X-ray is the best method for
accurately determining the level and direction of vertebral
malposition.  Spinal X-rays are routinely taken with the
patient in an upright (weight-bearing) position and may include the selection of full spine or sectional anterior to
posterior and lateral views.
Traditionally, the alignment of the upper vertebrae is compared with the lower vertebrae, and any malpositions are
recorded accordingly. [8, 10, 11] Though much of the profession
uses some form of radiographic measurement and assessment
of spinal subluxation, there is considerable controversy as to
whether radiographic evaluation should play a significant role
in the diagnosis of spinal subluxation syndromes. [7, 9, 12, 17–20]
Claims of accuracy in detecting minor joint malpositions may
not be supportable against the technical limitations of radiography. [7, 9, 12, 17, 21–26] Inherent radiographic magnification and distortion, patient positional errors, and the exactness of marking procedures are common concerns. Interrater and intrarater
reliability have been investigated on a few of the profession's
unique spinographic procedures, and the results are
mixed. [7, 13, 24, 27–40] Harrison and colleagues  reviewed the literature regarding the reliability of spinal displacement analysis
using plain film X-rays and concluded that X -ray line drawing
is reliable. This conclusion is based on their assertion that
there is an ideal normal spinal configuration based on a
mathematical model and that radiographic marking procedures can identify real spinal displacements. However, the
vast majority of cited reliability studies were on curve measurements not spinal segment position. Furthermore, they did
not address validity. Haas and coworkers  challenged these
conclusions by questioning the biologic plausibility of an
ideal spine, the clinical sensibility, lack of validation, clinical
utility, and appropriateness. They concluded that there is
currently no justification for the routine use of radiographic
spinal displacement analysis in clinical practice. Although
recent attempts [7, 23, 29, 30, 35] have been made to address issues of
spinographic reliability, very little has been done to investigate the validity of radiographic measurement in diagnosing
and treating spinal dysfunction.
Range of motion abnormality
Changes in active, passive, and accessory joint motions are
noted. These changes may be an increase or decrease in
mobility. An interosseus decrease in motion is a common
component of joint dysfunction. Range of motion abnormalities are identified through motion palpation and stress X-ray.
Motion palpation is performed during active or passive joint
movement and involves the evaluation of accessory joint
movements. In most joint positions, a joint has some "play"
because joint surfaces do not fit tightly and the capsule and
ligaments remain somewhat lax. This joint play is essential for
normal joint function. Movement at a joint cannot occur
around a rigid axis because the joint surfaces are of varying
radii. The joint capsule must allow some play in order for full
movement to occur. The joint demonstrates joint play in the
neutral close-packed position, followed by a range of active
movement that is under the control of musculature. A small
degree of passive movement then occurs that is followed by an
elastic barrier of resistance called end feel. Joint play in the
neutral close-packed joint position and end feel at the end
point of joint movement are both accessory joint movements
that are necessary for normal joint function. A loss of either
movement can result in a restriction of motion, pain, or both.
Motion palpation procedures have been an integral part of
chiropractic since its inception; but only through the cultivation of Gillet, Faye, and Schafer [42–48] and colleagues have
formalized techniques been widely disseminated. Both active
and passive joint ranges of motion are assessed. During active
range of motion assessment, the patient performs the movement, and during passive motion assessment the examiner
produces the movement. When acute joint pain and muscle
splinting are involved, the patient may be unable to relax
sufficiently to allow for true motion assessment. In such cases,
the procedure is deferred, relying on other findings to determine treatment or deferring treatment until the evaluation can
During both active and passive motion assessments, the
clinician evaluates the total range, symmetry, and pattern of
movement as well as muscle tone. Any painful limitations,
abnormal movements, or painful arcs should be recorded.
Unless contraindicated by joint injury, additional "overpressure" should be applied at the end of passive movement to
assess for pain and end feel. Significant limitation and/or
asymmetry of movement are evidence of neuromusculoskeletal
(NMS) impairment.  Noted reductions in joint movement,
however, must be placed within the context of the normal
variations that exist between sexes and age groups.
Many different methods of measurement are employed in
the evaluation of joint and spinal range of motion. They range
from visual estimates and goniometric and inclinometric
measurements to the more technical approaches of computerized digitation. [50, 51] The use of inclinometers for spinal range of
motion and inclinometers or goniometers for extremity range
of motion is becoming a minimal standard for determining
impairment and for monitoring outcomes.  Range of motion
abnormalities are potential signs of dysfunction in both extremity and spinal joints, but regional restrictions to spinal
movement do not confirm the presence or absence of segmental spinal joint dysfunction. Spinal injuries may affect the
nonsegmental somatic tissues and spare the vertebral joints. In
these circumstances, altered regional movements are present,
and individual segmental range of joint movement may be
limited. However, the loss of mobility is uniform, and the
individual spinal motion segments demonstrate normal joint
play and end feel. Conversely, disorders that produce individual spinal joint restrictions may still demonstrate normal
regional movements, as individual joint restriction is concealed by compensatory hypermobility at adjacent joints.
Therefore, spinal abnormalities in global range of motion are
more valuable in identifying general NMS dysfunction and
the possibility of segmental dysfunction than they are in
confirming a specific level of dysfunction.
During the performance of motion palpation, the examiner
characteristically uses one hand to palpate joint movement
(palpation hand) while the other hand (indifferent hand)
produces or guides movement. The palpation hand establishes
bony or soft tissue contacts over the joint as attention is
directed to the assessment of joint range, pattern, and quality
of movement. When assessing joint motion, the palpator is
evaluating the quality and quantity of movement from the
starting or zero point to the end range of passive movement.
Stress X-ray evaluation may reveal regional or segmental
alterations in movement. However, stress X-rays involve
ionizing radiation and therefore are not routinely used. The
high cost of this type of evaluation also limits its clinical use.
Tissue tone, texture, temperature abnormality
Changes in the characteristics of contiguous and associated
soft tissues, including skin, fascia, muscle, and ligament, are
noted. These changes are identified through observation,
palpation, instrumentation, and tests for length and strength.
Muscle tone is the result of continuous mild contraction of
muscle dependent upon the integrity of nerves and their
central connections with the complex properties of muscles
such as contractibility, elasticity and extensibility.  Normal
. muscle at rest possesses resilience; thus, when joint movement passively stretches a muscle, a certain amount of involuntary resistance is encountered. The maintenance and control of muscle tone are dependent on normal function of the
pre-central motor cortex, the basal ganglia, the midbrain, the
vestibulum, the spine, and the neuromuscular system. Normal
muscle tone may be increased or decreased. Hypertonic
muscles are noted in spasticity, rigidity, and flexor spasms with increased resistance to sudden passive movements. Hypotonic/atonic muscles feel soft and flabby and offer less than
normal resistance to passive movement. The spinal cord is the
seat of the stretch reflex that functions in the maintenance of
muscle tone. The impulses pass through a simple reflex arc,
which includes the neuromuscular spindles, afferent nerves,
spinal cord connections to the anterior horn cells, and the
efferent motor nerves. Tests for muscle strength and reflex
integrity are used to identify spinal and peripheral nerve
involvement. In addition, tests for muscle length can help to
identify spastic, shortened, or hypertonic muscles (eg, Thomas test to determine hip flexor contracture, straight leg raise
to determine hamstring length).
Muscles that have had an abnormally high tone for long
periods may decompensate and develop nodular changes that
become palpable. These contracted, firm, tender areas are
often called trigger points. Depending on the muscle involved,
local or regional decreases in joint movement may be associated with muscle hypertonicity.
Local temperature regulation results from the interaction of
the multilevel spinal reflexes with the central autonomic
control mechanism. Control of the thermal regulatory system
is under the influence of the sympathetic nervous system via
vasomotor reflex mechanisms.  In a healthy individual,
paraspinal temperature radiation is regionally symmetric to
within O.5°C to 1°C. [53, 54] Temperature-detecting instruments
are used to localize segmental increases or decreases in
surface temperature. It is postulated that spinal subluxation
and dysfunction may produce a local inflammatory reaction or
reflex alteration in sympathetic tone, which in turn alters this
segmental temperature symmetry. [6, 55–58]
Another method to assess spinal dysfunction is paraspinal
electromyography scanning. Although it has garnered enthusiasm in the chiropractic profession, the use of surface
paraspinal electromyography must be questioned. Surface-scanning paraspinal electromyography gives a rough estimation of transient muscle activity. It cannot give information
about specific muscles because the recording electrodes are
placed over the skin and not into a muscle. In attempting to
document intersegmental dysfunction, the profession has
jumped too quickly onto an unproven technology. 
Special tests and considerations
Those testing procedures that are specific to a technique
system are performed (eg, leg check, arm fossa test, therapy
localization). Any other testing procedures deemed necessary
based on findings in data previously obtained are performed.
In addition, visceral relationships are considered.  Reflexive
or autonomic effects relate to evidence of change in tissues or
structures distal to or distant from the site of therapeutic
application. Moreover, involvement of the autonomic nervous system may be activated through connections with the lateral horn cells in the cord to produce vasomotor, trophic,
visceral, and/or metabolic changes. The impulse-based paradigm of neurodysfunction that has been developed from the
work of Homewood  suggests that somatic dysfunction and/
or joint dysfunction may induce persistent nociceptive and
altered proprioceptive input.  This persistent afferent input
triggers a segmental cord response, which in turn induces the
development of pathologic somatosomatic or somatovisceral
reflexes. [63–65] If these reflexes persist, they are hypothesized to
induce altered function in segmentally supplied somatic or
Numerous conditions have been linked to hyperactivity of
the sympathetic nervous system, including various types of
cardiovascular, gastrointestinal, and genitourinary disorders
and certain musculoskeletal disorders such as reflex sympathetic dystrophy. Most disease states have early manifestations of symptoms and signs that are part of a common
reaction pattern to injury or stress. Pain in the somatic tissues
is a frequent presenting symptom in acute conditions related
to visceral dysfunction. Common examples include gallbladder disease producing right shoulder pain, cardiac disease
producing left arm pain, and kidney disease producing flank
pain. Palpatory cues of transient muscle hypertonicity and
irritation or subcutaneous edema may be accompaniments of
ill-defined subclinical states.  Moreover, subtle changes in
tissue texture, joint position, and joint mobility identified by
discerning palpatory skills appear to be latent manifestations
of the somatic component of visceral disease. A study 
performed on cardiac patients in an intensive care unit identified autonomic spinal reference site changes for the involved
viscera (Table 2).
Autonomic changes in soft tissues identified in patients with viscera problems
Sudomotor reaction – Increase in skin moisture
Muscle tonelcontraction – Increase (hypertonicity)
Skin texture changes – Thickening
Subcutaneous fluid – Increased
A number of individuals have identified the segmental sympathetic nerve supply for the viscera. [68–75] While there is some variation among authors, the accepted range is shown in Table 3.
Segmental sympathetic nerve supply for the viscera
Any finding can have some significance when taken in
context with other clinical, historical, and laboratory findings.
In recent years, greater emphasis has been placed on the dynamic concepts of the subluxation complex. In some cases
static biomechanical relationship concepts have been totally
disregarded. Sandoz  feels that this shift of emphasis is
counterproductive. He suggests considering the mechanical,
static, and dynamic concepts in harmony with the neurologic
and reflex elements of spinal dysfunction/subluxation. Manual
therapies, including soft tissue techniques and other forms of
adjustive therapy, have the hypothetical potential for arresting
or slowing both the local and distant somatic and visceral
effects by terminating the altered neurogenic reflexes that are
associated with somatic/joint dysfunction. However, clinical
studies of the effectiveness ofthe use of manual manipulative
therapy in visceral conditions are limited.
The compilation of findings from a PARTS evaluation
serves as a guide in decision making regarding areas of the
spine in need of a chiropractic adjustment. In addition, this
multidimensional spinal index can be used in conjunction
with the remainder of the examination to decide whether an
adjustment will be made and precisely how, when, and where
it is to be applied. A recommended minimum evaluation
would be an asymmetry or range of motion abnormality with
at least one other finding. However, more findings associated
with a single joint dysfunction will increase the confidence
level that it indeed represents a subluxation. The mere presence or absence of a single characteristic of subluxation (ie,
misalignment) in a patient is not in itself sufficient evidence
of the need for adjustive therapy. Neurologic changes result
from many etiologies and may not occur each time with any
single characteristic of subluxation. A PARTS assessment
can serve as a tool for understanding the underlying cause and
mechanical components that produce subluxation.
Health care is in an era of accountability, and there is great
interest in outcome measures that support effectiveness and
efficiency of care. Objective findings determined by the
doctor can be used in planning a management strategy. The
objective manifestations of subluxation (PARTS) would logically be targeted for improvement as a goal of treatment in a
chiropractic office. Using the PARTS evaluation will docu-
ment the doctor's effectiveness in the care of the patient.
Certainly, if a chiropractic therapeutic intervention (adjustment) has the effect of reducing a subluxation, it would be
expected that the manifestations of subluxation should diminish as well. Sequential PARTS evaluations confirming the
effectiveness of care and the need to cease care can track these
improvements over time. The PARTS evaluation can also be
used as a means to determine when care is not effective,
prompting the doctor to use alternative care strategies.
Medicare's adoption of the PART portion of the PARTS
physical evaluation as the new alternative to X-ray for substantiation of spinal subluxation indicates the interest insurance carriers may have in this type of evaluation. Hopefully,
Medicare's identification of a need to examine the patient will
also result in changes in federal law to provide coverage for
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