b'CODING Update ComplianceLEGAL NUTRITIONCouncilANJC Leadership LEGAL EASE NUTRITION REHAB Council Executive Directors Update LEGAL Q&A CHIROASSISTINSURANCE Update INSURANCE Update Legislative UpdateWhere to Give TECHNIQUE Councilan AdjustmentBy Dr. David GraberChair, Council on Technique and Clinical ExcellenceSince the beginning of our education, Range of motionThe practice of locating where to adjust MedicareQ&AMedicare Update we chiropractors have been taught many currently remains as much or more art than methods to locate where to make anSkin rolling surface EMG for flexion-OUR HEALTHrelaxation science. Deliberate practice in any chosen adjustment. Sometimes it seems that if phenomenon in lumbar regionmethod is necessary to become proficient. you get 10 chiropractors together, you Motion palpation to localize the With more research, we can get even get 10 different ways of finding where to apply an adjustment. The methods oftensite of carebetter. contradict each other.Stiffness by joint springing or SOURCES: Several researchers have looked at theoverpressure testing Triano JJ, Budgell B, Bagnulo A, et al, Review of methods research evidence for various methodsThe following were found unfavorable: used by chiropractors to determine the site for applying of chiropractic analysis and have ratedmanipulation. Chiro & Man Ther, 2013;21:36 Manual muscle testing for non-Cooperstein R, Young M, Haneline M. Interexaminer their reliability. Those that showed goodreliability of cervical motion palpation using continuous evidence of reliability were designatedpathologic altered functionmeasures and rater confidence levels. J Can ChiroprPara-spinal skin temperature to Assoc. 2013;57(2):156-64.as favorable, and those that did not have adequate evidence were rated aslocate the site of careCooperstein, Robert & Young, Morgan. (2016). The unfavorable. Surface EMG for site of care reliability of spinal motion palpation determination ofthe location of the stiffest spinal site is influenced by The following methods were found confidence ratings: A secondary analysis of three studies. Radiographic imaging for localizingfavorable: the site of care Chiropractic & Manual Therapies. 24. 10.1186/s12998- Pain provocationFor daily visits, most chiropractors use016-0131-x.some sort of functional examinationHolt, Kelly et al. Interexaminer Reliability of Seated MotionPosture: antalgia, kyphosis, lordosis,Palpation for the Stiffest Spinal Site. Journal of Manipula- scoliosisprotocols. These include postural analysis,tive & Physiological Therapeutics. Oct. 2018 Stiffness as determined by instrumentsegmental alignment or position, rangeStatic palpation for major anatomicalof motion, reactive muscle testing, kineticDavid Graber, DC, CCSP, is the chairperson palpation, and provocative testing. The landmarkschart below shows a brief summary ofof the ANJC Council on Technique andMotion palpation with paineach, along with their strengths andClinical Excellence. He maintains a privateManual muscle testing for strength weaknesses.practice in Parsippany, NJ.METHOD RATIONALE STRENGTHS WEAKNESSESPositional and Postural Misalignment creates jointAssesses muscle imbalance and tightness Difficult to assess anomaliesand connective tissue stress Positional dyskinesia demonstrated Alignment doesnt correlate with kinetic disturbanceDoesnt identify unstable jointsROM Altered instantaneous axis ofEasy to implement Assesses quantity but not quality of motionrotation Quick screen Global, not-specificDemonstrative to patientReactive Muscle Testing Mechanoreceptor dysfunction Neurological indicator of joint stress Secondary indicator(Active MMT, Passive ReflexIndicates neurological dysfunction Poor validity and reliabilityTesting) Very demonstrative to patient Cant gauge prognosisHighly skill dependent with questionable accuracy and reliabilityMotion PalpationConnective, muscular, andPrimary indicator Labor intensive(Joint Play Testing) articular tissue restrictionsCan assess quality of motion Highly skill dependent requiring extensive practiceprevent normal arthokine- Can differentiate between acute and Modest to good intra-examiner reliability; fair to moderate matics chronic conditions inter-examiner reliabilityCan identify unstable joints Best used in combination with other exam methods rather Can monitor progress than as a stand-aloneCan offer prognosis informationProvocative Testing Pain on testing indicatesMost literature evidence support Narrow scope of assessment (pain only)articular tissue irritation orDemonstrative to patientinflammation Can be integrated with orthopedic exam (overpres-sure) and joint play end feel analysis'