He Tian-xiang, Cheng Ying-wu

1 Yueyang Hospital of Integrated Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China

2 Research Institute of Tuina，Shanghai Academy of Traditional Chinese Medicine, Shanghai 201203, China

Clinical Study Advance on Palpation for Cervical‘Vertebral Subluxation’

He Tian-xiang1, Cheng Ying-wu2

1 Yueyang Hospital of Integrated Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China

2 Research Institute of Tuina，Shanghai Academy of Traditional Chinese Medicine, Shanghai 201203, China

In order to understand clinical research advance on palpation for cervical‘vertebral subluxation’, we have retrieved, sorted and analyzed relevant literature on ‘vertebral subluxation’ palpation from database both home and abroad. The study has suggested that static palpation is the major method for cervical ‘vertebral subluxation’ palpation and motion palpation for cervical segmental mobility has great clinical significance. However, there is no sufficient evidence or ‘gold standard’ regarding motion palpation. As a result, the future research priority should be put on rigorous clinical studies according to evidence-based diagnostic trial design. This can help to assess palpation method for ‘vertebral subluxation’objectively, scientifically and practically, thus providing standardized palpation procedures for spinal manipulation.

Neck Pain; Spondylosis; Massage; Tuina; Chiropractic

Cervical spondylosis is a very common disorder. In Chinese medicine, its major pathology lies in cervical ‘vertebral subluxation’. Clinically palpation is often used to locate subluxated vertebral segments prior to spinal (adjustment) manipulation. Because of its guidance in treating cervical spondylosis, palpation was listed No. 1 of eight bone-setting manipulations in theYi Zong Jin Jian(Golden Mirror of Medicine). Today, palpation for ‘vertebral subluxation’ is mostly conducted in a static state[1-2]. However, there are no standardized technological specification texts on palpation procedures or reliability and validity study on diagnostic palpation for ‘vertebral subluxation’.

We retrieved CMB disc, TCMLRS, VIP database, CNKI database and Wanfang database using ‘palpation’, ‘cervical vertebrae’ and ‘vertebral subluxation’ as index words in Chinese, coupled with summation of previous data regarding ‘vertebral subluxation’ palpation using library collections at Shanghai University of Traditional Chinese Medicine. As for overseas literature, we retrieved PubMed database, Foreign Medical Journal Full-text Service (FMJS) database and Springer database using ‘palpation’, ‘subluxation’,‘motion palpation’ and ‘chiropractic’ as index words. The literature analysis is now summarized as follows.

1 Research Advance at Both Home and Abroad

Tuina manipulation for spine-related disorders in Chinese medicine is based on the ‘vertebral subluxation’ theory[3]. Sharing a similar concept with‘subluxation’ in modern manual therapy, ‘vertebral subluxation’ in Chinese medicine refers to a pathologic state in spine-related disorders (subtle abnormal changes in articulation spaces or relative positions as well as resultant restricted range of motion)[4]. Along with the in-depth study onthis theory, the connotation of ‘vertebral subluxation’has been extended to subtle changes in anatomic positions of joints as well as their functional limitations. Palpation is a key method for clinicians to assess‘vertebral subluxation’. Previously, the assessment is mostly done by static palpation. However, due to the extension of its connotation, static palpation cannot be used to assess functional limitations of joints. In modern manual medicine, ‘vertebral subluxation’ is often assessed by motion palpation that can reflect spinal segmental mobility.

1.1 Static palpation is the major diagnostic method for traditional ‘vertebral subluxation’

1.1.1 Palpation of the spinous processes

In 1970s, after learning new bone-setting methods from folk bone-setting practitioners, Feng TY[1,5]started to believe deviated spinous processes are important signs of one or more vertebral displacements. He created the methods of palpating the ‘four lines of spinous processes’ (central axis line, lateral line of the spinous process, apical line of the spinous process and tip line of the spinous process) using one thumb, double thumbs and three fingers (index, middle and ring fingers) to identify slight displacement of one or more vertebrae in 3-D six degrees of freedom. Li JP, et al[6]used this method to observe the measured changes of lumbar spinous processes in an anteroposterior radiographic view of 89 cases with low back pain. They found that deviations of lumbar spinous processes occurred in 80 cases (only 9 cases had no changes) and thus believed that deviation variance between apical lines of the lumbar spinous processes has great significance (P=0.002), whereas the deviation variance between tip lines of the lumbar spinous processes has no significance (P＞0.05).

However, the conclusion of ‘developmental deviation of the spinous processes’ based on data on healthy population or bone architecture of spinous processes does not support the clinical significance of ‘deviation of spinous processes[7]. Considering from the bifurcation of cervical spine, spinous processes on both sides may be asymmetrical and different in shape and length. This can make the longer spinous process palpate like a little deviated and mislead the tuina doctors. The location of palpation, hand feeling of tuina doctors and different experience may result in incorrect conclusions.

Under such circumstance, Zhang CJ, et al[8]believed that deviated spinous processes can be developmental, compensatory or pathological. Developmental spinous process deviation is just anatomical variation of bone architecture and has no clinical significance. Compensatory spinous process deviation may not cause clinical symptoms despite mild inflammatory reactions of soft tissues (such as muscle tension, absence of or mild tenderness) and thus has no direct clinical significance. Pathological spinous process deviation (deviation of normally developed spinous process to the central axis due to external force) can cause muscle tension, tenderness and other corresponding clinical symptoms and therefore help with clinical diagnosis and treatment. Consequently, the following conditions are necessary to diagnose deviation of spinous processes: the affected spinous process is deviated away from the central axis; localized tenderness of the soft tissue on the affected side; presence of clinical symptoms in the corresponding nerve and vascular territories.

1.1.2 Palpation of other processes

Palpating deviated spinous processes is not enough for clinical evaluation. Li ZM, et al[9]proposed three key palpation points, namely protuberance, thickness and pain. More specifically, it is necessary to palpate the‘eminent’ processes and ‘tenderness spots’ and compare the tissue ‘thickness’, hardness and nodules with the healthy side. According to Li ZM, other than spinous processes, it is also advisable to palpate the articular and transverse processes and focus on changes of the surrounding soft tissue. Additionally, the patient’s posture and motion palpation are also important. This is very similar to chiropractic examination method in highlighting both local pain and functional limitation.

1.1.3 Palpation of soft tissue around the spine

Since soft tissue around the spine helps to maintain the dynamic balance of spine, they cannot be neglected in ‘vertebral subluxation’ palpation. It’s generally believed that palpation of soft tissue includes skin temperature, local fascial pain, high tension of fascia, painful nodules, and muscle tension. Pain examination is important for soft tissue palpation. As tenderness spots on the spine are often associated with muscle tension and mostly located at the attachments of muscles, bones, periosteum and ligaments, it is advisable to press spinous process from top to bottom using the thumbs and also check the tenderness on intervertebral joints and transverse processes.

1.1.4 Dynamic examination of cervical spine

Conventional dynamic examination of cervical spine mainly targets the active and passive ranges of motion. This method is still used today in clinical settings. However, it is difficult to identify dysfunctions of specific segments due to its extensive range of motion and complicated motion components. Dong FH[10]supplemented vertebral mobility examination in his book on palpation.

It’s evident that palpation is a key part in diagnosing‘vertebral subluxation’. However, most palpations are done in a static state. Considering from the fact that spine is dynamic and vertebral subluxation mainly causes functional disturbance, it is of urgent need to figure out a way to reflect motor dysfunction of the spine through palpation.

1.2 Motion palpation of the spine

According to recent advance in manual medicine, subluxation (previously means anatomical displacement) now involves subtle changes of anatomical positions, limited movement and dysfunction of affected segments. As a result, static palpation alone cannot meet the clinical demand. Motion palpation is often used by chiropractors to assess patterns and affected segments due to spinal injury. It includes the end play, abnormal resistance and localized tenderness[11]. Motion palpation of cervical spine mainly includes passive range of motion, pressure to zygapophyseal joints, tenderness, spinal stiffness and passive intervertebral motion. In general, motion palpation is often used to identify and assess mechanical dysfunction of the cervical spine. The test result can be used as reference location for spinal manipulation. Relevant studies have proven that patients with mechanical neck pain may have some or all of the following symptoms: aggravated spinal stiffness, local muscle and joint pain, and reduced range of motion of affected segments[12]. Consequently, active range of motion is used to assess the gross range of motion in the cervical spine, irritation palpation test on connective tissue and zygapophyseal joint may cause inflammation or pain of affected tissue; spinal stiffness test is used to measure segmental mobility; and intervertebral motion palpation is used to assess functional impairment in quantity and quality of intervertebral movement.

1.3 Clinical studies on ‘vertebral subluxation’palpation

Any clinical trials need to be valid and reliable. There is little clinical research on ‘vertebral subluxation’ palpation. Feng Y, et al[13]have proven that clinicians could evaluate segments of herniated disc by palpating the apical line of spinous process through helical CT 3-D spinal reconstruction. Although they claimed a good effect by manual therapy, they did not provide coefficient of internal consistency between clinicians. Reliability of many cervical examination methods is only moderate. Recent studies have suggested that palpation on tenderness spots in cervical spine, reduced range of motion and some motion palpation methods can provide more reliable results. It’s been proven that physical defect, functional impairment and disability are all associated with dysfunctions of cervical vertebrae.

Motion palpation can at least assess functional impairment of cervical spine. Previous studies on motion palpation mainly target the lumbar vertebrae. In 1980s and early 1990s, rapid progress has been made in inter-examiner reliability on cervical motion palpation; however, the findings are not satisfactory due to test design and statistical analysis quality. Lacking appropriate gold standard to compare mechanical dysfunction also plays an important role. In system review on content validity of spine palpation, Najm WI, et al[14]pointed out that there is no unified ‘gold standard’ for palpation study, and actual standard (such as visual analogue pain scale), independent panel conference, clinical follow-up, standard protocol or prognosis standard were often adopted in the cited literature

2 Current Challenges

Currently there are not enough evidences or ‘gold standard’ for spinal palpation study. Only three studies are associated with motion palpation in the latest literature review[15-21]regarding spinal palpation procedures. All these studies employed mechanical models, which had no considerations concerning the possible effect of ligaments and muscles on segmental mobility. Mechanical failure occurred in many models during data collection. The zygapophyseal articulation injection has been used as the ‘gold standard’ to evaluate neck pain. To date, there has been no in vivo‘gold standard’ to assess the effectiveness of motion palpation for cervical segments.

Over the recent years, X-ray has become a standard examination method for vertebral disorders. X-ray diagnosis is also a major reference for cervical vertebral subluxation. Zhang Y, et al[22]believed that X-ray can show three-axial rotation shifting: asymmetrical uncovertebral joints and unequal left-right space in an anteroposterior radiographic view; ‘two border sign’ and‘un-overlapped articular processes’ sign of the affected vertebrae in a lateral radiographic view, coupled with the following findings: the affected vertebral inclined anterior and inferior, the superior border inclined and shifted anterior, the posterior border shifted posterior and superior, shortening the space to the spinous process of the upper cervical segment but widening the space with lower one. The aforementioned X-ray findings, local tenderness and positive signs of supraspinal ligament dissection can be used as a key basis for ‘fixed-point reposition’ using integrative Chinese and Western manual therapies. However, whether spinal curve changes, ‘two border sign’,‘un-overlapped articular processes’, ‘concave cutting and hyperplasia’ and ‘deviated spinous processes’ are sufficient evidence for vertebral subluxation is still controversial[23].

3 Research Prospect

Despite the unceasing progress in diagnostic and therapeutic technology, palpation in clinical perspective is still irreplaceable. A reliable effective palpation helps to make an objective evaluation on vertebralsubluxation. It is of great significance to develop rigorous clinical trials that met the EBM criteria, conduct objective assessment on scientific and practical palpation for ‘vertebral subluxation’ and thus provide standardized palpation procedures prior to spinal manipulation.

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[3] Tian JJ. Diagnosis and Treatment of Vertebral Subluxation. Taiyuan: Shanxi Science and Education Press, 1987: 16.

[4] Zhan HS, Shi YY, Zhang MC, Wang X, Huang SR. New diagnostic and treatment concepts of pathogenesis of intervertebral disc diseases. Shanghai Zhongyiyao Zazhi, 2007, 41(9): 4-6.

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[6] Li JP, Wang ZH, Li H, Li YK. Application of method of four lines in vertebrae-spinous process in diagnosing spinous process deviation of lumbar vertebra. Zhongguo Linchuang Kangfu, 2003, 7(6): 900-901.

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[9] Li ZM, Li P, Li J. Traditional Chinese Manual Therapy by Li Zuo-mo. Beijing: China Building Materials Press, 1998: 265-286.

[10] Dong FH. Palpation Diagnostics. Beijing: Beijing Science and Technology Press, 2005: 9-13.

[11] Leboeuf-Yde C, van Dijk J, Franz C, Hustad SA, Olsen D, Pihl T, R?bech R, Skov Vendrup S, Bendix T, Kyvik KO. Motion palpation findings and self-reported low back pain in a population-based study sample. J Manipulative Physiol Ther, 2002, 25(2): 80-87.

[12] Meridel I, Gatterman. Chiropractic Management of Spine Related Disorders. Lippincott Williams & Wilkins, 2004: 248.

[13] Feng Y, Sun P, Gao Y. Role of helical CT 3-D spinal reconstruction in imaging expression of the apical line of spinous processes. Jingyaotong Zazhi, 2005, 26(5): 345-346.

[14] Najm WI, Seffinger MA, Mishra SI, Dickerson VM, Adams A, Reinsch S, Murphy LS, Goodman AF. Content validity of manual spinal palpatory exams: a systematic review. BMC Complement Altern Med, 2003, 3: 1.

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[17] Peterson DH, Bergmann TF. Chiropractic Technique: Joint Assessment Principles and Procedures. New York: Churchill Livingstone, 1993: 3.

[18] DeBoer KF, Harmon R, Tuttle CD, Wallace H. Reliability study of detection of somatic dysfunction in the cervical spine. J Physiol Ther, 1985, 8(1): 9-16.

[19] Mior SA, King RS, McGregor M, Bernard M. Intra- and interexaminer reliability of motion palpation in the cervical spine. J Can Chiropr Assoc, 1985, 29(4): 195-198.

[20] Haas M, Groupp E, Panzer D, Partna L, Lumsden S, Aickin M. Efficacy of cervical endplay assessment as an indicator for spinal manipulation. Spine (Phila Pa 1976), 2003, 28(11): 1091-1096.

[21] Seffinger M, Adams A, Najm W, Dickerson V, Mishra S, Reinsch S, Murphy L. Spinal palpatory diagnostic procedures utilized by practitioners of spinal manipulation: annotated bibliography of content validity and reliability studies. J Can Chiropr Assoc, 2003, 47(2): 93-109.

[22] Zhang Y, Qu H. Traumatology Film Reading: Cervical and Lumbar Vertebral Diseases. Beijing: People’s Medical Publishing House, 2004: 30.

[23] Ye XS. Positive rate and X-ray finding analysis in 281 cases with cervical spondylosis. Fujian Yiyao Zazhi, 2002, 4(3): 92-93.

Translator: Han Chou-ping

R244.1

A

Date: July 20, 2013

Author: He Tian-xiang, M.M., attending physician.

E-mail: hetianxiang@126.com