hand. The examiner's non-palpating arm is used to rip the patient's shoulders and move the lumber spine into fixion and extension. A smooth opening and closing of the interspinous spaces can be felt if normal motion is presen: (Fig. 4). 2. Lateral Blexion motion is determined in a similar manner. The relative position of two adjacent spinous proceses is determined by hooking the lower spinous pass with one finger and puting the upper spinouocess with the other. Th. patient is passively assist into lateral flexion t; moving the patient's shoulders. Movement of the upper spinous process ove: the lower on car. be perceived and atsence of the movement is suggestive of a latera: bending fixation at that level. 3. In order to examine rotational movement, the examiner palpates to adjacen: spinous processes and guides the patient's trunk into rotation. Movement of the superior spinous proce.. over the inferior one can be perceived and should give the feeling of a step at the limit of rotation. Lack of Joint Play Springing of a joint and the determination of join: play and and feel is an integral part of the pre-manipulation spin. exam. (82,87) Neutra: or static en play is ortermined by springing each vertebra in the neutral position in both flexion/extension and rotation/lateral flexion directions. The patient is place in the prone position with the abdomen supported. Lateral pressure is exerted ove: the spinous process from each side using the examine:'s thumb. Counter pressure on the spinous process above or below with the thumb of the other hand can help localize the direction in which the vertebra is being stressed. Normally & pain-free spongy or "springy" movement can be perceived. Ex:reme tenderness with hard resistance to this pressure is considered ar. important indicator of a clinically sign: manipulable les.on (82.7). Joint springing in the flexion/extension direction is accomplished by pressing over the transverse processes of the lumbar vertebrae unilaterally or bilaterally (Fig. 5). The evaluation of "end play" or "esc feel" is achieved th: ugh the same technique as that used for motion palpun. The ver.ebral joint being tested is placed at the limit of its passive range of motion and then stressed slightly beyond this ::mit (Fig. 6). A soft, springy, painless end fee! at the limit of each motion should be palpable. The presence of pain or the feeling of solid resistan:: at the limit of motion is considered normal (42,82,87). Palpable Soft Tissue Changes i. On palpating the paraspinal tissues some clinicians believe it is possibi: te fee: areas of subcutaneous tissue "thickening" or muscle contractio: which are exquisitely tender. These "taut and tender fibers" or trigger points can be found ir. the long paraspinal muscles, shoulder girdle muscles (infraspinatus, supraspinatus, trapezius, rhomboids, levator scapulae), the pelvis (iliopsoas, piriformis, quadratus lumborum, glutei, tensor 53-293 - 92 - 25 Muscle Contraction or Imbalance One of the major goals of many manipulative procedures is to stretch or stimulate contracted muscles (86,115,121). The determination of muscular function is therefore an important part of the pre-manipulation spinal examination. The muscles which are most commonly evaluated for tender contraction in patients with low back pain include the piriformis, iliopsoas, quadratus lumborum, glutei, and erector spinae. The following examples will serve to illustrate how muscle imbalance is determined. The so-called piriformis syndrome presents as back pain with or without leg pain, external rotation of the leg at rest (Fig. 7), limited internal rotation of the leg with the hip extended, and extreme tenderness on palpation of the muscle at its insertion above the acetabulum or over its belly on palpation through the rectum (67,86). The iliopsoas muscle has been considered an important factor in causing abnormal hyperextension of the lumbar spine. The evaluation of this muscle is accom. plished by observing the change in lumbar lordosis in standing and sitting, measuring the degree of hip exten FIG. 6. The palpation of "end feel" in the lumbar spine on lateral flexion. sion and palpating for tenderness in the muscle as it passes over the pubic ramus to attach to the femur The role of the quadratus lumborum muscles in lat eral flexion of the lumbar spine has been described and a possible role in some forms of scoliosis proposed (71.98) Since a number of manipulative techniques are aimed partly at stretching this muscle, it should be examined. This is done by observing any restriction in the lateral flexion of the lumbar spine and any tenderness on palpation over the muscle just lateral to the erector spinae muscles (120). If the legs are determined radiographically to he of equal length and one leg is found to be higher than the other on lying prone or supine (Fig. 8), the short leg is considered to be due to elevation of the hip and pelvis on that side secondary to imbalance of the paraspinal muscles (120). Painful limitation of straight leg raising which is not accompanied by motor, sensory, or reflex changes, is not aggravated by dorsiflexion of the foot, and has no bowstring sign, may be due to stretching of tight hamstring muscles or restricted movement in the hip or sacroiliac joints rather than sciatic nerve irritation. Buerger 1594 / CHAPTER 73 (9) and Fisk (35) have shown that straight leg raising increases immediately after spinal manipulation when pelvis tilt is used as the end point for limited straight leg raising (Fig. 9). In the absence of sciatic nerve irritation, this maneuver first brings tension on the hip extensors followed by tilting of the pelvis and flattening of the lum bar lordosis. MANIPULATIVE TECHNIQUES The therapeutic goal of spinal manipulative therapy is to correct the manipulable lesion (subluxation, osteopathic lesion, somatic dysfunction, etc.), thereby presumably increasing motion in the hope that this, in turn, will benefit the patient. Since the exact mechanism of action of spinal manipulation and the nature of the lesion on which it has its effect are still theoretical, every manipulation must be considered a therapeutic trial. The effectiveness of any specific manipulative technique is therefore determined by its ability to correct the components of the manipulable lesion with the least amount of force and discomfort to the patient. The ideal manipulative procedure should take into account the structural relationship and facet orientation of the vertebrae being manipulated as well as any structural asymmetries. It should mobilize the areas of restricted or fixated joint movement, reduce painful or abnormal joint play and/ or end feel, eliminate palpable soft tissue taut or tender fibers, and correct areas of muscle contraction or imbalance. These goals must be achieved without traumatizing the spinal or paraspinal tissues or causing pain. There are a multitude of techniques which have been developed over the years to manipulate the spine. Each basic technique, in turn, has numerous variations and refinements. In the past there has been a tendency for practitioners of manipulation to form groups or factions under the leadership of a single teacher who has developed, perfected, and taught a particular system of techniques. Although this tendency is breaking down, there remain practitioners who practice exclusively those techniques as taught by Cyriax, while others practice techniques taught by Mennell, Lewit, Maigne, Paris, Kaltenbourn, Maitland, Palmer, Gonstead, DeJarnette, Toftness, Kimberly, Stoddard, Mitchell, etc. The relative effectiveness of one technique compared to another has yet to be evaluated, so te choice of manipulative technique continues to be used, to a large extent, on the skills a clinician has developed rather than on a rational understanding of the role of each separate manipulative procedure. Although the adherents of many of these technique systems claim to have unique approaches to manipulation, the various techniques have much in common. It is possible to classify the majonty of the spinal manipulative procedures into six subgroups. The remainder of this . chapter will be devoted to a discussion of these six classes of manipulation. Examples have been chosen to illustrate the basic principles in each subgroup. It is impossible to describe every technique in detail. For further information, published textbooks and notes (see references) should be reviewed The Non-Specific Long Lever Manipulations This class of manipulation includes all those procedures where a high velocity force is exerted on a part of the body some distance from the area where it is expected to have its beneficial effect. The long levers used for this type of manipulation include the leg, shoulder, pelvis, and thoracic spine. Although these manipulations have been widely used (17,21,44), they are generally considered to be the crudest and least effective of the manipulative techniques available. The long lever makes it very difficult, although not impossible, to make this type of manipulation specific to a particular segment. The force is exerted instead into a region of the spine. The segment which receives most of the mobilization is often the one which is already hypermobile rather than the vertebral level which is restricted. It is this type of manipulation which has been considered most likely to result in the herniation of degenerated intervertebral discs and damage to soft tissues. The most commonly used long lever technique for the lumbar spine is the rotational manipulation described by Cyriax (21) and Coplans (17). The patient is placed in the lateral side lying position with the symptomatic side up. The hip and knee of the superior leg are flexed while the inferior leg is held in extension. The clinician stands in front of the patient and steadies the shoulder with his superior hand pushing it down to the table. With the other (inferior) hand, he contacts the pelvis or buttock and pulls the patient's pelvis toward him while letting the flexed leg hang over the side of the table (Fig. 10). The rotational slack is taken up with the inferior hand and a sharp controlled thrust is given to the pelvis or leg in the direction of rotation (downward and laterally). There are a great number of variations to this technique: 1. It is possible to hook the foot of the patien.'s superior flexed leg into a popliteal fossa of the inferior leg. This allows the clinician to exert a force through the femur giving a long more powerful lever. 2. The patient can be placed in the supine position on the back with hips flexed and knees crossed. Both knees are twisted toward the clinician while the shoulders are kept flat on the table. The clinician holds the shoulders down with his superior hand while applying force through both legs at the knee. This forces rotation during lumbar side fle n. 3. A reversed long lever rotational manipulatio, can be |