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A Bigger Picture: Global
Extremity Assessment
In the May/June 2004 issue
of Today’s Chiropractic, the article “Principles of Extremity Adjusting:
An Overview” promised a follow-up piece examining “the integration
of the extremities with the spine from a global perspective.”
By Keith G. Rau, D.C., C.C.E.P., and John Downes, D.C., C.C.E.P.
In the previous article it was stated:
“It is generally accepted that the chiropractor should adjust the spine
before adjusting the extremities to insure proper nerve supply to the extremities.
Yet there is a sort of “chicken or egg” relationship between the
spine and extremities with problems in the one contributing or causing problems
in the other. First, the large muscles that move the extremities also move the
spine depended on which serves as the origin and insertion. Second, the spine
serves as the anchor of the extremities. While the lower extremity has muscle
attachments up to L1/T12 via the psoas, the entire spine serves as the attachment
of the upper extremity via the trapezius and latissimus dorsi. Aberrant patterns
in the extremities will feedback to the spine providing a source of noxious
biomechanical stresses. This is very important as the nerve supply for extremities
comes from spine.”
The “chicken or egg” questions remains. It may be fairly obvious
that an ankle dysfunction can contribute to a knee, hip or even low back problem.
Is it possible that a talus fixation could cause or perpetuate an upper extremity
or cervical spine subluxation? Could a shoulder problem be related to chronic
thoracic muscle tightness or spasm?
Relation of the Lower Extremity to Upper Extremity
As stated in the above quote from the last article the spine and extremities
are inexorably linked. We know that the extremities are linked functionally
via the cross crawl or gait mechanism of the reciprocal limbs. That is the right
upper limb is tied functionally to the left lower limb. The muscular and fascial
connections have been mapped out by many including Thomas Myers in his recent
book on “anatomy trains.” Porterfield and DeRosa describe the “the
continuous flow of muscles from the neck and thoracic spine via the levator
scapulae and rhomboid major to the serratus anterior that interdigitates with
the external oblique.i” They go on to describe the
connection from external oblique to the contralateral lower extremity. The upper
extremity is linked to the opposite lower extremity functionally and anatomically
as well.
Lephart and Henry’s Cycle of Injuries
Lephart and Henry considered athletes who originally had a ligamentous injury,
made a complete recovery with a return of ligamentous stability and yet continued
to have repetitive injuries.ii They proposed (Figure 1) that
this initial injury results in a proprioceptive deficit or dysafferentation
which leads to decreased neuromuscular control or lack of proper efferent output.
The result may be a loss of the feedforward mechanisms (learned pre-loading
of muscle) which develop to withstand the stress of a particular activity. This
loss results in functional instability which may lead to a repetitive injury.
Lephart and Henry used sophisticated testing with expensive equipment to determine
the proprioceptive deficits and decreased neuromuscular control.
A New Paradigm
A chiropractic component has been introduced to this cycle. It has been proposed
(Figure 2) that the subluxation with or without injury may cause proprioceptive
deficit and start the cycle. Relative muscle testing (RMT) has been suggested
as a means to determine if the patient has decreased neuromuscular control.
We have used this model in presentations to a wide variety of healthcare providers,
coaches and athletes over the last few years with great success. The model explains
many scenarios coaches and athletic trainers face regularly. It is the demonstration
that the chiropractic adjustment has a direct and profound impact on neuromuscular
control that causes eyes and doors to open.
In addition to the model, a paradigm (Figure 3) has been proposed for the care
of patients which we teach in our classes and in post-grad seminars. First,
chiropractors adjust subluxations of the spine that directly affect the CNS
and PNS. Second, we adjust the spine and extremities that are causing biomechanical
distortions and dysafferentation. Lastly, we address our patient’s soft
tissue issues. This would include active care such as stretching and strengthening,
passive modalities (ice, heat, etc.) and lastly, soft tissue work such as neuromuscular
therapy or other forms of massage. This work may be done by the chiropractor
or referred out depending on the chiropractor’s perspective.
Global Extremity Assessment
Instead of the making the distinction of checking and adjusting the spine before
the extremities we are suggesting a protocol that considers them altogether
or globally. In difficult cases (or on a regular basis) the following protocol
may be used. Using a large portion of the muscle tests that Dr. Hearon routinely
teaches we attempt to uncover the key area(s) to address, the right order or
sequence to address them and a plan to rehab the patient. All of this is done
after a standard workup of history and examination.
We begin with the patient supine and check forced dorsiflexion (FDF) of the
feet comparing right and left. The muscle tests are then begun on the side opposite
the one with restricted motion. If no FDF is found then start opposite the side
of the chief complaint of the lower extremity. For the lower extremity we test
the following muscles:
For the upper extremity, starting on the same side as the FDF we test:
Other upper extremity as warranted such as general internal and external rotators
of the shoulder.
It is particularly important to evaluate the RMT’s not simply for strength/function
but to see how the brain recruits other muscles and how the spine anchors the
movements. With practice less focused attention is put on the specific muscle
being tested than on watching how the body reacts to the stress of the test.
We have found several typical patterns emerge. First, and very commonly, there
may be a reciprocal limb or cross pattern. For instance the right lower limb
and the left upper limb would show positive RMT’s. Second, the problem
may be isolated to the lower extremity. Third, the problem may be isolated in
the upper extremity. Fourth, there may some mix thereof.
If the patient’s upper extremity and lower extremity RMT findings show
a reciprocal limb/cross-pattern check the cervical stress tests such as lateral
flexion and rotation to evaluate any change that may take place in the weak
muscles or decreased FDF. For lateral flexion we adjust on the side that strengthens
the muscle tests and or FDF. We prefer to toggle the patient. For rotation or
flexion/extension adjust with head in the direction that strengthens the muscle(s)
found weak.
If ipsilateral upper and lower extremity findings are found, consider adjusting
the lumbodorsal (LD) transition area (T10-L2) first. Afterward you would recheck
your findings especially since often the reciprocal limb pattern will then present.
If so precede as stated above. If the reciprocal limb findings do not present
the patient may truly have two separate and distinct problems that must be addressed
individually.
If the patient’s findings are only in the lower extremity, check T12 and
below as desired. Focus your adjusting on the LD transitional area then the
lumbar spine itself. Always check and adjust the lower extremities using the
typical Hearon procedures from distal to proximal.
If the patient’s findings are only upper extremity check T12 and above.
Include the cervical stress tests, especially rotation before adjusting the
extremities themselves. Often the upper extremity muscle tests are positive
because of cervical subluxations. Unfortunately our experience shows that the
cervical subluxations remain “hidden” until stressed in this fashion.
Focus your adjusting on the cervicothoracic transition and lower cervicals.
Always check and adjust the upper extremities using the typical Hearon procedures
from distal to proximal.
After you adjust recheck the patient after they have taken a few steps. Walking
essentially causes the body to “reset” the nervous system due to
the impact of gravity on proprioception. Recheck the patient doing the same
FDF and muscle testing as before. Recheck for the neurological component with
the cervical stress tests as counter-rotation sometimes presents in the cervical
spine. The upper cervical area may present after the LD transition has been
adjusted.
More commonly we find other neurological and biomechanical problems first at
cord levels, that is we use the nerve supply of our positive RMT’s to
indicate which levels to adjust. You may simply adjust the spine using your
other criteria and then proceed.
Secondly, at extremity joints using the typical Hearon procedures:
On subsequent visits the assessment is repeated with particular attention paid
to how findings change or remain the same. Typically we see the findings change.
If they do not, look well at the patient’s compliance to their rehab plan.
Soft Tissue Component
Initially, or after a period of time that is at your discretion, consider the
impact of the soft-tissue (acute or chronic) component on the patient’s
progress or lack thereof.
It is not unusual to find that having the patient perform abdominal hollowing
will negate some of the RMT(s) found. This is a clear indication that core stabilization
exercises should be done. A gradual program of increased difficulty should be
initiated to increase the patient’s core strength.iii
Remember the core provides the foundation for all trunk and extremity movements.
If trigger points can be located that replicate the patient’s symptoms
consider referral for specific neuromuscular therapy from a massage therapist.
In the shoulder it is common to find that doing massage for 10-15 seconds on
the weak muscle will negate the weakness. This may be an indicator that more
extensive neuromuscular therapy, trigger point work and or stretchingiv is in
order.
If the observation of posture indicates muscle imbalances of tight or overactive
muscles then massage and or stretching is indicated. As with the massage mentioned
above, a brief stretch may negate muscle weaknesses. It is generally accepted
that any tight muscles should be stretched before any weak muscles are strengthened.
If any sensorimotor testing is performed and positive having the patient perform
balance training such as with a progression of single leg standing should be
an effective from of rehabilitation.v Sensorimotor testing
provides a wonderful window into the function of the nervous system.
If there is indication of hyperpronation performing “short foot”
exercise progressionsvi are indicated. Orthotics may also
be helpful to support the arches and the entire lower kinetic chain either by
themselves or in conjunction with the short foot exercises.
Bracing, supports or taping may be indicated if any area is truly unstable.
Some chiropractors choose to use a variety of physiological therapeutics which
also may be used to support the healing process and or to deal with pain.
Lastly, co-management of the patient may be in order if they do not improve.
There are various medicolegal benefits to working with an orthopedist or orthopedic
surgeon in challenging cases, not the least of which is shared liability. It
is always reasonable to give patients a variety of management options but even
more so in difficult cases.
When patients get well quickly and easily everyone is happy. When the patient’s
problems recur something may be missing. The right components at the wrong time
may produce some gains. The right components at the right time usually produce
major gains. Patient compliance and patient expectations are also keys. It is
mandatory to involve the patient in the management of their problems to obtain
optimal results. Nevertheless healing takes time and regular monitoring of patients’
progress and compliance to your recommendations will yield better results.
We hope that you will try the protocol outlined on a patient that is not responding
to your regular protocols. Over the last several years we have found this method
of analysis helpful for all sorts of patient presentations whether students,
patients in our practice or athletes are various venues.
For more information and details including learning the muscle testing, extremity
adjusting and the above outline please consider attending the Council on Extremity
Adjusting’s Certified Chiropractic Extremity Practitioner seminars especially
the module on global extremity assessment.
Dr. John Downes is Dean of the College of Chiropractic at Life University
and has taught extremity adjusting and related topics around the world.
Dr. Keith Rau is an associate professor at Life University and teaches courses
in extremity management and rehab. He may be reached at 770-426-0831
References
i Porterfield, JA and DeRosa, C. Mechanical Shoulder Disorders: Perspectives
in Functional Anatomy, 2004, Saunders, St. Louis, page 64
ii Lephart, SM Henry,TJ. The physiological basis for open and closed chain rehabilitation
of the upper extremity. J Spor Rehab 5: 71-87, 1992
iii Liebenson, C. Rehabilitation of the Spine, 1996, Lippincott, Williams and
Wilkins, Baltimore, Chapter Fourteen, Spinal Stabilization Exercise Program
iv Liebenson, C. Rehabilitation of the Spine, Chapter 13, Manual Resistance
Techniques and Self-Stretches for Improving Flexibility/Mobility
v Janda, V in Liebenson, C., Chapter Fifteen, Sensory Motor Stimulation
vi Ibid, pages 322-328
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