Lumbars
It may be difficult to count or otherwise to palpate the Lumbars in this position because of the increase in the normal anterior curve when patient is suspended between the two sections of the bench. This will be obviated if a roll be placed under the thighs or if the bench has an adjustable rear section.
Cervicals
If a solid front bench is used remember the spiral turn in the Cervicals, which occurs because of the resting of the head on one side. The curve due to this rotation of the head is compounded with the ever present anterior curve to make a spiral. Do not expect the vertebrae in this position to agree in apparent direction with a record made with the head straight. It is better to make all decisions as to direction of Cervicals in position A and merely to count them in other positions.
In position B, if the patient’s face be away from the palpater it will be necessary to stand with back toward patient and body twisted, and to change hands for counting, resting the free hand on patient’s head to insure its steadiness.
Disagreements
If there be any apparent disagreement between findings in positions B and A, re-examine carefully in both positions, whereupon that which seemed a disagreement will probably prove to have been an error in one or the other palpation. If apparent disagreement persists after searching examination, position A furnishes the safest guide to adjustment because the patient is in his most usual attitude as regards the spinal curves, muscle tension, etc. But it is usually wisest when in grave doubt not to adjust the doubtful vertebra at all.
PALPATION IN POSITION C
Since palpation in this position, patient lying on his back with head supported by palpater’s hands, cannot be so reliable as that done in position A, the chief point to be observed is an accurate count. Only the Cervicals below the first can be properly palpated in this position.
Induce the patient to relax the neck muscles as much as may be, and use in palpation the first three fingers of one hand if the count alone is desired or the first three fingers of both hands if you desire to ascertain the direction of any vertebra. In the former case let the fingers press aside the muscles and glide downward from the second Cervical, being careful to lift the head high enough so that the third Cervical is not overlooked beneath the overlapping second. In the latter case let the fingers of both hands glide gently downward while the patient’s head rests upon the palpater’s wrists or knee. Palpate the transverses in much the same manner, paying special attention to their laterality, felt as a prominence on one side lateral to a transverse process and a corresponding depression on the opposite side. Do not be deceived by exceptionally long transverses where both project outward to an equal degree.
Since the greater mass of the vertebra is divided with fair equality by the intertransverse line, laterality of transverses indicates laterality of the whole vertebra with the possible exception of the anterior portion of the body. Laterality of a Cervical spinous process may indicate laterality of the entire vertebra or merely rotation around its vertical axis, in which the one articular process is separated from its fellow of the adjacent vertebra while the other remains in partial apposition.
Disagreements
If disagreements appear between palpation made in positions A and C, re-palpate in both positions. If still uncertain call a consultation or follow finding in position A. The Rotary adjustment may sometimes aid in deciding difficult questions if gently attempted and free movement secured. With this adjustment a vertebra will not usually move without rather extreme force unless the articular process on the side sought to be moved has lost its apposition with its fellow of the adjacent vertebra. In any case of disagreement nerve-tracing, the discovery of sensitive nerves on one side only may aid in decision. A knowledge of probabilities, previous experience, and the diagnosis may also serve as partial guides.
TRANSVERSE PALPATION
Palpation of the transverse processes is easiest in the Cervical and mid-dorsal regions and most difficult in upper Dorsal and Lumbar regions. It has two uses: first, to assist in making a record by verifying the work done on the spinous processes; second, to locate a given transverse process in order to use it as a lever for the adjustment of the vertebra.
It will be seen that fulfillment of the first purpose requires careful examination of the direction and position of the transverses as compared with each other and with the spinous process of the same vertebra, while the second requires only the discovery of the exact location of some particular transverse. It will be best to consider the three divisions of the spine separately, excluding from the present chapter Atlas palpation, which has been thoroughly described.
Cervicals
These can be best palpated in the position for Atlas palpation; that is, standing behind the patient and using the palmar surfaces of the fingers of both hands. From the Atlas transverses follow the anterior border of the sternomastoid muscle downward, and opposite each spinous process draw the muscles backward and inward until the tips of the transverses are found with the middle fingers. Their position on the two sides may then be easily compared as well as their relation to those above and below them.
The transverses of the second Cervical may sometimes be so prominent laterally that they are, or one of them is, mistaken for an Atlas transverse. As a rule, however, the width of the Cervicals increases from the second downward, the second being narrowest. Chassaignac’s tubercle, on the transverse process of the sixth Cervical and opposite the lower border of the cricoid cartilage, is a prominent point easily felt as a rule. The transverses of the fourth are usually opposite the upper border of the thyroid cartilage.
The Cervical transverses lie very close to the articular processes and the determination of their relation is a better guide to the condition of the articulation than is spinous process palpation. It is also more difficult.
Palpation of Cervical transverses to determine laterality of the vertebra as a whole or its rotation is possible in position C and has been described under that head.
Dorsals
Palpation for direction can be done best in position B. Use three fingers with a gliding movement along the line of the transverses, passing over several to determine which is most posterior. Then repeat the glide on the other side of the spine to determine whether the transverse corresponding to the anterior one is posterior or vice versa, showing that the entire vertebra is merely rotated or is displaced backward. Some palpaters prefer using both hands and palpating both transverses at once and there is no serious objection to this method, if confined to palpation in position B. In many cases, however, it leads to similar palpation of spinous processes, a most execrable habit.
It should be remembered that with the first two Dorsals the transverse will be found in a transverse plane which would pass between its own spinous process and that above. This is also true of the last three Dorsals, while in the middle Dorsals the transverse is usually (not always) level with the tip of the spinous process of the next superior vertebra.
Before adjusting, to determine the location of a transverse process in order to direct an adjustment against it, first palpate spinous process and hold it with the tip of the middle finger. Then approximate with the first finger a point even with the tip of the spinous process above and about one inch from the spine—this of course in mid-dorsal. Then let second and third fingers follow the first so that all three rest on or near the transverse to be palpated. Pressing gently, but firmly, move the three fingers until the process can be felt beneath them. Hold the process with the middle finger so as to direct with it the contact of the adjusting hand to a point exactly over the transverse process.
Lumbars
The transverses of a Lumbar vertebra lie just even with the interspace between their own and the adjacent superior spinous process. They are deeply embedded in muscle tissue and very hard to palpate. They may vary considerably in size or length and the last one or two may be absolutely impalpable. It is sometimes advisable to adjust a rotated Lumbar by using the transverse as a lever, but this should never be attempted unless the process can be distinctly felt. The method of locating in Lumbar is practically the same as in the Dorsal region.
Transverse Palpation with Patient Sitting
Palpation of Cervical transverses in position A has been described and is frequently done. Palpation of Dorsal or Lumbar transverses in the same position may sometimes be desirable. It can be done with the same movement as spinous process palpation, and may serve to detect a bent spinous process.
If it is necessary to palpate both transverses at the same time, stand in front of the patient and lean over his shoulder, letting his shoulders rest against your body. Use palmar surface of fingers of both hands and note which transverse is posterior to its fellow, if either, or whether both are posterior to the line of the others above and below them.
It is rarely possible to find if a transverse process be superior or inferior to its normal position, except the Atlas transverses, although this may occasionally be detected. Fortunately this is a rare form of subluxation, or appears rare, although it must be said that this apparent rarity may be due to our comparative inability to detect it in the living subject.
CURVES AND CURVATURES
For convenience, curve is used to denote the normal curvilinear deviation from a straight line naturally present in the normal spine or naturally assumed in response to the need for equilibrium during the erect position of the body: Curvature means either the abnormal increase of any normal curve or the appearance of any abnormal curvilinear deviation of vertebrae from their normal position. Deviations from normal must contain at least three vertebrae to be considered curvatures.
Visual Examination
The general inspection of the spine which precedes the count should bring to light, in addition to prominent subluxations, and general symptoms observable by inspection of the back, any marked curvatures. Their general locality and direction will be noted by this observation and their details left to be discovered by closer examination.
During palpation with a long and rapid glide one may also note these general points with respect to any curvature.
Do not mistake the four normal curves, the anterior Cervical and Lumbar and the posterior Dorsal and Sacral, for curvatures. The normal Lumbar curve is so unusual in practice that a novice has been known to name it a lordosis.
Description of Curvatures
Four varieties of curvature are commonly described. Kyphosis is a curvature with its convexity directed backward, usually, but not always, found in the Dorsal region. Lordosis, the opposite of Kyphosis, is an anterior curvature, usually in the Lumbar in which case it is an accentuation of the normal curve. Scoliosis has its convexity directed laterally either to the right or the left. It is commonly also Rotatory, having its vertebrae rotated around their vertical axes so as to make the outer or the inner transverses more prominent than those on the other side.
In a Scoliosis the rotation may swing either the bodies or the spinous processes toward the convex side of the curvature; the latter is much the easier of adjustment while the former furnishes one of the most intricate problems of adjustment.
Cause of Curvatures
Without entering here into a discussion of those disturbed metabolic processes—themselves the result of subluxation—which result in curvature by general softening of the bone, as in rachitis or spondylitis deformans, we will simply state the general proposition that almost all curvatures which are in any degree angular result from a single subluxation to be found at the point of the angle. It has been demonstrated in such cases that adjustment at that point will correct the curvature in time but it is usually wiser to hasten matters by selecting other points of attack by a method to be presently suggested.
Long, regular, but not pronounced, Scoliosis, usually in the Dorsal, may be an example of occupation curvature, following the continued use of muscles in a fixed position and not due to subluxation. Another example is the mailman’s Lordosis. These in themselves are not detrimental to health and are negligible unless some special point of impingement through individual subluxation exists within them.
The sharp, angular kyphosis of Pott’s Disease, tubercular caries of the vertebrae, the curvature involving three or four vertebrae which are extremely tender to palpation, should warn against adjustment unless one can be very certain that the vertebrae are sufficiently intact. Fracture of a decayed vertebra is easily possible under adjustment. The cause of Pott’s Disease is usually at the angle point, most frequently the tenth Dorsal but possibly any Dorsal from fifth to twelfth.
Record on Curvatures
If it is the purpose of the examiner to straighten the curvature he should choose for adjustment a series of non-adjacent vertebrae which are most prominent in the direction of the curvature; thus in a right scoliosis he should choose only those vertebrae most prominently out to the right, and in a kyphosis only posterior ones. A lordosis as such cannot be properly adjusted except in the Cervicals, but lordosis is usually a compensating curvature (see below) and can be otherwise corrected.
If the patient suffers from some disease which assumes more importance than the curvature and demands attention, select the one vertebra which is causing the disease, without reference to its position in the curvature, and adjust that vertebra into a proper relation with the adjacent ones, even though you adjust directly toward the convexity of the curvature. Disease may often be relieved by making a curvature regular more quickly than by eliminating the entire curvature. Sometimes both considerations may influence the selection of vertebrae.
In a curvature there is not necessarily pressure on nerves at every foramen. In fact, such pressure is the exception rather than the rule in curvature and a careful study of the spine must be made in order that adjustments may be accomplished without causing temporary impingement here and there.
A foot-note describing curvature may be appended to the record of palpation. It should contain the special name of the curvature, whether simple or compound, and the numbers of the first and last vertebrae in it. For instance, note may read: “Right rotary scoliosis from D 3 to L 1 inclusive.”
Compensatory Curvatures
When a primary curvature is present one or two secondary curvatures usually appear to preserve the equilibrium of the body. With a Dorsal kyphosis there is often a Lumbar lordosis and sometimes less marked lordosis in both Cervical and Lumbar. With a primary right scoliosis in the Lumbar there will be a secondary left scoliosis above. The secondary curvature is called compensatory. In selecting vertebrae for adjustment it is well to neglect the compensatory curvature as much as possible, leaving it to right itself as the primary one is corrected. If, however, the primary curvature be a lordosis, and not adjustable, work on the secondary curvature may gradually aid in reducing the primary, to a certain extent at least.
Ankylosis
This topic is discussed here partly because it is so often associated with curvature.
Ankylosis can be appreciated only by detecting the lack of normal movement between adjacent vertebrae. Place a finger in the interspace between suspected vertebrae and ask the patient to perform the movement calculated to separate the spinous processes in a normally movable spine. If in the Dorsals, ask him to drop the head and shoulders as far forward as possible without bending at the hips. Alternate repetitions of this movement with straightening and the spinous processes should alternately separate and approach each other. Test several successive vertebrae so as to note that all change their position except two.
In the Lumbars have the patient repeatedly bend the body forward from the hips striving to make his spine convex backward. In the Cervicals forward flexion of the head will serve. Occasionally general ankylosis is found with curvature, as in Spondylitis Deformans.
Many Chiropractors mistake failure to move a vertebra with an attempted adjustment for evidence of ankylosis. In nine cases out of ten such failure is due to other reasons, ankylosis being very infrequent. It is a much abused excuse for incapability. Free movement between spinous processes is absolute proof that the vertebrae are not ankylosed.
DIFFICULTIES IN PALPATION
The chief difficulty arises from failure to observe some of the rules herein laid down.
Carelessness or inattention precludes accuracy.
Pain may cause the patient to assume an unnatural or cramped attitude simulating curvature, especially of the Cervicals. More errors occur from this cause in judging the laterality of C 2 than with any other vertebra.
The occasional bent spinous process in Cervical or Dorsal regions may deceive the palpater unless transverse palpation is employed. But the frequency of slightly bent processes in dry spines and a superficiality of reasoning upon the subject have led to great overestimation of their importance. As a matter of fact only a very few maladjustments arise from deception of the palpater in this way, though the profession contains few practitioners who make a routine method of verifying by the transverses. The reason is simple. Bent processes are caused by direct violence applied before the union of shaft and epiphysis is complete. Sufficient force to produce a change of direction usually produces subluxation in the same direction. Adjustment continued until the offending process was quite aligned with its fellows would constitute overadjustment, but adjustment is not usually continued after all symptoms have subsided, so that actually small harm occurs through failure to detect bending.
An epiphyseal plate may be absent, having been broken off by trauma and absorbed. This can be discovered by noting the too-wide space between apparently adjacent vertebrae, and careful palpation will disclose the apparently much anterior vertebra, an appearance not borne out by the position of the transverses. When an epiphysis is absent a patient has a somewhat weak back from lack of muscular attachment.
Lipoma, or the heavy cicatrix following a burn or carbuncle, may render palpation of two or three vertebrae impossible. In such a case only the palpater’s experience and his knowledge of the characteristics of various vertebrae will enable him accurately to number the remainder.
Patients with much adipose tissue may require palpating in several positions in order to permit certainty.
A deep third Cervical which is absolutely impalpable may mislead one, but a careful count which shows one vertebra overlooked indicates the necessity for a careful re-examination of the Cervicals, by which the gap at the third at least may be appreciated. If the Axis is very much inferior the third is especially likely to be overlooked.
Anomalous cases have been found in which there were more or less than the usual number of movable vertebrae, the usual deviation being the presence of twenty-five, and the extra one being most commonly a Lumbar. In one case under my observation there were twenty-five movable vertebrae, apparently thirteen Dorsals according to shape, and only eleven pairs of ribs posteriorly, two pairs being dichotomous so that there appeared thirteen pairs anteriorly. Deviations in number occur, in my experience, about once in five hundred cases.
LANDMARKS
The regional location of vertebrae by means of certain landmarks (so called) in or near the spine, is a much discussed question in the profession. Without discussing the various arguments in favor of this method, chief of which is the inability of the untrained to count vertebrae, let us set forth the principal landmarks used and the facts in regard to them.
The seventh Cervical, called Vertebra Prominens, is usually considered a guide to the count. In over three hundred cases examined for that purpose the seventh Cervical was found to be Vertebra Prominens in about 65%, the other 35% showing the sixth Cervical or first Dorsal to be the prominent one. This method is two-thirds as accurate as counting.
The tubercle (Chassaignac’s) of the sixth Cervical transverse is said to be directly opposite the lower border of the cricoid cartilage and this is a better guide than the above.
The third Dorsal spinous process is said to be on a level with the root of the spine of the scapula, and with arms hanging at sides, the upper angle of the scapula to be on a line between first and second Dorsal spinous process. This is not at all constant.
The inferior angle of the scapula is said by some writers to be on a line with the tip of the seventh Dorsal spine. Others locate it opposite the interspace between seventh and eighth Dorsals. Still others give it as opposite the eighth Dorsal spine. All are correct—sometimes. In truth, the inferior angle may be opposite any part of the spine between the sixth and ninth Dorsals. There is nothing constant about it.
The twelfth rib may be followed to its articulation with the twelfth Dorsal vertebra. This is a good guide, providing that the rib can be palpated. The lower margin of the last rib is usually even with the spinous process of D 12 about one inch and a half from the mid-spinal line. The humor lies in the fact that the patient upon whom the count is so difficult as to require this verification is usually obese and obesity renders the rib impalpable.
The line drawn between the iliac crests falls between the third and fourth Lumbar spinous processes in about 98% of all cases. This is our most reliable landmark. It is used as described under the Count.
All landmarks except the last two show such variance in different individuals as to be quite unreliable. The correct method of numbering spinous processes is the obvious and logical method—count them. The skill and accuracy of touch required for successful counting is invaluable in determining direction of subluxations.
MENTAL ATTITUDE
In order to secure that absolute concentration without which it is impossible to appreciate properly those tactile impressions for the very reception of which such continued practice is necessary, the hands should leave the spine as little as possible during palpation; a second person should record subluxations found so that the palpater need only state, and not write, his conclusions; light pressure on the spine should always be used, as a heavy pressure desensitizes nerve-endings in the fingers; and silence should be maintained except for the necessary statement of points to be recorded.
Palpate as rapidly as is consistent with good work. The more rapid the palpation, if concentration is absolute, the more accurate the impressions received.
The end and aim of palpation is to determine the means by which impingement of nerves may be removed with the greatest rapidity and success. Palpation includes such a study of the vertebral column as will fix in your mind a clear thought-picture of the impinged nerves throughout its length.
FINALLY
If you would achieve success in Vertebral Palpation, be persistent. Spare no labor to acquire that accuracy of detail which distinguishes the expert from the amateur. You can make of yourself what you will. There is no limit to the ability which may be acquired. Another may guide your hands but with you lies your success.