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Extremity-Specific Evaluation
Eric Nelson, DC CCSP
President ANJC Sports Council
With the recent New Jersey Supreme Court decision allowing NJ chiropractors to once again
perform extremity adjustments, a hot topic of discussion lately has been centered on how to
document the relationship between an extremity adjustment and a spinal condition.
According to the ruling, determining a casual nexus between an extremity and spinal condition
should be done on a case-by-case basis. While there is no established protocol, it’s probably a
good idea to demonstrate this relationship with thorough documentation.
One proposed method is to perform an extremity-specific evaluation. In addition to ruling out red
flags, the goal of this evaluation will be used to gather information that will clearly demonstrate
the relationship between spine and extremity.
This evaluation should contain a thorough history that highlights the chief complaint and any
impact this complaint has on the patient’s spine. The exam should also contain postural and gait
analysis, range of motion (including active, passive, and resistive), orthopedic and neurological
tests, muscle assessment (length, tenderness, trigger points, etc.), the evaluation of movement
patterns, and of course, joint dysfunction/subluxation analysis.
In addition to containing your findings, your documentation should contain a summary paragraph
that highlights your findings and clearly demonstrates the relationship required by the recent NJ
Supreme Court decision.
One aspect of this exam that should be pointed out is the evaluation of movement patterns. By
watching our patients perform certain movements, we can clearly see the impact of an extremity
condition on their spine.
According to the late Vladimir Janda, MD there are six basic movement patterns that provide
overall information about the movement quality of a particular patient: hip extension, hip
abduction, curl-up, push-up, neck flexion, and shoulder abduction.1
A great example would be to look at a faulty hip extension movement pattern in a patient that
requires a chiropractic adjustment to their hip. For normal extension of the hip at the terminal
stance phase of gait to occur, the normal sequence of muscle activation can be observed with the
patient in the prone position.
During straight leg lifting into extension, the sequence should be hamstring, gluteus maximus,
and then the erector spinae activation. One possible faulty pattern that can occur would be when
the erector spinae on the ipsilateral side or even the shoulder girdle muscles initiate the movement
and activation of the gluteus maximus is delayed, decreased, or even absent.1
Due to the overactivity of the erector spinae, there is a clear connection between dysfunction in
the hip and spine. Further spinal and extremity joint dysfunction/subluxation analysis can be
performed to confirm this.
By performing an extremity-specific evaluation that contains the above-mentioned components
and provided that there is indeed a casual nexus between a spine and extremity condition, it
should be easy to demonstrate and document this connection.
1. Liebenson, C. Rehabilitation of the Spine, A Practitioner’s Manual 2nd Edition, 2007.