The Structural Fingerprint™ Program yields success in treatment of musculoskeletal disorders

Using low back pain merely as one of the many musculoskeletal (MS) disorders from which people suffer, a recently published article¹ took a severely myopic and an incomplete approach to any MS disorder.

The article states: "Perhaps 85% of patients with isolated low back pain cannot be given a precise pathoanatomical diagnosis...Because a precise and anatomical diagnosis is elusive, diagnostic evaluation is often frustrating for both physician and patients. Rather than perform an exhaustive search, it is generally more useful to address three questions: 1) Is a systemic disease causing the pain? 2) Is there social or psychological distress that may amplify or prolong the pain? and 3) Is there a neurologic compromise that may require surgical evaluation? For most patients, these questions can be answered from a careful history taking and physical examination, and imaging is often unnecessary."

Furthermore, this thinking contributes to the underlying erosion of the necessary methodology and benefits that are available to both physicians and patients in dealing with MS disorders.

Structural Analysis

The Structural Fingerprint™ Program provides an infrastructure or a methodology for clinicians and therapists. The program includes a thorough work-up, an accurate diagnosis, and comprehensive rehabilitation for many existing MS disorders. It is important to note that the testing and rehabilitative stages can be comprised of a variety of treatment techniques specifically chosen by doctors and therapists.

Success with MS disorders is based on the objectivity of improvements and findings. If an elusive diagnosis is the starting point for the treatment of MS disorders, the only measuring stick will be pain and symptom relief, not the objective changes in alignment, balance, and motion of the structure. Patients are architectural structures, not pathological diagnoses.

Every patient presenting an MS disorder is unique with regard to genetic make-up, prior traumas, job description, exercise program, diet, weight, shoes, mattresses, habits, activity level, and psychological profile. To generalize a prognosis or treatment program based on an elusive diagnosis will greatly reduce the likelihood for success, and to base success solely on pain-relief is insufficient. For practitioners dealing with biomechanics—especially those involved in sports and ergonomics—more demanding and stringent protocols must be used.

The search for structural changes, as evidenced by objective testing, should be the minimal criterion when working with patients suffering with structural symptoms. Pre- and post-testing must be the yardstick for success. Further evaluation with modification of recommendations should always be considered without objective changes and improvements.

History in the Making

Although a thorough history is encouraged, it is often overrated. The history becomes important when determining the mechanics leading up to the injury, but there are many factors that will never be uncovered. A history must be taken, but critical time should be spent on the evaluation instead of the consultation.

Structural evaluation: First, a visual evaluation should be performed. Patients should be viewed from the back, side, and front in the standing position. Postures should be recognized, as well as elevations—right vs left. From the posterior view, top to bottom, ears, base of occiput, shoulders, scapulae, inferior thoracic crease, iliac crests, gluteal folds, popliteal fossas, and achilles tendons should be noted. The spine should also be studied, noting curvature as well as muscle formation at all levels. From the side view, the objective is to note the position of the head in relationship to the body.

These questions should be asked: Is there anterior positioning? Is the head positioned over the body? Is there a hyperkyphosis or a flattening in the thoracic area? Is the pelvis leaning anteriorly (hyperlordosis) or posteriorly (hypolordosis)? Do the knees appear to be in a semiflexed position vs hyperextended position? From the front view, ears again should be noted, as well as shoulders, hips, knees, and feet. If the patient is not wearing a gown, note the level of the pectoralis muscles and the centralized position of the naval.

Active and passive range of motion (ROM) of all joints is also a critical part of this evaluation. Active motion of the spine and passive motion of the hips, knees, ankles, shoulders, elbows, and wrists are typically acceptable. It is important to note both restriction and pain on any movement. Muscle strength and size should also be tested. The number of muscles tested is optional, however, more information typically leads to a more accurate diagnosis and rehabilitative program.

Muscle evaluation: Once a sport-specific position or job description is understood, those repetitively used muscles will become the focus of testing. There are various means for determining strength, but Kendall and Kendall provide established guidelines for rating muscle function during testing.² Measurement should be taken on right and left arms and legs for comparison.

Leg length evaluation: Determine leg lengths primarily to assess if there is a leg length discrepancy, and whether it is anatomical or functional. With the patient in the prone position, measure from the greater trochanter to the lateral malleolus. Then mark these findings.

A secondary test, the Deerfield Test, is also administered in the same position. With the patient lying prone, level the heels of the patient and note which leg is longer, then flex the knees to 90°, making note of any change in the leg length. A cross-over (the short leg now becoming the long leg) is indicative of a functional shortness. Keep in mind, many people can have both anatomical and functional differences, and each must be addressed differently.

Arches evaluation: At this point, the arches of the feet should be evaluated. A thorough inspection would involve a complete foot exam. This would include a visualization, palpation, ROM, and determination of medial arch height. Corns, calluses, and bony defects should be noted. With the patient in the standing position without shoes and socks, slide fingers underneath the medial arch of both feet, and note how far the fingers slide under the arch, comparing right to left. Very often, there will be a difference between the two, but there often will be flattening of one or both medial arches.

Specific area evaluation: The patient is then put through standard tests that will stress specific areas of the body, such as the hips (Patrick-Fabere), sacro-iliac joints (Gaenslens), lumbo-sacral joint (bilateral leg raise), and lumbar, thoracic, and cervical spine. Any pain or restriction should be noted. There are many tests that will accomplish these objectives, and the goal is to determine the integrity of the spine and pelvic areas.

X-ray evaluation: The final and most important tests are X-rays. These should be done in the standing position. Many doctors limit X-ray studies to the area of involvement, but the cervical and lumbo-sacral spine are extremely influential on the function of the entire body and should be studied. A limited series is recommended, such as an anterior-posterior (A-P) open mouth and lateral cervical, and A-P and lateral lumbo-sacral (L-S) views. This provides the examiner with a significant amount of biomechanical information, while still maintaining the opportunity to X-ray the patient again at a later date for comparison without fear of overexposure. Additional X-rays should be taken if a condition, such as spondylolisthesis, is present.

A Heart to Heart Talk

Once a list of objective defects has been collected, interpretation and communication to the patient is considered. When more defects exist, increased rehabilitation is needed to reach true maximum medical improvement.

The lack of normal ROM, especially accompanied by pain, indicates the body has defensively restricted ROM. Often, a patient has not used full ROM of a particular joint, and coupled with the aging process, has lost some degree of motion. Also, prior injuries to an area without the necessary rehabilitation at the time of injury will cause restriction in normal ROM. Regardless of the cause, loss of motion in a joint is reason enough to begin a rehabilitative program to restore ROM.

X-rays are a valuable component of the evaluation, and there are specific concerns, other than pathology, that can be found. First, in the cervical views, the lordotic curve with healthy disc spaces and the head positioned directly over the spine are the desired findings and can be viewed on the lateral film. Anything other than normal suggests abnormal stresses in the involved muscles and joints.

On the open-mouth view, it is important to look for alignment between the odontoid process and the spinous process of C2, as well as the atlanto-axial joint spaces. On the low back films, the lateral view demonstrates invaluable information, such as the L-S gravity line, which originates at the center of L-3 and should intersect the anterior third of the sacral base and the sacral base angle, which should measure between 36° and 42°. Any increase or decrease from this range will increase vulnerability to injury and delay normal recovery.

Other positive findings on the examination should be noted. Correction of abnormal findings should now become the objective when structuring a rehabilitative program. The first objective should be symptom relief. Spasms, inflammation, and restriction of motion make rehabilitative exercises difficult. The modalities can consist of physical therapy, restrictions, ice or heat treatment, chiropractic, nutritional supplementation, medication, rest, acupuncture, or a variety of other available modalities.

Once pain is reduced, the corrective program begins. This phase of the program can require from 4 to 9 months of work, depending on the age of the patient and degree of defects found on the original exam. The goal of this phase is to work toward an improved structural positioning of the body. A patient needs to know that objective improvements on an X-ray are not the only means for determining success in a case. If a patient has a genetically induced hypolordosis of the cervical spine, correction or alteration can be difficult. However, if a patient has increased ROM, decreased muscle spasm, and improved symptoms with X-rays showing improvement in biomechanical positioning, then the case is deemed a success.

Under Strict Management

Patients are difficult to manage when experiencing excruciating pain. Patients cannot be expected to go through 4 to 6 months of care based on original recommendations. They get bored, and as a result, they quit care. Success is often contingent on periodic reevaluations. With every exam, a new objective should be determined. This objective can be pain relief, increased joint mobility, improved physical ability, radiographic changes, or maximum exercise without negative response from muscles and joints. Regardless of the objective, the time frame of care needs to be 2 to 4 weeks or longer, with explicit instructions and goals, as well as frequency of treatments and home exercises and treatment.

As long as doctors clearly communicate and evaluate at every stage, patients can tolerate the specifics involved. People are tired of superficial treatment for pain only. The Structural Fingerprint Program should be made available to all patients. The fact that the spine houses the nervous system should make many people immediately take an interest.

Patients can either pay for a thorough work-up and a rehabilitative program to improve structures, or they can pay with the normal wear and tear and symptoms that occur when pain relief is the primary objective.

Tim Maggs, DC, is a columnist for 13 running and triathlon magazines and manager of a sports injuries website, www.RunningDr.com.  He can be reached at 518-393-6566 or via email: running dr@aol.com. 

1. Deyo R, Weinstein J. Low Back Pain. New Eng J Med. 2001;344:363–370.

2. Christensen KD. Clinical Chiropractic Orthopedics. 1st ed. Dubuque, Iowa: Foot Levelers Inc; 1984:3.