Archive for category Leg Length Inequality/Analysis

Abstract

OBJECTIVE:

To assess the validity and reliability of prone and supine measurements of leg length inequality and to determine the potential use of measurements at the iliac crests and patient demographics as predictors to estimate standing leg length differential.

DESIGN:

Repeated prone and supine measurements of leg length inequality were made by an experienced chiropractor and compared with iliac crest and femur head measurements made on X-rays of standing patients. Multiple regression analysis was performed.

SETTING:

Private chiropractic practice.

PARTICIPANTS:

The first 50 new patients with low back pain that were X-rayed were included in the study.

RESULTS:

Intraexaminer reliability was excellent for the prone measurements. The supine tests were less reliable. The prone measurements were highly correlated with the standing X-ray femur head measurement. The supine measurements were poorly correlated. Measurements of deficiency at the iliac crests on X-ray were most highly correlated with X-ray measurements of discrepancy. In multiple regression, the prone measurements and duration of problem were the only significant predictors of standing X-ray difference.

CONCLUSIONS:

In this study, crest measurements were made on X-ray; the degree of accuracy with which millimeter differences can be measured clinically on patients is unknown. In a few cases, the supine measurements were more accurate than the prone; however, the supine test validity was poor when compared with the standing X-ray measurements, and reliability was less than expected. Supine measurements should not be used to estimate standing leg length discrepancy in new low back pain patients but perhaps can be used in other clinically meaningful ways. Intraexaminer reliability of the prone measurements was higher, but further investigations need to focus on interexaminer reliability. The prone measurement as a predictor holds promise, but new measurement tools must be developed.


J Manipulative Physiol Ther. 1995 Sep;18(7):448-52. [PMID:8568426]

Author information: Rhodes DW, Mansfield ER, Bishop PA, Smith JF. University of Alabama, Tuscaloosa, AL,USA.

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Abstract

Objective: The objective of this paper is to investigate if there is a relationship between the side of leg length inequality (LLI) and the side of low back pain (LBP).

Design: Carefully standardised radiographic technique as described by Giles (1,2) and reviewed by Rock (3) was utilised to evaluate LLI in individuals who presented for assessment of LBP. Age, sex and the side of LBP were extracted from patient records. The side of LBP was determined by marking a pain diagram, taking the form of a body outline, included in the patient questionnaires. These findings were examined to reveal any relationship between the side of LLI and the side of LBP.

Setting: The study was conducted in a private chiropractic practice.

Participants: From January 1993 to September 1993 all patients presenting for chiropractic assessment of LBP where included. Patients whose history revealed relevant trauma, surgery or whose radiographic examination showed anomaly or pathology, likely to confound results, were excluded from the study.

Results and Conclusion: A relationship has been demonstrated between the LLI side and the side of LBP. The broad age range of subjects may well have been a confounding factor in this study. Re-analysis of the sample of patients aged 34 years or less demonstrated that the LBP side is most commonly opposite the side of LLI.


 COMSIG Rev. 1995 Jul 1; 4(2): 33–36. [PMCID: PMC2050381]

Author information: Anderson RG, Hayek R, Foggerty MP.


Free PMC Article

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Fuhr Optoelectric

Abstract

OBJECTIVE:

a) Establish a precise, standardized method to assess prone leg alignment changes (functional “leg length inequality”), which have, until now, been reported clinically to occur as a result putative chiropractic subluxation isolation tests [neck flexion (C5) and extension (C1)]; and b) describe differences in leg alignment changes in a group of healthy subjects and patients with chronic spinal complaints.

DESIGN:

Two group, two isolation tests, descriptive, repeated measure analysis of variance.

SETTING:

Exercise and Sport Research Institute, Arizona State University.

PARTICIPANTS:

Eight healthy controls, eight patients with a history of chronic spinal complaints and observable leg alignment reactivity.

INTERVENTIONS:

Active cervical flexion/extension maneuvers.

OUTCOME MEASURES:

Optoelectric markers affixed to heels and occiput, as subjects lay prone. Marker locations sampled at 100 Hz for 10 sec during: a) three no movement trials, b) three cervical extension and c) three flexion trials. Data transformed to local reference frame approximately each subject’s longitudinal axis prior to analysis.

RESULTS:

Heel position movement occurred during trials and were highly individualistic. Patients exhibited more asymmetrical movements than the controls during the head-up trials. No differences existed between controls and patients for range of heel displacement or net displacement.

CONCLUSIONS:

The results of this study allow the following to be concluded: 1) small leg displacements (< 1 mm) were recorded by the optoelectric measurement system; 2) heel position changes during isolation tests were identifiable; 3) as a result of head-up maneuvers, patients exhibited more asymmetrical heel movement than controls (t = 8.743, p < .01); 4) The heel range of motion was not different between the groups; and 5) The net change in heel position was not different between the groups. Patients exhibited more asymmetrical heel motion during head-up isolation tests, suggesting that some phenomena may separate these two groups, warranting future study.


J Manipulative Physiol Ther. 1994 Oct;17(8):530-8. [PMID:7836876]

Author information: De Witt JK, Osterbauer PJ, Stelmach GE, Fuhr AW. Exercise and Sport Research Institute, Arizona State University, Tempe 85287-0404.

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ABSTRACT

BACKGROUND AND OBJECTIVE

The prone comparison of  changes in leg alignment is commonly used to identify musculoskeletal  dysfunction by chiropractors. Despite its widespread use as a diagnostic  tool, confusion exists about the reliability of these measures. A  possible problem is this methods dependence upon the clinician to  accurately assess leg length asymmetries by visual inspection. The  purpose of this investigation was to utilize a precise optoelectric  device to determine 1) Leg length asymmetries prior to and after a  random series of isolation tests, and 2) Heel trajectories during the  performance of these isolation tests.

METHOD

-Four subjects were tested in the Motor Control  Laboratory at ASU. During each testing Session the subjects lay prone on  a portable adjusting table with infrared light emitting diodes affixed  with adhesive to their posterior heels, and posterior occiput.  Additional markers were placed on a moveable reference bar placed near  the subject’s feet. The reference bar was aligned to be perpendicular to  the body, and was independent of the adjusting table. Prior to any data  ‘Collection, each patient was assessed visually by a chiropractor for  the incidence of any leg length inequality, which was recorded for later  use. After the visual assessment, the reference bar was placed at its  permanent location, and a second leg length measurement was made by a  second investigator by measuring marker location of each heel from the  bar with a scale marked in millimeters. Each measurement (visual and  from the bar) were kept blind from the other respective investigator.  Data collection then proceeded with the optoelectric device. Data were  collected for 8 seconds at 50 Hz during the following conditions: no  movement, head-up, chin-tuck, pressure test right transverse process of  C-1, or pressure test left transverse process of C-1, The initial 5  trials were in the order mentioned in the prior sentence; 5 trials of  each condition were then collected in a randomized order for a total of  30 trials. After all data were collected, leg length assessments were  carried out by the two investigators as was completed prior to data  collection. After data collection was complete, digital data were  filtered at 2 Hz and 0′ rotated mathematically into a local reference  frame within which the bar represented one axis in a 3-D frame. This  allowed measurements to be examined along an axis perpendicular to the  bar, the expected axis of lengthening or shortening of each leg. Two types of analyses were completed for each subject. Leg  length difference analysis consisted of examining the heel positions at  the; beginning and end of the entire testing session and comparing the  data to the investigator’s manually measured reports.


Reference: John K. DeWitt, B.Sc.E., Paul J. Osterbauer.  D.C., George E. Stelmach, Ed.D. & Arlan W. Fuhr. D.C.;  Optoelectric Measurement of Leg Length Inequalities Before, During, and  After Isolation Tests; Proceedings of the 1994 International  Conference on Spinal Manipulation. Palm Spring, CA, June 10-11, 1994, p.  24-25.

Exercise and Sport Research Institute, Arizona State University Tempe, AZ 85287-0404 +Activator Methods. Inc. 3714 E. Indian School Road, Phoenix. AZ.

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ABSTRACT

Changes in apparent leg length”(leg retraction) have been used  by many as a means of locating subluxation in various Joints. The leg  assessment is based on the assumption that unequal muscular contraction  (e.g. hyper irritable muscles) about the spine and pelvis have the  ability to retract one leg relative to the other. Despite Claims of  usefulness, many problems are inherent in the prone leg assessment such  as: a) measurement error; b) subject positioning by the examiner  (expectancy bias) and; c) interference with die surface of the examining  table. There have been prior attempts to quantify the amount of leg  length changes that occur during a treatment session, but most have  suffered due to the lack of a measurement technique which provides the  necessary accuracy in the recording of slight changes in heel position.  The purpose of this study was to quantify involuntary, movements that  result from neck flexion and extension maneuvers. Five subjects  exhibiting involuntary leg reactions were tested using an optoelectric  motion analysis system. During each testing session, the subject lay  prone on an adjusting table while infrared light emitting diodes (IREDs)  were affixed to the heels of fracture boots. In the rest position, the  neck was in neutral flexion so the face rested on the surface of the  table. Prior to testing, the examination area was in neutral flexion so  the face rested on the surface of the table. Prior to testing, the  examination area was calibrated resulting in RMS errors of less than 0.3  mm. Data were collected for ten seconds by three cameras positioned to  record movement of the IREDs. During each testing session, each subject  preformed two movements; a head-up movement, during which the subject  extended the neck and then returned to a resting position, and a  chin-tuck movement, in which the subject flexed the neck and then  returned to a resting position. A testing session consisted of three  no-movement baseline trials, followed by three head-up trials and three  chin-tuck trials. Examination of output displacement histories showed  that during all trials, movement occurred at the heels in the direction  of the subject’s longitudinal axis. During the head-up trials, a  majority of cases showed a net shortening in heel position during head  movement.


Reference: John K. Dewitt. B.Sc.E, Paul J.  Osterbauer, D.C., George E. Stelmach, Ed.D., & Arlan W. Fuhr. D.C.;  Optoelectric Measurement of Leg Length Changes During Isolation Tests;  Proceedings of the CCR’s 8th Annual Conference on Chiropractic  Science in Health Policy and Research, Monterey, CA, June 18-20, 1993,  pp. 156-7.

Affiliation: Arizona State University, Phoenix. Arizona and National Institute for Chiropractic Research, Phoenix, AZ.

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Abstract

OBJECTIVE:

A study was undertaken to assess the stability of leg alignment reaction to a pressure challenge and its responsiveness to an adjustive intervention.

DESIGN:

Prospective, double-blind clinical trial of a diagnostic test.

SETTING:

Laboratory: Center for Technique Research.

PARTICIPANTS:

Forty-two chiropractic college students, faculty and staff.

INTERVENTIONS:

A high-velocity, low-amplitude, short lever adjustment of a single vertebra from among C1 and T3-T7; or a sham adjustment similar to a manual diagnostic pressure test at C1, T3-T7 or T9-T10.

MAIN OUTCOME MEASURES:

Leg alignment reactivity: An increase in leg alignment discrepancy (yes or no) following a metered pressure challenge to a vertebra.

RESULTS:

On average, stability was poor at T3-T7 (Kappa = 0.04), moderate at C1 (K = 0.47), and fair for sham pressure tests (K = 0.30). Responsiveness: The proportion of positive baseline leg alignment reactions that responded (became negative) to sham adjustment was 95% at T3-T7 and 55% at C1. Further analysis was untenable since too few vertebrae were implicated for an adjustment.

CONCLUSIONS:

For the population investigated, the majority of the responsiveness of the leg alignment diagnostic test to a rotatory adjustment appears to be a diagnostic illusion (i.e., background noise unrelated to a treatment intervention). Further research with different subject populations, regions of investigation, leg alignment measurement techniques and vertebral challenge techniques are indicated.


J Manipulative Physiol Ther. 1993 Jun;16(5):306-11. [PMID:8345313]

Author information: Haas M, Peterson D, Rothman EH, Panzer D, Krein R, Johansen R, Solomon S. Research Department, Western States Chiropractic College, Portland, OR 97230.

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Abstract

OBJECTIVE:

A study was undertaken to assess the reliability of detecting leg alignment changes (reactivity) and to determine if the observed leg alignment reactivity can be attributed to a rotatory articular pressure challenge.

DESIGN:

Prospective double-blind crossover trial of a diagnostic test.

SETTING:

Laboratory: Center for Technique Research.

PARTICIPANTS:

Forty-two chiropractic college students, faculty and staff.

INTERVENTIONS:

A standardized force of 2 or 3 kg was applied with a 1 cmrubber-tipped pressure algometer on the lateral aspect of the T3-T7 spinous processes and the posterior aspect of the lateral masses of C1.

MAIN OUTCOME MEASURES:

Leg alignment reactivity: an increase in leg alignment discrepancy (yes or no) following a diagnostic intervention.

RESULTS:

The reliability for detecting leg alignment reactivity was poor: on average, Kappa = 0.05 in the thoracics and 0.06 at C1. On average, the attributable risk of leg alignment reactivity (pressure test risk–sham test risk) was less than 4%. In many cases, the sham rate was greater than the pressure test rate.

CONCLUSIONS:

For the population investigated, leg alignment reactivity to rotatory pressure testing can, in the majority of cases, be attributable to background noise. This procedure was not found to be viable for identifying vertebrae for adjustment. Further research with different subject populations, regions of investigation, leg alignment measurement techniques and vertebral challenge techniques are indicated.


J Manipulative Physiol Ther. 1993 May;16(4):220-7. [PMID:8340716]

Author information: Haas M, Peterson D, Panzer D, Rothman EH, Solomon S, Krein R, Johansen R. Research Department, Western States Chiropractic College, Portland, OR.

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Introduction:

Changes in apparent leg length (LL) (leg  retraction) have been used by many as a means of locating subluxation in  various joints. The leg check is based on the assumption that unequal  muscular contraction (e.g. hyper irritable muscles) about the spine and  pelvis have the ability to retract one leg relative to the other.  Despite claims of usefulness, many problems are inherent in the prone  leg check such as: a) measurement error; b) subject positioning by the  examiner (expectancy bias); c) interference with the surface of the  examination table; d) possible overwhelming effects of large muscles  over smaller intersegmental muscles and; e) lack of information of the  validity of subluxation (eg. segmental aberration) and it’s supposed  neurological effects. While observation of leg retraction has not yet been  correlated with patient outcome or health measures, it is implied that  the phenomenon apparent changes in LL occur due to altered tonic neck  and back reflexes which coordinate spinal movements and posture. A video  recording has been made of a patient who exhibited an unusually large  amount of leg retraction which appeared to be due to asymmetrical  contraction of their supra-pelvic musculature upon maneuvers such as  tucking their chin.

Objective:

The purpose of this study is to quantify  the involuntary movements which nave been observed about the spine,  pelvis and extremities using a 2D motion analysis system.

Methods:

A subject exhibiting a large involuntary leg  retraction will be sought. The patient will be positioned prone on an  adjusting table. Retro reflective markers will be placed about their  spine, pelvis and extremities. The markers will be recorded by two video  cameras during maneuvers which cause the leg to retract.

Results:

This data will yield 2D maker locations which will be used to quantify the amount and type of movement.

Conclusion:

Despite claims of utility of the prone leg  check to locate subluxation and treatment success, many confounders  occur. Lack of objective documentation and theoretical basis of the leg  retraction phenomena has hindered its acceptance as an examination  procedure. Only indirect evidence exists for its validity in several  small observational studies where it was used to determine were to  adjust. Motion analysis, and EMG studies may help in understanding the  physiology of this phenomena using. Further work is necessary to  correlate the relationship of leg retraction to other methods of  subluxation assessment, treatment outcome and patient health status, if  any.


Reference: Paul J. Osterbauer,DC; Arlan W. Fuhr,DC. Proceedings of the California Chiropractic Foundation’s 7th Annual  Conference on Research and Education, June 19-21,1992; pp.291-292.

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Abstract

The interexaminer reliability of noninvasive methods of examining lumbar spinal segments is not well established. In this project the interexaminer reliability of three experienced chiropractic examiners, who evaluated 21 symptomatic and 25 asymptomatic subjects, was explored. Eight noninvasive segmental examination strategies (dimensions) were employed at each spinal segment from T11/T12 through L5/S1. Marginal to good agreement beyond chance was noted for palpatory pain over osseous structures and in paraspinal soft-tissues. Weaker and less frequently, significant concordance between examiners was noted for detection of temperature differences (greater than or equal to 1.5 degrees F) between adjacent segments and for visual inspection for segmental abnormality. Little significant agreement between examiner was found for active and passive motion palpation, muscle tension palpation and misalignment palpation. This study suggests that “subjective” findings (pain) may be among the most reliable of conservative spinal observations. Weak but significant correlations were found when positive findings for the eight dimensions at each lumbar segment were summed to form a composite joint abnormality index. When the multidimension index was developed using the four most reliable dimensions, slightly stronger correlations were found. The strongest agreement between examiners tended to be found in the lower lumbar spine.


J Manipulative Physiol Ther. 1990 Oct;13(8):463-70. [PMID:2146357]

Author information: Keating JC Jr, Bergmann TF, Jacobs GE, Finer BA, Larson K. Palmer College of Chiropractic/West, Sunnyvale, CA 94087.

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Abstract

A series of blinded studies to determine the feasibility of documenting functional leg length inequalities and changes in functional leg length in normal and non-normal patients were performed. A new apparatus designed to minimize or eliminate subjective components of inequality assessment, while attaining high levels of precision, was developed. Subjects were evaluated for presence of cervical spine lesion by five independent examiners and grouped into “lesioned” and “nonlesioned” categories. Subjects’ leg length inequalities were measured by different evaluators as well as multiple measurements by a single evaluator to determine interrater and intrarater reliability coefficients. Measurements were taken on both flat and hi-low tables for changes during active cervical spine rotation. In addition, leg length measurements were taken during induced tetanic contraction by ipsilateral galvanic paravertebral muscle stimulation. Results indicated an absence of any significant effect of head rotation, type of table, galvanic stimulation, or any difference between persons classified as cervically lesioned or not cervically lesioned. Interrater and intrarater reliability coefficients for the measuring apparatus were statistically significant with small error variances. Failure to obtain subjects with frank pain as well as absence of an applied cephalad pressure (as is performed clinically) during leg length evaluation were considered as possible explanations for the failure to detect an effect of head rotation in the leg lengths. Discussion addresses the need for sensitive leg length inequality assessment techniques which eliminate subjectivity and contribute to decreased error variances.


J Manipulative Physiol Ther. 1989 Oct;12(5):364-8. [PMID:2607227]

Author information: Falltrick DR, Pierson SD. Research Department, Life Chiropractic College-West, San Lorenzo, CA 94580.

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