Chiropractic Subluxation Indicators

1
Chiropractic Subluxation Indicators

• Leg Length Inequality
• Thermography
• Palpation
• Spinographic X-Ray

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Chiropractic Subluxation Indicators

• The Specific Upper Cervical Chiropractic
  Spinograph is the most important and significant
  analytical tool used by the chiropractor to
  determine misalignment.
• The following assessment tests are used to
  determine the presence of neurologic
  interference.
• The presence of misalignment on x-ray with a
  positive, persistent and consistent indicator
  subluxation

3
Subluxation

• A complex of function and/or structural and/or
  pathological articular changes that compromise
  neural integrity and may influence organ system
  function and general health.
• Association of Chiropractic Colleges

Owens, E. J Can Chiropr Assoc 200246(4)
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The Evidence-Based Subluxation

• Operational Definitions of Subluxation
• Technology Assessment (Osterbauer)
• using palpation, ROM, LLI, VAS.
• P.A.R.T.S. (Bergmann, Finer)
• Function Definition (Owens, Pennacchio)
• Pattern Analysis, LLI, X-ray, Palpation
• Functional Spinal Lesion (Triano)
• Structural approach, buckling

Owens, E. J Can Chiropr Assoc 200246(4)
5
The Evidence-Based Subluxation

• What is needed?
• An operational definition which describes
  Subluxation in the measurements used to locate
  it.
• A definition which can be tested for reliability
  and validity.

Owens, E. J Can Chiropr Assoc 200246(4)
6
The Evidence-Based Subluxation

• Still, no definition gives detail as to how the
  nervous system is effected in the Subluxation.
• What is needed to help define the neurologic
  component of subluxation?
• Tests
• Reliable (repeatability)
• Validated (accuracy, does the test do what it
  says it does)

Owens, E. J Can Chiropr Assoc 200246(4)
7
Finding the UC Subluxation

• Posture
• Thermography
• Palpation
• X-Ray

8
Pelvic Unleveling

• Lawrence reminds us the functional short leg is
  not measurement of a changing leg length but a
  distortion of the pelvic and lumbar biomechanics.
  
• For this reason, the term pelvic distortion may
  replace the LLI measurement for the functional
  short leg.

9
Pelvic Unleveling

• Upper Cervical Chiropractors have reported that
  90 of their patients can be balanced after the
  reduction of he UC subluxation.
• Test it, get them up and have them walk, then
  recheck.

10
Pelvic Unleveling

• Proprioceptive impulses from nerve endings in
  ligaments, joint capsules, tendons, and muscles
  form a very large part of the input pattern and
  are most closely related to postural tone.
• Other afferent fibers from the muscle spindles
  carry impulse patterns about muscle length to the
  CNS, where patterns must be integrated in higher
  centers with patterns of changing tension and
  position that have originated in other
  proprioceptors.

Bailey. J Am Osteopath Assoc, 1978 77(6)452-455
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Pelvic Unleveling

• Muscle tension is maintained by negative feedback
  from integrative centers in the central nervous
  system.
• When the normal function of any part of the
  somatic system is exceeded, a vicious cycle of
  dysfunction is initiated.
• Dysfunction may involve visceral as well as
  somatic structures.
• Maintenance of normal mobility of all components
  of the somatic system helps minimize the stress
  of gravity and of postural imbalance.

Bailey. J Am Osteopath Assoc, 1978 77(6)452-455
12
Pelvic Unleveling

• Leg Check Reliability
• The observed difference (no measuring tool) in
  leg length is reliable within 3/8 of an inch
  (mean SD)
• The measured (measuring tool used) is reliable to
  within 1/8 of an inch
• Compressive leg checks have shown the greatest
  degree of reliability
• The difference in a pre/post measurement should gt
  4mm (1/8 inch)

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Pelvic Unleveling

• Important factors for the Leg length Measurement
• Proper patient positioning
• Proper doctor positioning
• Measurement must be taken from he vertical plane
• Noise in the system must be reduced and
  accounted for
• Patient movement, doctor movement, accommodation

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Anatometer
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Anatometer

• Measures pelvic distortion in the frontal
  (horizontal), transverse (rotatory), and fixed
  point (vertical) planes, as well as weight
  difference from side to side.
• It is hypothesized that after a successful
  reduction of an atlas subluxation, the pelvis
  will return to zero degrees in all three planes.
• Studies have shown evidence of reliability and
  validity in pre/post postural measurements with
  the Anatomitor

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Thermometry

• Thermocouple direct contact with the skin
• Infrared allows for no contact with the skin
• Both have shown to be reliable in producing
  pattern
• When enough constant features are found, the
  patient is considered in pattern and most
  likely in a subluxated state
• Thermographic study of patients with spinal root
  compression nearly always reveals thermal
  asymmetry... the American Medical Associations
  Council on Scientific Affairs, 1987

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Neurophysiologic Basis For Infrared
Dermothermographic Scanning

• Infrared imaging detects and analyzes the
  cutaneous infrared emissions of the body.
• These surface thermal patterns are a direct
  reflection of the sympathetic and sensory nervous
  system's control over the dermal
  microcirculation.
• The main controlling factor, however, is the
  sympathetic division.
• This division of the autonomic nervous system
  controls the vasodilatory and vasoconstriction
  action of the body's arterial supply.
• Theories espoused around the turn of the century,
  and before, professed that the source of this
  surface heat came from internal areas of the body
  (chiropractic - heat from nerves, medicine - heat
  from diseased organs).

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Thermometry

• Landmark research on the origin of skin surface
  temperature regulation has since clarified these
  theories.
• In several studies, independent heat sources of
  significant magnitude were placed at varying
  depths under the skin and an attempt to detect
  the heat source was made with sensitive thermal
  instruments.
• It was found that if a heat source was placed 5
  mm or more under the skin it could not be
  detected. Consequently, if skin surface
  temperatures are altered in any way, it must be a
  direct reflection of the controlling factors
  involved in the regulation of the dermal
  microvasculature.

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Thermometry

• Pattern analysis of paraspinal heat differentials
  is based on the following 3 points
• Skin temperature is largely under the control of
  the sympathetic nervous system.
• The nervous system should be changing, adapting,
  to meet internal and external demands on the body
• The degree of dynamicness, the extent to which
  the nervous system is dynamic (adapting to meet
  internal and external demands of the body), can
  be assessed by comparing sequential skin
  temperature readings

Hart, Owens Jr. J Manipulative Physiol Ther
200427109-17
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Thermometry

• Indirect measures of neural function, including
  paraspinal thermography, have been used to assess
  the impact of vertebral subluxation on the
  nervous system.
• Thermocouple devices were used in chiropractic as
  early as 1924 to measure the side-to-side skin
  temperature difference, with the information used
  as a clinical indicator of the need for vertebral
  adjustment.
• Plaugher et al showed fair to good interexaminer
  reliability for the Nervoscope device as it is
  used to locate segmental side-to-side temperature
  differences, as well as moderate to excellent
  intraexaminer reliability.
• DeBoer et al specifically tested interexaminer
  and intraexaminer reliability of an infrared
  system and found very high reliability.

Owens et al. (J Manipulative Physiol Ther
200427155-9
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Thermometry

• 2 examiners assessing the same patient on 2
  occasions. Thirty asymptomatic students served as
  subjects
• The left and right channel data show slightly
  higher congruence than the Delta channel.

Owens et al. (J Manipulative Physiol Ther
200427155-9
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Thermometry

• Conclusion Intraexaminer and interexaminer
  reliability of paraspinal thermal scans using the
  TyTron C-3000 were found to be very high, with
  ICC values between 0.91 and 0.98.
• Changes seen in thermal scans when properly done
  are most likely due to actual physiological
  changes rather than equipment error.

Owens et al. (J Manipulative Physiol Ther
200427155-9
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Thermometry

• Results
• Cervical spine temperatures remained relatively
  constant while lower back temperatures, in
  general, decreased for the entire 31-minute
  recording period. Although the results varied
  among subjects, on the average, the patterns
  stabilized after 16 minutes.
• Conclusions
• the pattern becomes stable after 16 minutes.
• Readings taken for the purpose of pattern
  analysis during this 16-minute period may be
  unreliable for some patients.
• a 16-minute acclimation period is recommended.

Hart, Owens Jr. J Manipulative Physiol Ther
200427109-17
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Palpation

• When the scanning palpation is positive in the
  C-1 and C-2 area it relates to direct
  neurological insult or neurological insult with
  resultant trigger point.
• When the scanning palpation is positive from C-3
  to C-7 it relates to muscle spasms, contractions,
  trigger points, and posterior zygapophyseal joint
  compression.

http//www.atlasorthogonality.com/PhysiciansSite/P
hysHtml/Publ.DocumentationOf.htm
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Scanning Palpation

• Scanning Palpation Scanning palpation is the
  tactile examination of the cervical spine with
  objective findings of muscular spasms,
  contractions, enlargements, swelling or osseous
  protuberances.
• Subjective findings will be extreme tenderness,
  pain, hypersensitivity, hyperirritability and
  neurological insult in the positive palpated
  areas.

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Scanning Palpation

• Findings from the examination are classified as
• Including taut muscle fibers, trigger points and
  edematous soft tissue.
• Palpation in the cervical spine may also reveal
  osseous prominences and facet joint rigidity.
• Grading Scanning Palpation
• 1 Mild
• 2Moderate
• 3 Severe

SWEAT. JAN/FEB,1988 The Digest of Chiropractic
Economics
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Upper Cervical X-Rays

• Palmer Hole-In-One, Palmer Upper Cervical (PUC)
• Orthogonal Studies
• NUCCA, AO, ORTHOSPINOLOGY
• Articular Studies
• BLAIR, KESSINGER (KCUCS)

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Eriksen K, Upper Cervical Subluxation Complex, a
review of the chiropractic and medical
literature. 2004 Lippincott, Williams Wilkins,
Baltimore, MD

• Spinographs are to be taken in the Neutral Plane
• It is apparent that there is some variation in
  the literature, although the consensus is that
  there is very little movement between these
  joints in lateral flexion, rotation, and
  translation (with the exception of atlanto-axial
  rotation).
• These are the main movements that upper cervical
  chiropractors are concerned with in assessing the
  occipito-atlanto-axial subluxation complex.
• The limited motion at the CO-C1 articulation
  tends to occur at the extremes of motion.
• The lateral, nasium, and vertex cervical views
  are taken in the neutral position, so
  theoretically little or no misalignment should be
  measured for atlas laterality and rotation.

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Normal Alignment

• von Torklus D, Gehle W. The Upper Cervical Spine,
  Regional Anatomy, Pathology and Traumatology A
  Systematic Radiologic Atlas and Textbook. Grune
  Stratton, New York, 1972.
• normal atlas alignment has the anterior arch
  being horizontal.
• Uncoordinated movement between atlas and axis can
  result in kyphosis as a compensating mechanism.

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Normal Alignment

• The important observations are that the atlas
  sits squarely upon the axis with the dens
  equidistant between the lateral masses of the
  atlas, that the lateral atlanto-axial joint
  spaces are open and their contiguous surfaces
  parallel,
• that the lateral margins of the lateral
  atlanto-axial surfaces are precisely superimposed
  and symmetrical, and that the bifid spinous
  process of the axis is in the midline.

Harris JH. The Radiology of Acute Cervical Spine
Trauma, Third Edition, Williams Wilkins,
Baltimore/London, 1996.
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Gregory RR. Biomechanics of C1 Subluxation
Production. Upper Cervical Monograph, 1988
4(5)12.

• . . . all vertebrae are capable of a normal range
  of motion only if they align to the vertical
  axis, i.e., are in their normal positions.
• When in their normal positions, they can execute
  concentric (from a common center) motion. To the
  extent that they deviate from the vertical axis,
  or normal position, they execute eccentric
  (off-center) motion, resulting in an abnormal
  range of motion.
• The cause of an abnormal range of motion lies in
  a displaced vertebra the correction of the
  abnormal range of motion lies in restoring the
  vertebra or vertebrae that are displaced.

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Sweat RW. Atlas Orthogonality, Part One of
Three.Today's Chiropr, 1983 12(2)10-14.

• OR-THOG-O-NAL-I-TY (N) - the quality or state of
  being orthogonal.
• OR-THOG-O-NAL (ADJ) - having to do with or
  involving right angles, intersecting at right
  angles, mutually perpendicular.
• In abnormal or congenital conditions where one
  occipital condyle is higher than the other,
  innate always tries to adapt by having one
  lateral mass wider than the other, or one side of
  the axis body higher than the other side to keep
  the body balanced as vertical as possible.
• In our orthogonal adjusting procedure we are
  always trying to make the head vertical, the
  atlas horizontal, and the cervical spine vertical.

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Asymmetry

• Febbo T, Morrison R, Bartlett P. A. Preliminary
  study of Occipital Condyle in Dried Specimens.
  Chiropr Technique 1990 2(2)49-52
• out of 24 skulls measured to assess their
  bilateral symmetry. Differences in a)
  longitudinal diameter, b) transverse diameter,
  and c) convergence angles were measured.
• In every film analyzed there was a difference in
  left/right measurements. These differences in
  individual measurements, however, were not
  sufficient to claim statistical significance (p gt
  0.05).
• Mysorekar and Nandedkar studied the effect of
  human beings' tendency to incline their heads
  predominantly to one side or the other. They
  examined 101 skulls and found that "the occipital
  bones tend to have larger condyles on the right
  side" Ellertsson AB, Sigurjousson
  K,ThorsteinssonT. Clinical and Radiographic Study
  of 100 Cases of Whiplash Injury. Acta Neurol
  Scand (Suppl), 1978 67269

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Febbo TA, Morrison R, Valente R. Asymmetry of the
Occipitai Condyles A Computer-Assisted Analysis,
J Manipulative Physiol Ther, 1992 15(9)565-569.

• 151 submentovertex radiographs were randomly
  obtained.
• Main Outcome Measures Surface area of left and
  right condyles for 151 examined pairs.
• Results Analysis with Pearson's correlation
  coefficient implied a lack of symmetry between
  condyles (p lt .0001).
• The scatterplot revealed values widely dispersed
  about the regression line, and the standard error
  of the estimate was 36.7.

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Gottlieb MS. J Manipulate Physiol Ther, 1994
17(5)314-320

• Palpation and unaided visual examination was
  performed on thirty atlases. The shape, size,
  angle, texture, border, and number or superior
  articular facets on each atlas were recorded to
  determine symmetry.
• Results The classically described kidney-shaped
  facet was an infrequent finding.
• Upon comparison of right and left sides, none
  (0) of the facets were mirror images of
  symmetry, while nineteen of the atlases (63) had
  grossly asymmetrical facets, and eleven out of
  thirty atlases (37) had facets which were only
  slightly asymmetrical in regard to shape, border,
  depth, and angle.
• Furthermore, seven of the nineteen grossly
  asymmetrical atlases (37) had three or four
  separate superior articular facets. Three atlases
  had two facets on the left and one on the right,
  while two atlases had two facets on the right
  with a single facet on the left, and two atlases
  had four superior facets (two on each side).

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Van Roy P, Caboor D, DeBoelpaep S, Barbaix E,
Clarys JP. Man Therapy, 1997 21)24-36.

• This study found that upon examining 82 atlas
  vertebrae, the posterior arch showed the highest
  number of asymmetries.
• They found unequal grooves for the vertebral
  artery, tropism of the superior facets, frequent
  asymmetries of the atlas transverse processes and
  foramina.

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If such asymmetry exists, how can orthogonal
cervical alignment be considered normaft As Dr.
John D. Grostic so clearly stated?

• The Grostic Procedure did not dictate the
  "normal position" of the atlas. It instead
  provided a system of measurement that made
  possible the locating of that position of the
  atlas that resulted in the removal of abnormal
  clinical findings for the greatest period of
  time.
• This procedure no more dictates the "normal"
  position of atlas than physiology texts dictate
  the normal oral temperature to be 98.6 degrees.
• The Procedure has made it possible to observe
  clinically the effect of various positions of the
  atlas on the findings of clinical tests.

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X-ray designed to account asymmetry

• William G. Blair, DC, developed his upper
  cervical chiropractic procedure in part because
  of his concern over asymmetry in this region of
  the spine.
• 79 asymmetrically anterior to the contralateral
  condyle.
• 77 the foramen magnum apex turned off center.
• 77 short occipital condyle compared to the
  contralateral side when compared with the orbital
  floor.
• 64 short condyle compared with a baseline of the
  skull.
• 66 short condyle compared with a vertical median
  line.
• C2 odontoid process is off-center of the axis
  body in 57 of cases.

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Asymmetry

• When significant architectural asymmetry exists
  in occipito-atlanto-axial articulations, there
  usually appear to be developmental adaptations.
  For example, when one occipital condyle appears
  shorter, the atlas lateral mass and/or the axis
  superior articulating surface has been commonly
  observed to be larger on the ipsilateral side.
• This could be true particularly if an injury
  occurred at birth and the body adapted over time
  to improve the architectural balance.
• Dr. Blair believed that the upper cervical
  subluxation occurred at the articulation and
  required a different approach to its analysis, in
  comparison to the orthogonally-based procedures.
• (Grostic/Orthospinology doctors have observed
  this asymmetry to occur in -20 of cases in
  clinical practice).

Eriksens editorial comment
42
X-rays
Lateral Vertex
Nasium
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X-rays
Base Posterior Right Protracto Left
Protracto APOM
Left Lateral stereo, Right Shift
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Palmer Hole-In-One, Palmer Upper Cervical (PUC)

• Base Posterior
• Anterior-Posterior Open Mouth (APOM)
• Neutral Lateral
• Nasium
• Anterior-Posterior Cervical (AP Cervical) may
  also be included

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Orthogonal X-rays

• Nasium
• Vertex
• Neutral Lateral
• Post x-ray for correction validation

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Blair X-Rays

• Used by the Blair and Knee Chest Upper Cervical
  Specific techniques.
• Articular Study of the cervical spine.
• Series includes (along with APOM, AP cervical
  and the Lateral cervical)
• Base Posterior
• Left and Right Oblique Nasium (Blair Protractos)
• Stereo Lateral Cervicals