Chiropractic Subluxation Indicators

Leg Length InequalityThermography

PalpationSpinographic X-Ray

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

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 2002;46(4)

The Evidence-Based SubluxationOperational 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 2002;46(4)

The Evidence-Based SubluxationWhat 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 2002;46(4)

The Evidence-Based SubluxationStill, 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 2002;46(4)

Finding the UC Subluxation Posture Thermography Palpation X-Ray

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.

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.

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

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

Pelvic UnlevelingLeg 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 > 4mm (1/8 inch)

Pelvic UnlevelingImportant 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

Anatometer

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

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 Association’s Council on Scientific

Affairs, 1987

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).

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.

Thermometry

ThermometryPattern 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 2004;27:109-17

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 2004;27:155-9

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 2004;27:155-9

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 2004;27:155-9

ThermometryResults: 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 2004;27:109-17

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/PhysHtml/Publ.DocumentationOf.htm

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.

Scanning PalpationFindings 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

Upper Cervical X-Rays Palmer Hole-In-One, Palmer Upper Cervical

(PUC) Orthogonal Studies

NUCCA, AO, ORTHOSPINOLOGY Articular Studies

BLAIR, KESSINGER (KCUCS)

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.

Normal Alignmentvon 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.

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.

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.

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.

AsymmetryFebbo 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 > 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; 67:269

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 < .0001).

The scatterplot revealed values widely dispersed about the regression line, and the standard error of the estimate was 36.7.

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).

Van Roy P, Caboor D, DeBoelpaep S, Barbaix E, Clarys JP. Man Therapy, 1997; 2{1):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.

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.”

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.

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).

Eriksen’s editorial comment

X-rays

Lateral Vertex Nasium

X-rays

Base Posterior Right Protracto Left Protracto APOM

Left Lateral stereo, Right Shift

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

Orthogonal X-rays Nasium Vertex Neutral Lateral

Post x-ray for correction validation

Blair X-Ray’s 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