John Hart, D.C. and others*

April 2000

This study compared the inter-examiner reliability of two approaches for determining vertebral alignment of the upper cervical spine: 1. by x-ray and 2. by palpation. The study also compared final x-ray listings to final palpation listings. A statistical analysis was performed for the individual parameters for both x-ray and palpation. Twenty out of a total of thirty (66.6%) x-ray paramters had acceptable percent agreement (Po) scores compared to eight out of thirty-five (22.8%) for palpation that had acceptable percent agreements (Po). Six out of the thirty x-ray parameters had acceptable kappa scores. There were no palpation scores that had acceptable kappa scores. There were 15 segments listed according to x-ray out of a total of 62 (24.1%) possible segments (atlas and axis for 31 patients) that had very good agreement between x-ray examiners for a final listing. There were 6 out of 62 (9.6%) segments for palpation that had very good agreement between the palpation examiners for a final listing. There was one segment (out of 62) where both x-ray examiners agreed with each other for a final axis listing, and where the palpation examiners also agreed with each other for their final axis listing, but between the x-rayers and the palpators, there was not such an agreement for this segment. There were 19 out of 31 atlases (61.2%) where the x-ray examiners agreed on laterality-only, compared to 12 out of 31 (38.7%) for palpation. There were 16 out of 28 (57.1%) axes where the x-ray examiners agreed on axis body laterality, compared to 8 out of 31 (25.8%) agreement between palpators. In this study, x-ray was a little more reliable than palpation.

* Acknowledgement of others who participated in this research:

Sherman faculty who performed either the x-ray analysis (x) or the palpation analysis (p) along with the number of cases examined:

Sherman interns who performed either the x-ray analysis (x) or palpation analysis (p):

Sherman interns, and their patients, for agreeing to participate in this study.

Ed Owens, D.C. for his advice concerning the scientific method for this project.

Sherman College administration for their support of this project.

Dissecting the Prone Leg Check

Alan Hartley

According to theory, the presence of Leg length Inequality (LLI), barring physical defect, is indicative of an asymmetry in the underlying neuromuscular tone of the body, supposedly caused by the presence of vertebral subluxation. While much effort has been expended in assessing the intra- and inter-examiner reliability of the prone leg check, we contend that it is, at present, an interesting clinical observation that requires accurate description before its significance can be explored.

Most descriptions of the prone leg check include the application of a slight cephalad force through the long axis of the legs. We have developed a system to measure these forces using calibrated force transducers (LBC-100, Transducer Techniques) affixed to the heel and through which the cephalad force is applied for each leg. In a pilot study, comprising six DCs, three student doctors and 6 randomly selected patients; we found the average force applied was 5.54 lb to the left leg and 5.64lb to the right leg. The range of force used by different doctors was 0.75lb to 11.14lb. The slight right-sided bias may reflect the handedness of the doctor (all but one doctor was right handed). The doctors were internally consistent, most operating within +/- 0.5lb difference left to right. We found no statistical relationship between side of perceived LLI and side of greatest force application. The amount of force required to cause previously unbalanced legs to become balanced was significantly larger (by a factor of 10) than the average difference in applied force left to right.

Chiropractic and The Immune Response: A Literature Review

Kathryn T. Hoiriis, BS, DC, David Edenfield, BA

Abstract

Objective: This review of the literature focuses on published research in which immune response to nervous system influence has been observed. The primary objective of this review is to investigate and document the scientific evidence that supports a correlation between subluxation, chiropractic adjustments and the immune system.

Data source: Online searches were performed using National Library of Medicine PubMed, Mantis and world wide web medical and non-medical search engines using key words of chiropractic, chiropractic adjustment, spinal manipulation, mechanical stimulation, neuroimmunology, and immunology.

Study selection: To date, twenty-eight research articles have been retrieved from the search. Three animal studies were included in this review. At least seven articles report on clinical trials with relevant findings to the specific effects of nervous system by quantifiable methods i.e. detecting concentrations of cells and/or soluble factors of immunity. Other articles have reported on various biological rationales for neuroimmune mechanisms and the relationship to the spine. Twenty-one percent (6/28) of the articles selected were found in the Journal of Manipulative and Physiological Therapeutics. Some additional sources were the Chiropractic Research Journal, Spine, Annals of Neurology, Journal of Neuroscience, and Medical Times.

Discussion: This investigation was aimed at identifying whether there is evidence to demonstrate a cause and effect relationship between subluxation and immunologic function and further, whether chiropractic spinal adjustment positively influences the immune response. Our evaluation of the literature is in progress.

A New Approach to the Upper Cervical Specific, Knee Chest Adjusting Procedure

Robert Kessinger, DC

Dessislava Boneva, DC

Abstract

Purpose: The purpose of this paper is to outline an original upper cervical knee chest adjusting procedure for correction of the atlas and axis subluxation.

Methods: A retrospective study has been performed on a random selection of patients receiving the upper cervical knee chest adjusting procedure outlined in this presentation. Pre and post examinations have been performed on various patients. These examinations include x-rays (Blair Protracto views and neutral lateral views), infra-red spinal thermography, leg length equality, computerized dual inclinometry range of motion and muscle testing, and various laboratory observations.

Results and Conclusions: The findings of this retrospective study lends validation to the proposal that the upper cervical specific, knee chest adjusting procedure presented is a viable method for correction of the upper cervical subluxation.

The functional "short leg"; physiological mechanisms and clinical manifestations

Leg length inequality (LLI) is one of the most common subluxation/postural analysis checks used by chiropractors. This presentation seeks to expose and examine the complexities of LLI, propose a mechanism of action, outline suggestive evidence and present possible clinical manifestations.

LLI is divided into two groups; anisomelia or actual anatomic asymmetry (aLLI) due to injury, disease and developmental asymmetry, and physiologic/postural or functional (fLLI) which is suspected of being due to hypertonicity in supra-pelvic and pelvic muscles (1-5).

In most examinations of the LLI phenomenon, anatomic and functional are not differentiated from one other. However, these two types of LLI differ as to their cause and may be expected to produce dissimilar signs and symptoms.

Radiographic and orthopedic methods have been developed to determine LLI. Orthoroentgenography, a radiographic technique that measures actual bony leg length, is the preferred method when planning for surgical equalization of leg lengths of children and young adults (6). Studies done using orthoroentgenography have found anatomic LLI to be both frequent (6) and, when less than 19mm (~¾ in), not related to chronic back pain (6-8). This data lends credence to the belief that anatomic LLI is so common as to be a normal variant (9).

Pelvic x-ray of femoral head height as a method to determine aLLI is often flawed due to patient positioning, central ray location and biomechanical alterations of foot structure (2). Pelvic x-ray results also differ significantly compared with orthoroengenography in determining aLLI (7).

Non-weight bearing leg check tests are thought to be demonstrative of functional LLI. These tests have the advantage of being technologically simple, have been shown to be inter- and intra-examiner reliable (10-13), and are thought to assess activity of pelvic and supra-pelvic muscles.

Initially, the idea of muscular contraction causing fLLI looks simple and straightforward. However, difficult questions remain to be answered; for instance, how can muscles hypothetically causing fLLI stay tonically active for long periods of time? Long-term muscle contraction is a problem with functional leg length inequality that is often overlooked, but one that must be addressed.

Prolonged muscle contraction depends, in part, on the type fibers that make up the muscle. Type II fibers provide for fast, powerful contractions. An example would be the gastrocnemius muscle – think sprinter. Type I muscle fibers allow for slow, sustained contractions that may not be subject to fatigue (14). An example muscle would be the soleus, a postural muscle – think marathoner

In erector muscles, including longissimus, iliocostalis and multifidus, there is a general trend (54-73%) towards increased concentrations of the slow, postural type I fibers (15). Interestingly, the rhesus monkey has a lower proportion of type I fibers in the back muscles when compared with the human. The monkey is mainly quadrupedal, with the vertebral column mostly in a horizontal position, so fewer type I fibers are required for postural tone and balance (15).

Muscle fibers, in order to undergo contraction, need blood flow for nutrient supply and waste removal. Yet contraction itself reduces vascular flow. How can the muscle fibers get blood flow during contraction, especially if that contraction has to be endured for long periods of time?

There is a phenomenon called sub-maximal contraction in which the intramuscular blood supply has the capability of supplying a muscle contracted at a low level. Contraction intensity above the sub-maximal level – called the critical force point – causes ischemia and loss of the muscle’s ability to continue the contraction. Typically, sub-maximal contraction amounts to a 30% maximal voluntary contraction (MVC) (16) or less in most muscle, to 40% MVC or less in erector muscles (17). Another way to maintain steady contraction is through substitution/rotation of muscle fasciculi (18-20).

As a muscle contracts, the metabolites generated signal the CNS initiating what is called the pressor reflex which alters physiology in order to increase blood pressure, thus forcing blood through the contracted muscle (21-23). The pressor reflex is powerful. An experiment in which the metabolic products of contraction were trapped in the flexor muscles of the little finger there was an overall increase in systolic blood pressure of 70 mm Hg (22). The pressor reflex in response to muscle contraction metabolites causes changes in blood pressure by altering the heart rate (21,24,25), lung (21,24) kidney (26,27) and adrenal gland function (28), skin (24,25,29), and spleen blood flow (30) and sympathetic stimulation of the glucoregulatory system (31).

Given Type I muscle fibers and the pressor reflex, long-term sub-maximal contractions that could produce fLLI are physiologically possible. Indeed, there are several lines of evidence for the existence of long-term sub-maximal muscle contraction, including clinical case studies of reversible long-term postural distortion (32,33). The stiffness and tension of the erector spinae in subjects with chronic back pain (34) implies long-term sub-maximal contraction. Postural reflexes have been shown to cause long-term tonic changes in muscle tone (e.g., tonic neck reflexes) (35-37). Some EMG studies have demonstrated chronic sub-maximal contraction in subjects with back pain (38-41). Muscle damage and wasting, noted in chronic back pain, is associated with ischemia (42-45), as is muscle weakness/fatigue (46,47). A most interesting possible sign of chronic sub-maximal muscle contraction is the alleviation of organic symptoms potentially related to the pressor reflex (48-50), which, as outlined above, can alter a wide variety of organic functioning.

Clinically, chronic sub-maximal contraction and the effects of the pressor reflex may be noted in patient examination. Recall that the physiology of critical force or sub-maximal contraction involves a dynamic equilibrium between sufficient and insufficient (causing ischemic pain) blood supply to the working muscle. Signs and symptoms of long-term muscular contraction include complaints of pain during extended resting (e.g. sitting for long periods of time, lying in bed); any active sub-maximal contraction unopposed by motion/stretching could lead to metabolic build-up and ischemic pain. Other signs include the rapid onset of pain with strenuous exercise (e.g. intermittent claudication). In the case of sub-maximal contraction, the muscles are already partially contracted, and as they are more heavily worked, blood flow is further reduced causing pain. Pain from chronic sub-maximal contraction is often relieved with stretching and mild motion/exercise/massage that acts to increase blood flow. Pain relief also comes with heat that promotes vascularity. Finally, a symptom of chronic sub-maximal muscle contraction may be organic symptoms due to the effects of the pressor reflex, including chronic changes in the blood pressure, heart, lungs, kidneys, spleen and glucoregulatory system.

Chronic sub-maximal muscle contractions are physiologically possible, and signs of such contractions, while mostly indirect, are abundant. Such muscular contractions may be responsible for the postural distortion of functional leg length inequality and for a variety of somatic and organic signs and symptoms.

Bibiolography

Point Testing to Localize Lumbo-Pelvic Fixations

Illya Kondratyev MD, ND

BACKGROUND: Fixation is a component of the Vertebral Subluxation Complex that causes dysfunction of lumbo-pelvic motor units. Lesions that produce motion restriction may be located in the soft tissues of the muscles, joints and discs. Chiropractors have traditionally examined joints for subluxation restrictions. Muscular tissues are part of the motor unit and may contain lesions that should be corrected as part of a complete adjustment.

OBJECTIVE: To review both manual and computerized methods for analyzing specific fixation lesions in lumbar and pelvic motor units. Since corrective procedures are applied to precise points, testing will be directed towards locating these points or zones. Both segmental and postural considerations will be made in demonstration of this analysis procedure.

DISCUSSION: Joint fixations are intersegmental. Muscular fixations may be either intersegmental or zonal. Observations of posture and movement suggest areas of involvement. Manual palpation and special compliance testing instruments can locate exact levels and side of joint fixation. These same methods may be used to pinpoint muscular restrictions such as myofascial lesions, trigger points and tendonopathy.

CONCLUSIONS: The lumbo-pelvic area is the spine=s foundation and the location of the body center of gravity. All types of motion restrictions in this area should be located and effectively mobilized for the spine to be in proper compensation. Points of fixation in joints and muscles can be located by both manual and instrument methods. The testing procedure is fast and precise, so checking should also be done after adjustment to confirm results.

Improvement in Paraspinal Muscle Tone, Autonomic Function and Quality of Life in Four Children with Cerebral Palsy Undergoing Subluxation Based Chiropractic Care: Four Retrospective Case Studies

Dr. Matthew McCoy, Dr. Ekaterina Malokhova, Dr. Yuri Safronov

Regional Center for Chiropractic "Spine"

Vladivostok, Russia

Objective: To present results experienced by 4 patients with cerebral palsy who underwent chiropractic care to reduce vertebral subluxation.

Clinical Features: 4 children previously diagnosed with cerebral palsy secondary to birth trauma. All four demonstrated evidence of vertebral subluxation.

Interventions and Outcomes: Chiropractic care directed at reduction of subluxation was undertaken. Paraspinal Surface Electromyography and Thermography readings were taken prior to the initiation of care and approximately one month (12 visits) later. The mothers and care providers in each case monitored changes in activities of daily living and quality of life.

All four children showed improvement in paraspinal muscle tone (improved symmetry and decreased amplitude) as well as a decrease in the number of levels of abnormal thermography readings. All four children showed improvement in activities of daily living including mobility, feeding, and postural control.

Conclusion: Improvement in muscle tone and autonomic function coupled with improvement in activities of daily living occurred in these four patients undergoing chiropractic care for reduction of subluxation. It is suggested that larger studies of this nature be carried out.

The relationship between science, philosophy, and art in chiropractic research: the three-legged stool revisited

Ed Owens

The profession of chiropractic has been defined in many different ways and from various perspectives throughout its 105 year history. For example the definition of straight chiropractic used at Sherman College is "a vitalistic philosophy of life and health, and the art and science of locating and correcting vertebral subluxations in accordance with that philosophy. "

Other definitions may stress a scientific approach rather than a philosophic approach to patient care, but most descriptions concede that science, philosophy and art all play a part in the practice of chiropractic. This presentation will lay out a model of the interrelationships between philosophy, science and art in straight chiropractic as they apply to research and practice. Of particular interest are the interfaces between the approaches, areas where conflict and interchange arise.

Philosophy, particularly its branches of metaphysics and epistemology helps guide practitioners and research and gives meaning to the knowledge gained through scientific research. Ethics, another branch of philosophy, helps guide the daily practice of the chiropractic arts of locating and correcting vertebral subluxations.

Science interacts with philosophy in the way that deductions and approaches can be tested through an inductive process. Conflicts arise when the findings of science seem to contradict philosophic views. Science also interacts with the art of chiropractic in the way that scientific knowledge is applied in daily evaluation and care of patients.

Art is a cornerstone of chiropractic practice as it involves the patient to doctor interactions, particularly in the way that doctors use their sensitivity and experience to locate and correct subluxations. In many instances the doctor uses palpatory and communication skills that are crucial to the doctor patient interaction, but are very difficult to quantify from a scientific standpoint. Hence there are often conflicts between what is scientifically known or measureable, and what is felt by the doctor and patient. An evidence base that does not allow for the inclusion of the art in chiropractic may miss a most important aspect of the practice.

Using all three legs of the "three legged stool" allows us to derive a balanced definition of chiropractic that reflects the familiar elements of straight chiropractic: Chiropractic is the philosophy, art and science of the location, analysis and correction of vertebral subluxations in order to promote health.

The Theory of Chiropractic Pattern Analysis Based On The New Biology

Simon A. Senzon, M.A., D.C.

Abstract

It is a common practice amongst chiropractors to monitor physiological patterns of the body in order to decide when a chiropractic adjustment is necessary. A pattern is defined as when the body is not adapting to its environment in a regular, dynamic and healthy way. Some pattern findings related to vertebral subluxation are measurement of leg length, sacroiliac motion, spinal palpation, and thermographic and infrared imaging.(1) B.J. Palmer,(2) promoted pattern analysis in the 1930’s, based on the teachings of his father D.D. Palmer.(3) This form of analysis is taught at Sherman College of Straight Chiropractic. It is also common practice in several forms of chiropractic analysis such as Pierce Results System,(4) Thompson, Gonstead, Network Spinal Anaylsis,(5) BioGeometric Integration,(6) and Logan Basic,(7) to name a few. There is evidence that current biological theories such as dissipative structures,(8) self-organization,(9) autopoiesis,(10) structural coupling,(11) and morphological formation(12) are congruent with chiropractic theories.(13, 14, 15) This paper will explain the rationale for the SCSC pattern analysis, and the other chiropractic models as one theory, based on the vertebral subluxation model.(16) By applying the newer theories of biological organization in support of pattern analysis as a practice, a link will be made. It will be hypothesized that the term "alexithymia,"(17) be used in reference to the hyperaroused state of the autonomic nervous system which may be related to the vertebral subluxation, and hence present as a systemic and fixed tonic pattern that the cortex is dis-connected from. This dis-connection may be related to the vertebral subluxation.

Key Words: Chiropractic Pattern Anaylsis, Vertebral Subluxation Model, Self-Organization, Dissipative Structures, Autopoiesis, Structural Coupling, Morphological Formation, Alexithymia, Chiropractic Philosophy.

1. Kent C. 2000. June. Today’s Chiropractic.
2. Palmer BJ.: 1934, Subluxation Specific Adjustment Specific
3. Palmer DD.: 1910. Reprinted as Palmer DD.: 1921, The Chiropractic Adjustor. vol IV
4. Auger G.S. ed. (1998). The Pierce Results System manual: Sherman College Lyceum 1999.
5. Epstein, D. (1996). Network Spinal Analysis: A system of health care delivery within the subluxation-based chiropractic model. JVSR, vol 1, no. 1.
6. Brown, S.M. (1998). Triune 1: Force integration and the geometric nature of the spine. Illinois, Essence Quality of Life Center.
7. Hutti L.J. ed. (1998). Textbook of Logan Basic Methods clinical applications of basic technique: edited from the original manuscript of Hugh B. Logan, D.C. Chesterfield, L.B.M., Inc.
8. Prigogine I., Stengers I. (1984). Order out of chaos. Bantam.
9. Kauffman S: 1995, At home in the universe: The search for the laws of self-organization and complexity. Oxford University Press, London.
10. Maturana H, Varela F.: 1980, Autopoiesis and Cognition; the realization of the living, D. Reidel Pub. Co. Dordrecht, Holland.
11. Maturana H., Varela F. (1987). The tree of knowledge. Shambhala, Boston.
12. Goodwin B. (1993). Development as a robust natural process. Printed in, Varela F. and Stein, W. (eds.). (1993) Thinking about biology. MA, Addison – Wesley Publishing Company.
13. Senzon SA; 1999, "Causation as Related to Self-organization and Emergent Health Related Quality of Life Expression based on the Vertebral Subluxation Model, the Philosophy of Chiropractic and the New Biology". JVSR, 3, 3.
14. Koch D. (1999) "Principles of Straight Chiropractic" as printed in Straight from Sherman; Spring, pp. 13.
15. Stephenson. (1927, 1948) The chiropractic text book. The Palmer School of Chiropractic, Iowa.
16. Boone W.R., Dobson G. J. (1996). A proposed vertebral subluxation model reflecting traditional concepts and recent advances in health and science. JVSR, 1, 1.
17. Lumley M.A., Stettner L., Wehmer F. (1996). How are alexithymia and physical illness linked? A review and critique of pathways. Journal of Psychosomatic Medicine, Vol 41. No. 6., pp. 505-518.

Inter- and Intra-examiner Reliability of the Tytron C-3000

Bryan J. Salminen, DC

Tunu Misra, MS

Objective: We tested the inter- and intra-examiner reliability of doctors scanning subjects using the Tytron C-3000.

Methods:

Patient Selection: We selected 5 healthy subjects between the ages 20 – 45.

Protocol: Subjects were asked not to utilize procedures that can affect vasculature changes as per standard operating procedures set by the Tytron manual. One subject at a time entered the examining room, which was partitioned for their privacy. Each subject was set up for a full spine graph and set in a posture constant chair. The total number of scans collected from the 5 subjects was 45. Each doctor performed 3 scans on each of the subjects for a total of 15 scans per doctor. No marks were made on subjects, as the study attempted to determine the doctors’ ability to successfully reproduce start and end points.

Discussion

All data for this study has been collected. We will complete the analysis by the middle of June. This study will assess the ability of doctors to reproduce results from single samples by comparing the graphic output for each subject’s scan by each doctor. Second, the study will compare reproducibility between doctors for each patient.

Analysis: We plan to use a data analysis which includes the comparison of delta T values. The following will be evaluated: A. Slope Comparison D. Stewart Boone Method of Analysis.

Acknowledgement: We would like to recognize the co-operative effort by Sherman College with aiding of the computer analysis of the thermal graphs.

Structural Abnormalities And Aberrancies At The Base Of The Skull And Cervical Spine: Congenital And Acquired

Roy Sweat

Matthew Sweat

This lecture will show examples of structural abnormalities that may appear in radiographic studies of the occiput and upper cervical spine. Structural abnormalities may be congenital, acquired through trauma, or due to surgical intervention. The radiographic presentation of each abnormality will be shown using radiographs from the authors’ patient files. The clinical presentation will be discussed along with modifications to the care plan and adjusting strategy that may be required to accommodate for these aberrancies.

Outline of structural abnormalities to be covered:

1. Congentital
1. Platybasia
2. Occipitalized C1
3. Atlas Aplasia
4. Klippelfeil Syndrome
5. Fusion of C1/C2
6. Fusion of C1/C2/C3
7. Posticulus Ponticus
1. Incomplete
2. Complete
8. Abnormal Mastoids
9. Abnormal Styloids
10. Abnormal Condyles
11. Abnormal Axis Bodies
12. Abnormal Lateral Masses
13. Abnormal Posterior Arches
14. Abnormal Lateral Skull Formations
15. Abnormal Foramen Magnum
1. Sagittal
2. Frontal
3. Horizontal
16. Calcified Stylohyoid Ligament
2. Acquired
1. Fractured Dens
2. Jefferson Fracture
3. Surgical Intervention
1. C1/C2
2. C1/C2/C3
3. C4/C5
4. C5/C6
5. C4/C5/C6
6. Cadaver Disc Impant