Вы находитесь на странице: 1из 46

Chiropractic Subluxation

Leg Length Inequality
Spinographic 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
The presence of misalignment on x-ray
with a positive, persistent and consistent
indicator = 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 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 2002;46(4)
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 2002;46(4)
The Evidence-Based Subluxation
Still, no definition gives detail as to how the
nervous system is effected in the

What is needed to help define the neurologic
component of subluxation?
Reliable (repeatability)
Validated (accuracy, does the test do what it says it

Owens, E. J Can Chiropr Assoc 2002;46(4)
Finding the UC Subluxation

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
Test it, get them up and have them walk, then

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
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 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 > 4mm (1/8 inch)
Pelvic Unleveling
Important factors for the Leg length
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,
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
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

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
This division of the autonomic nervous system controls the
vasodilatory and vasoconstriction action of the body's arterial
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
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
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.
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 2004;27:109-17
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
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

Owens et al. (J Manipulative Physiol Ther 2004;27:155-9
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
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.
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
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

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 Palpation
Findings from the examination are classified
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
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
Articular Studies
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
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
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,
normal atlas alignment has the anterior arch
being horizontal.
Uncoordinated movement between atlas and axis
can result in kyphosis as a compensating

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.
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
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
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;

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
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

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
Lateral Vertex Nasium
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

Anterior-Posterior Cervical (AP Cervical)
may also be included

Orthogonal X-rays
Neutral Lateral

Post x-ray for correction validation

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