An autonomic efferent nerve has two major functions:

(1) impulse conduction and
(2) a trophic influence on receptor organ growth, repair, immunity, and cellular alterations in disease.

While these conduction and trophic functions are of equal importance and separate actions, trophic functions have unfortunately received secondary interest by most research neurologists. Because interference with trophic function serves an important role within chiropractic concepts, several pertinent findings are described in this section.

Research on nonimpulse initiated communication between the neuron and its end structures has increased in recent years. Singer relates that despite considerable controversy modern consensus accepts the role of neurotrophic and impulse stimulation in the maintenance of muscle tissue. He feels that, experimentally, it has been difficult to report these two mechanisms for individual study because most information has been obtained in model systems.


Autoadaptation and Immunity

Guth, Gutmann, and Gurkalo/Zabezhinski show that there should be no question that the autonomic nervous system regulates directly and indirectly the functions of all organs and tissues and influences even biochemical processes at the cellular and subcellular level.

After observing more than 15,000 patients with infectious diseases and studying the host-parasitic relation in infectious disease, Sato found that the adaptation of the human body to the internal environment is maintained by an autoadaptation mechanism operating upon the biological binary digit. That is, the autoadaptation mechanism has two antagonistic systems (sympathetic and parasympathetic divisions) that are composed of many antagonistic links:

(1) the two reciprocal nerves of the autonomic nervous system;
(2) two phases (rise and fall) of mitosis of the neurotrophic system in bone marrow; and
(3) two defense reactions (the cell-stimulant factor reaction and the antibody-antigen reaction). These binary antagonistic links are interconnected into two systems that are controlled by the two antagonistically functioning nerves (sympathetic and parasympathetic) of the autonomic nervous system.

In a following study, Sato found that the autoadaptation mechanism of the human body loses its rationality and purposefulness by an imbalance of the autonomic nervous system, and the host body falls into adaptational disturbances. He reports that hosts with sympathicotonia often fall into acute adaptational disturbances in the acme to the convalescent stage by stimuli of the second-phase factors (the factors lowering mitosis of the neurotrophic system in the bone marrow), resulting sometimes in death.

The disturbances are prominent, particularly in the early stage of stimulation and recognized as shock. Hosts with parasympathicotonia, states Sato, are resistant against the second-phase factors such as typhoid bacilli but weak against the first-phase factors such as cocci. In contrast, hosts with sympathicotonia show strong resistance against the first-phase factors but weak resistance against the second-phase factors.

There are several studies in process investigating the effects of spinal adjustments on the immunologic system. A preliminary study by Vora/Bates demonstrated a significant increase in B-lymphocytes following 4 weeks of semiweekly spinal adjustments in patients exhibiting spinal subluxations radiographically.

Also see Chapter 2, Neurologic Aspects of Immunogenesis.


Tissue Repair

Singer/Schade suggest that one important role of the nervous system is to regulate tissue repair a projection made by D. D. Palmer before the turn of the century. Several studies have associated this process with neurotubules and axoplasmic mechanisms leading to the formation of vesicles in the terminal buttons that release certain chemical substances which appear to have a distinct influence on trophic activity.


Cellular Alterations

Chronic hyperactivity of the autonomic nervous system is highly detrimental to the tissues and organs innervated and may be related to dysfunction in the spinal area. In this context, Korr explains that the physiologic influence of sympathetic innervation is more varied than previously believed. It extends to

(1) skeletal muscle,
(2) peripheral sensory mechanisms,
(3) the CNS system,
(4) collateral circulation,
(5) bone growth,
(6) adipose tissue,
(7) the reticuloendothelial system, and
(8) the endocrine system.

Habitual patterns of motor activity can modify bone structure according to Wolf's law, and faulty postural habits can produce fibrous deposits within articular cavities that have been chronically overstressed. Feldenkrais reports that the result is contractures within certain muscles and ligaments, hypertrophy of others, and weakening and atrophy of still others. In this context, Homewood postulates that the nervous system, even in its early developmental stages, is in command and remains as the correlating, integrating, and modifying factor that controls the responses of the body to exteroceptive and interoceptive stimuli in both health and disease.

Many postural changes can be attributed to Davis' law, which states: "If the origin and insertion of a muscle are moved farther apart for some time, the muscle becomes relaxed and hypotonic. If they are approximated, the muscle contracts, becomes hypertonic, and may become contractured." It thus can be recognized that changes in muscle tone as the effect of chronic tension can result in overt trophic changes.

Il'in and associates report that the similarity between the changes in the isoenzyme composition of muscle, with reversion to the embryonic type, that is found both in muscular dystrophy of neurogenic origin and in primary lesions (myopathies) of the muscle itself is explained on the following grounds:

(1) In neurogenic dystrophy, the changes are the result of a disturbance in the conduction of neural impulses to and into the muscle.
(2) In myopathy, although the damaged muscle receives the neural impulses, the muscle cells cannot respond adequately.

An understanding of visceral neurology is indispensable to appreciate and explain the possible pathophysiologic processes involved in a patient's condition because

(1) the chief purpose of the vegetative nerves is that of correlating and integrating action in the body, and
(2) these nerves may be subject to the amount of stimulation necessary to overbalance their normal function whenever an abnormal irritation arises in any organ or its innervation.

Factors Involved in Autonomic Imbalance

Almost all organs are innervated through the functionally antagonistic sympathetic and parasympathetic divisions of the autonomic nervous system. Disturbed activity balance of these two divisions results in some degree of visceral dysfunction. In health, the divisions are tonically stimulated to maintain a physiological balance. For various reasons, however, this balanced harmony may be shifted in favor of one or the other division and create visceral malfunction. Sachs states that every pathologic condition is obviously associated with disturbances in the autonomic nervous system.

Normal vegetative function can usually be maintained if proper nutrition is supplied the cells and their colloidal phases are usual for the structure under consideration provided

(1) the necessary electrolytes are supplied in the right proportions,
(2) the hormones from the various endocrine glands and vitamins are supplied in normal amounts, and
(3) the activating and inhibiting impulses carried to the cells balance each other or at least fail to overbalance one another. If these factors are not provided, deviations from the norm will lead to vegetative imbalance.

 	Allergies
 	Angiospastic conditions
 	Bradycardia
 	Dermographism 
 	Erythromelalgia
 	Hypertonia of the pelvic nerve
 	Ileocecal spasm
 	Impotence
 	Immune deficiency diseases (controversial)
 	Intestinal block (eg, gallbladder reflex)
 	Pupil disorders
 	Pylorospasm
 	Raynaud's disease
 	Reflex motor effects from viscera
 	Reflex sensory effects from viscera
 	Reflex trophic effects from viscera
 	The neurogenic process in essential hypertension
 	The pathophysiology involved in gallbladder and biliary tract disease
 	Trophic changes in dermal tissues
 	Vasomotor imbalances

Clinical Signs and Tests

      General Screening: The Saliva Test

A convenient way to screen autonomic balance is by determining the pH of saliva. A strip of litmus, nitrazine, or pHydrion paper is moistened with the patient's saliva about a half hour away from food or drink, comparing the resultant color with a standard scale. Normally, saliva has a pH of 7.0, neutral. Normal blood pH is about 7.3 or 7.4, and, at this level, the saliva will be pH 7.0, always a few tenths of a pH more acid than blood serum.

If the test paper indicates a pH below 7.0, it is hyperacidic and the sympathetics will be overactive. The patient will usually present with anxiety, hyperkinesis, tachycardia, a dry mouth and eyes and nose, gooseflesh raised easily, a marked gag reflex, insomnia after excitement, and easy blushing. Rhodifer believes a potassium deficiency will also be present.

If the test paper indicates a pH above 7.0, the saliva is hyperalkaline and the parasympathetics are thought to be overactive. Rhodifer feels that an overactive parasympathetic system accommodates hyperalkalinity or alkalosis. The normal calcium/phosphorus ratio is distorted in alkalosis. Since phosphorus is needed in alkalosis, it also indicates that the normal calcium/phosphorus ratio of 10 calcium to 4 phosphorus in the blood is distorted, in which condition excess calcium exists for which not enough phosphorus is available to unite with it in this ratio. During rest periods, the calcium may be deposited in joints, muscles, and bursae in the form of calcium carbonate crystals, resulting in stiffness, soreness, bursitis, tendinitis, and cramps. A phosphorus deficiency would thus be indicated.

      Tests for Sympathicotonia

Vannerson points out that inasmuch as sympathetic nerves are closely intertwined with blood vessels, any deviation from normal sympathetic function will be first registered in the blood vessels and then other structures will become helplessly vulnerable to the possible harm of an altered blood flow.

Cold Test.   This test is used to decide the vasospastic gradient in cases of essential hypertension. It is accomplished by immersing the patient's hand and wrist in ice water with salt added to produce a temperature of approximately 4ºC. Blood pressure readings are determined before and at intervals during and after the hand has been immersed from 15 to 30 seconds. When there is no great element of vasospasm or vasomotor activity present, namely, in the normal individual, a rise of 8–10 mm Hg takes place. When vasospastic phenomena take part in the elevation of blood pressure, a marked rise, often as high as 50 mm Hg promptly occurs. If this happens, a large vasomotor element undoubtedly exists.

Finger Wrinkle Test.   The functioning of upper extremity sympathetic nerves is tested by placing the patient's hands in warm water for a minimum of 30 minutes and observing if the skin of the fingers wrinkles after the soaking. The skin will normally wrinkle after such soaking, but it will not in diseases of the sympathetic nervous system. Thus, the test is indicated when there is a suspicion of diabetes mellitus, Guillain-Barr syndrome, Raynaud's disease, and other disorders associated with autonomic imbalance.

Sargent's Sign.   This sign is produced by a light stroke drawn in the median line from above downward over the abdominal wall. When a white line appears, it shows increased sympathetic tonus or hyperadrenia.

Pende's Reflex.   In subjects who are distinctly sympathicotonic, stroking of the skin (especially of the abdomen) produces a "goose flesh" response; ie, a pilomotor reflex.

Electrical Resistance of the Skin.   When cutaneous nerve conduction is disrupted, a loss of sweat secretion occurs because this function is under the control of the sympathetic nervous system. Because moist skin has less resistance to an electric current than dry skin, such tests, using small-diameter probes, are commonly used to aid localization. Minor's iodine-starch reaction and Moberg's ninhydrine test also can be used to show the presence of sweat.

Thermography.   Infrared or liquid crystal thermography may be helpful in locating "cold spots" and areas of subcutaneous hyperemia, suggesting a degree of abnormal vascular tone as the result of increased or decreased sympathetic activity.

      Tests for Vagotonia

Oculocardiac Reflex.   With the patient in the recumbent position, compression of the eyeball upon closed lids for about 30 seconds and without producing pain may produce slowing of the heart by 5–10 beats. In people who are distinctly vagotonic, it has been found that this slowing may amount to 12 beats or more. Under conditions of excessive stress in marked parasympathicotonics, the heart has often been temporarily inhibited. In people of stable nerve balance, neither inclined to sympathicotonia nor parasympathicotonia, the slowing is usually less than 10 beats; in fact, in those who are markedly sympathicotonic, no slowing may occur.

The reflex is caused by stimulating the ocular fibers of the trigeminus, through which the impulse is transmitted to the cardiac inhibitory fibers of the vagus. In individuals who are distinctly vagotonic, the reflex may show itself in the gastrointestinal tract as well as in the heart. Pressure over the vagus in the neck will result in a similar manifestation.

Erben's Reflex.   This test consists of a slowing of the pulse when the head is bent strongly forward. It is marked in those who are distinctly vagotonic.

Ruggeri's Sign.   This sign shows an acceleration of the pulse, following convergence of the eyeballs, produced by fixing attention on an object that is brought quite close to the eyes. It is less marked in vagotonics.

Somagyi's Reflex.   This response is a manifestation of the instability of the cardiac branch of the vagus. It consists of dilation of the pupils on deep inspiration and contraction on full expiration.

Carotid Sinus Massage.   Pressure applied to the carotid area in the neck slows the heart rate and produces a fall in blood pressure. The reflex originates in the wall of the sinus of the internal carotid artery. If heavy prolonged pressure is applied, dizziness or fainting may result. This normal reflex becomes hyperactive during attacks of vasomotor instability and hypoactive in inhibitory lesions of Cranial IX (afferent portion) and Cranial X (efferent portion).

In sinus tachycardia with a normal QRS duration, carotid sinus massage tends to slow the heart gradually but the rate usually reverts to its original rate after the stimulation is released. Carotid sinus massage, states H. H. Friedman, either terminates or has no effect on most paroxysmal atrial or AV junctional tachycardias. In atrial flutter, carotid sinus pressure increases the degree of AV block so that fewer flutter impulses are transmitted to the ventricles. The F waves are more clearly revealed with a smaller number of ventricular complexes, making this a useful maneuver when the diagnosis of atrial flutter is uncertain.

Although carotid sinus massage is an excellent evaluative procedure, it should always be conducted with caution, particularly with the elderly, and under ECG control whenever possible. The procedure is contraindicated in heart block and advanced vascular disease.

As many patients are inclined to suffer from a particular group of disorders that represent vegetative imbalance, it is often helpful during the examination to classify the patient as sympathicotonic or vagotonic as a guide for future therapeutic applications.


Patient Classifications

The disorders most commonly associated with a sympathetic predominance are hyperthyroidism, dryness and paleness of the mucous membrane of the head, deficient salivary secretion, tachycardia, dilatation of the stomach, hypochlorhydria, poor digestion, and atonic constipation.

Common disorders associated with a parasympathetic predominance are lacrimation, hay fever, urticaria, angioneurotic edema, intestinal allergies, sinusitis, rhinitis, pharyngitis, excessive salivary secretion, bradycardia, asthma, hyperchlorhydria, peptic ulcer, diarrhea, spastic constipation, mucous colitis, and anaphylaxis. Addison's disease is a classic parasympathetic disorder.


Behavioral Characteristics

It can be generally stated that sympathicotonics tend toward an ectomorphic nature and body type while the parasympathicotonics tend toward an endomorphic nature and body type. In both conditions, structural and behavioral signs and symptoms become the outward manifestation of disturbed autonomic function.

Sympathicotonic individuals tend to be tall and thin, active, impatient, fast talkers, impulsive deciders, mentally alert, nervous, easily angered or fearful, hypersensitive to pain, hungry for excitement and adventure, and sexually aggressive. Strong emotional states are accompanied by dilated pupils, dry throat, peripheral vasoconstriction, raised blood pressure, bulging veins in the neck, increased adrenal secretion, increased blood sugar, erection of hairs, increased heat production, sweating, increased heart and respiratory rates, anorexia, and slowing of the digestive processes so that the body's energy may be massed in the periphery for defense of the organism. Because of this, they are in danger of exhausting the sympathetic nervous system leading to depletion syndromes such as low blood pressure or nervous breakdown. Anxiety syndromes are common. Their defense responses are usually active (eg, quick fever on slight provocation). In minor expressions of imbalance or emotions, the effects are less severe but may be more prolonged with the physiologic disturbances being less acute but more lasting.

Parasympathicotonic individuals, in contrast, tend to build excessive fat, enjoy good food and comfort, present a slower metabolism, are slow in their actions, are patient in trying situations, need but dislike exercise, are deliberate yet have difficulty in arriving at decisions, and are socially nonassertive. Depression is common. Their defense responses are sluggish, and they tend to acquire chronic diseases and prolonged states of general fatigue.

The above characteristics are general tendencies, not absolutes, that vary greatly in magnitude with specific individuals under specific situations.


Characteristics and Assessment of Autonomic Pain

The pain associated with the autonomic system is not well understood. It does not fit a dermatomal, myotomal, or sclerotomal pattern. Neither does it occur in a distinct location such as a specific joint, muscle, or finger. Gandhavadi and associates give the following examples of the nonspecific pain:

(1) pain and burning in the entire lower extremity,
(2) pain in the upper extremity with a "raglan sleeve" distribution, and
(3) pain in part of a limb not fitting the dermatomal area or peripheral nerve distribution. The major quadrants of the trunks literally supply the quadrants of the body. Thus, the disturbance may be expected to be in the quadrantic distribution.

Gandhavadi recommends that the assessment of the sympathetic system be done:

(1) physically (orthostatic hypotension, absence of ciliospinal reflex, hypohidrosis);
(2) physiologically (Valsalva maneuver, cold pressor, thermocoupling, plethysmography, sweat test, infrared thermography); and
(3) pharmacologically, if necessary.

Overgaard agrees with Bennett that the majority of pain sensations in humans are the result of visceral disorders of the thorax, abdomen, or pelvis. They state that autonomic pain may be projected or referred to structures outside the visceral cavity and is often felt in regions distant from the disorder. Overgaard believes that tissue trauma results in the release of agents that trigger nociceptors and produce the sensation of autonomic pain, while Bennett suggests that the initial cause is vasospasm leading to microcirculatory blockage.


Spinal Therapy in Visceral Dysfunction

In describing the role of spinal treatment in visceral disorders, Beal, an osteopath, summarizes the objectives of manipulative therapy as:

(1) to reduce somatic dysfunction,
(2) to interrupt the viscerosomatic reflex arcs,
(3) to influence the viscus through stimulation of somatovisceral afferents, and
(4) to reduce the potential preconditioning effects of somatic dysfunction to body stressors. He also points out several references substantiating that manipulation can reduce recovery time from visceral surgery. As research into the value of adjustive therapy in visceral dysfunction is continued, this list is certainly to expand and be refined.

Background

D. D. Palmer, the founder of chiropractic, believed that a vertebral subluxation could affect tone in either an excitatory or inhibitory manner. However, his son and successor, B. J. Palmer, placed great emphasis on the blockage of neural impulses ("pinched nerve") between the higher CNS centers and peripheral tissues at the IVF via inhibiting nerve or root pressure. This concept grew in popularity from the early 1900s through the 1940s primarily because it was helpful in explaining the effects of a vertebral subluxation to the lay public; viz, by the excessively simplistic analogy of "a foot (subluxation) on a hose (nerve channel)." Obviously, such an explanation was not acceptable to the scientific community.

Tachycardia, hyperhidrosis, decreased smooth muscle tone and glandular secretion, and increased vascular tone indicate vagal inhibition, and the vagal and sacral parasympathetic nerves have no direct relationship with vertebral IVFs. Thoracic sympathetic inhibition would exhibit opposite functional disturbances. However, clinical evidence gathered over the last 80 years has demonstrated that spinal adjustments are frequently effective in the treatment of disorders manifesting a picture of parasympathetic depression sympathetic excitation. Thus, a subluxation syndrome is far more complex than can be explained by the "pinched nerve theory," and a segmental chiropractic adjustment has far-reaching effects throughout the nervous system, which cannot be explained with our present knowledge.

According to the "interference in neural transmission concept," any disorder not exhibiting a pattern of inhibition would not be amenable to chiropractic care. There are few practitioners that would not take exception to such a statement. It is a general opinion that any static nerve or root pressure exerted at the IVF that would be strong enough to block autonomic transmission from the cord to peripheral tissues would likely be strong enough to block outflowing motor and inflowing sensory impulses. Such an occurrence would manifest signs of at least partial paralysis. This is rarely seen other than in severe vertebral trauma (eg, fracture-dislocation) or a space-occupying mass.

Much About Autonomic Function and Control Is Still a Mystery

Rare is the chiropractor whose understanding of neuroanatomy has not been put to the test by observations made in clinical practice. A typical example is seen in the female patient who enters the practice following a mild moderate "whiplash" injury, with the major subluxation determined to be at the C5 level, who reports during treatment that not only has the neck and upper extremity symptoms been relieved but the PMS symptoms and dysmennorhea suffered for many years have suddenly disappeared.

Early in practice, this author's first experience of this nature was with a 73-old female patient whose presenting complaint was a recently rising "nagging ache" in the left lumbar area. Motion tests revealed that the thoracic spine was almost completely immobile in all ranges, and radiographic evidence of osteoarthritis was extensive. Following the second adjustment to L2, she reported only minor relief of the low-back pain but that she had not had one asthmatic attack, a condition causing her distress for the past 60 years. Her asthma remained asymptomatic to her death, 8 years later. Because of its chronicity, treatment for the asthma was not given initial consideration; and why treatment directed to L2 apparently had an effect on the bronchi was bewildering.

Another example of the complexity of neural integration and adaptation is shown in Norman/Whitman's study of vagal contribution to changes to heart rate evoked by stimulation of cutaneous nerves. Their investigation showed that adrenalectomized dogs which have had their sympathetic nerves chemically blocked can have their heart increased by radial nerve stimulation. This is explained by a change in the activity of cardioinhibitory fibers in the vagus nerve.

In describing musculoskeletal involvement in chronic lung disease, Hoag shows that involvement of the musculoskeletal system is direct as well as subtle and complex. The bronchopulmonary disturbance may influence the musculoskeletal system, which in turn affects bronchopulmonary function, or else the primary musculoskeletal disturbance alters bronchopulmonary function by adverse somatogenic reflexes. Hoag recommends that the physician should determine whether responses within the musculoskeletal system are excessive or inappropriate. He states that when hypertonicity contributes to hypoventilation of the lungs, adjustive treatment is recommended as well as consideration of the use of muscle-relaxing therapy. The chief aim of spinal therapy is to aid the musculoskeletal system to respond to the pathophysiologic changes.

It is recommended that any somatic dysfunctions producing local or secondary visceral disturbances should be corrected first. Procedures can then be used to increase mobility of the thoracic cage, improve motions of the diaphragm, lessen bronchospasm, improve ventilation, normalize the amount of bronchial secretions, and improve circulatory function. It should be noted how these procedures differ from the normal allopathic approach of just drugs and bedrest for this condition.

Because of the highly complex, integrated nature of the nervous system, simplistic explanations of causes and effects are difficult to defend. Throughout this book, it has been emphasized that the effects of a vertebral subluxation are widespread and likely to be manifold because of the many neural (local and remote), vascular, CSF, axoplasmic, and hormonal mechanisms that possibly may be involved.

While numerous examples of the complexity of neural integration have been described previously, one more is appropriate here. In a study of cats by Young and associates, it was found that maximal effects on the infraorbital nerve fibers of the trigeminal nerve (cranial V) were produced by conditioning stimuli applied to the lumbar sympathetic chain. Significantly decreased excitability was observed when the conditioning stimulus was applied to the sciatic or sural nerves.


Spinal-Related Reflex Changes in Internal Dysfunction

In justifying the importance of spinal therapy in cases of splanchnic dysfunction, Rychilkov states that four types of reflex changes in vertebrogenic disorders have been differentiated:

1. Vertebrogenic and reflex changes imitating internal disease.
   
   

2. Internal disease caused by a vertebrogenic lesion.
   
   

3. Reflex changes and vertebrogenic lesions developing during the acute stage of internal disease. This effect is thought to be attributable to paravertebral spasm causing anomalous mobility in the corresponding spinal segment, which leads to blocking. The mechanism is believed to be a viscerosomatic consequence of painful stimuli from the malfunctioning organ.
   
   

4. Reflex changes occurring during the chronic stage of internal disease. Rychilkov states that it is as this stage that manipulation and reflex therapy are most successful. If, however, reflex changes recur in spite of therapy, this points to recurrence of the underlying visceral disease.

Beal makes the point that while somatic dysfunction may not initiate visceral dysfunction, somatic treatment such as spinal manipulation may be helpful for two reasons:

(1) visceral disorders may be influenced by reflex facilitation, and breaking this noxious reflex cycle will often allow recovery;
(2) reflex somatic pain may persist after the visceral disorder is resolved, mimicking the original problem, and this may resolve with manipulation.

Autonomic Symptoms Associated with Back Pain Syndromes

After studying 250 consecutive back pain subjects, Johnston found that 39% exhibited probable evidence of vertebrogenic autonomic dysfunction. The incidence was distributed as follows: 60% cervicogenic cephalgia (disturbed vision, dysequilibrium, gastrointestional disturbances); 54% thoracoalgia (nausea, flatus); and 31% lumbalgia (constipation, polyuria, menstrual disturbances).

During the analysis of disorders of vasomotor reactions in lumbosacral syndromes, Star and associates determined that vasomotor nociceptive reflexes are formed more easily and fixed more firmly in patients suffering from painful vertebrogenic syndromes. In arriving at this conclusion, these researchers found that vasodilation was observed especially after nociceptive stimulation and they suspected that the inverse vasodilator responses are mediated by a cholinergic mechanism because the response can be reversed by atropine injection.


Some Documented Effects of Spinal Adjustments on Autonomic Function

Fatigue Index.   Busch and associates found that chiropractic adjustments in the C5–T3 area of normal subjects decreased the fatigue ratio considerably, indicating a higher peripheral resistance (ie, increased sympathetic activity). It is theorized that the benefits of such therapy are produced by either a decreased stroke volume of the heart or a lessened pulsatile blood volume through the brachial artery which is caused by direct stimulation of the brachial vasculature.

Vital Capacity.   In comparing the results of chiropractic adjustments on respiratory function in patients with and without symptoms of respiratory distress, Hviid's findings suggest a change in peak respiratory flow and vital capacity in response to treatment. In measuring 50 chiropractic patients presenting with musculoskeletal complaints, Masarsky/Weber found that forced expiratory volume was greatly improved after adjustive therapy as compared to pretreatment measurements.

Induced Hypotension and Hypertension.   In a study of the effects of upper thoracic adjustments upon the normal physiology of the heart, Tran/Kirby found that adjustments of the T1 and T2 vertebrae, as compared with a control group, appeared to lower blood and pulse pressures within normal physiologic ranges. A similar study of the effects of upper cervical adjustments upon the normal physiology of the heart by Tran/Kirby gave evidence that a chiropractic adjustment, or the stimulation from the thrust alone, can induce increased peripheral tension in which the diastolic pressure and pulse pressure were most affected. ECG patterns showed no significant changes, but some degrees of variations in heart rate were noted. Their findings conclude that caution should be given to adjusting nonsubluxated vertebrae.

Although the efferent activity of the autonomics had been demonstrated for years, it was not until the 1930s that the existence of afferent fibers was proved. In 1930, H. G. Schwartz reported the finding of some sensory fibers that belonged intrinsically to the autonomic nervous system. Since then, numerous investigators have studied autonomic reflex activity and have attempted to determine their course.

Numerous autonomic and related reflexes have been described previously in this and previous chapters, but a few additional points are worthy of note in this section.

Autonomic reflexes may be initiated either intrinsically or as a by-product of somatic mechanisms. Concern must be given that the reflex phenomena observed in patients with musculoskeletal disorders are not misjudged as an entity within themselves when they are a by-product of some subclinical primary pathology.

In this context, Stiles advises clinicians to remember that a cause and effect relationship within the body will produce a compensatory change in one part of the body as a result of a dysfunction in another. The causes are often multifactorial, including not only the primary problem but also postural stress, anxiety, and microtrauma. The body responds to stress by distributing it to maintain homeostasis. This capability allows function through compensation; however, afferent overload from the primary area will eventually require outside help.


Somatosomatic and Somatovisceral Reflexes

      Somatosomatic Reflexes

By definition, somatosomatic reflexes should not involve the autonomic nervous system; however, it is rare when a spillover effect upon the autonomic supply does not occur. In review, a somatosomatic reflex develops whenever a somatic sensory receptor is stimulated to trigger a volley of reflex impulses to another anatomical location of the soma via efferent somatic motor or autonomic fibers.

Pain Control.   These reflexes are commonly evoked by cutaneous stimulation, and such reflexes are commonly applied therapeutically to inhibit pain (viz, by counterirritation). It is widely recognized that stimulation of large sensory fibers from the peripheral receptors depress the transmission of pain signs either within the same area of the body or from areas sometimes located many segments away.

Case Management.   An understanding of somatosomatic reflexes helps to explain the "stubborn" musculoskeletal case that fails to respond in the time anticipated, requiring frequent and repeated adjustive therapy far beyond average. This occurrence can be due to long-lasting changes in excitability of spinal reflex pathways. Animal studies have shown that if a lesion is induced in the cerebellum, a change in extremity posture is noted. It has been found that the involved limb remains in the abnormal posture if the spinal cord just above the level supplying the extremity is not severed for 45 minutes after the cerebellar lesion was produced; ie, allowing time for the local spinal reflexes to become habituated.

In contrast to such a CNS lesion, Patterson/Steinmetz found that long-lasting reflex habituation also could be caused by peripheral stimulation. Their study showed that if an abnormal peripheral stimulus (eg, low-back strain) is produced, the spinal reflexes are habituated for some time after the stimulus is removed and the lesion will spontaneously return with any subthreshold stressor. Thus, more is involved in treating a subluxation complex than simply making a mechanical correction of placement. Repetition is required until the habituation of the spinal reflex center is interrupted. Patterson/Steinmetz state that spinal reflexes should be considered as active participants in the symptoms treated with manipulative therapy, and the role of these reflexes in symptoms should be recognized in the therapy administered.

      Somatovisceral Reflexes

In writing of the basic functional aspects of somatosympathetic reflexes, Kuntz states that reflex responses on the viscera (including the splanchnic blood vessels) elicited by stimulation of localized cutaneous areas with the same segmental innervation as the viscera in question are common physiologic phenomena. Sato emphasizes that the functions of the various visceral organs can be influenced by a proper cutaneous stimulation as a result of the somatosympathetic or somatoparasympathetic reflexes.

A somatovisceral reflex is initiated when a somatic sensory receptor is stimulated sufficiently to trigger a volley of autonomic reflex impulses to viscera. These reflexes are commonly evoked by cutaneous or musculoskeletal stimulation. They can be initiated therapeutically by vibration, percussion, massage, manipulation, superficial heat or cold, electrotherapy, meridian therapy (possibly), hydrotherapy, traction, and compression.

      Cutaneovisceral Reflexes

In studying the autonomic and physiologic properties of cutaneovisceral vasomotor reflex arcs in rats, Kuntz found that the receptors through which thermal sensations and reflex reactions in viscera are mediated, elicited by thermal stimulation of the skin, appear to be closely associated with cutaneous blood vessels. Tissue deformation incident to tonic changes in the musculature of these vessels is thought to play an important role in the activation of the receptors in question and, consequently, in sensory adaptation.

In describing the importance of somatoautonomic reflexes in the regulation of visceral function, Sato shows how stimulation of abdominal skin produces a reflex sympathetic change in gastrointestinal tone. Likewise, stimulation of perineal skin causes either a reflex increase in vessel tone through a reflex increase in pelvic discharge activity or a reflex inhibition of the micturation contraction of the bladder through a reflex inhibition of pelvic nerve activity.

      Cutaneocardiac Reflexes

Reflex changes in heart rate after mechanical and thermal stimulation of the skin of cats at various segmental levels were studied by Kaufman and associates. They found that there was no doubt that heart rate changes occurred with cutaneous stimulation. In anesthetized cats with the CNS intact, a reflex increase in heart rate was elicited after natural stimuli were applied (eg, rubbing, pinching, warming, cooling) to the neck, chest, abdomen, or perineum.

It was shown that this cutaneocardiac acceleration effect was produced mainly by a reflex increase in the discharges of the cardiac sympathetic efferent nerves and partially by a reflex decrease in the discharges of the cardiac vagal efferents. On the other hand, in spinal cats, only stimulation of the chest and abdominal skin produced a reflex increase in heart rate. A possible explanation of the difference between reactions with and without an intact CNS is that a spinal, segmentally organized component of the cutaneocardiac acceleration reflex is dominated by a supraspinal, diffusely distributed component in CNS-intact cats.


Pain Inhibition

Conditioning stimuli to either the caudal sympathetic chain or the lateral femoral cutaneous nerve inhibit the actions of other nerves on dorsal horn interneurons. By recording dorsal root reflexes, reciprocal primary afferent terminal depolarizing actions between visceral and cutaneous afferents have been shown by Selzer/Spencer.

The existence of primary afferent terminal depolarization and the close correlation of its time course with that of the mutual inhibition suggest that at least part of this inhibition is of the presynaptic variety. The findings of this study suggest that the pronounced inhibition of visceral afferent action by conditioning cutaneous afferent volleys may underlie the clinical phenomenon of inhibition of visceral pain by cutaneous counterirritation. It is also suggested that the facilitation of cutaneous afferent actions by conditioning visceral afferent volleys might similarly underlie the clinical phenomenon of referred hyperalgesia during states of visceral pathology.


Somatovisceral and Viscerosomatic Reflexes

      Somatovisceral Reflexes

Except to mention that cutaneous stimulation has an important influence on visceral function (especially vascular tone), medical authorities rarely discuss somatovisceral reflexes in great detail. However, as Homewood points out, these reflexes form an important aspect of the basic chiropractic contention that a vertebral lesion can produce adverse splanchnic reactions. Most of our contemporary knowledge of these reflexes has come from Pottenger, Speransky, Kuntz, Coote, and Sachs.

A somatovisceral reflex is initiated when a sensory receptor in the skin, subcutaneous tissue, fascia, striated muscle, a tendon, a ligament, or a joint is stimulated to trigger a volley of autonomic reflex impulses to viscera. Body wall stimulation produces both segmental organ responses and suprasegmental responses. Janse postulated that somatosympathetic reflexes to be at least in part responsible for the visceral changes often observed after spinal adjustment, manipulation, trigger point therapy, and spondylotherapy.

After studying the response of some sympathetic neurons to volleys in various afferent nerves, Coote/Perez-Gonzales suggest that Group III and IV muscle afferents have a chemoreceptor function and are responsible for mediation of the pressor reflex during muscle exercise.

Koizumi's studies showed that pinching the abdominal skin produced profound inhibition on intestinal motility. The stimuli produce a strong effect on the intestines, which often become completely quiescent. Segmental input strongly affects intestinal movement and nonsegmental input augments intestinal motility.

In this mechanism, the control of the effector organ by the sympathetic supply plays a dominant role; ie, the parasympathetic system through vagal innervation of the intestines seems to contribute little to this reflex. To understand spinal adjustive therapy properly, it is Koizumi's opinion that the relationship between cutaneous and other somatic afferents and the autonomic responses must be further clarified.

Different forms of stimulation may produce similar organ responses and may produce different brain center responses affecting the body. The type of response, states Balduc, prolonged beyond stimulus termination, depends on the state of the organ and the body as a whole (ie, active, resting). Therapeutically, these reflexes are commonly evoked by manipulation, superficial heat or cold, electrotherapy, hydrotherapy, traction, compression, vibration, percussion, massage, and possibly meridian therapy.

      Viscerosomatic Reflexes

A viscerosomatic reflex develops whenever a sensory receptor of an internal organ, a gland, or a vessel is stimulated enough to trigger a volley of reflex impulses to the skin and subcutaneous tissues or to one or more striated muscles, tendons, ligaments, or joints. This type of reflex is commonly exhibited in the abdominal spasm overlying peritonitis and the origin of angina pectoris. Therapeutically, these reflexes are commonly evoked remotely by spinal manipulation, spondylotherapy, and spinal traction or compression. Biofeedback training is usually placed in this category.

The Head-McKenzie sensory zone concept attempts to explain how visceral pain can radiate to certain parts of the skin. A familiar example, states Hart, is cardiac ischemia with radiating pain to the left arm. According to Gaensler, Wernoe found that a visceral problem can exhibit in a specific dermatomal segment via a viscerocutaneous reflex and that the stimulation of the skin can have a distinct effect on a related visceral area via a cutaneovisceral reflex.

De Sterno and other researchers have attempted to show that visceral problems may refer to the skin or subcutaneous tissues and give rise to trigger points, acupuncture points, and/or other disorders. Diagnostically, certain superficial areas have long been known to relate to an underlying visceral condition such as pain in the right shoulder in gallbladder disease. It is often noted clinically that a disease in an internal organ will produce pain, tenderness, hyperesthesia, or hypesthesia, etc, in some area of the skin. Such a viscerocutaneous reflex is thought by many to be mediated by unknown pathways of the sympathetic chain.

Janse stated that viscerosomatic reflexes have important diagnostic connotations and are frequently reported to be an important cause of referred pain, reflex paravertebral spasm, vertebral subluxations, trigger points, and acupoints.

Most authorities agree that any irritant introduced into a viscus that is adequate to stimulate receptors will send impulses

(1) back over splanchnic efferents;
(2) produce paravertebral hyperalgesia, hypermyotonia, and frequently spasm; and
(3) send pain signals to higher CNS centers (the interpretation of which may be of either a local or referred nature).

The degree of increased muscle tension at the spine will depend upon the strength of the irritation at the receptor site, the functional state of the neurons and synapses involved, and the anatomical location of the lesion. On this latter point, Pottenger found that reflexes initiated at the posterior aspect of a lung manifest somatically at the back, while those initiated at the anterior aspect of a lung will involve the ventral chest muscles. Sachs, however, reports that viscerosensory reflexes cause greater pain posteriorly than anteriorly regardless of origin. This point becomes important in the differential diagnosis of spinal pain.

Balduc points out that viscerosomatic reflexes are intensity-oriented (ie, the reflex response is proportional to the intensity of the visceral input), mediated by gamma fibers (excitation of flexor motor neurons, inhibition of extensor motor neurons), converge on the spine in a spatial gradient, converge on the head and neck or the pelvis, and produce both spinal and extraspinal effects. It is postulated that increased visceral activity influences a neurologic "gate" in the affected spinal cord segment.

As the visceral gate opens, the somatic gate closes. The visceral impulses spread from the posterior to the anterior horn of the spinal cord and then to supraspinal centers that control the integrity of the reflex response, which, states Balduc, is prolonged beyond stimulation termination. The difference between somatovisceral and the viscerosomatic reflexes appears to be only quantitative and to be accounted for by the lesser density of the nociceptive receptors in the viscera.

      Viscerovisceral Reflexes

A viscerovisceral reflex develops when a sensory receptor in an internal organ, gland, or vessel is stimulated to trigger a volley of reflex impulses to another anatomical location of this type via efferents of the autonomic nervous system. Rarely, however, does this reflex exist alone; ie, it usually has a segmental somatic component. Therapeutically, similar reflexes are commonly evoked by spinal manipulation, deep heat, and hypnosis or other forms of psychotherapy.

Pottenger stated that viscerovisceral reflexes constitute the basis of normal physiologic integration and form the basis in most, if not all, disease conditions. In disease, exaggerated reflexes can readily confuse the diagnostic process. The classic example is a gallbladder reflex increasing the sympathetic output to the stomach, which produces gastric symptoms far greater than the initiating gallbladder lesion. Thus, therapy directed to the stomach would be of minimal benefit.

Viscerovisceral reflexes are not confined to segmentally related regions of the spine. The nausea and vomiting associated with gastrointestinal problems are generally considered viscerovisceral reflexes. Pottenger, Kuntz, and others relate the nausea-vomiting and headaches associated with many gynecologic disorders with viscerovisceral reflexes.

In Iggo/Leek's study of reflex regulation of gastric activity, they found that impulses could be recorded from single vagal motor axons in sheep during reflex gastric contractions. Several different patterns of activity associated with contractions of different parts of the stomach were found. Each unit had a stable and characteristic pattern of discharge, and the discharge of a unit could be modified by a general excitatory stimulus; eg, acidification of the gastric contents or by afferent feedback from the part of the stomach that as contracting.


Psychovisceral and Somatopsychic Reflexes

      Psychovisceral Reflexes

Because the body acts and reacts as a whole, some degrees of primary or secondary psychosomatic and psychovisceral reflexes are undoubtedly involved in any condition that causes personal distress (mental or physical). The classic example of a psychovisceral reflex is the relationship of chronic worry with gastric hyperacidity leading to the formation of peptic ulcers. In studying this phenomenon, Cobb has shown that stimulating the anterior nuclei of the diencephalon produces a barrage of vagal impulses that, in time, results in hemorrhage and ulceration of the lining of the stomach and other functional aberrations.

Freeman, Kuntz, and White/Smithwick state that just about every visceral function has shown to be subject to influence exerted by emotional states through the autonomic nerves, and Sachs suggests that psychic reflexes may produce viscerosensory, visceromotor, and/or viscerovisceral reflexes. Guyton credits the diarrhea associated with emotional stress to hyperparasympathetic activity and emotionally related constipation to hypersympathicotonia.

      Somatopsychic and Visceropsychic Reflexes

It also should be kept in mind, because the body is a whole, that the reverse is also true; ie, the role of somatopsychic and visceropsychic reflexes is just as important. Just as the mind can affect somatic and visceral structures, somatic and visceral stimulation can affect mental and emotional processes. Because the nervous system is so highly integrated, distress within the body can never truly have only a localized effect.

While some may not feel that emotional stress is a point for chiropractic treatment, it has been demonstrated by Quigley, Schwartz, Steward, and others that normalizing IVF and apophyseal lesions and reflex foci is a frequently effective method in reducing noxious afferent activity to the psychic centers. A large number of conditions are known to have psychosomatic and psychovisceral relationships.

It thus may be assumed that chronic articular fixations may be effective psychologic irritants after nonarticular mechanical, chemical, and thermal irritants have been removed. Janse frequently offered the hypothesis that spinal subluxations have inimical effects upon the ascending pathways of the reticular activating system, which can create numerous stress-producing symptoms, restlessness, and insomnia.

As the effectiveness of case management can be influenced by the psyche, it should be considered when determining diagnosis, scope of therapy, and prognosis. These psychic considerations do not require the scope and depth of clinical psychology, but they should consider the physical, personal, social, and environmental aspects involved in the case before a diagnosis is arrived at if holistic care is the goal.

Homewood points out that chiropractors should not underestimate the potency of their technical armamentarium for normalizing structure as a means of reaching and eliminating a large variety of psychic dysfunctions. This educator believes that the same is true for the normalization of spinal-related somatovisceral reflexes.

Unfortunately, there has been a trend in the profession during the past decade or so to quietly restrict chiropractic care to the correction of biomechanical faults and musculoskeletal injuries. While it can be argued that chiropractic care can be readily justified in such "orthopedic" cases, the empiric results obtained by chiropractic therapy directed to visceral and psychic disorders should not be ignored, even if the laboratory means to test the hypothetical mechanisms involved have not yet been developed. To do so would be an injustice to society.


Some Diagnostic and Therapeutic Procedures Under Investigation

At certain points on the body surface, Janse, Bennett, DeJarnette, Chapman, Goodheart, etc, have shown that there are areas from which the reflexes of muscle relaxation, homeostasis, and postural competence can be initiated. These are called Valleix points. Janse stated that the primary zones appear to be

(1) the parasacral areas,
(2) the suboccipital zones, and
(3) the soles of the feet.

Neurolymphatic points and neurovascular points also can be considered in this category, and some authorities place the cranial membranes and various acupoints and auricular points in this general category.

Noxious foci from hypothesized microcirculatory defects have long been thought to be an important consideration in the diagnosis and/or treatment of a wide variety of musculoskeletal and visceral dysfunctions. Because of this, a number of empiric approaches have been developed. The acupoints of meridian therapy might well be an example of such sites. Bennett postulated the concept of neurovascular reflexes, and Chapman (as described by Magoun, Mitchell) outlined a similar system of neurolymphatic reflexes. De Jarnette describes several topographic reflex sites in his Sacro-Occipital Technique (S.O.T.) manuals that are reported to have far-reaching effects, and Upledger/Vredevoogh have expounded on the studies of Sutherland (as described by Wales) on the effects of cranial subluxations on cerebrospinal circulation and reflexes.

Several empiric concepts frequently used have implications in physical diagnosis and therapy. A few of these are briefly described in this section. The exact interrelationships of the sensory, motor, and autonomic nervous systems, however, have not been determined to the degree they can be described in detail.

The various concepts and clinical approaches described in this section remain in the investigatory stage and may not be appropriate or authorized under state law. The American Chiropractic Association has not adopted specific policy on these concepts or procedures.

      Applied Kinesiology

Applied kinesiology is a relatively new branch of clinical chiropractic that uses muscle testing as a barometer and monitor of a patient's physiologic, anatomical, and emotional state of health. Analysis (therapy localization and the direction of therapy) is achieved by a complex method of interpreting body language expressing through the muscular system, according to Goodheart and Stoner.

Five basic elements are found within the IVF: nerves, blood vessels, lymph vessels, spinal fluid, and the acupuncture meridian connector. The systemic reflections of these elements are challenged during analysis, then therapy is directed to balancing any one or combination of the five basic elements along with adjusting specific vertebrae to relieve the dysfunction of the system(s).

Goodheart, Walther, and others have attempted to correlate the basic neurovascular concepts of Bennett and the neurolymphatic concepts of Chapman with the musculoskeletal system, and Mitchell and Schmitt have related them to the endocrine system. It should be noted that the charts used in applied kinesiology do not correspond in many instances with the original charts of Bennett and Chapman.

      Basic Technique

Basic technique is described by Coggins and Gabel as a system of body mechanics that is directed to normalizing body structure to maintain normal function, with emphasis on postural alignment of the spine and pelvis and balancing their associated soft tissues. Certain structural patterns and spinal distortions have been isolated, and their recognition and interpretation guide the direction of therapy.

The primary premise of basic technique states that the body of the lowest freely movable vertebra will rotate to the low side of the sacrum or the vertebral foundation upon which it rests. In other words, the body of the lowest freely movable vertebra will always rotate to the side of least support. This is thought to be indicated by the low side of the sacrum in most but not all instances. Another premise of basic technique is that the sacrum is the mechanical centrum of the body and strategically situated as the foundation of the spinal column. It is considered the key of the mechanical system of spinal levers; viz, the ligaments and muscles that are attached to the spine, pelvis, and rib cage.

Imbalances are treated by a specific cutaneous contact under the sacrotuberous ligament, the gluteal muscles, or other designated areas of the posterior pelvis. These contacts are commonly thought to evoke somatosomatic reflexes, but there is little doubt that somatovisceral reflexes are also associated.

      Craniotherapy

Craniotherapy, manipulation of the cranial and facial bones, was developed within pioneer chiropractic by Nephi Cottam and within osteopathy by W. G. Sutherland during the 1920s and 1930s. Interest in this procedure has remained stable within osteopathy, and investigation is currently being spearheaded by Upledger. Few, if any, chiropractic colleges currently teach the technique and rationale, but DeJarnette is developing a group with common interest in this area that appears to be growing within the chiropractic profession.

Craniosacral therapy emphasizes the concept of dynamic activity involving the cranial bones, meningeal membranes, cerebrospinal fluid, the intracranial vascular system, the sacrum, the movement of body fluids, and their effect on the function of all body systems.

      Meridian Therapy

Forms of stimulation to specific sites on the skin have been used for at least 3000 years. It is only within the last 20 years, however, that comprehensive studies of acupuncture as a legitimate therapy have been seriously undertaken in this country. Acupuncture is founded on the premise that stimulation of certain sites in the skin has an effect on distant functional mechanisms of the body. Various experimental data tend to support the involvement of a cutaneovisceral reflex, but the exact mechanism is unknown.

Meridian Point Foci.   Meridian therapy with needles, moxa, electrical stimulation, or other modalities most likely works by a neuromechanism; viz, by blocking pain signals in or to the brain by projecting inhibitory impulses to the thalamus and/or cerebral cortex and ultimately to the cord, and finally, by blocking noxious stimuli through the pathophysiologic reflex and thus producing muscular relaxation. Therefore, it should be noted that acupuncture, like the objectives of articular adjustment, is veiled in empiric evidence. Although the Melzack-Wall theory attempted to explain how pain pathways can be blocked, it does not adequately explain any possible localized tissue changes that are known to occur. By extension of this theory, however, local tissue changes may be postulated on the basis of localized vasomotor changes; ie, improvement in the local microcirculation.

Alarm Points.   As far as physical diagnosis is concerned, the most important contribution of acupuncture studies recognized in the United States has been the isolation of certain diagnostic "alarm points." Spontaneous pain, pain on pressure, or excessive electropermeability at one of these points are thought by many to indicate that some disorder is present in the associated meridian. For example, it is claimed that spontaneous or induced pain at a specific point on the thorax indicates a problem in the lung meridian; this alarm point is LU-1. All alarm points are located on the ventral surface of the thorax and the abdomen, and each point is associated with one of the 12 main meridians and its function.

It is thought by Oriental physicians that tenderness or pain elicited by light pressure on or spontaneous pain at any of these points indicates that the meridian has excessive "energy" (Chi). Tenderness only on heavy pressure indicates that there is a deficiency of Chi, according to acupuncturists. Generally, the alarm points are associated with the Yin types of diseases; viz, those diseases associated with cold, depression, and weakness.

Table 10.2 lists the alarm points for the 12 meridians and gives the anatomical location of each.

                       Alarm
Meridian               Point     Location                   
BILATERAL POINTS:

Lung                   LU-1      1 cun** below clavicle,
                                 lateral 2nd–3rd rib
                                 interspace.

Liver                  LV-14     On vertical nipple line,
                                 between 6th–7th ribs.

Gallbladder            GB-24     On vertical nipple line,
                                 between 8th–9 th ribs.

Spleen                 LV-13     Anterior tip of 11th rib.

Kidney                 GB-25     Anterior tip of 12th rib.

Large intestine        ST-25     2 cun lateral to navel.

MIDLINE POINTS:

Lung                   LU-1      1 cun** below clavicle,
                                 lateral 2nd–3rd rib interspace. 

Heart constrictor      CV-17     Midsternal, nipple level,
                                 3/4ths down from episternal 
                                 notch.

Heart                  CV-14     6 cun above navel, just
                                 below xiphoid process. 

Stomach                CV-12     4 cun above navel,
                                 epigastrium, midway between
                                 the sternum and navel. 

Triple heater          CV-5      2 cun below navel.

Small intestine        CV-4      3 cun below navel.

Bladder                CV-3      4 cun below navel. 
__________________________
*From Jaskoviak/Schafer: Applied Physiotherapy. 
**A cun is a "human inch," approximately the width of the individual's thumb.

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