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10th Annual Vertebral Subluxation Research ConferenceDecember 7-8, 2002
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Saturday, December 7 |
Sunday, December 8 |
| 8:30 - 9:30 am | Ed Owens, MS, DC | X-ray Analysis Accuracy Testing using Computer Simulated Radiographs - An Interactive Research Presentation - Part II, Results |
| 9:30 - 10:15 | Robert Cooperstein, MA, DC | Interdisciplinary Assay of Literature Pertaining to Leg Length Inequality |
| 10:15 - 10:30 | Break | _ |
| 10:30 - 11:30 | Robert Klingensmith, DC | The Relationship Between Pelvic Block Placement and Radiographic Pelvic Analysis |
| 11:30 - 12:30 | Panel Discussion, Ed Owens, Moderator | Panel Discussion - How can upper cervical technique practitioners and developers present their progressive side? |
Rebecca Clusserath
Phone 800-849-8771 ext 1229
fax 864-599-4860
email rclusserath@sherman.edu
This conference is offered in association with the Academy of Upper Cervical Chiropractic Organizations (AUCCO) as a module in the Upper Cervical Diplomate Program. It will provide 6 hours of credit toward the biomechanics requirement and 6 hours toward x-ray analysis.
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John Hart, DC
In the upper cervical specific technique, there are 12 basic listings for the atlas:
References
Susan H. Brown, PhD, DC
Abstract
William G. Blair studied thousands of radiographs and osseous specimens to give rise to his biomechanical model for the upper cervical spine. He quantified the prevalence of structural asymmetries and proposed models based on the assumption that misalignments take place at the articulations between bones. Anatomical relationships determine the possible misalignments of atlas relative to occiput and axis relative to third cervical. The specialized Blair radiographs, including proctractoviews and lateral stereo views, allow for direct visualization of misalignments.
This presentation will describe the Blair models for atlas and axis misalignment, using diagrams, computer animations and radiographs to demonstrate them. The radiographic positioning for Blair protractoviews and lateral stereo films will be outlined, and listings for atlas and axis will be illustrated.
Robert Kessinger, DC
ABSTRACT
PURPOSE: Due to the anatomical shape and supporting soft tissue, the upper cervical
spine is unique to all other areas of the spinal column. Other authors have adequately
discussed normal biomechanics of the occipito-atlantal-axial region. The purpose
of this presentation is to define biomechanics of the upper cervical spine in subluxation.
These biomechanical definitions will be supported by known factors such as anatomical
structure and function of supporting soft tissue along with plain view and stereo
X-ray analysis.
BACKGROUND AND OBJECTIVES: The anatomical structure of the atlas, axis and occiput are known factors although there are unique differences from any one person to the next. The muscles and ligaments supporting the upper cervical spine are known and their functions have been described. These universally known factors are put together with knowledge gained through Blair Protracto views and lateral stereo analysis to arrive at a new way of looking at the biomechanics of the upper cervical region in subluxation.
CONCLUSION: The fundamental basis for upper cervical chiropractic adjusting techniques is to correct the upper cervical subluxation. Varied upper cervical techniques attempt this through methods specific to their own procedure. Facilitating the upper cervical spine into juxtaposition, thus removing neurological impediment, through an adjusting procedure is the goal. A common ground for all techniques is in the above defined fundamental basis and goal. Understanding the biomechanics of the upper cervical spine in subluxation is a foundation upon which to build further insight into what we do, why we do it, ultimately bringing us to greater application, regardless of specific upper cervical chiropractic technique utilized.
Chung-Ha Suh, PhD
When the chiropractic research project began at the University of Colorado, Boulder in 1969, very little was known about human biomechanics. We very much had to start at the ground floor, making basic measurements of bony geometry and ligament and disc material properties using crude equipment that was designed for engineering of heavier materials. All of that is documented in the proceedings of the Biomechanics Conference of the Spine, which was held annually from 1970 until 1985.
Our early work involved a large group of faculty and graduate students. That work was presented at the first government sponsored conference on spinal manipulative therapies. We had an impressive enough program to be able to attract grant money from the NIH, the first federal grant that went to support research into chiropractic.
There were two main areas in which I was involved, the development of a computerized kinematic model of the spine, and the three-dimensional distortion-free x-ray analysis. A string of graduate students worked on these projects, getting their PhD's from me. After the NIH money ran out, we continued to receive funding from the ICA and particularly Life College in the most recent decade. In this talk, I will provide my perspective on how chiropractic biomechanics research should best proceed in the coming decade.
Kirk Eriksen, DC Course objective: To introduce the doctor/student to the X-ray portion of the Grostic Procedure of adjusting the atlas subluxation.
Upper Cervical Subluxation Biomechanics
Roy W. Sweat, DC, BCAO
Michael Sven Zabelin, D.C. COURSE OBJECTIVE: To familiarize the doctor/student to the Four Basic Types, from the analytical perspective to the biomechanical model. This will include force pathways dependent on Type, headpiece placement and line of drive.
Lisa K. Bloom, D.C.
The well-debated topic of maintenance or preventative care in chiropractic is generally understood to be the chiropractic management of a patient who presents without a chief complaint for the purpose of optimizing the function of the body through the adjustment of vertebral subluxations. Understanding the rationale for maintenance care mandates an understanding of two major well-documented concepts: 1) immobilization degeneration (ID); and 2) the neurology of pain processing.
If we can agree that a primary component of the chiropractic vertebral subluxation is hypomobility in a spinal joint complex, there is an immense body of research to support the ensuing degenerative process and the logical conclusion of restoring movement. Immobilization degeneration is supported by over 40 years of research. The literature notes a joint that has lost a degree of its normal movement will begin degenerating at a rate measurable within one week of onset. Notable is that this degenerative process is histologically distinct from osteoarthritis and will continue, often painlessly, until significant degeneration has occurred or sudden a significant biomechanical stress creates an acute injury.
ID alone is substantial enough to argue for the chiropractic care of a patient without back pain, but it is also important to understand why a vertebral subluxation may be present and the patient may remain asymptomatic. Nociceptors are peripheral receptors that depolarize with noxious stimuli. The impulse is carried into the spinal cord and ascends through the lateral spinothalamic tract to the thalamus. Once the signal reaches the thalamus the impulse is sent to three major cortical areas involved in the perception of pain: the postcentral gyrus, the anterior cingulated, and the insula. It is well understood that pain is perceived in the cortex. Three factors influence the perception of pain: 1) the intensity of the stimulus; 2) the duration of the stimulus; and 3) descending inhibition. It is also understood that most nociception never reaches the cortex allowing tissue damage to occur without symptoms.
The spinothalamic tract sends impulses into the hypothalamus and reticular formation (spinoreticular tract) in the brain stem which accounts for more systemic autonomic changes secondary to nociceptor activity which, again, may occur without the perception of pain. This is the same neural mechanism that allows serious disease processes to progress subclinically. Additionally, nociceptors synapse on excitatory interneurons in the dorsal horn, which fire directly into the intermediolateral cell column resulting in increased firing in postganglionic sympathetic efferents. This is the connection between the musculoskeletal and non-musculoskeletal systems.
Edward Owens, MS, DC Introduction
The major upper cervical techniques differ on the biomechanical models of Atlas misalignment they adhere to and on the methods they use to assess the misalignments. While HIO and Grostic style techniques consider the Atlas to be capable of lateral flexion malposition and rotational malposition with respect to the occiput, the Blair misalignment model is composed of a translation along the axis of one occipital condyle.
Likewise, each of the three techniques has its own particular x-ray views and analysis to determine the extent of misalignment in the different directions. The Blair technique and HIO use particular landmarks on the occipital condyles and Atlas articulations to assess alignment, while the Grostic Procedure uses landmarks on the skull edges and posterior arch/lateral mass intersection. It would be interesting to determine which of these methods provides the most accurate assessment of Atlanto-occipital relationship.
Methods
A computer model of the base of the occiput and the Atlas vertebra has been used to generate simulated x-ray views of just those two bones. The bones can be accurately positioned with respect to each other and simulated misalignments imposed with known displacements or rotations in 3 dimensions. Next, camera views were staged to represent the viewing positions for the HIO A/P open mouth, the Base Posterior view, the Nasium view and bilateral Blair Protractoviews. Finally, high quality images are rendered with semitransparent materials applied to the bones, producing a fair likeness of a radiograph.
For purposes of this study, printed copies of renderings of a mixture of misalignment patterns, from all 5 views, will be presented blindly to practitioners for analysis. The practitioners will be provided with pencils, rulers and protractors and asked to analyze the images with their preferred technique. Analyzers will not know what misalignments are shown on each image.
Data analysis will be carried out after the session and the results will be presented for discussion at a later session during the weekend. The main parameter will be the accuracy of each technique in determining the actual displacement shown on the images. If at least two assessors of each technique are present, then interexaminer reliability can be assessed as well.
Robert Cooperstein, MA, DC
At least five different professions are concerned with leg length inequality: chiropractic, podiatry, medicine, physical therapy, and osteopathy. We gathered literature from each profession concerning the following pertaining to leg length inequality:
The results of our interdisciplinary survey of LLI concepts and clinical implemation facillitate communication between practitioners from different professions, allowing more cross-fertilization of patient assessment and treatment parameters.
Robert D. Klingensmith, DC, DAAPM
From a study by Lisi, Cooperstein and Morschhauser entitled “A Pilot Study of Provacation Testing with Pelvic Wedges: Can Prone Blocking Demonstrate a Directional Preference?”[1] a relationship between block placement and pain was determined. The study found, “It appears that low back tenderness can change in response to various position of pelvic wedges, and that a preferred blocking pattern can be determined. “ Preliminary results of the study suggest that tenderness decreases on increases in response to various blocking positions. Also, the blocking positions that increase or decrease tenderness are typically diametrically opposed, that is, directional preference can be shown.”[1]
In another study, Cooperstein found that padded wedges or SOT pelvic blocks could be used for lumbopelvic mechanical analysis. [2] Unger noted that pelvic block placement could be shown to affect muscle strength. [3]
In the Lisi et al study [1] they determined a pain pressure threshold of patients in a neutral position, and then with a pair of padded wedges placed under the subject in each of four different positions: (Right Short Leg - Category One) left iliac crest, right greater trochanter; (Left short Leg - Category One) right iliac crest, left greater trochanter; (SB+) left and right iliac crests; and (SB-) left and right greater trochanters.
In this current study, radiographs were taken to determine whether pelvic distortions could be demonstrated on x-ray when pelvic blocks were placed under the patient in the prone position. One patient was placed prone in a neutral position and radiographs were taken in a neutral position, and then with a pair of pelvic blocks placed under the subject in each of four different positions: (Right Short Leg - Category One) left iliac crest, right greater trochanter; (Left short Leg - Category One) right iliac crest, left greater trochanter; (SB+) left and right iliac crests; and (SB-) left and right greater trochanters. Findings indicated that pelvic block placement could create or affect distortions of the pelvis. Further studies are indicated correlating radiographic analysis, pain provocation, and muscle strength to determine if a clear pelvic block preference can be determined definitively.
Edward Owens, Moderator
Upper cervical specific chiropractic techniques derive from traditional Hole-in-One (HIO) technique, which dates to the 1930s and B.J. Palmer. Sometimes these techniques are labeled as cultist or backward, perhaps reflecting Palmer's fascination with mysticism and philosophy. This perception may help account for the failure of upper cervical techniques to attract more than 5% of chiropractors.
On the other hand, upper cervical techniques have an element of progressiveness as well. Most are continually being modified and improved to reflect new discoveries and methods. There exists published research in the form of case and case series studies, reliability studies and some cohort studies that support the claims of upper cervical chiropractic's effectiveness. The fact that leaders of technique organizations are willing to come together at conferences such as this in an air of openness and curiosity to discuss their similarities and differences also points to their progressive nature.
This one-hour panel discussion will provide a forum for technique representatives to give their views on these questions: Is your technique open to progress and change? If not, why is it important to adhere to old notions? How can we best overcome the negative perception that the public seems to hold toward us?
It is expected that representatives from at least five techniques will be available for the panel. There will be time for questions and comments from the audience as well.
Associate Professor
Sherman College of Straight Chiropractic
There may be exceptions to the different rules for the x-ray analysis. For example an exception to the point wedge rule on the AP open mouth view could be caused by an anomalous occipital condyle (13). As another exception, an overlap or underlap also may be due to malformation, since opposing articular surfaces may not be exactly the same size or surface area (14). Knowing whether some checks demonstrate greater inter-examiner reliability will help the chiropractor to know whether more weight should be given to some checks (that have been shown to be more reliable) and less weight on others (that have been shown to be less reliable). Also, a preponderance of evidence would be sought in the case of conflicting indicators. For example, three checks that indicate a right atlas while another two indicate that the atlas is left, would suggest that there is more evidence for a right atlas than a left atlas.
Axis
The axis (C2) vertebra is also compared to the occiput condyles, and can misalign in the following directions:
ASL ASLA ASLP ASR ASRA ASRP AIL AILA AILP AIR AIRA AIRP
In upper cervical specific technique there are 14 basic listings for the axis:
The PLI and PRI listing are the same as the BPSL and BPSR respectively except that the spinous process (in PLI and PRI) is more inferior as designated by the “I”. Furthermore, there also exists in the PRI and PLI listings the component of posteriority as noted in the letter “P” as determined on the lateral neutral radiograph.
ESL ESR BPSL BPSR SPBL SPBR ESL-SL ESR-SR ESL-BL ESR-BR CPBL CPBR PLI PRI
Private Practice, Atlanta, GA
Private Practice, Cape Girardeau, MO
Professor Mechanical Engineering(retired)
President, Chiropractic Orthospinolgy Association
Private Practice
Dothan, Alabama
X-ray Analysis Lecture-showing properly taken lateral, nasium and vertex
David Amundsen DC, BCAO
Chairman, NUCCA Education Committee
Diplomate of the International Board of Chiropractic Neurology
Diplomate in Applied Chiropractic Sciences
Associate Professor, Department of Diagnosis and Practice
New York Chiropractic College
Director of Research
Sherman College of Straight Chiropractic
Jarrett Grunstein
Palmer College of Chiropractic - West
Our literature assay confirms that there are significant differences both within and between these professions in how they distinguish functional from anatomic short leg. Pronation, for example, may be considered by some a cause of functional LLI, in that it results from a correctable internal tibial torsion, whereas others may consider pronation a structural alteration by definition. Among the five professions, medicine is the least likely to address the functional short leg, and chiropractic the least likely to address the anatomic short leg. Chiropractors, despite their awareness of the ample literature on the prevalence of anatomical LLI, seem wont to simply ignore that evidence when performing prone and supine leg checks.
Sacro Occipital Technique Organization - USA
Winston-Salem, North Carolina