Sixth Annual National Subluxation Conference

Holiday Inn Boardwalk
Atlantic City, NJ

UTILIZATION OF SOMATO-SENSORY EVOKED POTENTIALS IN SUBLUXATION BASED CHIROPRACTIC RESEARCH

Karen Feeley Collins, D.C.

Somato-sensory evoked potential (SSEP) testing is a non-invasive, objective procedure for identifying neurological insult. This type of testing has been successfully utilized in clinical medicine for the past 25 years and has been shown to be a highly sensitive and very specific test of the functioning of the sensory neural pathways.

Since the original work of D.D. Palmer, chiropractic has had as its goal the reduction of the vertebral subluxation through chiropractic adjustments. Historically, the vertebral subluxation consists of two basic components: structural and functional. While the structure and biomechanics have been quantitatively and qualitatively assessed, the functional has only been partially observed through diagnostics like the EMG, thermography, muscle grading, etc. The underlying neurology has been more difficult to measure.

SSEP testing provides a unique opportunity for chiropractic researchers to directly assess the effects of the subluxation complex on the sensory nervous system. Even better, we can utilize these tests to show improvements in the sensory nervous system following chiropractic adjustment.

Several chiropractic studies are cited, documenting the neurologic component of the subluxation and the improvements in the sensory nervous system following chiropractic adjustments.

The Neurologic Basis of Upper Cervical Subluxation: Clinical Manifestations

Hal S. Crowe, Sr. D.C. and Thomas D. Kleinman, D.C.

Upper cervical subluxation producing whole-body symptoms and imbalance has been clinically apparent and a mainstay of chiropractic for more than six decades. It has been consistently observed in upper cervical chiropractic that balance in leg length, paraspinal temperature, and muscle tone occurs immediately with the full reduction of the atlas subluxation. The neural component that physiologically regulates the clinical constituates of the atlas subluxation is the reticular formation of the brainstem (Magoun, 1971)

Due to the proximity of the occipito-atlanto-axial structures to the reticular formation, chiropractic upper cervical specialists have speculated on various means of mechanical deformation by the subluxation to the brainstem. Although structural pressures from subluxation are undeniable, mechanical deformation to neural tissue causes injury and depolarization requiring healing time and does not allow for the immediate restoration of functions that are clinically observed with all patients following an adjustment.

Brainstem neuroanatomy and physiology and in-depth reviews of recent literature indicate a different and more viable process by which the atlas subluxation embarrasses reticular formation activity, also consistent with long standing observations connected with upper cervical adjusting.

The most important proprioceptive information needed for maintenance of equilibrium is derived from joint mechanoreceptors of the upper cervical spine, appraising the orientation of the head with respect to the body. This vital input is conducted along nerve fibers capable of the greatest velocity of transmission directly to the reticular formation for modulation of descending control. Descending control includes regulation of posture, autonomic response, consciousness, wakefulness, and pain.

Irregular input from this primary sensory modality due to physical disequilibrium and altered physiologic motion of atlas-axis has the potential to alter neural circuitry modulated at the reticular formation. Restoration of equilibrium has an immediate effect on restoration of function without necessitating healing time.

Key Words: Upper Cervical Subluxation, Reticular Formation, Healing Time, Primary Sensory Modality

THE SELF PERPETUATING SUBLUXATION

Hugh L. Crowe, DC

A vertebral subluxation exist after a vertebra becomes restricted in movement by its muscular attachments. This restriction causes it to articulate abnormally. Aside from pathology, dislocation and fractures, loss of joint movement results from aberrant or absent muscle action. Vertebral misalignment continues by a loss of action of the muscles that would return it to its normal position. Abnormal muscle action is a by-product of abnormal nerve action.

This study explores the anatomy of the Atlas vertebra and the neuromuscular involvement that prevents the atlas subluxation from self-correcting. Nowhere else in the spine is the nerve that controls the muscles that position a vertebra so closely related to that vertebra. It then becomes imperative that, in spinal subluxation, the atlas should be given special consideration.

In this study we will consider the normal movement of the atlas; the type of joint involved; the muscles involved; the nerves involved; the ligaments and supporting structures.

With the use of anatomical illustration and drawings, we will consider:

• The anatomy of the atlas.
• The movement of the atlas.
• The muscles, nerves, and ligaments involved in the self-perpetuating subluxation.

Comparison of AP Open Mouth and Base Posterior Radiographs Regarding Atlas Rotation Findings

John Hart, DC

Fifteen sets of x-ray films are in the process of being selected from patient files from the Health Center at Sherman College of Straight Chiropractic for the purpose of comparing findings on the AP open mouth and Base Posterior radiographs regarding rotation of the atlas vertebra. Three parameters commonly used in AP open mouth analysis of atlas rotation are being considered in this study and will be compared to findings of the base posterior view. The base posterior is considered the "gold standard" for the determination of atlas rotation. The purpose of this study is to see how well the AP open mouth findings compared to the base posterior findings. The three parameters used for the AP open mouth, so far, have varying agreement with the findings for the base posterior. Based upon the limited data generated thus far (the data will be complete within one month or so) the author suggests that, in the absence of a base posterior view, the AP open mouth parameters be weighted according to their respective agreement with the base posterior view as found herein.

Changes in Visual Acuity in Patients Receiving Upper Cervical Specific Chiropractic Care

Robert Kessinger, D.C., Dessy Boneva, D.C.

The present study was conducted to investigate the relationship between Upper Cervical Specific chiropractic care and changes in visual acuity. The population under study represented sixty-seven subjects who had not previously experienced chiropractic care. They ranged in age from 9 to 79 years, averaging 46.4 years. The subject group consisted of 37 females (48.7 + 18.9 years) and 30 males (43.5 +15.7 years). Visual accuity in each eye was evaluated using a Snellen chart before and six weeks after receiving chiropractic care. The Snellen chart consists of 11 rows in which a different number of letters of varying sizes were displayed. Scores for the population as a whole were reported as the mean and standard deviation of the absolute number missed in each row before and after care, and further expressed as a percent increase or decrease, pre/post chiropractic care, for each row as "percent change in distance visual acuity" (%DVA).

Findings from this initial study suggest that observed changes were not a function of gender. Thus, the population as a whole demonstrated statistically significant improvement in the right eye (paired two-tailed t-test, p < 0.05) in percent distance visual acuity at distances associated with less than "typical" normal vision (20/50, 20/40, 20/25),"typical" normal vision (20/20), and better than "typical" normal vision (20/16). Significant improvements were also shown for the left eye at the same distance acuity levels, as well as at the levels of 20/125, 20/80, and 20/60. Regression analysis (p < 0.05) of scores before chiropractic care revealed a positive correlation between increasing age and number of letters incorrectly identified at the levels of 20/20 and 20/16 for both the right and left eyes. Regression analysis performed on scores after chiropractic care revealed the same relationship for the left eye as before care. However, after care, this relationship was only apparent at the 20/16 level in the right eye.

Thus, evaluation of these data show improvements in % DVA following Upper Cervical Specific chiropractic care, at distances "typically" associated with less than normal, normal, and better than normal vision, with no correlation between upper cervical vertebral "listing." Improvement in the left eye was evident at greater extremes of low vision than in the right eye. However, age related differences in the number of incorrectly identified letters, associated "typically'' with normal and better than normal vision, showed apparent improvement in normal vision in the right eye following care. Possible implications and explanations for these findings are discussed.

Key Words: Upper cervical chiropractic care, vertebral subluxation, visual acuity.

Risk Assessment of Neurological and/or Vertebrobasilar Complications in the Pediatric Chiropractic Patient

Richard A. Pistolese, B.Sc.

Reports suggest that chiropractic accounts for a large percentage of visits to alternative health practitioners. Moreover, pediatric patients represent a significant proportion of these visits. In light of this trend, it is important to evaluate the risk potential to the pediatric patient presenting for chiropractic care. This paper has reviewed literature concerning the occurrence of neurological and/or vertebrobasilar (N/VB) complications in patients receiving either specific chiropractic adjustments and/or non-specific manipulations of the spine. This topic was chosen due to the potentially severe consequences of neurological and/or vertebrobasilar insult, regardless of the etiology. The current study was conducted in a quasi-meta analysis format using a collection of chiropractic surveys spanning 1977-1994. Based on this information, the number of pediatric visits, extrapolated to also include the periods between 1966 and 1977, as well as 1995-the first quarter of 1998, was estimated to be 502,184,156. Reports of the occurrence of neurological and/or vertebrobasilar complications in chiropractic pediatric patients was also investigated over the same time period by searching the scientific/clinical literature. The estimate of risk due neurological and/or vertebrobasilar complications to the pediatric chiropractic patient occurred in approximately 4.0 x 10^-7% of all visits. Stated otherwise, there would be a chance of about 1 in 250 million pediatric visits that a N/VB complication would result. While some pre-existing conditions may predispose a pediatric patient to a higher incidence of such complications, the estimates derived in the present study are considered applicable to the general pediatric population. The estimates derived in the present study are intended to be initial risk assessments. Since very few reports exist relative to the incidence of neurological and/or vertebrobasilar complications in children, additional studies will be necessary to confirm this risk estimate.

ATLAS ORTHOGONAL COMPUTERIZED X-RAY ANALYSIS PROGRAM

Roy Sweat, D.C.

The GP-8 Sonic Digitizer utilizes the principle of measuring the transit time of a sound impulse generated by a stylus or cursor to calculate the distance traveled to the "X" and "Y" microphones, called the "L frame".

The linear microphones can be manufactured to accommodate active areas ranging from 14" x 14" to 60" x 72". The microphones incorporate temperature compensation providing system stability from 13 degrees and 33 degrees Celsius.

The GP-8 Sonic Digitizer is manufactured by Science Accessories Corporation, 970 Kings Highway West, Southport, Connecticut 06490, (203) 255-1525 serial number 52211.

The GP-8 Sonic Digitizer is attached to an x-ray view box.

• A. The doctor uses a cursor to digitize the landmarks on the radiographs.
• B. The doctor does not draw a line on the radiographs. The doctor does not measure a line on the radiographs.
• C. The radiographs must be taken accurately and correctly.

In my opinion all chiropractors' x-rays in the future will be done on computerized x-ray programs.

SPINAL MODELING USING DISTORTION ANALYSIS OF FRONTAL PLANE RADIOGRAPH REVEALS COMPENSATORY REORGANIZATION AS THE PATHWAY OF SPINAL REHABILITATION

Ray Wiegand, D.C.

The spinal pelvic system predictably reorganizes into an intermediate biomechanical configuration called ideal compensation or functional scoliosis as the patient is subjected to chiropractic adjustments. The organizational process is a pathway during spinal rehabilitation whereby normal biomechanical coupling is reestablished segmentally, regionally and globally.

The projectional configuration of ideal compensation as seen on the frontal plane radiograph results from three dimensional adaptation which includes lateral bending and rotation. It is also seen as a result of oblique two dimensional imaging of the spine's inherent three dimensional architecture within a coherently distorted x-ray field. Whether the ideal pattern is seen as a result of adaptation, oblique viewing or a combination of both, the pattern presents as an organized, symmetrical, balanced and efficient system of reciprocating convex curves. The compensatory image is predictable, measurable and can be interpreted based on alignment coherency.

Understanding the nature of and comparing the patient to the ideal compensatory configuration takes into consideration all factors related to x-ray distortion, malposition, static imaging and functional loading. Using compensatory relationships and statistical analysis, the A-P radiograph can be accurately interpreted for chiropractic intervention based on intersegmental alignment, regional coupling and global system balance. Comparison of the patient to this intermediate spinal configuration permits identification and distinction between compensation and subluxation. It also separates stabilization goals from rehabilitative goals.

This paper presents the scientific principles of x-ray imaging, a spinal system model based on malposition and distortion, a graphical methodology of displaying it, the statistics of interpretation and a database design to research it. Patient findings are also presented to further exemplify the methodology of clinical application and interpretation.

Using Heart Rate Variability to Monitor the Balance of the Autonomic Nervous System

John Zhang, Ph.D., MD

Chiropractic care is concerned with the integrity of the nervous system. The sympathetic and parasympathetic nervous systems are responsible for physiological regulatory mechanisms. Heart rate variability (HRV) is a noninvasive measurement developed over the past two decades to determine the balance of the autonomic nervous system. HRV is a phenomenon where the heart rate of a normal individual changes continuously around its mean value. This constant changing in heart rate is a response to the interplay between sympathetic and vagal modulation of sinus node pacemaker activity. An increased activity in one system is accompanied by decreased activity in the other. Analysis of HRV data generates important information concerning sympatho-vagal balance. HRV measurement is a recording of ECG readings and monitoring the heart rate changes. The HRV has been used in a wide variety of clinical interests, especially to monitor stress and predict cardiovascular diseases. Research has found that lowered HRV is associated with aging and increased incidence of sudden death. Changes in HRV are associated with major depression, panic disorders, anxiety, and worry. HRV analysis has also shown that, during mental or emotional stress, sympathetic activity increases and parasympathetic activity decreases.

This cohort study was designed to investigate the reliability of HRV measurement on the balance of sympathetic and parasympathetic nervous system in the first year chiropractic student who received varying forms of chiropractic care in SCSC. The goal of the study was to determine whether their care received during the period of study had any effect on their autonomic nervous system. Twenty-seven 'normal' students, 22 to 49 years old, voluntarily participated in the study. HRV was measured four times within a twelve-month period. The first three measurements were made within three months and the fourth reading was taken after a 12 month period. The mean heart rate decreased from 80+9, 81+12, and 83+10 beats per minute in the first three tests to 73+10 beats per minute in the fourth test (P<0.05). The mean high frequency component that represents parasympathetic stimulation increased from 95, 121 and 67 Hz in the first three measurements to 218 Hz in the fourth measurement. The low frequency component that represents sympathetic stimulation showed dominant pattern in all four readings, ranging from 522, 592, 487 to 676 Hz (P>0.05). There was a slight increase in sympathetic stimulation in the fourth reading compared to the first three measurements but the change did not reach statistical significance.

A high sympathetic stimulation was found in the first year chiropractic students. A significant improvement in heart rate and increased parasympathetic stimulation was noted one year later with varying chiropractic care. Further research will assign subjects into different chiropractic care groups and isolate the effect of varying chiropractic care on the autonomic nervous system. HRV used in the study appeared to be a reliable measurement of sympathetic and parasympathetic balance.

UPPER CERVICAL CHIROPRACTIC: What every doctor needs to know

Karen Feeley Collins, D.C.

Upper Cervical Chiropractic began as a separate entity with BJ Palmer in the late 1920's. He eventually concluded that almost all spinal problems are related to the misalignment patterns of the upper cervical area. Since then, many prominent chiropractors and chiropractic researchers have continued the search for relationships to the upper cervical spine in order to better understand the anatomy, neurology and physiology of the upper cervical subluxation complex.

The upper cervical area is a unique area of the spine. Because of its complex nature there are many theories and differing techniques. Almost every chiropractic technique includes an evaluation of the upper cervical spine, with several techniques focusing only on the upper cervical spine.

This presentation attempts to summarize the history of Upper Cervical Chiropractic and to share the vast amount of information available on this crucial area of the spine.

QUANTITATIVE ASSESSMENT OF THE STATIC GEOMETRIC FORM AND DYNAMIC FUNCTION OF THE CERVICAL SPINE IN THE SAGITTAL PLANE

Ray Wiegand, D.C.

Chiropractic attempts to restore the normal static form and dynamic function of the global spinal pelvic system. This clinical goal necessitates developing an objective methodology which establishes the patient's departure from normal, monitors the effectiveness of treatment intervention and identifies maximum improvement.

In the clinical setting, many patients present with multiple manifestations of an acceleration injury. These include physical findings as well as alterations to the neutral lateral cervical curve as viewed on x-ray. Interpretation of the cervical x-ray has traditionally relied on the subjective experience of the observer. An alternate methodology for assessing the static form and dynamic function of the cervical spine can be accomplished by identifying multiple osseous landmarks, recording the landmarks through digital data point transfer into computers and performing quantitative analysis through specific software routines. This methodology objectively assesses the patient's departure from normal over multiple geometric variables.

The dynamic function of each cervical motion segment can also be determined from x-ray by measuring the disc angle at the extreme positions of flexion and extension and calculating the angular change that occurs from the neutral position. Asymmetry of motion is used to identify segmental dysfunction and the appropriate chiropractic adjustment vector. Symmetry of motion is a direct indicator of the quality of function.

These combined biomechanical analyses establish an objective baseline parameter within the clinical trial which identifies the patient's static and functional deficiencies. This paper develops the theory and application of quantitative analysis of the cervical spine. A clinical case study is presented using this methodology. The findings demonstrate that chiropractic intervention resulted in the restoration of geometric form and dynamic function.

CHANGES IN GENERAL HEALTH STATUS DURING UPPER CERVICAL CHIROPRACTIC CARE - A PRACTICE BASED RESEARCH PROJECT

Kathryn T. Hoiriis, D.C.

Edward F. Owens, Jr. MS, DC

A practice-based research (PBR) project specifically focused on the upper cervical chiropractic practice was proposed at the 13th Annual Upper Cervical Spine conference in November 1996.

The primary measures of health status were the RAND (SF-36) health survey and a visual analog scale for global well-being (GWBS). The SF-36 is administered to patients at the outset of care, after four weeks of care, and when the doctor determines that the patient has reached maximum improvement. The GWBS is given at each visit to gage the patient's assessment of their improvement on a more frequent basis. Demographic information, as well as the chief complaint for patients was collected as part of the enrollment process. Additionally, the characteristics of the cervical misalignments for each patient as measured on radiographs have been tabulated.

Since the onset of the study 16 months ago, data have been collected on 153 patients. The preliminary results show that patients enter into upper cervical chiropractic care with a variety of mostly musculoskeletal complaints. At the outset of care, those patients have significantly lower health status, as measured by the SF-36, than the general population. There is a general trend for patients to experience an upward trend in their perception of health as measured by both the SF-36 and the GWBS. Analysis of x-ray listing factors suggests that upper cervical chiropractic adjustment improves alignment of the occipito-atlanto-axial spine.

Although these results are encouraging, many of our original questions go unanswered because of a lack of follow up data. In addition, the sample size is too small to make any general conclusions. To enlarge the scope of the study, we would like to incorporate data from a wider sample of chiropractors, including those who use full spine techniques aimed at the correction of subluxation.

Key words: chiropractic, subluxation, practice-based research, upper cervical, RAND Health Survey, global well-being scale.