Home | A New Approach | Specific Up C Techniques | Orthospinology/Grostic
In order to do justice to Dr. Eriksen’s
work I provide herein the unedited paper as provided to me by him. In
this paper he summarises the orthogonal approach to upper cervical analysis,
correction, puts forward some theories as to the casual mechanisms of
ill health and provides a rich list of references for further reading.
The evidence that ‘specific’ upper cervical chiropractic is
effective in promoting wellness is compelling and widespread. You need
only look for it.
PAPER FOR ORTHOGONALLY-BASED UPPER CERVICAL CHIROPRACTIC CARE
By Kirk Eriksen, D.C.
First, I would like to provide a definition
for orthogonally-based upper cervical chiropractic care as follows: A
method for analyzing and correcting the occipito-atlanto-axial subluxation
complex. It is actually a series of steps in the total care of the patient
and is therefore a chiropractic procedure and not simply a spinal adjusting
technique. The procedure employs a method of X-ray analysis that quantifies
the lateral and rotational misalignments between atlas and axis as well
as atlas and occiput. The analytical procedure examines the spatial orientation
of the atlas, the geometry of the articulating surfaces, and the misalignment
configuration to arrive at an effective correction vector. In addition
to the X-ray analysis, the system contains steps for ensuring the precision
of the X-ray analysis, adjusting procedures, and post-adjustment re-evaluation
procedures. These procedures allow the doctor to assess the effectiveness
of the adjustment and, equally important, to fine-tune the adjustment
to the individual patient. The adjustment can be administered manually
or by using an adjusting instrument. The hand delivered adjustment involves
a light contact and a shallow thrust. The contact point, the pisiform,
usually travels less than 3/16" during the thrust. Many doctors utilize
a hand-held solenoid-powered instrument to deliver a very quick and shallow
thrust, or various forms of table-mounted instruments.
A thorough understanding of the anatomy,
biomechanics and neurophysiology of the upper cervical spine is a prerequisite
to be able to appreciate the clinical manifestations of the occipito-atlanto-axial
subluxation complex. White and Panjabi describe the upper cervical articulations
as “…the most complex joints of the axial skeleton, both anatomically
and kinematically.”  The two upper
cervical vertebrae differ in shape and function from the remainder of
the spine. The configuration of the atlanto(C1) and axial(C2) joints,
enables these structures to carry the head and determine its movement.
These articulations also provide protection for the intimate neurologic
and vascular structures. The atlas and axis are two of the nine atypical
vertebrae. The atlas articulation is diarthrodial and is the most freely
movable segment in the spine, in relation to C1-C2 rotation and C0-C1
flexion/extension. The occipito(C0)-C1 articulation consists of reciprocally
curved superior facets of the lateral masses of the atlas and the ellipsoid
synovial joints of the occipital condyles. This articulation allows for
primarily flexion-extension motion, with very little rotation or lateral
flexion. The atlas vertebra has a condyloid articulation with the axis
that allows for 45-50% of rotation in the cervical spine, but the consensus
of the studies show that little motion occurs between the atlas and occiput.
The small amount of movement that does occur is found at the end point
of the range of motion. This is a critical point when discussion is made
about the misalignment component of the subluxation.
The neurological dysfunction related
to the upper cervical subluxation can be explained by a few different
mechanisms. However, it is likely that these mechanisms manifest concurrently
in many patients. The two most plausible hypotheses have to do with spinal
cord tension and mechanoreceptive dysafferentation. The upper cervical
spinal cord is directly attached to the circumference of the foramen magnum,
to the second and third cervical vertebrae and by fibrous slips to the
posterior longitudinal ligament. Hinson,
Grostic and others discuss dissection evidence
showing a dural attachment at the atlas level. The uppermost denticulate
ligaments are arranged almost horizontally, as compared to the inferiorly
angled ligaments found around the rest of spinal cord. The most cephalad
ligaments are also thicker and stronger to help anchor the spinal cord
around the foramen magnum. These ligaments are so strong that they have
been found to sever the upper cervical spinal cord in some cases of hydrocephalus.
Recent studies have also revealed a connective tissue bridge between the
rectus capitis posterior minor muscle and the dura mater of the upper
cervical spinal cord. A similar attachment
has also been found to the spinal cord via the ligamentum nuchae.
The spinal dura mater has been found to be innervated and a possible source
of pain and neurological dysfunction.[8,9] These anatomical facts, as well as the biomechanical descriptions covered
previously, reveal that the upper cervical spine is quite susceptible
to injury and/or the entity called subluxation. The upper cervical spine
has sacrificed stability for mobility as evidenced by ~50% of cervical
rotation occurring between the atlanto-axial articulation. Grostic’s
paper, The Dentate Ligament—Cord Distortion Hypothesis4, provides
a compelling hypothesis for how these anatomical connections can lead
to spinal cord distortion, in the presence of upper cervical misalignment.
It is posited that the neurological dysfunction can occur via two mechanisms:
1) direct mechanical irritation of the nerves of the spinal cord, and/or
2) collapse of the small veins of the cord, producing venular congestion
with a loss of nutrients necessary to carry on the high energy reactions
necessary for nerve conduction. Spinal cord tension can affect the spinocerebellar
tracts which can result in a functional short leg.
Afferent/efferent joint mechanoreceptive
neurology also has interesting implications in this area of the spine.
Mechanoreceptive innervation has been found in the cervical facet joints,
ligaments, intervertebral discs.[10-13] The muscle spindle may be the
most important proprioceptive receptor in the upper cervical spine. The
spindles are intrafusal fibers that are imbedded within all muscles of
the body; however, they are extremely dense in the suboccipital muscles.[14-20]
The human experience is governed by receptors of all types. Cerebral cortical
firing initiates efferent activity. However, the thalamus regulates the
cerebral cortex through summation and integration. Another key point is
that all sensory information goes through the thalamus (except aspects
of olfaction). It is apparent how these two functions are vitally
important for neurological integrity and appropriate cortical representation.
Mechanoreception is the primary input into the cerebellum due to life
in a gravity environment. The primary load to the thalamus is via the
cerebellum due to the vast amount of afferent input required to maintain
upright posture. It is plausible to theorize that stimulating or regulating
mechanoreceptors can have a significant impact on the neurological activity
of the brain and many bodily functions.
It appears that the cervical spine has
more mechanoreceptors per surface area than any other region of the spinal
column. It is thought that the upper cervical articulations have the
greatest amount or receptors in the cervical spine. This may give the
region the greatest potential for spinal mechanoreceptive afferentation
into the neuraxis. There is also evidence suggesting that the upper cervical
afferents feed directly into the vestibular and other high order nuclei.[23-32]
This enables a less modified input of information from the upper cervical
articulations into the brain stem nuclei, as opposed to the lower segments
of the spine. Inappropriate afferentation (i.e. subluxation) and appropriate
input (subluxation correction) into the vestibular nuclei is yet another
plausible explanation for the functional short leg/pelvic distortion that
is observed clinically with patients under upper cervical chiropractic
care. This can occur by way of upper cervical mechanoreceptive functional
integrity through the anterior and posterior spinal cerebellar tracts,
cerebellum, vestibular nuclei, descending medial longitudinal fasciculus
(medial and lateral vestibular spinal tracts), regulatory anterior horn
cell pathway which affects postural motor tone.
The X-ray analysis is the real core
of upper cervical procedures. Because the radiological assessment is so
important, early developers, such as Dr. John Francis Grostic, felt that
chiropractors should always lead the way in X-ray quality and patient
safety. He was the first in the profession to advocate and teach doctors
the use of aligned X-ray equipment. He collaborated with Travis Utterback
to help develop self-centering head clamps, the X-ray turn-table chair
and "L-Frame" apparatus. Many X-ray equipment setups (such as
my own) are installed with the utilization of laser alignment to ensure
precision. The issue of X-ray safety is addressed with the utilization
of lead filters, high film/screen speed combinations, shielding and high
kVp technique by many doctors who utilize upper cervical procedures. The
use of lead filters has been shown to reduce radiation to the patient
by as much as 80-90%.[33-34] Increasing film screen speed from 250 to
800 can also reduce the milliamperage per second (mas) setting by almost
70%, while not sacrificing image quality to any clinical significance.
radiological assessment provides a quantitative analysis as opposed to
only qualitative information. This makes it possible to determine if the
care is actually reducing the subluxation, or if it is just moving the
structures around with no net correction. Thus, quantification of the
misalignment provides a means of evaluating the effectiveness of the adjustment.
Orthogonally-based procedures utilize several measurements from the X-rays
to calculate the correction vector used in the adjustment. The films are
analyzed with manual template analysis and/or computer-aided digitization.
By using this information, the goal is to compute a correction vector
which will reduce all of the misalignment factors proportionately. In
essence, the Procedure enables the doctor to provide a "tailor-made"
It should be noted that the upper cervical
X-ray analysis involves angular measurements of the atlas in the frontal
(Z), sagittal (X) and transverse (Y) planes. Angular measurements in degrees
are utilized, as this analysis is less prone to magnification errors in
comparison to linear measurements. Inter- and intra-examiner reliability
in the marking and reading of the films has been demonstrated and reveals
error of only <.6o and <.5o, respectively.[36-39] Rochester and
Owens have studied the issue of patient placement and the potential distortion
errors that can take place in the measurement of upper cervical X-rays.
Patient-to-film error can occur if head rotation is present when the film
is taken. According to their study, the distortion is insignificant in
most all cases seen in clinical practice. The study involved the development
of a computerized algorithm, with the utilization of a three-dimensional
computerized model of the cervical spine and head, as well as the measurement
of X-rays from a clinical practice. Other potential errors include human
measurement that can occur when the doctor draws lines on the X-rays and
measures the deviations. He/she could either measure or record it incorrectly.
This potential error has been greatly decreased with the development of
computerized digitization programs. The previous reliability study by
Rochester tested the DOC! program and revealed that it was as good as,
if not superior to, manual analysis.
Post X-ray Assessment
Two large studies (n=45841 and n=20042)
found that in these orthogonally-based practices, the more the subluxation
was reduced, the better the patient outcome. The study by Eriksen and
Owens determined this by measuring patient rating of symptoms as well
as number of visits and adjustments necessary. This study concluded that
post X-ray assessment was recommended to ascertain that at least 50% correction
was achieved after the initial adjustment. Post X-ray assessment is also
important to determine if an errant adjustment occurs; and provides information
for the doctor to make the appropriate correction(s) for future adjustments.
A series of case studies have been published which found that significant
errors in upper cervical adjusting caused temporary iatrogenic symptomatic
reactions in unsuspecting patients. This is an important finding since
many believe that the upper cervical adjustment is innocuous since very
little force, if any, is actually felt by the patient. This type of adjustment
is too gentle to “injure” the patient, but osseous structure
is realigned and the central nervous system is affected in the process.
The “seasoned” doctor understands that the true tragedy is
not correcting the subluxation so the patient can experience neurological
integrity, as opposed to temporarily increasing the misalignment. A single
reported case revealed a patient’s upper cervical subluxation being
reduced significantly after a NUCCA upper cervical adjustment. The
patient was then sent to a practitioner who utilized diversified/ Maitland
manipulation. The patient was once again X-rayed, which revealed that
the misalignments had increased more than the original subluxation. Fortunately,
the patient was re-adjusted by the NUCCA doctor and the subluxation was
reduced once again.
Studies have revealed that the radiographic
measurement of misalignment between the occiput and atlas is not affected
when the head is placed, up to a certain degree, in off-centered positions.[45-47]
However, this does not indicate that X-ray placement is not important,
as it can cause errors in other measurement parameters. A study by Jackson
et al. involved 38 subjects who had two sets of anterior to posterior
nasium and lateral cervical radiographs. The second set of X-rays was
taken from one-half to four hours after the initial set. No chiropractic
adjustment was administered between radiographs, although a simulated
adjustment was conducted. The analyzed data revealed a reliability measurement
of one-half degree for the upper angle and two-thirds of a degree for
the lower angle. This study helps to further establish that the upper
cervical misalignments that are measured on precision X-rays are static
and that post adjustment radiography is a valid outcome assessment. One
study has shown that barring trauma, an upper cervical misalignment pattern
in a patient with signs of subluxation tends to be static (although the
magnitude of the misalignment tends to decrease over time when the patient
becomes subluxated). In other words, the upper cervical spine does
not move around freely finding a new position each time the patient is
radiographed. It appears that the reduction of the misalignment post adjustment
is due to something other than patient placement. These reasons, taken
together, explain why upper cervical protocol calls for X-ray assessment
of misalignment factors in an occipito-atlanto-axial subluxation.
Upper cervical subluxations manifest
clinically in various forms of postural distortion (i.e. functional leg
length inequality, pelvic distortion, head and shoulder tilt, head translation,
unequal weight distribution, etc.). The functional leg check is an outcome
assessment utilized by most all upper cervical doctors on a visit-by-visit
basis. It is my opinion that functional pelvic distortion (FPD) is a more
accurate term; for what the doctor is actually measuring is muscle tone
and resultant pelvic imbalance, instead of only leg length. Functional
pelvic distortion contrasts with anisomelia, which is an anatomical short
leg. Leg length inequality (LLI) often has a different significance to
various physicians. For some, this condition is thought to have no importance
until the inequality is ½” or greater. To the other extreme,
many authors feel that a difference of just a few millimeters is significant
for various musculoskeletal complaints.[51-59] LLI has been related to
lower back pain[60-68], disc/joint degeneration[54,60,65,69-75], an increased
susceptibility to sports injuries and potential improved performance[71,76-84],
an association with scoliosis58,69,74,75,85-93, and its effect on bilateral
weight deviation.94-99 Preliminary data have been published showing very
high intra- and inter-reliability for the supine leg check assessment.100
Moderate reliability has been assessed for the prone leg check.[101-103]
Pilot studies on pre- and post-assessment of FPD after an upper cervical
adjustment have been conducted[104-106], with larger validity studies
planned for the future.
A blinded single case study did show
a statistically significant correlation between an objective measure and
the FPD test for when an adjustment was indicated. Another case study
involved atlanto-occipital intra-articular injection that moderated postural
distortion. Another study also revealed postural changes occurring
in subjects after undergoing upper cervical care. Two studies have
shown statistically significant changes in right and left weight bearing
pre- and post- upper cervical adjustment.[95,96] In addition, there are
reports of relief of low back and leg pain[110-127], knee pain and
idiopathic scoliosis[129,130] with the utilization of upper cervical specific
care. This implies, but does not prove, a causal link between global postural
distortion and upper cervical chiropractic care.
Other outcome assessments that have
been studied in clinical and research settings with specific upper cervical
chiropractic care include the following: thermocouple scanning[131-134],
surface electromyography[105,106,135], somatosensory evoked potentials[136-141],
static palpation[142-144] and range of motion. Palpatory and other
methods of determining upper cervical misalignments and asymmetry have
not been shown to be reliable.[143,144,146,147] There is also research
that reveals how non-radiographic methods of determining upper cervical
subluxation listings have poor concordance when compared to X-ray analysis.[146,148]
The motion of the upper cervical spine is quite complicated, capable of
excursion into the x, y and z planes. The X-ray procedure provides the
information for the appropriate direction or vector to adjust the patient.
Studies on Patient Efficacy
Orthogonally-based upper cervical care
is not a treatment for conditions or diseases, however, this subluxation-centered
care has been shown to have an associative effect on various conditions.
The following is a review of the peer-reviewed literature that shows a
documented correlation between orthogonally-based care (Grostic/ Orthospinology,
NUCCA and Atlas Orthogonality) and the improvement of various patient
complaints. Studies have been published showing positive outcome for patients
with cervical curve distortion[153,154], neck pain[155-156], cervicobrachialgia[157,158],
motor vehicle trauma, headaches[160-161], low back pain[110-116],
scoliosis, postural distortion[95,96,108], knee pain, general
health enhancement[158-160], cerebral palsy, autism, Tourette’s
syndrome, seizure disorders, mental dysfunction, multiple
sclerosis, Arnold-Chiari malformation, HIV, cystic hygroma,
asthma, bowel dysfunction[171-172] and hypertension[173-174] The
previous papers involve various levels of scientific evidence which range
from case studies to randomized controlled clinical trials.
paper has provided a compelling and cogent argument for the clinical and
scientific efficacy of orthogonally-based upper cervical chiropractic
care. There is a logical chain of arguments that support specific upper
cervical work. This chain is supported by some evidence at each link,
with the evidence for some aspects being stronger than others. Given the
anatomical, biomechanical and neurological complexity of the upper cervical
spine, specific upper cervical work is an appropriate approach to adjust
the upper cervical subluxation.
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