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The Harder You Look,
The More You See:
Less Common Subluxations
By Jerry Hochman, D.C.
Many chiropractic techniques
offer several tools for the determination of neuro-mechanical spinal dysfunction
(subluxation), including palpation, motion analysis and postural observation.
The addition of muscle response analysis to standard technical methodologies
enables the examiner to use the resulting information to help locate and adjust
the spine effectively. These procedures enable the clinician to determine the
next logical step towards reduction of the subluxation.
Muscle testing has been used for many years, both in medical and chiropractic
practice, but often for different reasons. Standard diagnostic muscle testing
is used to determine the integrity of neurological efferent motor function.
A C5 nerve root problem can result in weak deltoids. Applied Kinesiology and
related disciplines use the organ/muscle relationship to help determine the
specific organ that is dysfunctional and to determine whether a certain treatment
will restore normal function. Many practitioners previously have used a string
indicator muscle combined with vertebral challenges or therapy localizations
to find where and how to adjust.
Tests have not been devised that have successfully demonstrated the clinical
validity of kinesiologic muscle testing yet, however there seems to be some
clinical usefulness of such procedures for those skilled enough to use them.
Although we try to explain the effectiveness and rationale of why we do what
we do in terms of mechanics and neurology, these explanations undoubtedly fall
short of the whole truth most of the time. Teaching has taught me that there
is little doubt that what we do works, but there is great doubt that our explanations
of why it works are complete and accurate. Clinical procedures are an art, based
on experience and expertise. The issue of whether to use a procedure only if
its scientific integrity has been firmly established is one which must be decided
by the individual practitioner. The purposeful disposal of such “unproven”
techniques is probably unwise. The inappropriate application of badly designed
reliability studies too often results in ignorant statements made by otherwise
intelligent people regarding certain procedures common in many offices. The
perspective one takes in deciding a clinical approach with patients is a function
not only of technique and rationale but also of habit, and routine. Constant
re-examination of our procedures is, therefore, practical and beneficial.
Posture and Distortion
Postural analysis can be performed with observation of all body parts, implying
imbalance of many different muscles or muscle groups. Sacro Occipital Technique
distortion analysis only looks for three primary postural defects, greatly simplifying
the clinical picture and offering organization to the clinician: anterior to
posterior sway, lateral deviation of the pelvis and spine off the midline, and
antalgia. These three observations lead the examiner to suspect one or more
of three primary subluxation-related dysfunctions known as the three Categories.
A-P sway in excess of 1/2-inch total sway may indicate an inability of the synovial
parts of the sacro iliac boots to move properly, disabling the ability of the
cranium to achieve a balanced position with respect to the sacrum. Dr. Major
DeJarnette thought this constituted a dural dysfunction problem, which he named
Category I (See figure 1 showing distortions, page 48)
Obvious lateral deviation of the pelvis and spine to the right or left away
from the string (center line on posture analysis) usually means that one or
both sacro iliac joints cannot bear the weight of the trunk above in a balanced
fashion. This weight-bearing ability is likely a function of the sacro iliac
ligaments and pelvic musculature, and is known as Category II in S.O.T. Lateral
deviation can also be due to lower extremity dysfunction or upper cervical subluxation.
Structural or significant functional change in lumbar disc mechanics, with associated
neurological implications, results in enough muscular compensation in the low
back to pull the nerve root away from the disc enough to create some degree
of pain relief. This finding is called Category III in S.O.T. Therefore, these
three simple observations give significant information to guide the clinician
to the next analytical step.
Muscle Compensations
A DeJarnette invention, first rib palpation is easily used to determine which
sacro iliac joint is most dysfunctional (incapable of bearing weight normally).
Palpation of the musculature over the medial posterior aspect of the first and
second ribs may reveal greater motion and palpatory pain on one side. This is
considered evidence of a scalene imbalance secondary to sacro iliac instability
on the same side in an effort to keep the head on straight even when the foundation
is unstable. Constant hypertonicity of the scalenes probably results in inflammation
at the costo-transverse (and costo-sternal) joints, leading to greater motion
of the first rib during neck flexion. The scalenes have lost their stable base
of support (ribs 1 and 2), resulting in palpatory hypermotion over the first
ribs felt by the examiner. This test is performed with the patient in the standing
position (See figure 2, rib head technique, page 52).
Figure 2. rib head technique
Mechanical Stress Tests
Years ago, frustrated by the DeJarnette arm fossa test used to verify sacro
iliac subluxation (Category II), I introduced the “Standing Stress”
test to students at Life University. The stress tests do not require an inguinal
ligament contact on the patient, and these stress tests directly exacerbate
the problems they are designed to expose. This test is now used by some S.O.T.
practitioners and others in the profession because it is easy, quick, definitive
and more easily understood than the arm fossa test. I must now admit that part
of my original motivation was my lack of expertise in performing the arm fossa
and rib head tests.
If a flat-footed jump on the right foot causes an outstretched arm to yield
to floorward pressure applied by the examiner (weaken), the S/I joint on that
side is weight-bearing dysfunctional (subluxated). Of course, it could be the
lower extremity on that side, or even the lower lumbars in cases of pain exacerbation
in those areas. Usually this test reveals unilateral S/I subluxation. Further
analysis reveals the nature of the subluxation. If a previously weak test becomes
strong during held inhalation, expect to find further indicators of sacral subluxation.
If toe standing (plantarflexion) weakens the arm, you should suspect foot or
ankle dysfunction.
Hyperextension of one knee with slight flexion of the opposite knee resulting
in a weak arm indicates laterality of the sacral base to the side of the bend
knee, or apex deviation to the hyperextended side.
Figure 3. Sacral base laterality
Bioenergetics?
A controversial test introduced by Dr. DeJarnette in the 1960s, known as “mind
language” and promoted by George Goodheart as “therapy localization,”
always fascinated me. How could a test with no known anatomical or physiological
explanation be so easy to do and feel and give so much information so easily,
yet be vilified as unscientific and bogus by the chiropractic scientists? My
understanding is that even some of DeJarnette’s own students rejected
his use of such a procedure, and it did not reappear in his books until the
1980s. My attitude regarding the scientific validity of certain procedures and
the controversy that surrounds them is: “If it proves to be clinically
useful, I will use it until someone proves it is incorrect.”
Three skin surface locations have been identified as having a neurological or
energetic relationship to the three categories of spinal dysfunction described
above:
Category I cranio sacral spinal dysfunction: The left (or right) P.S.I.S.
Category II sacroiliac dysfunction: The L5 transverse process
Category III lumbar disc dysfunction: The styloid fossa.
Figure 4. Mind Language
Less Common Subluxations
I have repeatedly found that some patients require some focused attention regarding
their spinal analysis. The use of packaged technique procedures often does not
go far enough in addressing their needs. An appreciation of the sensitivity
of the patient in exposing their subluxations coupled with the examiner’s
sensitivity in seeing the problem results in a successful doctor-patient encounter
often when the rote application of a named technique fails to expose such a
problem. I have identified a short list of less common subluxations that, in
some cases, are much more common than I previously thought.
The
Atlanto Occipital Joint
Examination of referred patients often reveals atlanto occipital dysfunction.
It may just be a standard PS occiput. More often, however, a lateral occiput
is exposed. Perhaps, when the upper cervical practitioner fails to achieve the
desired results, a look at occiput is warranted. The idea that the mechanics
of a joint can be totally normalized with a single adjustment on only one segment
is somewhat theoretical, and may not reflect the spinal reality of some patients.
DeJarnette wrote about the lateral occiput in several of his manuals. This was
a possibility I had never been taught, although it seemed reasonable considering
what I knew about upper cervical mechanical theory. The lateral occiput is simply
a straight lateral side slip, so to speak, of the occipital condyles on the
Atlas. The adjustment is a straight lateral to medial thrust applied to the
occiput itself, not to the mastoid process. Analysis of occipital side slip
can be done using various methods. I position the patient’s neck into
lateral flexion, coupled with held inhalation and sometimes a chin tuck, and
monitor muscle strength or leg length. If a previously strong indicator muscle
weakens or previously balanced legs become uneven, I assume laterality of the
occiput opposite to neck flexion. My assumption is that held inhalation increases
cranial intrathecal pressure. (See figure 5 occipital laterality adj.)
Figure 5. Occipatal laterality adjustment
Sacro Iliac Distortion
Sacral adjusting is often used to help normalize sacro iliac function. My friend
Nelson DeCamp, an eminent Florida chiropractor and certified chiropractic neurologist,
noticed the difficulty inherent in blindly following the instructions in the
technique manual when he tried to correct all sacro iliac problems using only
DeJarnette blocks. This led to his development of a variety of pelvic side posture
adjustments and associated analyses which, to some degree, had already been
developed earlier in the context of Gonstead protocol. The two most prominent
findings were the superior or inferior innominates and the sacral segmental
subluxations.
Superiority or inferiority of the innominates refers to side posture adjusting
of the sacrum with the involved side down, using appropriate torque. DeCamp’s
indicators are palpatory pain and tightness of the medial hamstrings and the
quadratus lumborum. This finding constitutes frontal plane rotation of the pelvis
requiring either sacral or iliac contacts for correction. The issue, in this
case, is frontal distortion, with all associated muscular and ligamentous abnormalities.
Monitoring the prone leg lengths while challenging the ilia superiorly or inferiorly
while stabilizing sacrum will reveal the presence of superior or inferior innominates.
Sacral segmental subluxation involves side posture adjustment of the sacrum,
involved side up, with a specific segmental contact on the sacrum, indicated
by palpatory and painful muscle fiber on the posterior segmental location. This
analysis exposes the most efficient segmental contact for correction of sacro
iliac fixation/dysfunction. The issue in this case is transverse plane pelvic
distortion. Challenging the sacrum within the transverse plane while monitoring
leg length easily exposes the most common level of sacral posteriority: S3.
(See figure 6, sacral transverse challenge)
Figure 6. Sacral tranverse challenge
Knowledge that less common subluxations exist may help many chiropractors with
tough cases that do not respond to a standard technique approach. Although this
short paper covers several possibilities, it is safe to assume many others exist.
I am sure that central neurological dysfunctions are to blame for many non-responsive
cases. One rule that seems to govern quality analysis is: The harder you look,
the more you see.
About the author: Dr. Jerry Hochman has taught chiropractic techniques at
Life University for 20 years. Dr. Hochman is certified in chiropractic craniopathy
through the Sacro Occipital Research Society International and has taught S.O.T.,
Thompson Terminal Point, and Dynamic Spinal Analysis, across the Southeast,
in Canada and South America. He is currently studying chiropractic neurology.
Dr. Hochman maintains a private practice in Marietta, Ga.
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