Orthospinology Upper Cervical Care
Supine Leg Check and Postural Assessments
By Kirk Eriksen, D.C.
Upper cervical subluxations manifest in various forms of postural distortion
(i.e., functional leg length inequality, pelvic distortion, head and shoulder
tilt, head translation, unequal weight distribution). Clinically, it has been
found that functional leg length inequality (LLI) and upper cervical subluxations
occur concomitantly. The supine leg check (SLC) has been the primary assessment
used by orthogonally-based upper cervical practitioners for over 50 years. The
term functional pelvic distortion (FPD) has been previously introduced.1
This may be a more accurate descriptor for what the doctor is actually measuring—muscle
tone imbalance and resultant pelvic distortion, as opposed to LLI.
FPD contrasts with anisomelia, which is an anatomical short leg. Various studies
have revealed that an anatomical short leg of five millimeters or more occurs
in approximately half of the adult population.2–5 However,
several possible inaccuracies in this observation have been previously covered.1
Subluxations and the resultant postural distortion can have a significant effect
on the measurement of femur head heights. It is generally recognized that anatomical
short legs do exist, although the frequency can be debated. In clinical practice,
upper cervical practitioners have observed that more than 90 percent of their
patients are “balanced” (equalization of the SLC) after the subluxation
is reduced. However, a balanced supine or prone leg check does not necessarily
mean that the patient does not have an anisomelia as these two phenomena likely
occur concurrently in many cases.
Research has shown very high (>0.9 ICC) intra- and inter-examiner reliability
for the SLC6 and moderate reliability for prone leg checks.7-9
Pilot studies on pre- and post-assessment of FPD after an upper cervical adjustment
have been conducted,10-12 with larger validity studies
to be conducted.13 These type of studies involve a group
of patients being initially examined by a group of doctors with a SLC. The patients
will then receive either an upper cervical adjustment, sham adjustment (in some
study designs), or no adjustment. This is followed by the same group of doctors
conducting a follow-up SLC that are blinded to the type of intervention. The
purpose of the study is to determine if the doctors can assess a marked change
in FPD as a result of the chiropractic intervention, as opposed to the doctor’s
bias. Pilot studies have been promising but more published research is necessary.
Another type of study has revealed postural changes resulting in subjects undergoing
upper cervical adjustments.14 Two other studies have
shown statistically significant changes in bilateral weight bearing pre- and
post- upper cervical adjustments.15,16
It should be noted that conducting an accurate SLC is an art that is not consistently
possible unless the doctor adheres to a strict protocol. Space is not allotted
in the article to provide the step-by-step procedure for conducting an appropriate
SLC. However, potential errors in conducting an accurate SLC must be carefully
avoided as they can include the following:
LLI (structural and functional) has a different significance to various physicians.
For some, this condition is thought to have no importance until the inequality
is half an inch or greater.17 To the other extreme, many
authors feel that a difference of just a few millimeters is significant for
various musculoskeletal complaints.18–25 Compelling
evidence has been published that shows the following:
You may ask, “What does an upper cervical subluxation have to do with
a functional LLI?” The neurological mechanism for this explanation was
covered in a previous issue of Today’s Chiropractic (March/April 2004:42-47)
and much more extensively in the textbook Upper Cervical Subluxation Complex,
which is published by Lippincott Williams & Wilkins. A thorough understanding
of neuroanatomy and neurophysiology enables the doctor to not only understand
this mechanism, but also realize that it makes logical sense. The key is to
not only provide an adjustment and balance a patient’s spine, but to enable
the patient to hold the correction. Most patients in an Orthospinology-based
practice will hold their adjustments for weeks to several months at a time.
A successful upper cervical adjustment occurs when the biomechanical and neurological
dysfunctions are reduced, and spinal stability is established. The latter point
is critical as it is our contention that the adjustment is not the modality
that helps the patient. Rather, it is the “holding” of the adjustment
that enables the patient to experience neurological integrity and improved health.
Postural Assessment
The spine helps to keep the body upright. This is no easy feat, considering
the forces of gravity working against the human frame. Normal posture in the
frontal plane is defined as the spine being vertical and the centers of mass
for the skull, thorax and pelvis being aligned with the middle of the feet.
The head, shoulders and hips should also be level. The sagittal posture should
reveal normal lateral spinal curvatures. The thoracic and sacral curves are
considered primary, while the cervical and lumbar curves are referred to as
secondary. The center of the axis odontoid process and shoulder should line
up with the bisection of the transverse axis of the hip and ankle joints
The assessment of upright posture is also an important outcome that is monitored
by upper cervical doctors. Structure dictates function, just as posture plays
a significant role in the overall health of the individual. Posture has been
shown to be a somewhat stable condition65-69 that can
be reliably assessed.70-79 The challenge is to objectify
postural analysis, so devices ranging from wall-mounted grids to computerized
technology have been used to improve such assessments.
The patient should be viewed in the anterior to posterior (A-P) and lateral
dimensions. Posture can be visually assessed with the patient standing near
a bare wall; however, the analysis can be aided with the use of a posture board
or chart. This can be made out of various materials but it should be comprised
of a single vertical line located in the center with several horizontal lines
that are spaced about four inches apart. The posture board/chart can be mounted
on the back of the door or on the wall of the treatment room. A plumb line should
be utilized during installation to ensure that the vertical line is accurate.
The lines on the posture board or chart will greatly aid the doctor with his/her
visual assessment.
Postural analysis can be further objectified with computerized technology. The
Posture Pro (VenturaDesigns) has been found to be quite useful by various Orthospinology
doctors. The software assists the doctor in analyzing A-P and lateral posture
images of patients that are obtained with a digital camera. The findings from
the initial postural assessment can be referred to on a visit-by-visit basis
to determine if the patient is in their original subluxated pattern. A brief
visual evaluation is usually sufficient and can be aided with the use of a posture
board/chart. Assessing the patient’s degree of anterior head carriage
has shown to be a critical clinical assessment.1 Cailliet has stated that in
a forward head posture, the head weighs the weight of the head times the inches
ahead of the center of gravity (e.g., 3”=30 lb, 4”=40 lb).80
Indeed, posture is a vital outcome assessment according to Lennon et al., “…posture
affects and moderates every physiologic function from breathing to hormonal
production.”81
The patient’s bilateral weight deviation can be measured with the use
of two digital scales. It is preferable to use a high quality scale that will
“lock in” the weight after obtaining a stable reading. The patient
is asked to place each foot on a specific spot on each scale that is symmetrically
located from one scale to another. The Anatometer is another instrument that
is used to measure postural distortion and bilateral weight deviation as a concomitant
to an upper cervical subluxation. This instrument was researched and developed
by the National Upper Cervical Chiropractors Association. Reliability studies
on the Anatometer have shown correlation coefficients ranging from as low as
0.30 to as high as 0.953, depending on the study and the variable being tested.16,82,83
Kirk Eriksen, D.C. is president of the Society of Chiropractic Orthospinology
and is a part-time faculty member of Northwestern Health Sciences University.
He has published various research studies and is the author of “Upper
Cervical Subluxation Complex, A Review of the Chiropractic and Medical Literature.”
Dr. Eriksen can be contacted at drkirke@ala.net.
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