The Orthospinology adjustment is the culmination of the precision of the X-ray equipment alignment, the accuracy of the X-ray analysis and the attention to detail of the patient placement on the side posture/mastoid support adjusting table. With the adjustment goes a tremendous responsibility for the practitioner to be as accurate and careful as possible, for the adjustment is a specific procedure utilized to move bone structure and affect the central nervous system.
The Orthospinology philosophy holds that any attempt to change the function of the nervous system must be undertaken with great care and planning. A favorable outcome should be predictable with a high degree of probability. Dr. John Francis Grostic used to describe the importance of taking care of patients as “how wonderful the opportunity, how great the responsibility.”
The manual adjustment evolved from its original Palmer-type toggle. In 1952, modifications to the adjustment included adopting a closed stance, a lighter contact and a shallower thrust. The adjustment was modified again in 1957 when it was determined that the light thrust produced better reductions by providing more control.
The hand-delivered adjustment utilizes the pisiform as the contact point, which usually travels less than 3/16-inch during the thrust. In the 1960s Dr. Cecil Laney began researching and developing hand-held (and later, table-mounted) adjusting instruments.
Various hand-held, solenoid-powered instruments have been produced to deliver a quick, shallow adjusting force. Dr. Laney and the Spinalight Corporation have produced the Torque-Specific table-mounted instrument, which is being sold through Dynamic Essentials.
Post X-Ray Assessment
The primary value of the post-adjustment X-ray evaluation is in refining the adjustment to more completely reduce the misalignment. The Orthospinology Procedure does not dictate the normal position of the upper cervical spine for all patients. Instead, it provides a system of measurement that makes it possible to locate the position of the upper cervical spine that results in the removal of abnormal neurological findings for the longest period of time.
This is accomplished by taking one or two post X-rays after the first adjustment, as well as the evaluation of other outcome assessments (Figures 1 and 2). The initial post adjustment protocol allows the doctor to assess the effectiveness of the adjustment and, equally important, to fine-tune the adjustment to the individual patient, if necessary. It has been observed for more than 50 years that “normal,” while somewhat variable, is not nearly as variable as one might think. It appears that the closer the upper cervical spine is to the orthogonal position, the longer the patient’s clinical findings remain balanced. If it is determined that the biomechanical component of the occipito-atlanto-axial subluxation constitutes abnormal position, then there must exist a “normal” alignment. This is where the doctor’s clinical judgment is essential.
Two large studies (n=4,581 and n=2,002) found that in an Orthospinology and NUCCA practice, the more the upper cervical subluxation was reduced, the better the patient outcome. The study by Eriksen and Owens determined this by compiling patients’ ratings of symptoms as well as number of visits and adjustments necessary. The study concluded that post X-ray assessment was recommended to ascertain that at least 50 percent correction was achieved after the initial adjustment.
Post X-ray assessment is also important to determine whether an errant adjustment occurs and provide information for the doctor to make the appropriate correction(s) for future adjustments. Knutson published a series of case studies which found that significant errors in upper cervical adjusting caused temporary iatrogenic symptomatic reactions in unsuspecting patients.3 This is an important finding, since some believe that the upper cervical adjustment is innocuous because very little force is utilized.
A single case has also revealed a patient’s upper cervical subluxation being reduced significantly after a NUCCA upper cervical adjustment.4 The patient was then seen by a practitioner who utilized a diversified/Maitland manipulation. X-rays revealed that the patient’s misalignments had increased more than the original subluxation. The NUCCA practitioner re-adjusted the patient, whose subluxation was reduced once again.
However, more research is necessary to determine which method(s) are more effective in reducing upper cervical subluxations.
Outcome Assessments
Upper cervical subluxations manifest clinically in various forms of postural distortion. Some outcomes of upper cervical subluxations include functional leg length inequality, pelvic distortion, head and shoulder tilt, head translation, and even unequal weight distribution, to name a few of the manifestations. The functional leg check is an outcome assessment utilized by most upper cervical doctors on a visit-by-visit basis.
Functional pelvic distortion (FPD) may be a more accurate term, however, since what the doctor is actually measuring is muscle tone and resultant pelvic distortion, instead of only leg length (see Figure 3). Preliminary research has shown very high intra- and
inter-reliability
for the supine leg check.5 Moderate reliability has also been assessed for prone
leg checks.6-8 Pilot studies on pre- and post-assessment of FPD after an upper
cervical adjustment have been conducted,9-11 with higher validity studies being
conducted for future publication.A study has also revealed postural changes resulting in subjects undergoing upper cervical adjustments.12 Two studies have shown statistically significant changes in right and left weight-bearing pre- and post-upper cervical adjustment.13,14
Other outcome assessments that have been studied in clinical and research settings with specific upper cervical care include the following: thermocouple scanning,15-18 surface electromyography,10,11,19 somatosensory evoked potentials,20-25 static palpation26-28 and range of motion.29 As a general rule, the supine leg check, thermometry (thermocouple or infrared scanning utilized for break analysis), scanning palpation and postural analysis are the assessments utilized by most Orthospinology practitioners on a visit-by-visit basis. Palpatory and other methods of determining upper cervical misalignments and asymmetry have not been shown to be reliable.27,28,30,31
There is also research that reveals how non-radiographic methods of determining upper cervical subluxation listings have poor concordance when compared to Orthospinology X-ray analysis.30,32 The motion of the upper cervical spine is quite complicated, capable of excursion into the x, y and z planes. This is why the X-ray procedure is utilized to provide information for the appropriate direction or vector to adjust the patient.
Motion palpation is typically not utilized in the assessment of the upper cervical subluxation. Many research studies have found little to no reliability for this type of assessment.33-36 The auditory evaluation of a “crack” or “audible release” is also not utilized as an outcome to determine whether the subluxation has been reduced. The “liberation of decibels” does not necessarily signify that a successful adjustment has been accomplished. This only indicates that an articulation has been opened.
It has even been shown that joint cavitation alone does not produce an electromyographic reflex response.37,38 A successful upper cervical adjustment occurs when the biomechanical and neurological dysfunction is reduced and spinal stability is established. The latter point is critical, as 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. The longevity of this stability should be the basis by which techniques are judged.
Acknowledgement: Dr. Eriksen gives credit to the late Dr. John D. Grostic for his research in preparing the two-part series.
[References are available from the author upon request.]
About the author: Kirk Eriksen, D.C., a 1991 Life Chiropractic College graduate, is president of the Society of Chiropractic Orthospinology. A lecturer and author, he manages a private practice in Dothan, Ala. For more information, call (334) 793-7992; e-mail to drkeriksen@ala.net; or access his web site at www.orthospinology.org.